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Hydronephrosis: Diagnosis and Treatment of Ureteropelvic Obstructions
THE JOURNAL OF UROLOGY
Vol. 75, No. l, January 1956 Printed in U.S.A.
HYDRO::--JEPHROSIS: DIAGNOSIS AND TREATMENT OF URETEROPEL VIC OBSTRUCTIONS THOMAS E. GIBSO:'if
Increasing interest in the management of ureteropelvic obstructions is clearly evident on perusal of the current medical literature. It is gratifying to note that as a result of more widespread knowledge and experience with the many ingenious types of pyeloplasty, realization of the proper role of splinting and intubation, and the aid of potent drugs to combat infection, surgical conservation of hydro nephrotic kidneys is being practiced with greater confidence and success and fewer kidneys are being subjected to nephrectomy. Unfortunately the entire subject is still in an evolutionary phase and there are wide differences of opinion on various aspects of the problem. My purpose here is to discuss, and perhaps reconcile, divergent views on some of the controversial phases of diagnosis and treatment. DIAGNOSIS AND INDICATIONS FOR OPERA'l'ION
Diagnosis is not without its pitfalls, and demands the most meticulous attention to detail, because only a most complete urological study can answer the many questions arising in each individual patient as to whether or not the case requires surgery, and if so, ·whether some type of plastic procedure is indicated or whether a nephrectomy should be done. The successive steps of a complete urological investigation should be carefully carried out, and many times a second confirmatory study done if there is the least doubt about the decision as to treatment. The function of the hydronephrotic kidney is difficult to evaluate, as the following cases will illustrate. In figure 1 is shown the retrograde pyelogram of a man, :\8 years old, whose right kidney exhibited a large hydronephrotic sac of 2000 cc capacity. Preliminary excretion urography and retrograde study revealed that it had no function. Follmving nephrectomy, I was nonplussed on finding that the kidney exhibited good parenchyma of almost normal thickness. Furthermore, the urine from this kidney was sterile, an important factor which should always be evaluated. An infected hydronephrosis in which there are chronic pyelonephritic changes, even though the hydronephrotic sac is small, is not likely to respond well to any type of pyeloplasty. Thus, it is important to judge hydronephrosis not by its size but by the thickness of the parenchyma, and to note also whether the opposite kidney shows any degree of compensatory hypertrophy. The next case (fig. 2), a man of 40 years, exhibited unilateral hydronephrosis of moderate size. Excretory urography as well as retrograde study, in which separate renal function ,vas determined by phenolsulfonphthalein excretion, revealed no function on the side of the hydroneph.rotic kidney. The ureteral catheter ,vas left indwelling for 24 hours and the phenolsulfonphthalein test repeated. Quantitative output of dye, to my surprise, was practically normal. It was then possible Read at aIJnual meeting, Southeastern Section of American lirological Associaiion, Xe\\' Orlea.n,;, La. March 20--24, 195,5
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THOMAS E. GIBSON
FIG. 1. Right hydronephrosis, 2000 cc capacity. Intrinsic ureteropelvic obstruction of unusual type, consisting of miniature bicuspid valve simulating mitral valve of heart.
FIG. 2. A, hydronephrosis (left). Initial study showed only trace of PSP excretion. After 24 hours catheter drainage, PSP excretion almost normal. B, pyelogram made 6 months after operation. Ureteropelvic obstruction was entirely extrinsic, so no splinting or intubation was used.
to do a successful pyeloplasty without resorting to nephrectomy. When excretoryurography fails to outline the kidney pelvis it is good practice to repeat the roentgenogram in 4 hours, or even 24 hours if there is no evidence of excretion in the first hour. It has been said that a hydronephrotic kidney which cannot by physiological
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tests perform 25 per cent of total renal function is not worth conserving, although there are exceptions to all rules. This statement is based on the assumption that a kidney to be worthy of conservation should be able to carry the total load should it ever become necessary. Such a rule cannot be followed too rigidly for two reasons: First of all, the difficulty of accurately determining the function of the damaged kidney prior to surgery is obvious, and to estimate the potential function of the kidney after surgery is still more difficult. In the second place, one can readily conceive of a situation in which some intercurrent pathological change might compromise the function of the contralateral organ so that the increment of function in the repaired hydronephrotic kidney, however small, say even 5 or 10 per cent, might contribute sufficiently to the total function to sustain life. The ultimate decision in questionable cases in my experience is frequently reserved until the time of surgery. If the parenchyma is reasonably healthy in appearance and has a thickness of one centimeter or more, it is conserved rather than removed. If one is dealing with a solitary kidney or a case in which the opposite kidney is hydronephrotic or pathological from any cause, then conservation is of course mandatory even though it may have only a trace of function. The solitary kidney requiring pyeloplasty responds surprisingly well compared to a similar kidney having a healthy mate, a fact which tends to support the doctrine of renal counterbalance. Obviously, excretory urography does not give us all the information we should have, and may be actually misleading. The corroborative findings of retrograde pyelography are most essential and it is helpful to do both a ureteropyelogram and a pyeloureterogram. The former is done by inserting either a Braasch bulb or Garceau catheter into the lower ureter and injecting radiopaque media. This will usually outline clearly the obstructed area and give some idea of its character. Then an ordinary ureteral catheter is passed to the kidney pelvis, provided it will pass the obstructed area, and a pyelogram is done. On withdrawal of the catheter, a delayed film is exposed. Ordinarily a normal, unobstructed kidney pelvis should show no retained medium after ten or fifteen minutes. The danger of lighting up an infection in the affected kidney is negligible at the present time, using aseptic technique and prophylactic medication with urinary antiseptics. Another diagnostic pitfall deserves emphasis at this point. As a result of the widespread use of excretory urography, many unsuspected instances of hydronephrosis of varying degree are being discovered. It may be difficult in some cases to distinguish between the large normal pelvis and an early hydronephrosis. The distinguishing point, as mentioned by O'Conor, is the fact that a true hydronephrosis will show blunted minor calyces whereas in the kidney with an abnormally large pelvis the minor calyces will exhibit their normal sharp cupping. Another phase of the diagnosis and evaluation of hydronephrosis which has been neglected, or at least not sufficiently emphasized, is the problem of progression versus nonprogression of the disease. We are accustomed to think in terms of experimental hydronephrosis in which ureteral ligation leads invariably to progressive hydronephrotic changes in the kidney. Growing experience has proved that this is not invariably true in clinical practice. In some instances where
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THOMAS E. GIBSON
FIG. 3. A, pyelogram (left). An example of static or nonprogressive hydronephrosis. B, pyelogram made in same case 12 years later. This patient was not operated upon, and had no treatment other than passage of diagnostic catheter for purpose of pyelography. Dilatation appears to have regressed rather than progressed.
