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Cutaneous Ureterostomy for the Relief of Intractable Bladder Tuberculosis*
CUTANEOUS URETEROSTOMY FOR THE RELIEF OF INTRACTABLE BLADDER TUBERCULOSIS* EDWARD L. KEYES
The Journal d'Urologie, in 1934, published a contribution by Jean Fresnais, reporting the histories of ten patients upon whom Marion had, during the preceding decade, performed cutaneous ureterostomy for the relief of severe bladder spasm that persisted in spite of nephrectomy for tuberculosis. During the ensuing year or two a few less important papers followed, since which the subject has hardly been mentioned. No wonder: there is little to discuss in the technique of this simple operation while as for results its rival, uretero-enterostomy, has been progressively perfected until it claims our attention not only as a challenge to surgical skill but also as a promise of relief for the better part of those operated upon. Granted that, for the treatment of cancer, cutaneous ureterostomy is less neat than implantation of the ureter into the intestine, it is yet my hope that the cases I report may suggest that, for a young person with intractable bladder tuberculosis, the ~utaneous implantation has more to offer than would be supposed. Indeed if further observations confirm my impression it is not impossible that, in the long run and for conditions other than tuberculosis, drainage of the ureter to the skin may be found to compare favorably with that through the bowel both in point of infection-and-secondary-stone and in the preservation of renal function to a degree that outweighs the inconvenience of the drip. Perilous to prophecy, is it not? Yet I have the advantage that I shall not be here to learn whether the prophecy is fulfilled or not. In all seriousness, though, my experience warrants me to assert no more than that cutaneous ureterostomy seems adaptable to both classes of tuberculous patients, a) those with bilateral renal tuberculosis whose ureters are doubtless going to drain badly and, b) those with unilateral tuberculosis whose ureters should drain well. It is a consolation, too, to know that the latter without catheter need not endure chafe or stink : one of my patients is a surgeon whose practice has not thereby been interrupted a single day during the 19 years he has survived ureterostomy. My friend Dr. A. R. Stevens has twice anastomosed the ureter to the *Read May 9, 1940, before the Detroit Branch of the American Urological Association. 40
URETEROSTOMY FOR INTRACTABLE BLADDER TUBERCULOSIS
41
bowel after nephrectomy for tuberculosis. Both patients have survived in excellent health for years, one with secondary stone, one without. I do not dispute him here beyond noting that I have thought anastomosis inapplicable to tuberculosis because of the lack of assurance that the surviving kidney is not itself tuberculous. My tuberculous patients who have been operated upon by cutaneous ureterostomy total 6. Three of them with no suggestion of tubercle in the surviving kidney have been able to do without the indwelling catheter and have been-if one may be permitted the term-cured by operation. The three with bilateral renal tuberculosis have required the indwelling catheter and have been a disappointment both to themselves and to me. Yet one of them has shown an unforeseen subsidence of multiple tuberculous lesions in ribs and in epididymes attributable in part to the good drainage afforded by the cat4eter. He has survived ureterostomy 13 years; I do not believe any other system of drainage would have served him so well. The operation is a simple one. Through a high inguinal incision, over McBurney's point if on the right side, the ureter is picked up extraperitoneally, divided low in the pelvis and freed upward-to the kidney pelvis as often as not-until it can be brought out without tension and without kink through the wound or through a stabwound alongside. A centimeter or more is left protruding: much of this will slough but the base will form a nipple of everted mucosa which, if we are lucky, will not so much as need a meatotomy thereafter. The ureter is fixed-fixed rather than drawn-in its new position by as few sutures as may be and the rest of the wound closed without drainage. A catheter is left in the ureter until the skin sutures are out and then removed in the hope that for the future the patient may dispense with it. Retention of urine, signalled by pain and/or fever, is relieved by catheter. Those who can dispense with the catheter will find the Bard-Whitfield cup adequate, I hope, to keep them dry by night as well as by day. Until the skin has become immune to irritation by urine, vaseline is applied twice a day. Thereafter the apparatus need only be boiled twice a day and the skin washed as often in the bathtub. Case 1 (the records are lost.) The patient was operated upon about 20 years ago, a bilateral cutaneous ureterostomy. After operation acid-fast bacilli were recovered from each ureter. One ureter sloughed and became strictured to such an extent that nephrectomy was performed-and the patient lost sight of shortly thereafter, about 2 years after ureterostomy. He had to
42
EDWARD L. KEYES
