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Cystoscopic Removal of Ureteral Calculi. Presentation of a New Instrument
CYSTOSCOPIC REMOVAL OF URETERAL CALCULI PRESENTATION OF A NEW INSTRUMENT HOWARD L. CECIL Dallas, Texas
For many years ureteral calculi have been removed by cys.,. toscopic manipulation; but it has been only within the last decade that the methods have gained some of the recognition they deserve. Bransford Lewis was the first to sponsor the method of ureteral dilatation. Later Crowell called attention to the soundness of this method and added some important points to the technique. Livermore designed an instrument "to change the position of the stone very slightly or to separate it from the walls of the ureter, where it is often imbedded or held by spicules." He did not intend that the instrument should be used to grasp a stone and pull it out. Doumashkin has recently devised an instrument intended to pull a stone out after the ureter had been sufficiently dilated. The cystoscopic removal of ureteral calculi at the present time consists in dilating the ureter to a sufficient size to permit the passing of the stone or to render the passing quicker and less painful. In conjunction with dilatation, the injection of a local anesthetic is done to render the passing of the instruments less painful and to relax the ureter, thus facilitating manipulation. After the ureter has been dilated oil is frequently injected above the stone to make its passing easier and quicker. In my hands the injection of oil has done little, if any, good. It certainly should not be done through a catheter that has been allowed to remain in the ureter for a long time; as the danger of introducing infection into the kidney is great. One other method in common use by urologists is to enlarge the ureteral meatus by cutting it either with scissors, or by a highfrequency current. Unless the ureteral meatus is large enough 529 THE JOURNAL OF UROLOGY, VOL. XV, NO.
6
530
HOWARD L. CECIL
to permit the easy passing of the instruments, the procedure is of the greatest benefit. It also facilitates the descent of a stone by giving a free outlet to the urine. When the stone is in the intramural portion of the ureter it is the method of choice. These methods lack precision and sufficient force to deal with all the cases presented. To dilate the ureter to a sufficient size for the passing of the stone is not always successful. It may be imbedded or held by spicules. Frequently the injection of oil above the stone does not accomplish the desired result. Many times preexisting or intervening infection makes it imperative to abandon dilatation and inexact methods, and to resort to open operation in order to save the kidney from irreparable mJury. The two following cases well illustrate this fact: Case 1. Aged thirty-five. Twelve years ago he passed a stone from the right kidney. The appendix was removed by a surgeon, who diagnosed this illness acute appendicitis. His present illness began three months ago, with pain in the abdomen, but it became localized on the right side. This attack lasted about six to eight hours. Two months later he had a similar attack, and another two days later. A rontgenogram showed the stone in the right ureter, opposite the lower border of the third lumbar vertebrae. The shadow was approximately 1 by 0.75 crn. Examination of the urines showed a trace of albumin; a few red blood cells. There was no pus or infection. A No. 7 catheter was passed above the stone and allowed to remain for twenty-four hours. It was then withdrawn and a No. 11 Garceau replaced. This was also allowed to remain twenty-four hours. After it was removed, very small fragments of stone were passed. Four days later, the patient reported that during his absence from town he had a very severe colic. A wax-tip catheter was passed and it was determined that the stone had descended about 3 to 4 inches. A No. 12 Garceau catheter was then passed above the stone and allowed to remain for twenty-four hours. When it was withdrawn, small particles of stone were recovered from the urine. The patient was not seen for about a month and a half (traveling necessitated his absence) during which time he had several mild attacks of colic. On his return a rontgenogram showed the stone had descended to about 2 inches