operation had been deferred, it has been found that over a period of years there has been no advance in the degree of hydronephrosis, the condition becoming static or nonprogressive. Mention of this fact has been made by Hellstrom, Giertz, and Lindblom (1949) and O'Conor (1954). Hoyt (1954) speaks of the condition as "Equilibrium in Hydronephrosis." Pyelograms in cases of this kind are shown in figures 3, 4, 5, 6 and 7. This concept presents clinical implications which require reappraisal of our views concerning prognosis and therapy. Unquestionably, many cases of hydronephrosis are congenital in origin, yet are not diagnosed until adulthood is attained. Over this long period of years the hydronephrotic sac would reach enormous proportions were it not for the fact that there are counteracting forces at work tending to relieve it. Giant hydronephroses are rare, and one wonders what mechanism comes into play to produce a massive hydronephrosis containing 18 liters, as was recently reported by Earlam (1950). Recognition of the fact that hydronephrosis in some instances may reach equilibrium and become nonprogressive should restrain the too eager surgeon from unnecessary intervention. Conservative treatment should consist in watchful waiting for a period of months, or even years, if the condition remains asymptomatic and excretion urographic outlines remain unchanged. If appreciable functional impairment, pain, urinary infection, or reflex gastrointestinal symptoms develop, then surgery should be done without further delay. TREATMENT
Pelvioureteroplasty. vVhen surgical intervention is deemed necessary, after careful diagnostic: appraisal, the surgeon is faced first of all with the decision as
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Fm. 4. Another example of equilibrium or nonprogression in hydroncphrosis. This i;, :H-year-old woman. There is an interval of P years between the two pyelogrnms (A. and FJ). Pntient had no surgery or other treatment. (Courtesy of Dr. J. L. Goebel.)
Frn. 5. Another example of nonprogression in hydronephrosis. There is an interval of between pyelograms A and B. Patient likewise had no treatment. surgi.enJ or other(Courtesy of Dr. Hoyt.)
THOMAS E. GIBSON
Fm. 6. Another example of nonprogressive hydronephrosis (right). There is an interval of 9 years between pyelograms A and B. Sharp cupping of calyces would seem to indicate that this is probably an instance of a kidney with a large pelvis rather than a true hydronephrosis. (Courtesy of Dr. Spencer Hoyt.)
Fm. 7. Another example of hydronephrotic equilibrium. There is an interval of 13 years between pyelograms A and B. (Courtesy of Dr. Spencer Hoyt.)
• .. ,i
.:.~t,
fl
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to whether to perform a nephrectomy or attempt some corrective plastic procedure. Solution of the problem of treatment is easy ,vhen one kidney i" normal and the opposite kidney has reached the end stage of hydronephrotic atrophy. A nephrectomy is then advisable and can be done with little risk or mortality. However, many are borderline cases which will call forth all the experience and skill that. the urologist can muster to come to a proper decision as to treatment.. He should be thoroughly familiar ,vith the many ingenious surgical procedures used in plastic repair of ureteropelvic obstructions. He must likewise be thoroughly familiar with the various methods of splinting and intubation in eommon usage, with their indications and contraindications. (These have already been revie,rnd in my preliminary lantern slide demonstration.) Time does not permit evaluation of all these procedures. The choice of operation depends npon the nature of the obstruction. It so happens that several types of pyeloplasty may be applicable to one type of obstruction and one',', choice depends upon individual preference. A parallel situation exists with bladder neck ob,;tructions which can be treated by several procedures depending upon tlw surgeon's individual preference. The principal types of pyeloplasty and nrcteral splinting were published by the author in 1945. In 1952, in conjunct.ion with Schwartz and Hewitt, an evaluation of nisults was published . Different methOlfa were used successfnUy, but in general, for the majority of cases, we found a modified Davis procedure the most satisfactory. This consisted of nephrostomy drainage with a Foley catheter, simple longitudinal incision through t,he obstructed area and intubation with polyethylene tubing throughout the entire course of the ureter. No sutures were used. The results were uniformly good, and ,ye felt. that, because of its simplicity and speed of performance, it was generally prefern,ble to flap operations requiring metiwlous and tediou;; suturing. The so-called Y plastic, or Foley modification of the Schwyzer pelvimueteroplasty has many enthusiastic adherents, both here and abroad. It is par1;icularly useful in cases of high insertion of the ureter in the pelvi;; with valve-like formation. The more recent operation of Culp and DevVeerd (1951) appears tu be a further elaboration of tho Y plasty, and the operation of Scardino and Pr·ince (193:3) is practically identical ffith that of Culp. fo cases of large extra.renal pelves, radical excision of tho eutire pelvis includi ug; the ureteropelvic junction and reanastomosis of the ureter to the lmrnr end cif trw pelvis has been advocated by Priestley, Mclver, Deming and others. Dorsey (19Ei4) recently reported an interesting modification of this procedure in which the pelvis is completely resected and reanastomosed above the level of the ureteropelvic junction. The latter is then longitudinally incised and intuha),ed according to the method of Davis. This obviates the danger of stricture formation at the site of reirnplantation of the ureter into the pelvis, as might happen in the Kuester operation (1892) and other types of ureteropyeloneostorny. Ureter-al splinting and intubation. The ultimate goal of all plastic procedures for the correction of ureteropelvic obstruction is to permanently relieve the patient of all discomfort, to promote permanent emptying of the kidney pelvis
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THOMAS E. GIBSON