wear indwelling catheters and these annoyed him so he used to clamor to have his bladder function restored. Case 2. This patient had no previous history of tubercle. Renal tuberculosis in 1918. I removed the left kidney in 1923, at which time the right one was supposed to be sound. Severe bladder spasms persisted and, in 1927, 4 years after nephrectomy foci of tuberculosis appeared in a rib and in the epididymes. Ureterostomy and epididymectomy were promptly performed and in the ensuing years the scrotal and rib sinuses were at various times curetted, a second rib focus having appeared within a few years. Since 1935 all sinuses have remained healed. During the first 6 months after ureterostomy tubercle bacilli were repeatedly recovered from the urine but since then I have seen him every 6 months or so and have not found acid-fast organisms in the urine. In 1930, 3 years after ureterostomy, a small stone was discovered in the kidney pelvis and within the year there were 2 large round calculi, giving him so much pain that I performed nephrolithotomy. He nearly died of the operation, the loin wound took more than a year to heal and, what with the nervous breakdown that ensued, he was in hospital 18 months and a few months thereafter x-ray showed another stone. This has grown to a more convenient staghorn shape than its predecessors and I do not tell him there is recurrence. Six months ago when I last saw him he weighed 125 pounds, about 10 pounds less than his usual weight since I have known him. The urine is, of course, foul and dilute, the Mosenthal shows no power to concentrate and he is unable to concentrate phenolsulphonphthalein more than 10 per cent in any 15 minute period. Fortunately he has a devoted mother: between them they drive the car from Vermont to Florida and back again yearly. Three winters ago he spent in Europe and, having learned, like a cardiac, to live within his capacity, he is happy and, barring accident or intercurrent disease, may go several years yet. His pension helps. It is 13 years now since ureterostomy. Case 3. This patient, upon whom simultaneous nephrectomy and ureterostomy were done, is the most interesting of the series. In 1932 when I :first saw him he was 3Oyears old, a handsome, temperamental Greek with a stormy history of wine, women, gonorrhea and syphilis. The tuberculosis had shown first as a pleurisy with effusion in his fourteenth year. At 17 the sternum was involved and later a knee. The bony lesions had quieted down when he got to me. When admitted to the ward he was running an irregular temperature, both lungs were full of tubercle and there was a cavity at the right apex. The prostate, the bladder and both kidneys were believed to be tuberculous though under spinal anesthesia neither ureter could be catheterized. Urogram showed
URETEROSTOMY FOR INTRACTABLE BLADDER TUBERCULOSIS
better function from the left kidney. The blood showed no retention of urea. The phthalein excretion was 35 per cent in the second half-hour. The Kline reaction was mildly positive. The cough he was accustomed. to and his chief complaint was that he urinated at least every hour day and night. He confessed to being 20 pounds under weight. With active tuberculosis throughout the urinary tract and. disseminated tuberculosis in both lungs it did not seem that he had enough expectation of a useful or a happy life to make it a matter of great moment whether we killed him or not-I would not dare confess that unless I were safely out of practiceand our internist seemed to believe as I did that the :first indication was a night's sleep. Under spinal anesthesia I therefore performed, without mishap and simultaneously, a right nephrectomy and cutaneous ureterostomy on the left side. Both wounds were closed without drainage and healed promptly. The surgical convalescence was uneventful and for a month thereafter we struggled in vain to get along without indwelling catheter in the ureter from which we could always recover acid.fast bacilli. But in spite of our best efforts his condition grew steadily worse, he lost weight and the temperature range was higher. So, with a bad prognosis, we sent him to a tuberculosis sanatorium. Not long thereafter he was transferred to Saranac where the fever subsided and he gained 30 pounds in weight. When I next saw him in 1935, almost 3 years after ureterostomy, his general condition had improved for, thanks to sanatorium care during about half the intervening months, the lungs were clearer, the cavitation less, the fever gone, though bacilli were still present in the sputum. No acid-fast bacilli could be recovered from the foul proteus-laden urine. There was a small oval stone in the kidney pelvis. He appealed to us, inspired by fear and by hope. The fear had been excited by a recent flare-up of temperature due to the calculus plugging the ureter. His hope was that the disappearance of acid-fast bacilli from the urine argued that the tuberculous kidney was healed and that now the ureter would drain once the stone and the filthy catheter were out. The kidney function was found to be surprisingly good; urea clearance 40 per cent, phathalein excretion 55 per cent in an hour. We tried in vain for a fortnight to make the catheter drain consistently, then yielded to his importunity and, once again under spinal anesthesia, exposed the lower pole of the kidney, which looked normal. We lifted this away from the pelvis enough to permit an easy pyelolithotomy. He die septic the twenty-fifth day, exploration of the wound having failed to disclose the small proteus abscess between the pelvic wound and the lower pole of the kidney. Autopsy further disclosed tuberculosis of lungs, liver, spleen, peritoneum, prostate and upper third of the kidney.