CYSTOSCOPIC REMOVAL OF URETERAL CALCULI
531
above the bladder. In spite of further dilatation, injections of oil, and attempts to grasp it with forceps, the stone remained fixed. At this time be began to have very severe pain in the kidney region, associated with temperature between 102 and 104. Thinking that further dilatation would accomplish little, and fearing a destructive pyelonephritis, the stone was removed by open operation. The recovery was uneventful. Case 2. Aged twenty-four. Previous history unimportant. Present illness began in April, 1919, as a very severe pain beneath the left costal margin, which radiated along the course of the ureter to the bladder. The attack lasted from three to four hours. Blood was present in the urine at this time; and he said pus was always present. Six months later he had another very severe attack which lasted about six hours. These severe attacks were interspersed by milder ones. About a year later he experienced the same symptoms. During the last two severe attacks the pain radiated to the groin. These were accompanied by nausea, vomiting and chills and fever. A rontgenogram showed a stone 1.25 by 0.75 cm. opposite the lower pole of the left kidney. The urine contained much pus, and was infected with a bacillus. Intravenous phthalein test showed 48 per cent in the first hour and 12 per cent in the second. Ureteral catheterization showed the right kidney normal, whereas the left showed pus, infection (bacillus)-phthalein output of 10 per cent in twenty minutes. A No. 6 catheter passed the stone with difficulty. It was left for eight hours, at which time the patient removed it. Four days later a No. 7 catheter was passed with the intention of leaving for twentyfour hours, but the patient removed it six hours later. He had no colic from these treatments. Five days later a No. 9 catheter was left to remain eighteen hours. Ten days later a No. 11 catheter was passed into the ureter, but would go only 1½ or 2 inches. Smaller catheters refused to pass the obstruction. Seven days later he had a mild attack of colic. He now had bladder irritation. A wax-tip catheter and rontgenogram showed the stone about 1½ inches above the ureteral meatus. During the next month he had similar dilitation with Nos. 9, 11 and 12 catheters, but the stone would not pass, it remaining 1½ to 2 inches up the ureter. At this time he was having very severe colic and temperature to 104. A number No. 9 catheter was passed above
532
HOWARD L. CECIL
the stone, and about 40 cc. of foul bloody urine escaped in a continuous flow. At this time the catheter plugged and refused to operate properly. It was withdrawn. The temperature quickly rose to 105. Attempts to pass other catheters failed, even with stiff stilettos in them. He was very toxic now and in spite of the desire to succeed by manipulation, it was thought best to remove the stone by open operation.
Had an instrument existed at this time capable of grasping a stone and pulling it out or crushing it, these unfortunat e and humiliating experiences would have been avoided.
FIG. 1. DIAGRAM O~' HAN DLE OF T HE INSTRUMEN T The heavy black lines represent the sleeves, the t wo thin lines t he wires
d
F IG . 2.
DIAGRAM OF T HE JAWS AND T HE A TTACHM ENT O F T H E WIRES l e-I 'l'HE PROX I MAL J AWS
Being thoroughly impressed with the need of such an instrument I, therefore, designed and made the one here presented. The instrument consists of a telescope handle (fig. 1) , a flexible shaft (figs. 1 and 2a) , two small jaws (fig. 2, b and b'), a flexible guide (fig. 2, c), and a steel wire extending the entire length of the instrument (figs. 1 and 2, d) . T he jaws are opened and closed by manipulating the sleeve handle, this being accomplished by means of the steel wire extending through the instrument. This wire, which functions as two wires, is in reality one. It is looped over a steel lug in the terminal jaw b' and the two
----- ~---------------------
CYSTOSCOPIC REMOVAL OF URETERAL CALCULI
FIG.
3.
533
INSTRUMENT WITH JAWS FULLY OPENED
¥
FIG.
4.
INSTRUMENT WITH JAWS CLOSED
•
FIG .
5.