without stasis, and optimum renal function without the presence of residual infection. The perfect operation would be one requiring neither drainage nor splinting. Unfortunately, this ideal appears to be unattainable in the majority of cases. Opinion is divided on this point between the "splinters" and the "nonsplinters". In previous publications (1939, 1940, 1945, 1952 and 1954) I have emphasized the importance of splinting as a necessary corollary to pelvioureteroplasty in order to insure a successful outcome for the vast majority of cases. Reference to the literature shows that most urologists concur in this opinion. However, there are dissenters, notably Bischoff (1953) and Hamm and Weinberg (1954) who state that these cases can be operated upon successfully without the use of splinting and nephrostomy tubes. Hamm and Weinberg state that adequate drainage is obtained by leaving a vent in the renal pelvis. Furthermore, they maintain that the strictured area can be treated by simple linear incision without splinting or intubation, and that healing by primary intention with adequate caliber will result. Perhaps the pendulum has swung too far in favoring the doctrine of universal splinting, but I feel that over a period of years it has been the most important factor in the successful outcome of a great many cases, and I would be very reluctant to abandon it except in certain cases of extrinsic obstruction. Splinting or intubation (synonomous terms) have often been the determining factors which have given me the necessary courage to attempt a plastic procedure in difficult cases that I might otherwise have subjected to nephrectomy. I feel that intubation is essential in those cases presenting an elongated type of stricture at the ureteropelvic junction such as Davis (1951) has described. Certainly no one can deny that it is absolutely necessary in those occasional cases in which there is a complete avulsion or dissolution of continuity of the ureter. The report of Howard and Hinman (1952) is illuminating in this respect. Two cases have occurred in personal experience, one in a case of solitary kidney in which the ureter had been destroyed for a distance of two or three centimeters below the ureteropelvic junction. In both instances the gap was bridged solely by intubation which acted as a scaffolding for the regeneration of the ureteral wall. The intubation was maintained in these cases for seven weeks. Less flagrant cases may require splinting for periods of one to three weeks depending upon their severity. An excellent result was obtained in both cases as shown by urograms made 1 and 2 years later. Experiences such as these attest to the wonderful capacity of the ureter to regenerate. That this regeneration is not simply a tube of fibrous tissue has been proved by several independent investigators who have demonstrated the ability of the ureter to regenerate and fill i11. large gaps not only with connective tissue but also with smooth muscle and mucosa as well. Your attention is directed particularly to the experimental work of Davis, Strong and Drake (1948), Weaver and Henderson (1953), Lapides and Caffery (1955), and Boyarsky and Duque (1955). One of the main objections to splinting and intubation is the tendency for infection to occur when a foreign body is left in the urinary tract for any period
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of time. I have not found this a serious consideration, because in personal ex-perieuce infections have been of minor degree and have cleared up promptly with proper therapy soon after removal of the splinting and drainage tubefi. During the 8plinting period I have not often resorted to irrigation8 but O'Conor advises frequent instillations of 15 to :=m cc of 0.1 per cent aero8porin solution to combat Pseudomonas aeruginosa, and also daily subcutaneous injections of :mo units of hyaluronidase to keep the urine clear and prevent encrustation. The use of polyethylene tubing, as shown by Schlumberger and Riparetti (1952) ha:o proved to be of value in reducing the latter possibility to a negligible factor. A fair percentage of case:,; of ureteropelvic obstruction will be found to be purely extrinsic in nature, due to congenital fascial bands and adhesions and occasionally to an anomalous artery or vein. Correction of extrinsic factors may be sufficiently curatiYe without having to resort to splinting. Blood vessels may obstruct primarily but in most cases some other factor will be found to be the primary cause of the obstruction. Even though the obstruction may appear to be entirely extrinsic:, it is always wise to calibrate the uretero pelvic: outlet so as not to overlook a possible intrinsic obstruction, suc:h as a stricture of the ureteropelvic junction, which might be of even greater importance than the extrinsic in a given c:ase. This is easily accomplished by either opening the pelvis and calibrating it with a hemostat, Braasch bulbs, or by injecting water into the pelvis through a needle attached to a large Luer syringe. One can ob serve in this way how readily the pelvis empties itself. Even in intrinsic obstructions, such as a stricture of the ureteropelvic junction of minor degree, it is not always necessary to splint. Such a case is illustrated in figure 8: A 6-year--old girl suffered repeated attacks of acute pyelitis and had a stricture of the left ureteropelvic: junction. This was corrected by a double Fenger type operation. This is done as described by the author (194.5) by transfixing the ureteropelvic: junction longitudinally with a No. 11 scalpel blade which pas8es through both sides of the obstructed area simultaneously. 'fhe double incision is made long enough to extend beyond the area of narrowing. The incision is closed transversely with 5-0 chromic: gut on an atraumatic needle, according to the Heineke-Mic:kulic:z principle. This operation is preferable to the original Fenger operation which often failed due to postoperative buckling at the site of incision. Splinting is not necessary in this so-called double Fenger or transfixion operation. Another factor which :ohould not be overlooked in plastic procedures is nephropexy. The hydronephrotic kidney often undergoes more or less ptosis and torsion which am conducive to ureteral kinking. Suspension of the kidney ·will cause the ureter to heal in good alignment and afford the kidney pelvis more adequate dependent drainage. The Deming type of nephropexy is admirably suited to those cases requiring suspension. For the purpose of splinting or intubation, it is now possible to obtain polyethylene tubing in various calibers of the right degree of flexibility. It is in general preferable to rubber or latex because of its nonirritating and nonencrusting qualities. In former years my experiences ,vith the Cumming and
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THOMAS E. GIBSON
FIG. 8. A, hydronephrosis (left) in 8-year-old girl due to a combination of extrinsic fascial bands and intrinsic stricture. B, pyelogram (left) showing result of pyeloplasty 6 months postoperatively. Stricture was treated by a double Fenger (transfixion) type of operation. This is type of case in which splinting or intubation was not deemed necessar 0·.