44
EDWARD L. KEYES
The following are cases of unilateral renal tuberculosis: Case 4. This patient was chauffeur when I first knew him, now out of a job. He had tuberculosis of the hip early in life: this discharged for a time and left the joint anchylosed. Curiously enough this sinus that had remained closed for some 30 years opened in 1938 and still discharges but without impairing the general condition or, so far as I know, influencing the renal condition. Urinary symptoms began in 1917 and I removed a tuberculous kidney from the left loin in 1919. Thereafter the bladder symptoms continued as tempestuous as ever and in 1921, when he entered the hospital, he was on the verge of delirium tremens and in need of so much morphine that I had to stand guard over him to prevent the hospital authorities from throwing him out. Ureterostomy was immediately performed with no mishap beyond an acute nephritis attributed to alcohol, with a recurrence 6 months later. Thereafter we heard no more of his drug habits. No acidfast bacilli have ever been recovered from the ureter and, without indwelling catheter, there are but a few pus cells in the urine, a few casts and a trace of albumin. He concentrates up to 1.016 and the maximum concentration of phthalein is 20 per cent in 15 minutes. He needed meatotomy a year after operation. He has had a singularly mild urethral gonorrhea and the hip sinus: otherwise he has remained well for the 19 years since ureterostomy. The homemade apparatus he wears is built up around a Beer suprapubic cup and a bicycle tire. The cup keeps him dry day and night but cuts the skin at times. It has the virtue of costing him nothing. Case 5. This patient, a surgeon now, had a lesion, presumably tuberculous, in a costal cartilege in 1914, when he was 9 years old. A year later acid-fast bacilli were found in the urine and a hydronephrotic kidney removed in which no lesions of tuberculosis were found . (The diagnosis of tuberculosis might be doubted for since that time no acid-fast bacilli have been found in the urine nor any other proof of active tuberculosis.) Bladder symptoms continued and when I first sa:w him in 1920 he was discharging a "pea soup" urine at brief intervals and running a hectic temperature. At this time he was an interne in an out-of-town hospital and acutely ill. I make no further excuse for the rather brutal method of diagnosis and treatment employed. I found the bladder capacity reduced to 50 cc. or so, and prostate and vesicles scarred, the kidney impalpable. Assuming that the kidney was tuberculous I expored and found it apparently normal so I drained the bladder above the bone and performed internal urethrotomy. A month later the suprapubic sinus was still open, the temperature down and the ureter irregularly dilated so, it being in the heyday of "ureteral stricture," I freed the lower ureter and removed the appendix.