•
JAWS WITH LUGS TAKEN OUT AND WIRE AS IT IS BENT TO FIT THE JAWS
Note very simple but strong construction
534
HOWARD L. CECIL
ends are attached firmly to the handle by means of the set screw (e figs. 1 and 3). This wire is made of steel and has a very high tensile strength. The jaws b and b' are made of steel. Into one end of the terminal jaw (b') is soldered a flexible guide (fig. 2, c) made of the same material as the shaft of the instrument. It serves two purposes: First, to guide the instrument by the stone and, second, to prevent the terminal jaw from turning sideways, or at too great an angle, at the time of crushing a stone. Into the other end of this jaw a hole is drilled, a thread cut, and a small piece of steel screwed in. This small lug (fig. 2, f), has two longitudinal grooves cut to a sufficient depth to enable the wire of desired size to pass through. A similar lug is screwed into the proximal jaw. The proximal jaw (b) is soldered to the flexible shaft (fig. 2, a) of the instrument. It will be noted in figure 2 that a cuff has been cut on the flexible shaft to fit into the terminal jaw. This cuff makes it impossible for the shaft to telescope into the jaw when pressure is exerted. The flexible shaft is made of wound steel wire such as is used in cystoscopic forceps, scissors, etc. The other end of the flexible shaft is soldered to the handle, with a cuff to prevent telescoping as in the case of the jaw. To this portion of the handle are attached two rings (fig. 1, i ) which_. in manipulating the instrument, are engaged by the index and middle fingers. The movable part of the handle (fig. 1, j), telescopes into this sleeve. On to the end of this movable handle is attached a ring (fig. 1, k), which ring is engaged by the thumb in manipulating the jaws. One side of this shaft is flattened firstly, for the purpose of a scale (figs. 1 and 4), to tell how far the jaws are separated and, secondly, to prevent its turning in its fellow. Both of these are necessary for an intelligent and proper manipulation of the instrument. It is self-evident that if a stone is grasped, the distance the jaws are separated is very important, the size of the stone having previously been determined. If one portion of the handle is allowed to turn within the other, the steel lugs in the jaws may be unscrewed, thus taking the instrument apart in the ureter. This is not so apt to occur, but such turning of one
CYSTOSCOPIC REMOVAL OF URETERAL CALCULI
535
handle within the other causes a twisting of the wires between the jaws after they are separated, thus preventing the jaws from engaging a stone. The shaft is also threaded (see fig. 4). These threads engage a wing-tap (fig. 1, l, also fig. 4). This tap is used to hold a stone after it has been engaged and also to crush one if desired. From a study of the instrument it is evident that traction on a stone can be exerted equal to the strength of the steel wire traversing the entire length of the instrument. It is also evident that such a force would never be necessary or desirable to pull a stone from the ureter. To crush a stone a compression force can be exerted equal to the weakest point from the proximal jaw to the sleeve handle; or a tensile force, equal to pull the steel lug from the terminal jaw, to pull the wires from the set screw, or to break the wire. The instrument that I have made has been tested on some twenty-five stones, that were removed by ureteral dilatation, and in not one instance did it fail to crush the stones. Some of these were oxalated ones. In addition to this practical test, the instrument has withstood an actual force of 100 pounds and possibly would have stood much more. I, therefore, believe that it is the only instrument so far designed that embodies the advantages of small size and great strength, and that it is the only one that was designed, and has been actually used to crush a stone in the ureter. With some slight variations the instrument might be used to crush a stone in the pelvis of the kidney though at present, to me, such procedure would not seem advisable. In employing all methods one usually works out his own technique. It will be seen from the cases reported that I have passed both jaws (closed) by the stone, opened them, and then withdrawn the instrument until the proximal jaw wa.s felt t o pass the stone. By so doing the stones have been easily grasped, and it would seen difficult not to grasp one by this maneuver. After it is determined tht a stone has been grasped (scale on handle) the wing-tap is turned down till the stone is held firmly. Traction on the stone can then be made. If it seems that the stone cannot be removed by pulling it out, the wing-ta.p should
536
HOWARD L. CECIL
be employed to crush it. Direct traction by hand should not be employed for, if a stone is so crushed, the unavoidable impact might injure the ureter. Such injury would be avoided if gentle, slow and controlled force is exerted by the tap. The instrument has been tested to withstand all requirements likely to be placed on it, and unless the wire has been allowed to deteriorate by rust or has been injured by kinks, there is little likelihood of its being broken. By careful and intelligent manipulation of the instrument injury to the ureter should not occur. If a stone is crushed the larger portion of it is automatically released from the instrument and the instrument may then be easily removed. After the instrument was completed a suitable patient did not present himself for about six months. A patient upon whom I did a total cystectomy1 and implanted the ureters in the loin, had a stone in the left ureter about 4 inches from the lower end. A rontgenogram was negative for stone but a wax-tip catheter demonstrated its presence. All of the methods in common use failed to remove it. At this time there was almost, if not quite, a complete block. The temperature rose to 103 to 104. He had not completely recovered from the total cystectomy and for this reason a ureterotomy did not seem advisable. My ureteral calculus remover was passed by the stone quite easily and the jaws separated. Traction was then made and a decided jump was then felt as the proximal jaw passed the stone. The jaws were closed and traction made on the stone. In spite of quite strong traction the stone could not be extracted. Fearing injury would be inflicted to the ureter, the jaws were forcibly closed, crushing the stone. The instrument was removed. On the following day the stone was passed in small pieces. Further examinations with wax-tip catheters were negative for stone.