the Mclver combination nephrostomy and splinting tubes were not satisfactory because they were made of soft flexible latex, and tended too easily to crawl out of the ureter and become displaced. However, a polyethylene Cumming tube ici now available which promises to obviate this difficulty, since it has more rigidity. The T tube type of splinting favored by Deming has its merits in certain cases. Thus, one has a rather wide choice of splinting, as well as plastic procedures with which the operator should be familiar in order that he may utilize the procedure that will be best for the individual patient. SUMMARY
The management of ureteropelvic obstructions 1s discussed with special emphasis on diagnosis and indications for operation. Particular stress is placed on the differentiation of the normal large pelvis and the small hydronephrotic pelvis, as well as the problem of "progressive" versus "nonprogressive" hydronephrosis. Emphasis on these phases of the problem injects clinical implications requiring reappraisal of our views concerning prognosis and therapy. It has been shown that many patients with varying degrees of hydronephrosis may not require operation, and may be kept under observa-
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hon for an indefinite period of time provided the hydronephrosis remams 11onprog;re8sive and devoid of symptoms or infection. \Vhen surgery becomes necessary the surgeon should be guided as to hi:,; choice of procedure by the mm,t thorough and, if necerosary, repeatE'd preliminary L!rologic rotudies, Careful functional evaluation of both kidneys is of paramom1t importance. The operator rohould be thoroughly familiar ,vith the various methods of plastic repair and splinting so as to be capable of applying the procedure best suited io the individual problem at hand. 1:50 8ulter
San Frandseo 8, Cal~/. REFERE~CES
S. AND DuQUl·:, 0 .. Greteral regeneration in dogs: An cxpcrinw11tnJ slncly Lttsed on 1he Davis intubated ureterotorny. J. Urol., 73: 5:1-Gl, HJ55. BERK1,urn, R. R ..um DEMINO, C. L. · The results of treatment of hrclroncphrnsis tir u plastic surgical procedure, \,·ith and without, T-tubc drainage. J. Urol., 66: G8-76, l\J5l. BrscHOFF, P : ½ur Teclmik Jer Hydronephrosen Plasti!c Ztschr f. Tho!., 46: 565-576. HJfi:1. Cr;1,P, 0. S. ,\ND DEWEJoRD, J_ H - Pelvic finµ operation for nreicropclvic olmtructiun ..L Urol., 71: 523-529, 1%1 DORSEY, J. vV, - Pyeloplasty utilizing modified urcteroneopyelost omy, .J Urol ., 73: J 8\) HJ7, 1\l5,5. DAVIS, D, M.: Intubated ureterot.omy: A new operation for ureteral and meteropelvic stridure. Surg., & Obst., 76: 513--523, HJ43. DAnts, D. 1I., STRONO, IL AXD DRAKE, \V,\L, .JR.· Intubated nrctero(,omy: Experimenkd work and clinicnl results. ,f. Crol., 59: 851-8G2, 1948. DAVIS, D. 1\I.: Intubate,! ureterntom,· ..L UroL, 66: 77-85, 1951. D1cThn;,,w, C. L.: Uret(,ropclvic obstruction due to extrinsic and in1rinsic lesions of the \Jreter ns a clinical entitc· and its tren1.rnent, .J. Urol., 50: 420-4:31, 194;:L (See also Bernnike a,nd Deming.) DE,uum, C. L.: Tho pathological physiology and treatment of hydt'Oll('µhrosi,,. Trnns. Soc. Internat. de Urol., 1: !3-67, 1949. KrnLA,f, :\I. S. S.: Giant hyclronephrosis. J. Urol., 63: 195-202, H)50. GrnsoN, T. K: The ureteral splint J. Urol., 42: 1169-1175, 1939. Grnsox, T. E. Hydroncphrosis· Standardization of surgical trnatment, '\;ew Eng. ,J .Med., 222: 910-917, J940. Grnso:,,c, T. E. · Hydronephrosis, Clussifieai,ion and plastic repair of ureteropelvic obstrnct.ions. Surg., Gyncc & Obst., 80: 485-4[!6, HJ45. (See also Sdnrnrtz, et al.) GtRso;,,r, T, E.: Surg;icoJ a,,pects of bydronephrosis. Trnns. Am, Assoc. Ge11ito-lJri11. Surg,, 46: 107-108, 1954 f-L"11IM, F C. AND W,JJNBJ>;R(L S. R. Renal and ureternl surgery without intubation. Trans. Arn. As.soc. Genito-Urin. Surg, 46: 109-114, 1954. HE:LLSTniiJI, J,, GrnH:rz, G. AND L1NDBL0:1r, K,: Pathogenesis and l r·catmeut of hydro-uophrosis. Trn11s. :--!oc, InternaL de Urol., L 163--202, 1949. Hm1ARD, F. S. ANll HtN;\HN, F., .JR.: The ureternl splint in the repair of ureteropelvi<.; ,1.vulsion. ,J. Urol., 68: 148-157, 1952. HovT, H. S.: Equilibrium in hydronephrosis. Stanford l\fed, Bull., 12: 71-7:), J95>±. L.,\ rums, J. AXD CAFFlGRY, E. L.: Observations on healiug of uretern! musclo: Rolationship 1o intubated ureierotom_,·. J. Urn!., 73: 47-52, 1955. . O'CoxoR, Y, J.: Diagnosis ancl treatment of hyclronephrnsis. Trans. Amer. ,lassoc, Gemto-Urin Surg., 46: 103-lOG, 1954. Sc1r1,u~rn1cRGEH., F. C. AXD RrPi,lUJT'rr, P. P.: Use of plastic (polyethylei,e) tul,ing in surgical management of meLeropelvic obstructions. J. Urol., 68: 158-167, HJ52. Sc,\RDINO, P. L. AND Pm ;,,rel£, C. L.: Vertical flap ure1eroµelvioplas1y: Pn,liminar~' report. South ..Med ..J., 46: 325-:331 ]95:3. ScrnYAHTZ, .L VV., HE,HTT, C, AND GrnsoN, T. E.: H,,droncphrosis: Evaluation uf pyeloplas(y in the trnaLment of urcleropelvic obstructions. Arch. Surg., 65: 894--905, 1!J52, Il G, AXD HEND,:m,ON, J. H.: (Tretera! regcrn,raliow Experiment,:il all(] clinical. ,J. 72: '.l50
Vol. 75, No. l, January 1956 Printed in U.S.A.