URETEROSTOMY FOR INTRACTABLE BLADDER TVBERCULOSIS
45
The operation was successful to the extent that the ureter leaked and the suprapubic fistula closed. This ureteral leak persisted until 10 months later, in March 1921, ureterostomy was performed. Since then he bas been well and no acid-fast bacilli have been found. His active surgical practice has been interrupted only by matrimony and the rupture, in 1932, of a duodenal ulcer. He wears bath towels at night and a homemade apparatus by day. Now, at the age of 45, he bowls and enjoys deep-sea fishing without mishap. Case 6. The only woman in this series lost her tuberculous kidney in 1931, when she was 24. X-ray and physical examination at this time revealed no tuberculosis elsewhere and the bladder symptoms subsided. Three years later she became pregnant and was found to have "hilum tuberculosis." Abortion was therefore performed and the pulmonary lesions subsided. Two years thereafter dysuria reappeared and pus and acid-fast bacilli were found in the unne. Then, in 1936, she came to us. No lesions were found except in the urinary tract. The stump of the left ureter was clear but the right could not be catheterized even after 3 months of trntment had somewhat alleviated the cystitis. As soon as she left hospital, however, the bladder became as irritable as ever and in December, 1936, ureterostomy was performed to relieve t.he dysuria and dyspareunia and to make pregnancy possible. Convalescence was uneventful and in June 1938, when pus and albumin had dis:tppeared from the urine, the renal function seemed normal. She became pregnant and bore a child in the summer of 1939 without inconvenience to her except great nocturnal polyuria and an advanced elate of delivery because of a sudden increase in albuminuria. Dr. Charles R. Kingsley promises to report the obstetrical experience. She keeps herself dry day and night with the Bard-Whitfield cup. She is well, her urine uninfecte
Six cases of cutaneous ureterostomy for tuberculosis are reported. The operations of nephrectomy and contralateral ureterostomy were once performed simultaneously, once ureterostomy preceded nephrectomy and 4 times followed it at intervals, respectively, of 2, 4, 5, and 6 years. There were no postoperative deaths. Three patients have not shown any suggestion of tuberculosis in kidney or ureter since ureterostomy. But for one who needed meatotomy they have had no complaint or treatment during a postoperative interval of 3 (l case) to 19 (2 cases) years. Two of them keep themselves dry by night as well as by day. They do not stink and are well. One has
46
EDWARD L. KEYES
married since ureterostomy, one has borne the child she was deemed incapable of before. All 3 patients with tuberculosis in the surviving kidney have had to wear an indwelling ureter catheter. The 2 who have been followed had phosphatic stone within 3 years of ureterostomy. Yet, thanks doubtless to the good ureteral drainage, the progress of the renal tuberculosis has been slow and other tuberculous lesions have improved or healed. One of them is alive 13 years after ureterostomy. This report justifies no larger conclusion than that cutaneous ureterostomy may bring joy and long life to the patient tortured by a tuberculous bladder.
Tuxedo, N. Y.
The Journal d'Urologie, in 1934, published a contribution by Jean Fresnais, reporting the histories of ten patients upon whom Marion had, during the preceding decade, performed cutaneous ureterostomy for the relief of severe bladder spasm that persisted in spite of nephrectomy for tuberculosis. During the ensuing year or two a few less important papers followed, since which the subject has hardly been mentioned. No wonder: there is little to discuss in the technique of this simple operation while as for results its rival, uretero-enterostomy, has been progressively perfected until it claims our attention not only as a challenge to surgical skill but also as a promise of relief for the better part of those operated upon. Granted that, for the treatment of cancer, cutaneous ureterostomy is less neat than implantation of the ureter into the intestine, it is yet my hope that the cases I report may suggest that, for a young person with intractable bladder tuberculosis, the ~utaneous implantation has more to offer than would be supposed. Indeed if further observations confirm my impression it is not impossible that, in the long run and for conditions other than tuberculosis, drainage of the ureter to the skin may be found to compare favorably with that through the bowel both in point of infection-and-secondary-stone and in the preservation of renal function to a degree that outweighs the inconvenience of the drip. Perilous to prophecy, is it not? Yet I have the advantage that I shall not be here to learn whether the prophecy is fulfilled or not. In all seriousness, though, my experience warrants me to assert no more than that cutaneous ureterostomy seems adaptable to both classes of tuberculous patients, a) those with bilateral renal tuberculosis whose ureters are doubtless going to drain badly and, b) those with unilateral tuberculosis whose ureters should drain well. It is a consolation, too, to know that the latter without catheter need not endure chafe or stink : one of my patients is a surgeon whose practice has not thereby been interrupted a single day during the 19 years he has survived ureterostomy. My friend Dr. A. R. Stevens has twice anastomosed the ureter to the *Read May 9, 1940, before the Detroit Branch of the American Urological Association. 40
URETEROSTOMY FOR INTRACTABLE BLADDER TUBERCULOSIS
41