Knowing this not to be a fair test as to the possibilities of the instrument through the cystoscope, I decided to wait until such a patient presented himself before publishing the method. About three months ago a patient presents himself for removal of a ureteral calculus. 1 This most interesting bladder tumor, probably sarcoma, will be reported in the near future.
CYSTOSCOPIC REMOVAL OF URETERAL CALCULI
537
The history is as follows: Two years ago he passed a stone about the size of a pea from the right kidney. Since passing this stone he has had five similar attacks of pain, without passing a stone. In all of these attacks the pain has been in the kidney region, without downward radiation. The day before consulting me he had a very severe pain under the right costal margin. It radiated along the ureter to the bladder, and to the hip. Four hyperdermic injections of morphine were necessary to control the pain. A ri:intgenogram showed the stone 1 by 0.75 cm. about 2½ inches above the ureteral meatus. This was confirmed by wax-tip catheter. The ureteral meatus was very small and was enlarged by fulguration. A No. 6 catheter was passed by the stone and remained for twentyfour hours. Four days later a No. 11 catheter was left in the ureter for eighteen hours. A few days later a No. 12 catheter remained in for twenty-four hours, and again five days later. A rontgenogram and wax-tip examination revealed the stone in the same position as on the first visit. At this time I passed my instrument (after coconizing the ureter) above the stone, separated the jaws, withdrew the instrument till the proximal jaw was felt to pass the stone, and then closed the jaws on the stone by means of the wing-tap. The stone was pulled into the bladder, picked up with a cystoscope forcep and removed through the cystoscope. There was not the slightest ill effect from the manipulation-not even macroscopic blood. The patient had a preexisting infection which is being treated at the present to prevent recurrence. The instrument is a decided advance in the cystoscopic removal of ureteral calculi and possesses the following advantages over any I have seen described. 1. It can be passed by a stone with as much ease as a catheter of like size. 2. The jaws open vertically- thus it is much easier to grasp a stone than with instruments with forcep jaws. 3. When traction is made the force exerted is from above the stone directly downward. 4. When a stone is grasped the diameter occupied by the stone and instrument is very little, if any, greater than the stone alone. 5. It is the only instrument yet designed with sufficient strength to remove by traction or to crush a stone in the ureter.
For many years ureteral calculi have been removed by cys.,. toscopic manipulation; but it has been only within the last decade that the methods have gained some of the recognition they deserve. Bransford Lewis was the first to sponsor the method of ureteral dilatation. Later Crowell called attention to the soundness of this method and added some important points to the technique. Livermore designed an instrument "to change the position of the stone very slightly or to separate it from the walls of the ureter, where it is often imbedded or held by spicules." He did not intend that the instrument should be used to grasp a stone and pull it out. Doumashkin has recently devised an instrument intended to pull a stone out after the ureter had been sufficiently dilated. The cystoscopic removal of ureteral calculi at the present time consists in dilating the ureter to a sufficient size to permit the passing of the stone or to render the passing quicker and less painful. In conjunction with dilatation, the injection of a local anesthetic is done to render the passing of the instruments less painful and to relax the ureter, thus facilitating manipulation. After the ureter has been dilated oil is frequently injected above the stone to make its passing easier and quicker. In my hands the injection of oil has done little, if any, good. It certainly should not be done through a catheter that has been allowed to remain in the ureter for a long time; as the danger of introducing infection into the kidney is great. One other method in common use by urologists is to enlarge the ureteral meatus by cutting it either with scissors, or by a highfrequency current. Unless the ureteral meatus is large enough 529 THE JOURNAL OF UROLOGY, VOL. XV, NO.