HYDRO::--JEPHROSIS: DIAGNOSIS AND TREATMENT OF URETEROPEL VIC OBSTRUCTIONS THOMAS E. GIBSO:'if
Increasing interest in the management of ureteropelvic obstructions is clearly evident on perusal of the current medical literature. It is gratifying to note that as a result of more widespread knowledge and experience with the many ingenious types of pyeloplasty, realization of the proper role of splinting and intubation, and the aid of potent drugs to combat infection, surgical conservation of hydro nephrotic kidneys is being practiced with greater confidence and success and fewer kidneys are being subjected to nephrectomy. Unfortunately the entire subject is still in an evolutionary phase and there are wide differences of opinion on various aspects of the problem. My purpose here is to discuss, and perhaps reconcile, divergent views on some of the controversial phases of diagnosis and treatment. DIAGNOSIS AND INDICATIONS FOR OPERA'l'ION
Diagnosis is not without its pitfalls, and demands the most meticulous attention to detail, because only a most complete urological study can answer the many questions arising in each individual patient as to whether or not the case requires surgery, and if so, ·whether some type of plastic procedure is indicated or whether a nephrectomy should be done. The successive steps of a complete urological investigation should be carefully carried out, and many times a second confirmatory study done if there is the least doubt about the decision as to treatment. The function of the hydronephrotic kidney is difficult to evaluate, as the following cases will illustrate. In figure 1 is shown the retrograde pyelogram of a man, :\8 years old, whose right kidney exhibited a large hydronephrotic sac of 2000 cc capacity. Preliminary excretion urography and retrograde study revealed that it had no function. Follmving nephrectomy, I was nonplussed on finding that the kidney exhibited good parenchyma of almost normal thickness. Furthermore, the urine from this kidney was sterile, an important factor which should always be evaluated. An infected hydronephrosis in which there are chronic pyelonephritic changes, even though the hydronephrotic sac is small, is not likely to respond well to any type of pyeloplasty. Thus, it is important to judge hydronephrosis not by its size but by the thickness of the parenchyma, and to note also whether the opposite kidney shows any degree of compensatory hypertrophy. The next case (fig. 2), a man of 40 years, exhibited unilateral hydronephrosis of moderate size. Excretory urography as well as retrograde study, in which separate renal function ,vas determined by phenolsulfonphthalein excretion, revealed no function on the side of the hydroneph.rotic kidney. The ureteral catheter ,vas left indwelling for 24 hours and the phenolsulfonphthalein test repeated. Quantitative output of dye, to my surprise, was practically normal. It was then possible Read at aIJnual meeting, Southeastern Section of American lirological Associaiion, Xe\\' Orlea.n,;, La. March 20--24, 195,5
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THOMAS E. GIBSON
FIG. 1. Right hydronephrosis, 2000 cc capacity. Intrinsic ureteropelvic obstruction of unusual type, consisting of miniature bicuspid valve simulating mitral valve of heart.
FIG. 2. A, hydronephrosis (left). Initial study showed only trace of PSP excretion. After 24 hours catheter drainage, PSP excretion almost normal. B, pyelogram made 6 months after operation. Ureteropelvic obstruction was entirely extrinsic, so no splinting or intubation was used.
to do a successful pyeloplasty without resorting to nephrectomy. When excretoryurography fails to outline the kidney pelvis it is good practice to repeat the roentgenogram in 4 hours, or even 24 hours if there is no evidence of excretion in the first hour. It has been said that a hydronephrotic kidney which cannot by physiological
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tests perform 25 per cent of total renal function is not worth conserving, although there are exceptions to all rules. This statement is based on the assumption that a kidney to be worthy of conservation should be able to carry the total load should it ever become necessary. Such a rule cannot be followed too rigidly for two reasons: First of all, the difficulty of accurately determining the function of the damaged kidney prior to surgery is obvious, and to estimate the potential function of the kidney after surgery is still more difficult. In the second place, one can readily conceive of a situation in which some intercurrent pathological change might compromise the function of the contralateral organ so that the increment of function in the repaired hydronephrotic kidney, however small, say even 5 or 10 per cent, might contribute sufficiently to the total function to sustain life. The ultimate decision in questionable cases in my experience is frequently reserved until the time of surgery. If the parenchyma is reasonably healthy in appearance and has a thickness of one centimeter or more, it is conserved rather than removed. If one is dealing with a solitary kidney or a case in which the opposite kidney is hydronephrotic or pathological from any cause, then conservation is of course mandatory even though it may have only a trace of function. The solitary kidney requiring pyeloplasty responds surprisingly well compared to a similar kidney having a healthy mate, a fact which tends to support the doctrine of renal counterbalance. Obviously, excretory urography does not give us all the information we should have, and may be actually misleading. The corroborative findings of retrograde pyelography are most essential and it is helpful to do both a ureteropyelogram and a pyeloureterogram. The former is done by inserting either a Braasch bulb or Garceau catheter into the lower ureter and injecting radiopaque media. This will usually outline clearly the obstructed area and give some idea of its character. Then an ordinary ureteral catheter is passed to the kidney pelvis, provided it will pass the obstructed area, and a pyelogram is done. On withdrawal of the catheter, a delayed film is exposed. Ordinarily a normal, unobstructed kidney pelvis should show no retained medium after ten or fifteen minutes. The danger of lighting up an infection in the affected kidney is negligible at the present time, using aseptic technique and prophylactic medication with urinary antiseptics. Another diagnostic pitfall deserves emphasis at this point. As a result of the widespread use of excretory urography, many unsuspected instances of hydronephrosis of varying degree are being discovered. It may be difficult in some cases to distinguish between the large normal pelvis and an early hydronephrosis. The distinguishing point, as mentioned by O'Conor, is the fact that a true hydronephrosis will show blunted minor calyces whereas in the kidney with an abnormally large pelvis the minor calyces will exhibit their normal sharp cupping. Another phase of the diagnosis and evaluation of hydronephrosis which has been neglected, or at least not sufficiently emphasized, is the problem of progression versus nonprogression of the disease. We are accustomed to think in terms of experimental hydronephrosis in which ureteral ligation leads invariably to progressive hydronephrotic changes in the kidney. Growing experience has proved that this is not invariably true in clinical practice. In some instances where
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THOMAS E. GIBSON
FIG. 3. A, pyelogram (left). An example of static or nonprogressive hydronephrosis. B, pyelogram made in same case 12 years later. This patient was not operated upon, and had no treatment other than passage of diagnostic catheter for purpose of pyelography. Dilatation appears to have regressed rather than progressed.
