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Digital Extraction Of Bladder Calculi in a female Paraplegic
THE .JOURNAL OF UROLOGY
Vol. 73, No. 5, May 19i53 Printed in U.S.A.
DIGITAL EXTRACTION OF BLADDER CALCULI IN A FEMALE PARAPLEGIC HOW ARD A. HOFFMAN
AND
FRANK R. LEARY
From St. Luke's Hospital, New Bedford, Mass.
A 21 year old white woman was brought to the emergency room of St. Luke's Hospital because of caking and poor drainage of her indwelling Foley catheter. Four years previously she had been in an automobile accident at which time she sustained an injury to the spinal cord resulting in paralysis of both lower extremities as well as the bladder and bowel. After a spine fusion operation in the area of Dll, she attended a rehabilitation center in Boston for 10 months, but showed no progress and finally returned home. She remained in bed, during which time her bladder dysfunction was managed by an indwelling catheter with daily irrigations of 1-20,000 aqueous zephiran solution. The catheter was changed about once a month. She took various types of urinary antiseptics on occasion, when the urine seemed particularly purulent. A few days before she appeared at the emergency room it was noticed that the catheter would not drain well spontaneously, nor could it be irrigated effectively. It was thought by her family physician that she probably had the usual alkaline encrusted cystitis so common with long-standing indwelling catheter drainage, and that some of these crusts had partially blocked the tube. He advised urological consultation. The 21F Brown-Buerger cystoscope was introduced into the bladder, immediately producing a grating sensation and sound characteristic of rubbing metal on stone. It was possible to distend the bladder sufficiently with fluid so that observation to a certain degree could be carried out, which confirmed the presence of numerous calculi in the bladder. A plain film of the abdomen was taken to determine further the extent of the calculous deposits in the bladder and to ascertain the size of those stones which could not be visualized cystoscopically, as well as to rule out the presence of lithiasis in the upper urinary tract (fig. 1, A). While the film was being developed, we contemplated with great concern the thought of having to operate upon a young woman who had already had more than her share of tragic experiences. At this point, it occurred to us that perhaps in a female paraplegic patient with a short urethra, and with patulousness and atony of the sphincter and bladder neck, a finger might be inserted into the bladder and the stones removed by digital manipulation. It was felt that certainly many of the smaller ones could be extracted this way; the fate of the larger ones could not be told until the procedure was tried. Having determined that the urolithiasis was confined to the bladder, and having an idea of the extent of the calculous deposits, the fifth finger was inAccepted for publication October 15, 1954. Read at meeting of New England Section of American Urological Association, Springfield, Mass., April 14, 1955. 794
BLADDER CALCULI
795
Frn. 1. A, x-ray prior to manipulation. B, stones removed digitally.
serted transurethrally into the bladder. Of course no anesthesia was required in view of the paraplegia. Discovering that the urethra admitted the fifth finger readily, this finger was removed and in its place the index finger was inserted. The smaller calculi ·were brought down between the ball of the index finger and the urethral wall and gently teased all the way out. There remained 5 larger ones which would warrant suprapubic cystolithotomy in the ordinary case. CWe have ordinarily been loathe to carry out litholapaxy or lithotriptoscopy because in our experience the small fragments of stone are frequently ground into the lining of the bladder and act as a nidus for subsequent infection and further stone formation.) It seemed perfectly reasonable therefore to continue this same technique in attempting to remove the larger stones. It was striking how readily the index finger of the right hand could bring the almond-shaped stones into the posterior urethra. At this location the stone was engaged by using two fingers of the left hand to press upward on the anterior vaginal wall, thus preventing the stone from slipping back into the bladder from the posterior urethra. The fingers of the left hand in the vagina were pressed against the proximal end of the long stone in the urethra, and thus made the distal end present visibly at the external urethral meatus. Then the thumb and index finger of the right hand gently rotated the stone on its long axis until it was delivered. This procedure was repeated until no further calculi could be felt in the bladder. The cystoscope was reinserted, and the absence of residual calcific
796
H. A. HOFFMAN AND F. R. LEARY
FIG. 2. X-ray following manipulation.