6
530
HOWARD L. CECIL
to permit the easy passing of the instruments, the procedure is of the greatest benefit. It also facilitates the descent of a stone by giving a free outlet to the urine. When the stone is in the intramural portion of the ureter it is the method of choice. These methods lack precision and sufficient force to deal with all the cases presented. To dilate the ureter to a sufficient size for the passing of the stone is not always successful. It may be imbedded or held by spicules. Frequently the injection of oil above the stone does not accomplish the desired result. Many times preexisting or intervening infection makes it imperative to abandon dilatation and inexact methods, and to resort to open operation in order to save the kidney from irreparable mJury. The two following cases well illustrate this fact: Case 1. Aged thirty-five. Twelve years ago he passed a stone from the right kidney. The appendix was removed by a surgeon, who diagnosed this illness acute appendicitis. His present illness began three months ago, with pain in the abdomen, but it became localized on the right side. This attack lasted about six to eight hours. Two months later he had a similar attack, and another two days later. A rontgenogram showed the stone in the right ureter, opposite the lower border of the third lumbar vertebrae. The shadow was approximately 1 by 0.75 crn. Examination of the urines showed a trace of albumin; a few red blood cells. There was no pus or infection. A No. 7 catheter was passed above the stone and allowed to remain for twenty-four hours. It was then withdrawn and a No. 11 Garceau replaced. This was also allowed to remain twenty-four hours. After it was removed, very small fragments of stone were passed. Four days later, the patient reported that during his absence from town he had a very severe colic. A wax-tip catheter was passed and it was determined that the stone had descended about 3 to 4 inches. A No. 12 Garceau catheter was then passed above the stone and allowed to remain for twenty-four hours. When it was withdrawn, small particles of stone were recovered from the urine. The patient was not seen for about a month and a half (traveling necessitated his absence) during which time he had several mild attacks of colic. On his return a rontgenogram showed the stone had descended to about 2 inches
CYSTOSCOPIC REMOVAL OF URETERAL CALCULI
531
above the bladder. In spite of further dilatation, injections of oil, and attempts to grasp it with forceps, the stone remained fixed. At this time be began to have very severe pain in the kidney region, associated with temperature between 102 and 104. Thinking that further dilatation would accomplish little, and fearing a destructive pyelonephritis, the stone was removed by open operation. The recovery was uneventful. Case 2. Aged twenty-four. Previous history unimportant. Present illness began in April, 1919, as a very severe pain beneath the left costal margin, which radiated along the course of the ureter to the bladder. The attack lasted from three to four hours. Blood was present in the urine at this time; and he said pus was always present. Six months later he had another very severe attack which lasted about six hours. These severe attacks were interspersed by milder ones. About a year later he experienced the same symptoms. During the last two severe attacks the pain radiated to the groin. These were accompanied by nausea, vomiting and chills and fever. A rontgenogram showed a stone 1.25 by 0.75 cm. opposite the lower pole of the left kidney. The urine contained much pus, and was infected with a bacillus. Intravenous phthalein test showed 48 per cent in the first hour and 12 per cent in the second. Ureteral catheterization showed the right kidney normal, whereas the left showed pus, infection (bacillus)-phthalein output of 10 per cent in twenty minutes. A No. 6 catheter passed the stone with difficulty. It was left for eight hours, at which time the patient removed it. Four days later a No. 7 catheter was passed with the intention of leaving for twentyfour hours, but the patient removed it six hours later. He had no colic from these treatments. Five days later a No. 9 catheter was left to remain eighteen hours. Ten days later a No. 11 catheter was passed into the ureter, but would go only 1½ or 2 inches. Smaller catheters refused to pass the obstruction. Seven days later he had a mild attack of colic. He now had bladder irritation. A wax-tip catheter and rontgenogram showed the stone about 1½ inches above the ureteral meatus. During the next month he had similar dilitation with Nos. 9, 11 and 12 catheters, but the stone would not pass, it remaining 1½ to 2 inches up the ureter. At this time he was having very severe colic and temperature to 104. A number No. 9 catheter was passed above
532
HOWARD L. CECIL
the stone, and about 40 cc. of foul bloody urine escaped in a continuous flow. At this time the catheter plugged and refused to operate properly. It was withdrawn. The temperature quickly rose to 105. Attempts to pass other catheters failed, even with stiff stilettos in them. He was very toxic now and in spite of the desire to succeed by manipulation, it was thought best to remove the stone by open operation.
Had an instrument existed at this time capable of grasping a stone and pulling it out or crushing it, these unfortunat e and humiliating experiences would have been avoided.
FIG. 1. DIAGRAM O~' HAN DLE OF T HE INSTRUMEN T The heavy black lines represent the sleeves, the t wo thin lines t he wires
d
F IG . 2.