operation had been deferred, it has been found that over a period of years there has been no advance in the degree of hydronephrosis, the condition becoming static or nonprogressive. Mention of this fact has been made by Hellstrom, Giertz, and Lindblom (1949) and O'Conor (1954). Hoyt (1954) speaks of the condition as "Equilibrium in Hydronephrosis." Pyelograms in cases of this kind are shown in figures 3, 4, 5, 6 and 7. This concept presents clinical implications which require reappraisal of our views concerning prognosis and therapy. Unquestionably, many cases of hydronephrosis are congenital in origin, yet are not diagnosed until adulthood is attained. Over this long period of years the hydronephrotic sac would reach enormous proportions were it not for the fact that there are counteracting forces at work tending to relieve it. Giant hydronephroses are rare, and one wonders what mechanism comes into play to produce a massive hydronephrosis containing 18 liters, as was recently reported by Earlam (1950). Recognition of the fact that hydronephrosis in some instances may reach equilibrium and become nonprogressive should restrain the too eager surgeon from unnecessary intervention. Conservative treatment should consist in watchful waiting for a period of months, or even years, if the condition remains asymptomatic and excretion urographic outlines remain unchanged. If appreciable functional impairment, pain, urinary infection, or reflex gastrointestinal symptoms develop, then surgery should be done without further delay. TREATMENT
Pelvioureteroplasty. vVhen surgical intervention is deemed necessary, after careful diagnostic: appraisal, the surgeon is faced first of all with the decision as
HYDRONEPHROSIS
5
Fm. 4. Another example of equilibrium or nonprogression in hydroncphrosis. This i;, :H-year-old woman. There is an interval of P years between the two pyelogrnms (A. and FJ). Pntient had no surgery or other treatment. (Courtesy of Dr. J. L. Goebel.)
Frn. 5. Another example of nonprogression in hydronephrosis. There is an interval of between pyelograms A and B. Patient likewise had no treatment. surgi.enJ or other(Courtesy of Dr. Hoyt.)
THOMAS E. GIBSON
Fm. 6. Another example of nonprogressive hydronephrosis (right). There is an interval of 9 years between pyelograms A and B. Sharp cupping of calyces would seem to indicate that this is probably an instance of a kidney with a large pelvis rather than a true hydronephrosis. (Courtesy of Dr. Spencer Hoyt.)
Fm. 7. Another example of hydronephrotic equilibrium. There is an interval of 13 years between pyelograms A and B. (Courtesy of Dr. Spencer Hoyt.)
• .. ,i
.:.~t,
fl
HYJlRONEPHH.OSlS
7
to whether to perform a nephrectomy or attempt some corrective plastic procedure. Solution of the problem of treatment is easy ,vhen one kidney i" normal and the opposite kidney has reached the end stage of hydronephrotic atrophy. A nephrectomy is then advisable and can be done with little risk or mortality. However, many are borderline cases which will call forth all the experience and skill that. the urologist can muster to come to a proper decision as to treatment.. He should be thoroughly familiar ,vith the many ingenious surgical procedures used in plastic repair of ureteropelvic obstructions. He must likewise be thoroughly familiar with the various methods of splinting and intubation in eommon usage, with their indications and contraindications. (These have already been revie,rnd in my preliminary lantern slide demonstration.) Time does not permit evaluation of all these procedures. The choice of operation depends npon the nature of the obstruction. It so happens that several types of pyeloplasty may be applicable to one type of obstruction and one',', choice depends upon individual preference. A parallel situation exists with bladder neck ob,;tructions which can be treated by several procedures depending upon tlw surgeon's individual preference. The principal types of pyeloplasty and nrcteral splinting were published by the author in 1945. In 1952, in conjunct.ion with Schwartz and Hewitt, an evaluation of nisults was published . Different methOlfa were used successfnUy, but in general, for the majority of cases, we found a modified Davis procedure the most satisfactory. This consisted of nephrostomy drainage with a Foley catheter, simple longitudinal incision through t,he obstructed area and intubation with polyethylene tubing throughout the entire course of the ureter. No sutures were used. The results were uniformly good, and ,ye felt. that, because of its simplicity and speed of performance, it was generally prefern,ble to flap operations requiring metiwlous and tediou;; suturing. The so-called Y plastic, or Foley modification of the Schwyzer pelvimueteroplasty has many enthusiastic adherents, both here and abroad. It is par1;icularly useful in cases of high insertion of the ureter in the pelvi;; with valve-like formation. The more recent operation of Culp and DevVeerd (1951) appears tu be a further elaboration of tho Y plasty, and the operation of Scardino and Pr·ince (193:3) is practically identical ffith that of Culp. fo cases of large extra.renal pelves, radical excision of tho eutire pelvis includi ug; the ureteropelvic junction and reanastomosis of the ureter to the lmrnr end cif trw pelvis has been advocated by Priestley, Mclver, Deming and others. Dorsey (19Ei4) recently reported an interesting modification of this procedure in which the pelvis is completely resected and reanastomosed above the level of the ureteropelvic junction. The latter is then longitudinally incised and intuha),ed according to the method of Davis. This obviates the danger of stricture formation at the site of reirnplantation of the ureter into the pelvis, as might happen in the Kuester operation (1892) and other types of ureteropyeloneostorny. Ureter-al splinting and intubation. The ultimate goal of all plastic procedures for the correction of ureteropelvic obstruction is to permanently relieve the patient of all discomfort, to promote permanent emptying of the kidney pelvis
8
THOMAS E. GIBSON