bowel after nephrectomy for tuberculosis. Both patients have survived in excellent health for years, one with secondary stone, one without. I do not dispute him here beyond noting that I have thought anastomosis inapplicable to tuberculosis because of the lack of assurance that the surviving kidney is not itself tuberculous. My tuberculous patients who have been operated upon by cutaneous ureterostomy total 6. Three of them with no suggestion of tubercle in the surviving kidney have been able to do without the indwelling catheter and have been-if one may be permitted the term-cured by operation. The three with bilateral renal tuberculosis have required the indwelling catheter and have been a disappointment both to themselves and to me. Yet one of them has shown an unforeseen subsidence of multiple tuberculous lesions in ribs and in epididymes attributable in part to the good drainage afforded by the cat4eter. He has survived ureterostomy 13 years; I do not believe any other system of drainage would have served him so well. The operation is a simple one. Through a high inguinal incision, over McBurney's point if on the right side, the ureter is picked up extraperitoneally, divided low in the pelvis and freed upward-to the kidney pelvis as often as not-until it can be brought out without tension and without kink through the wound or through a stabwound alongside. A centimeter or more is left protruding: much of this will slough but the base will form a nipple of everted mucosa which, if we are lucky, will not so much as need a meatotomy thereafter. The ureter is fixed-fixed rather than drawn-in its new position by as few sutures as may be and the rest of the wound closed without drainage. A catheter is left in the ureter until the skin sutures are out and then removed in the hope that for the future the patient may dispense with it. Retention of urine, signalled by pain and/or fever, is relieved by catheter. Those who can dispense with the catheter will find the Bard-Whitfield cup adequate, I hope, to keep them dry by night as well as by day. Until the skin has become immune to irritation by urine, vaseline is applied twice a day. Thereafter the apparatus need only be boiled twice a day and the skin washed as often in the bathtub. Case 1 (the records are lost.) The patient was operated upon about 20 years ago, a bilateral cutaneous ureterostomy. After operation acid-fast bacilli were recovered from each ureter. One ureter sloughed and became strictured to such an extent that nephrectomy was performed-and the patient lost sight of shortly thereafter, about 2 years after ureterostomy. He had to
42
EDWARD L. KEYES
wear indwelling catheters and these annoyed him so he used to clamor to have his bladder function restored. Case 2. This patient had no previous history of tubercle. Renal tuberculosis in 1918. I removed the left kidney in 1923, at which time the right one was supposed to be sound. Severe bladder spasms persisted and, in 1927, 4 years after nephrectomy foci of tuberculosis appeared in a rib and in the epididymes. Ureterostomy and epididymectomy were promptly performed and in the ensuing years the scrotal and rib sinuses were at various times curetted, a second rib focus having appeared within a few years. Since 1935 all sinuses have remained healed. During the first 6 months after ureterostomy tubercle bacilli were repeatedly recovered from the urine but since then I have seen him every 6 months or so and have not found acid-fast organisms in the urine. In 1930, 3 years after ureterostomy, a small stone was discovered in the kidney pelvis and within the year there were 2 large round calculi, giving him so much pain that I performed nephrolithotomy. He nearly died of the operation, the loin wound took more than a year to heal and, what with the nervous breakdown that ensued, he was in hospital 18 months and a few months thereafter x-ray showed another stone. This has grown to a more convenient staghorn shape than its predecessors and I do not tell him there is recurrence. Six months ago when I last saw him he weighed 125 pounds, about 10 pounds less than his usual weight since I have known him. The urine is, of course, foul and dilute, the Mosenthal shows no power to concentrate and he is unable to concentrate phenolsulphonphthalein more than 10 per cent in any 15 minute period. Fortunately he has a devoted mother: between them they drive the car from Vermont to Florida and back again yearly. Three winters ago he spent in Europe and, having learned, like a cardiac, to live within his capacity, he is happy and, barring accident or intercurrent disease, may go several years yet. His pension helps. It is 13 years now since ureterostomy. Case 3. This patient, upon whom simultaneous nephrectomy and ureterostomy were done, is the most interesting of the series. In 1932 when I :first saw him he was 3Oyears old, a handsome, temperamental Greek with a stormy history of wine, women, gonorrhea and syphilis. The tuberculosis had shown first as a pleurisy with effusion in his fourteenth year. At 17 the sternum was involved and later a knee. The bony lesions had quieted down when he got to me. When admitted to the ward he was running an irregular temperature, both lungs were full of tubercle and there was a cavity at the right apex. The prostate, the bladder and both kidneys were believed to be tuberculous though under spinal anesthesia neither ureter could be catheterized. Urogram showed
URETEROSTOMY FOR INTRACTABLE BLADDER TUBERCULOSIS