DIAGRAM OF T HE JAWS AND T HE A TTACHM ENT O F T H E WIRES l e-I 'l'HE PROX I MAL J AWS
Being thoroughly impressed with the need of such an instrument I, therefore, designed and made the one here presented. The instrument consists of a telescope handle (fig. 1) , a flexible shaft (figs. 1 and 2a) , two small jaws (fig. 2, b and b'), a flexible guide (fig. 2, c), and a steel wire extending the entire length of the instrument (figs. 1 and 2, d) . T he jaws are opened and closed by manipulating the sleeve handle, this being accomplished by means of the steel wire extending through the instrument. This wire, which functions as two wires, is in reality one. It is looped over a steel lug in the terminal jaw b' and the two
----- ~---------------------
CYSTOSCOPIC REMOVAL OF URETERAL CALCULI
FIG.
3.
533
INSTRUMENT WITH JAWS FULLY OPENED
¥
FIG.
4.
INSTRUMENT WITH JAWS CLOSED
•
FIG .
5.
•
JAWS WITH LUGS TAKEN OUT AND WIRE AS IT IS BENT TO FIT THE JAWS
Note very simple but strong construction
534
HOWARD L. CECIL
ends are attached firmly to the handle by means of the set screw (e figs. 1 and 3). This wire is made of steel and has a very high tensile strength. The jaws b and b' are made of steel. Into one end of the terminal jaw (b') is soldered a flexible guide (fig. 2, c) made of the same material as the shaft of the instrument. It serves two purposes: First, to guide the instrument by the stone and, second, to prevent the terminal jaw from turning sideways, or at too great an angle, at the time of crushing a stone. Into the other end of this jaw a hole is drilled, a thread cut, and a small piece of steel screwed in. This small lug (fig. 2, f), has two longitudinal grooves cut to a sufficient depth to enable the wire of desired size to pass through. A similar lug is screwed into the proximal jaw. The proximal jaw (b) is soldered to the flexible shaft (fig. 2, a) of the instrument. It will be noted in figure 2 that a cuff has been cut on the flexible shaft to fit into the terminal jaw. This cuff makes it impossible for the shaft to telescope into the jaw when pressure is exerted. The flexible shaft is made of wound steel wire such as is used in cystoscopic forceps, scissors, etc. The other end of the flexible shaft is soldered to the handle, with a cuff to prevent telescoping as in the case of the jaw. To this portion of the handle are attached two rings (fig. 1, i ) which_. in manipulating the instrument, are engaged by the index and middle fingers. The movable part of the handle (fig. 1, j), telescopes into this sleeve. On to the end of this movable handle is attached a ring (fig. 1, k), which ring is engaged by the thumb in manipulating the jaws. One side of this shaft is flattened firstly, for the purpose of a scale (figs. 1 and 4), to tell how far the jaws are separated and, secondly, to prevent its turning in its fellow. Both of these are necessary for an intelligent and proper manipulation of the instrument. It is self-evident that if a stone is grasped, the distance the jaws are separated is very important, the size of the stone having previously been determined. If one portion of the handle is allowed to turn within the other, the steel lugs in the jaws may be unscrewed, thus taking the instrument apart in the ureter. This is not so apt to occur, but such turning of one
CYSTOSCOPIC REMOVAL OF URETERAL CALCULI
535
handle within the other causes a twisting of the wires between the jaws after they are separated, thus preventing the jaws from engaging a stone. The shaft is also threaded (see fig. 4). These threads engage a wing-tap (fig. 1, l, also fig. 4). This tap is used to hold a stone after it has been engaged and also to crush one if desired. From a study of the instrument it is evident that traction on a stone can be exerted equal to the strength of the steel wire traversing the entire length of the instrument. It is also evident that such a force would never be necessary or desirable to pull a stone from the ureter. To crush a stone a compression force can be exerted equal to the weakest point from the proximal jaw to the sleeve handle; or a tensile force, equal to pull the steel lug from the terminal jaw, to pull the wires from the set screw, or to break the wire. The instrument that I have made has been tested on some twenty-five stones, that were removed by ureteral dilatation, and in not one instance did it fail to crush the stones. Some of these were oxalated ones. In addition to this practical test, the instrument has withstood an actual force of 100 pounds and possibly would have stood much more. I, therefore, believe that it is the only instrument so far designed that embodies the advantages of small size and great strength, and that it is the only one that was designed, and has been actually used to crush a stone in the ureter. With some slight variations the instrument might be used to crush a stone in the pelvis of the kidney though at present, to me, such procedure would not seem advisable. In employing all methods one usually works out his own technique. It will be seen from the cases reported that I have passed both jaws (closed) by the stone, opened them, and then withdrawn the instrument until the proximal jaw wa.s felt t o pass the stone. By so doing the stones have been easily grasped, and it would seen difficult not to grasp one by this maneuver. After it is determined tht a stone has been grasped (scale on handle) the wing-tap is turned down till the stone is held firmly. Traction on the stone can then be made. If it seems that the stone cannot be removed by pulling it out, the wing-ta.p should