without stasis, and optimum renal function without the presence of residual infection. The perfect operation would be one requiring neither drainage nor splinting. Unfortunately, this ideal appears to be unattainable in the majority of cases. Opinion is divided on this point between the "splinters" and the "nonsplinters". In previous publications (1939, 1940, 1945, 1952 and 1954) I have emphasized the importance of splinting as a necessary corollary to pelvioureteroplasty in order to insure a successful outcome for the vast majority of cases. Reference to the literature shows that most urologists concur in this opinion. However, there are dissenters, notably Bischoff (1953) and Hamm and Weinberg (1954) who state that these cases can be operated upon successfully without the use of splinting and nephrostomy tubes. Hamm and Weinberg state that adequate drainage is obtained by leaving a vent in the renal pelvis. Furthermore, they maintain that the strictured area can be treated by simple linear incision without splinting or intubation, and that healing by primary intention with adequate caliber will result. Perhaps the pendulum has swung too far in favoring the doctrine of universal splinting, but I feel that over a period of years it has been the most important factor in the successful outcome of a great many cases, and I would be very reluctant to abandon it except in certain cases of extrinsic obstruction. Splinting or intubation (synonomous terms) have often been the determining factors which have given me the necessary courage to attempt a plastic procedure in difficult cases that I might otherwise have subjected to nephrectomy. I feel that intubation is essential in those cases presenting an elongated type of stricture at the ureteropelvic junction such as Davis (1951) has described. Certainly no one can deny that it is absolutely necessary in those occasional cases in which there is a complete avulsion or dissolution of continuity of the ureter. The report of Howard and Hinman (1952) is illuminating in this respect. Two cases have occurred in personal experience, one in a case of solitary kidney in which the ureter had been destroyed for a distance of two or three centimeters below the ureteropelvic junction. In both instances the gap was bridged solely by intubation which acted as a scaffolding for the regeneration of the ureteral wall. The intubation was maintained in these cases for seven weeks. Less flagrant cases may require splinting for periods of one to three weeks depending upon their severity. An excellent result was obtained in both cases as shown by urograms made 1 and 2 years later. Experiences such as these attest to the wonderful capacity of the ureter to regenerate. That this regeneration is not simply a tube of fibrous tissue has been proved by several independent investigators who have demonstrated the ability of the ureter to regenerate and fill i11. large gaps not only with connective tissue but also with smooth muscle and mucosa as well. Your attention is directed particularly to the experimental work of Davis, Strong and Drake (1948), Weaver and Henderson (1953), Lapides and Caffery (1955), and Boyarsky and Duque (1955). One of the main objections to splinting and intubation is the tendency for infection to occur when a foreign body is left in the urinary tract for any period
HYDRONEPHROSIS
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1
g
of time. I have not found this a serious consideration, because in personal ex-perieuce infections have been of minor degree and have cleared up promptly with proper therapy soon after removal of the splinting and drainage tubefi. During the 8plinting period I have not often resorted to irrigation8 but O'Conor advises frequent instillations of 15 to :=m cc of 0.1 per cent aero8porin solution to combat Pseudomonas aeruginosa, and also daily subcutaneous injections of :mo units of hyaluronidase to keep the urine clear and prevent encrustation. The use of polyethylene tubing, as shown by Schlumberger and Riparetti (1952) ha:o proved to be of value in reducing the latter possibility to a negligible factor. A fair percentage of case:,; of ureteropelvic obstruction will be found to be purely extrinsic in nature, due to congenital fascial bands and adhesions and occasionally to an anomalous artery or vein. Correction of extrinsic factors may be sufficiently curatiYe without having to resort to splinting. Blood vessels may obstruct primarily but in most cases some other factor will be found to be the primary cause of the obstruction. Even though the obstruction may appear to be entirely extrinsic:, it is always wise to calibrate the uretero pelvic: outlet so as not to overlook a possible intrinsic obstruction, suc:h as a stricture of the ureteropelvic junction, which might be of even greater importance than the extrinsic in a given c:ase. This is easily accomplished by either opening the pelvis and calibrating it with a hemostat, Braasch bulbs, or by injecting water into the pelvis through a needle attached to a large Luer syringe. One can ob serve in this way how readily the pelvis empties itself. Even in intrinsic obstructions, such as a stricture of the ureteropelvic junction of minor degree, it is not always necessary to splint. Such a case is illustrated in figure 8: A 6-year--old girl suffered repeated attacks of acute pyelitis and had a stricture of the left ureteropelvic: junction. This was corrected by a double Fenger type operation. This is done as described by the author (194.5) by transfixing the ureteropelvic: junction longitudinally with a No. 11 scalpel blade which pas8es through both sides of the obstructed area simultaneously. 'fhe double incision is made long enough to extend beyond the area of narrowing. The incision is closed transversely with 5-0 chromic: gut on an atraumatic needle, according to the Heineke-Mic:kulic:z principle. This operation is preferable to the original Fenger operation which often failed due to postoperative buckling at the site of incision. Splinting is not necessary in this so-called double Fenger or transfixion operation. Another factor which :ohould not be overlooked in plastic procedures is nephropexy. The hydronephrotic kidney often undergoes more or less ptosis and torsion which am conducive to ureteral kinking. Suspension of the kidney ·will cause the ureter to heal in good alignment and afford the kidney pelvis more adequate dependent drainage. The Deming type of nephropexy is admirably suited to those cases requiring suspension. For the purpose of splinting or intubation, it is now possible to obtain polyethylene tubing in various calibers of the right degree of flexibility. It is in general preferable to rubber or latex because of its nonirritating and nonencrusting qualities. In former years my experiences ,vith the Cumming and
10
THOMAS E. GIBSON
FIG. 8. A, hydronephrosis (left) in 8-year-old girl due to a combination of extrinsic fascial bands and intrinsic stricture. B, pyelogram (left) showing result of pyeloplasty 6 months postoperatively. Stricture was treated by a double Fenger (transfixion) type of operation. This is type of case in which splinting or intubation was not deemed necessar 0·.