better function from the left kidney. The blood showed no retention of urea. The phthalein excretion was 35 per cent in the second half-hour. The Kline reaction was mildly positive. The cough he was accustomed. to and his chief complaint was that he urinated at least every hour day and night. He confessed to being 20 pounds under weight. With active tuberculosis throughout the urinary tract and. disseminated tuberculosis in both lungs it did not seem that he had enough expectation of a useful or a happy life to make it a matter of great moment whether we killed him or not-I would not dare confess that unless I were safely out of practiceand our internist seemed to believe as I did that the :first indication was a night's sleep. Under spinal anesthesia I therefore performed, without mishap and simultaneously, a right nephrectomy and cutaneous ureterostomy on the left side. Both wounds were closed without drainage and healed promptly. The surgical convalescence was uneventful and for a month thereafter we struggled in vain to get along without indwelling catheter in the ureter from which we could always recover acid.fast bacilli. But in spite of our best efforts his condition grew steadily worse, he lost weight and the temperature range was higher. So, with a bad prognosis, we sent him to a tuberculosis sanatorium. Not long thereafter he was transferred to Saranac where the fever subsided and he gained 30 pounds in weight. When I next saw him in 1935, almost 3 years after ureterostomy, his general condition had improved for, thanks to sanatorium care during about half the intervening months, the lungs were clearer, the cavitation less, the fever gone, though bacilli were still present in the sputum. No acid-fast bacilli could be recovered from the foul proteus-laden urine. There was a small oval stone in the kidney pelvis. He appealed to us, inspired by fear and by hope. The fear had been excited by a recent flare-up of temperature due to the calculus plugging the ureter. His hope was that the disappearance of acid-fast bacilli from the urine argued that the tuberculous kidney was healed and that now the ureter would drain once the stone and the filthy catheter were out. The kidney function was found to be surprisingly good; urea clearance 40 per cent, phathalein excretion 55 per cent in an hour. We tried in vain for a fortnight to make the catheter drain consistently, then yielded to his importunity and, once again under spinal anesthesia, exposed the lower pole of the kidney, which looked normal. We lifted this away from the pelvis enough to permit an easy pyelolithotomy. He die septic the twenty-fifth day, exploration of the wound having failed to disclose the small proteus abscess between the pelvic wound and the lower pole of the kidney. Autopsy further disclosed tuberculosis of lungs, liver, spleen, peritoneum, prostate and upper third of the kidney.
44
EDWARD L. KEYES
The following are cases of unilateral renal tuberculosis: Case 4. This patient was chauffeur when I first knew him, now out of a job. He had tuberculosis of the hip early in life: this discharged for a time and left the joint anchylosed. Curiously enough this sinus that had remained closed for some 30 years opened in 1938 and still discharges but without impairing the general condition or, so far as I know, influencing the renal condition. Urinary symptoms began in 1917 and I removed a tuberculous kidney from the left loin in 1919. Thereafter the bladder symptoms continued as tempestuous as ever and in 1921, when he entered the hospital, he was on the verge of delirium tremens and in need of so much morphine that I had to stand guard over him to prevent the hospital authorities from throwing him out. Ureterostomy was immediately performed with no mishap beyond an acute nephritis attributed to alcohol, with a recurrence 6 months later. Thereafter we heard no more of his drug habits. No acidfast bacilli have ever been recovered from the ureter and, without indwelling catheter, there are but a few pus cells in the urine, a few casts and a trace of albumin. He concentrates up to 1.016 and the maximum concentration of phthalein is 20 per cent in 15 minutes. He needed meatotomy a year after operation. He has had a singularly mild urethral gonorrhea and the hip sinus: otherwise he has remained well for the 19 years since ureterostomy. The homemade apparatus he wears is built up around a Beer suprapubic cup and a bicycle tire. The cup keeps him dry day and night but cuts the skin at times. It has the virtue of costing him nothing. Case 5. This patient, a surgeon now, had a lesion, presumably tuberculous, in a costal cartilege in 1914, when he was 9 years old. A year later acid-fast bacilli were found in the urine and a hydronephrotic kidney removed in which no lesions of tuberculosis were found . (The diagnosis of tuberculosis might be doubted for since that time no acid-fast bacilli have been found in the urine nor any other proof of active tuberculosis.) Bladder symptoms continued and when I first sa:w him in 1920 he was discharging a "pea soup" urine at brief intervals and running a hectic temperature. At this time he was an interne in an out-of-town hospital and acutely ill. I make no further excuse for the rather brutal method of diagnosis and treatment employed. I found the bladder capacity reduced to 50 cc. or so, and prostate and vesicles scarred, the kidney impalpable. Assuming that the kidney was tuberculous I expored and found it apparently normal so I drained the bladder above the bone and performed internal urethrotomy. A month later the suprapubic sinus was still open, the temperature down and the ureter irregularly dilated so, it being in the heyday of "ureteral stricture," I freed the lower ureter and removed the appendix.