536
HOWARD L. CECIL
be employed to crush it. Direct traction by hand should not be employed for, if a stone is so crushed, the unavoidable impact might injure the ureter. Such injury would be avoided if gentle, slow and controlled force is exerted by the tap. The instrument has been tested to withstand all requirements likely to be placed on it, and unless the wire has been allowed to deteriorate by rust or has been injured by kinks, there is little likelihood of its being broken. By careful and intelligent manipulation of the instrument injury to the ureter should not occur. If a stone is crushed the larger portion of it is automatically released from the instrument and the instrument may then be easily removed. After the instrument was completed a suitable patient did not present himself for about six months. A patient upon whom I did a total cystectomy1 and implanted the ureters in the loin, had a stone in the left ureter about 4 inches from the lower end. A rontgenogram was negative for stone but a wax-tip catheter demonstrated its presence. All of the methods in common use failed to remove it. At this time there was almost, if not quite, a complete block. The temperature rose to 103 to 104. He had not completely recovered from the total cystectomy and for this reason a ureterotomy did not seem advisable. My ureteral calculus remover was passed by the stone quite easily and the jaws separated. Traction was then made and a decided jump was then felt as the proximal jaw passed the stone. The jaws were closed and traction made on the stone. In spite of quite strong traction the stone could not be extracted. Fearing injury would be inflicted to the ureter, the jaws were forcibly closed, crushing the stone. The instrument was removed. On the following day the stone was passed in small pieces. Further examinations with wax-tip catheters were negative for stone.
Knowing this not to be a fair test as to the possibilities of the instrument through the cystoscope, I decided to wait until such a patient presented himself before publishing the method. About three months ago a patient presents himself for removal of a ureteral calculus. 1 This most interesting bladder tumor, probably sarcoma, will be reported in the near future.
CYSTOSCOPIC REMOVAL OF URETERAL CALCULI
537
The history is as follows: Two years ago he passed a stone about the size of a pea from the right kidney. Since passing this stone he has had five similar attacks of pain, without passing a stone. In all of these attacks the pain has been in the kidney region, without downward radiation. The day before consulting me he had a very severe pain under the right costal margin. It radiated along the ureter to the bladder, and to the hip. Four hyperdermic injections of morphine were necessary to control the pain. A ri:intgenogram showed the stone 1 by 0.75 cm. about 2½ inches above the ureteral meatus. This was confirmed by wax-tip catheter. The ureteral meatus was very small and was enlarged by fulguration. A No. 6 catheter was passed by the stone and remained for twentyfour hours. Four days later a No. 11 catheter was left in the ureter for eighteen hours. A few days later a No. 12 catheter remained in for twenty-four hours, and again five days later. A rontgenogram and wax-tip examination revealed the stone in the same position as on the first visit. At this time I passed my instrument (after coconizing the ureter) above the stone, separated the jaws, withdrew the instrument till the proximal jaw was felt to pass the stone, and then closed the jaws on the stone by means of the wing-tap. The stone was pulled into the bladder, picked up with a cystoscope forcep and removed through the cystoscope. There was not the slightest ill effect from the manipulation-not even macroscopic blood. The patient had a preexisting infection which is being treated at the present to prevent recurrence. The instrument is a decided advance in the cystoscopic removal of ureteral calculi and possesses the following advantages over any I have seen described. 1. It can be passed by a stone with as much ease as a catheter of like size. 2. The jaws open vertically- thus it is much easier to grasp a stone than with instruments with forcep jaws. 3. When traction is made the force exerted is from above the stone directly downward. 4. When a stone is grasped the diameter occupied by the stone and instrument is very little, if any, greater than the stone alone. 5. It is the only instrument yet designed with sufficient strength to remove by traction or to crush a stone in the ureter.