deposits was confirmed. It was striking how relatively healthy the bladder mucosa appeared after this procedure. There was no evidence of trauma. Forty stones in all were removed (fig. 1, B). These ranged all the way from 4 cm. in the largest diameter to several that were only 7 mm. Many had the three-dimensional shape of a date and others had the more typical flat or plaque-like shape that is commonly encountered in this type of problem. They all presented an off-white color. Chemical analysis subsequently revealed them to be composed of phosphate with a trace of calcium carbonate. The urinary pH was 8.0. There were numerous pus cells in the sediment. The culture revealed a mixed infection of E. coli and nonhemolytic staphylococci and streptococci. Sensitivity tests revealed these organisms to be responsive chiefly to furadantin. The entire manipulation took less than 10 minutes following which a plain film of the abdomen showed no stones at all present (fig. 2). The appropriate follow-up therapy was prescribed, and the patient was back in her home less than an hour from the time she was first seen in the emergency room. COMMENT
The concept of removing vesical foreign bodies through the urethra in a female was discussed by McCune in 1952. He mentioned in particular thermometers and eye droppers and wished to avoid breaking them with mechanical instruments, His cases were in relatively normal females, i.e., without paraplegia. Frankly, when we first noted this article we were not favorably impressed, since we felt that the procedure was not particularly physiological, and we were concerned about the outcome of the sphincter's integrity after such a seemingly traumatic experience. Although Dr. McCune's results tended to
BLADDER CALCULI
797
justify his procedure, we were unable conscientiously to accept it as good surgical technique and promptly discarded the thought. However, when faced with our situation, and the thought suggested by this report 2 years previously flashed through our minds, it seemed like a reasonable thing to try. The results were gratifying. It would seem that many paraplegic women ,Yith this all-too-frequent complication in the urinary tract might well be saved an open surgical procedure by considering this simple method of digital extraction that can actually be done in the office or at home. We should like to commend it to your attention and will be pleased to have your comments at a subsequent date regarding your own experience with it. SUMMARY
A case of a young woman with multiple bladder stones complicating paraplegia has been presented. Open operation was avoided by the simple measure of removing the stones by digital manipulation through the urethra.
REFERE~CE jVIcCuNE, D. P. : Method of removing foreign bodies from the femttle bladder. Trnns. Sou theastern Sect., Am. Urol. Assn., 16: 44, 1952.
Vol. 73, No. 5, May 19i53 Printed in U.S.A.
DIGITAL EXTRACTION OF BLADDER CALCULI IN A FEMALE PARAPLEGIC HOW ARD A. HOFFMAN
AND
FRANK R. LEARY
From St. Luke's Hospital, New Bedford, Mass.
A 21 year old white woman was brought to the emergency room of St. Luke's Hospital because of caking and poor drainage of her indwelling Foley catheter. Four years previously she had been in an automobile accident at which time she sustained an injury to the spinal cord resulting in paralysis of both lower extremities as well as the bladder and bowel. After a spine fusion operation in the area of Dll, she attended a rehabilitation center in Boston for 10 months, but showed no progress and finally returned home. She remained in bed, during which time her bladder dysfunction was managed by an indwelling catheter with daily irrigations of 1-20,000 aqueous zephiran solution. The catheter was changed about once a month. She took various types of urinary antiseptics on occasion, when the urine seemed particularly purulent. A few days before she appeared at the emergency room it was noticed that the catheter would not drain well spontaneously, nor could it be irrigated effectively. It was thought by her family physician that she probably had the usual alkaline encrusted cystitis so common with long-standing indwelling catheter drainage, and that some of these crusts had partially blocked the tube. He advised urological consultation. The 21F Brown-Buerger cystoscope was introduced into the bladder, immediately producing a grating sensation and sound characteristic of rubbing metal on stone. It was possible to distend the bladder sufficiently with fluid so that observation to a certain degree could be carried out, which confirmed the presence of numerous calculi in the bladder. A plain film of the abdomen was taken to determine further the extent of the calculous deposits in the bladder and to ascertain the size of those stones which could not be visualized cystoscopically, as well as to rule out the presence of lithiasis in the upper urinary tract (fig. 1, A). While the film was being developed, we contemplated with great concern the thought of having to operate upon a young woman who had already had more than her share of tragic experiences. At this point, it occurred to us that perhaps in a female paraplegic patient with a short urethra, and with patulousness and atony of the sphincter and bladder neck, a finger might be inserted into the bladder and the stones removed by digital manipulation. It was felt that certainly many of the smaller ones could be extracted this way; the fate of the larger ones could not be told until the procedure was tried. Having determined that the urolithiasis was confined to the bladder, and having an idea of the extent of the calculous deposits, the fifth finger was inAccepted for publication October 15, 1954. Read at meeting of New England Section of American Urological Association, Springfield, Mass., April 14, 1955. 794
BLADDER CALCULI
795
Frn. 1. A, x-ray prior to manipulation. B, stones removed digitally.