URETEROSTOMY FOR INTRACTABLE BLADDER TVBERCULOSIS
45
The operation was successful to the extent that the ureter leaked and the suprapubic fistula closed. This ureteral leak persisted until 10 months later, in March 1921, ureterostomy was performed. Since then he bas been well and no acid-fast bacilli have been found. His active surgical practice has been interrupted only by matrimony and the rupture, in 1932, of a duodenal ulcer. He wears bath towels at night and a homemade apparatus by day. Now, at the age of 45, he bowls and enjoys deep-sea fishing without mishap. Case 6. The only woman in this series lost her tuberculous kidney in 1931, when she was 24. X-ray and physical examination at this time revealed no tuberculosis elsewhere and the bladder symptoms subsided. Three years later she became pregnant and was found to have "hilum tuberculosis." Abortion was therefore performed and the pulmonary lesions subsided. Two years thereafter dysuria reappeared and pus and acid-fast bacilli were found in the unne. Then, in 1936, she came to us. No lesions were found except in the urinary tract. The stump of the left ureter was clear but the right could not be catheterized even after 3 months of trntment had somewhat alleviated the cystitis. As soon as she left hospital, however, the bladder became as irritable as ever and in December, 1936, ureterostomy was performed to relieve t.he dysuria and dyspareunia and to make pregnancy possible. Convalescence was uneventful and in June 1938, when pus and albumin had dis:tppeared from the urine, the renal function seemed normal. She became pregnant and bore a child in the summer of 1939 without inconvenience to her except great nocturnal polyuria and an advanced elate of delivery because of a sudden increase in albuminuria. Dr. Charles R. Kingsley promises to report the obstetrical experience. She keeps herself dry day and night with the Bard-Whitfield cup. She is well, her urine uninfecte
Six cases of cutaneous ureterostomy for tuberculosis are reported. The operations of nephrectomy and contralateral ureterostomy were once performed simultaneously, once ureterostomy preceded nephrectomy and 4 times followed it at intervals, respectively, of 2, 4, 5, and 6 years. There were no postoperative deaths. Three patients have not shown any suggestion of tuberculosis in kidney or ureter since ureterostomy. But for one who needed meatotomy they have had no complaint or treatment during a postoperative interval of 3 (l case) to 19 (2 cases) years. Two of them keep themselves dry by night as well as by day. They do not stink and are well. One has
46
EDWARD L. KEYES
married since ureterostomy, one has borne the child she was deemed incapable of before. All 3 patients with tuberculosis in the surviving kidney have had to wear an indwelling ureter catheter. The 2 who have been followed had phosphatic stone within 3 years of ureterostomy. Yet, thanks doubtless to the good ureteral drainage, the progress of the renal tuberculosis has been slow and other tuberculous lesions have improved or healed. One of them is alive 13 years after ureterostomy. This report justifies no larger conclusion than that cutaneous ureterostomy may bring joy and long life to the patient tortured by a tuberculous bladder.
Tuxedo, N. Y.