serted transurethrally into the bladder. Of course no anesthesia was required in view of the paraplegia. Discovering that the urethra admitted the fifth finger readily, this finger was removed and in its place the index finger was inserted. The smaller calculi ·were brought down between the ball of the index finger and the urethral wall and gently teased all the way out. There remained 5 larger ones which would warrant suprapubic cystolithotomy in the ordinary case. CWe have ordinarily been loathe to carry out litholapaxy or lithotriptoscopy because in our experience the small fragments of stone are frequently ground into the lining of the bladder and act as a nidus for subsequent infection and further stone formation.) It seemed perfectly reasonable therefore to continue this same technique in attempting to remove the larger stones. It was striking how readily the index finger of the right hand could bring the almond-shaped stones into the posterior urethra. At this location the stone was engaged by using two fingers of the left hand to press upward on the anterior vaginal wall, thus preventing the stone from slipping back into the bladder from the posterior urethra. The fingers of the left hand in the vagina were pressed against the proximal end of the long stone in the urethra, and thus made the distal end present visibly at the external urethral meatus. Then the thumb and index finger of the right hand gently rotated the stone on its long axis until it was delivered. This procedure was repeated until no further calculi could be felt in the bladder. The cystoscope was reinserted, and the absence of residual calcific
796
H. A. HOFFMAN AND F. R. LEARY
FIG. 2. X-ray following manipulation.
deposits was confirmed. It was striking how relatively healthy the bladder mucosa appeared after this procedure. There was no evidence of trauma. Forty stones in all were removed (fig. 1, B). These ranged all the way from 4 cm. in the largest diameter to several that were only 7 mm. Many had the three-dimensional shape of a date and others had the more typical flat or plaque-like shape that is commonly encountered in this type of problem. They all presented an off-white color. Chemical analysis subsequently revealed them to be composed of phosphate with a trace of calcium carbonate. The urinary pH was 8.0. There were numerous pus cells in the sediment. The culture revealed a mixed infection of E. coli and nonhemolytic staphylococci and streptococci. Sensitivity tests revealed these organisms to be responsive chiefly to furadantin. The entire manipulation took less than 10 minutes following which a plain film of the abdomen showed no stones at all present (fig. 2). The appropriate follow-up therapy was prescribed, and the patient was back in her home less than an hour from the time she was first seen in the emergency room. COMMENT
The concept of removing vesical foreign bodies through the urethra in a female was discussed by McCune in 1952. He mentioned in particular thermometers and eye droppers and wished to avoid breaking them with mechanical instruments, His cases were in relatively normal females, i.e., without paraplegia. Frankly, when we first noted this article we were not favorably impressed, since we felt that the procedure was not particularly physiological, and we were concerned about the outcome of the sphincter's integrity after such a seemingly traumatic experience. Although Dr. McCune's results tended to
BLADDER CALCULI
797
justify his procedure, we were unable conscientiously to accept it as good surgical technique and promptly discarded the thought. However, when faced with our situation, and the thought suggested by this report 2 years previously flashed through our minds, it seemed like a reasonable thing to try. The results were gratifying. It would seem that many paraplegic women ,Yith this all-too-frequent complication in the urinary tract might well be saved an open surgical procedure by considering this simple method of digital extraction that can actually be done in the office or at home. We should like to commend it to your attention and will be pleased to have your comments at a subsequent date regarding your own experience with it. SUMMARY
A case of a young woman with multiple bladder stones complicating paraplegia has been presented. Open operation was avoided by the simple measure of removing the stones by digital manipulation through the urethra.
REFERE~CE jVIcCuNE, D. P. : Method of removing foreign bodies from the femttle bladder. Trnns. Sou theastern Sect., Am. Urol. Assn., 16: 44, 1952.