the Mclver combination nephrostomy and splinting tubes were not satisfactory because they were made of soft flexible latex, and tended too easily to crawl out of the ureter and become displaced. However, a polyethylene Cumming tube ici now available which promises to obviate this difficulty, since it has more rigidity. The T tube type of splinting favored by Deming has its merits in certain cases. Thus, one has a rather wide choice of splinting, as well as plastic procedures with which the operator should be familiar in order that he may utilize the procedure that will be best for the individual patient. SUMMARY
The management of ureteropelvic obstructions 1s discussed with special emphasis on diagnosis and indications for operation. Particular stress is placed on the differentiation of the normal large pelvis and the small hydronephrotic pelvis, as well as the problem of "progressive" versus "nonprogressive" hydronephrosis. Emphasis on these phases of the problem injects clinical implications requiring reappraisal of our views concerning prognosis and therapy. It has been shown that many patients with varying degrees of hydronephrosis may not require operation, and may be kept under observa-
l-1 YDRONl!:PHROSlS
11
hon for an indefinite period of time provided the hydronephrosis remams 11onprog;re8sive and devoid of symptoms or infection. \Vhen surgery becomes necessary the surgeon should be guided as to hi:,; choice of procedure by the mm,t thorough and, if necerosary, repeatE'd preliminary L!rologic rotudies, Careful functional evaluation of both kidneys is of paramom1t importance. The operator rohould be thoroughly familiar ,vith the various methods of plastic repair and splinting so as to be capable of applying the procedure best suited io the individual problem at hand. 1:50 8ulter
San Frandseo 8, Cal~/. REFERE~CES
S. AND DuQUl·:, 0 .. Greteral regeneration in dogs: An cxpcrinw11tnJ slncly Lttsed on 1he Davis intubated ureterotorny. J. Urol., 73: 5:1-Gl, HJ55. BERK1,urn, R. R ..um DEMINO, C. L. · The results of treatment of hrclroncphrnsis tir u plastic surgical procedure, \,·ith and without, T-tubc drainage. J. Urol., 66: G8-76, l\J5l. BrscHOFF, P : ½ur Teclmik Jer Hydronephrosen Plasti!c Ztschr f. Tho!., 46: 565-576. HJfi:1. Cr;1,P, 0. S. ,\ND DEWEJoRD, J_ H - Pelvic finµ operation for nreicropclvic olmtructiun ..L Urol., 71: 523-529, 1%1 DORSEY, J. vV, - Pyeloplasty utilizing modified urcteroneopyelost omy, .J Urol ., 73: J 8\) HJ7, 1\l5,5. DAVIS, D, M.: Intubated ureterot.omy: A new operation for ureteral and meteropelvic stridure. Surg., & Obst., 76: 513--523, HJ43. DAnts, D. 1I., STRONO, IL AXD DRAKE, \V,\L, .JR.· Intubated nrctero(,omy: Experimenkd work and clinicnl results. ,f. Crol., 59: 851-8G2, 1948. DAVIS, D. 1\I.: Intubate,! ureterntom,· ..L UroL, 66: 77-85, 1951. D1cThn;,,w, C. L.: Uret(,ropclvic obstruction due to extrinsic and in1rinsic lesions of the \Jreter ns a clinical entitc· and its tren1.rnent, .J. Urol., 50: 420-4:31, 194;:L (See also Bernnike a,nd Deming.) DE,uum, C. L.: Tho pathological physiology and treatment of hydt'Oll('µhrosi,,. Trnns. Soc. Internat. de Urol., 1: !3-67, 1949. KrnLA,f, :\I. S. S.: Giant hyclronephrosis. J. Urol., 63: 195-202, H)50. GrnsoN, T. K: The ureteral splint J. Urol., 42: 1169-1175, 1939. Grnsox, T. E. Hydroncphrosis· Standardization of surgical trnatment, '\;ew Eng. ,J .Med., 222: 910-917, J940. Grnso:,,c, T. E. · Hydronephrosis, Clussifieai,ion and plastic repair of ureteropelvic obstrnct.ions. Surg., Gyncc & Obst., 80: 485-4[!6, HJ45. (See also Sdnrnrtz, et al.) GtRso;,,r, T, E.: Surg;icoJ a,,pects of bydronephrosis. Trnns. Am, Assoc. Ge11ito-lJri11. Surg,, 46: 107-108, 1954 f-L"11IM, F C. AND W,JJNBJ>;R(L S. R. Renal and ureternl surgery without intubation. Trans. Arn. As.soc. Genito-Urin. Surg, 46: 109-114, 1954. HE:LLSTniiJI, J,, GrnH:rz, G. AND L1NDBL0:1r, K,: Pathogenesis and l r·catmeut of hydro-uophrosis. Trn11s. :--!oc, InternaL de Urol., L 163--202, 1949. Hm1ARD, F. S. ANll HtN;\HN, F., .JR.: The ureternl splint in the repair of ureteropelvi<.; ,1.vulsion. ,J. Urol., 68: 148-157, 1952. HovT, H. S.: Equilibrium in hydronephrosis. Stanford l\fed, Bull., 12: 71-7:), J95>±. L.,\ rums, J. AXD CAFFlGRY, E. L.: Observations on healiug of uretern! musclo: Rolationship 1o intubated ureierotom_,·. J. Urn!., 73: 47-52, 1955. . O'CoxoR, Y, J.: Diagnosis ancl treatment of hyclronephrnsis. Trans. Amer. ,lassoc, Gemto-Urin Surg., 46: 103-lOG, 1954. Sc1r1,u~rn1cRGEH., F. C. AXD RrPi,lUJT'rr, P. P.: Use of plastic (polyethylei,e) tul,ing in surgical management of meLeropelvic obstructions. J. Urol., 68: 158-167, HJ52. Sc,\RDINO, P. L. AND Pm ;,,rel£, C. L.: Vertical flap ure1eroµelvioplas1y: Pn,liminar~' report. South ..Med ..J., 46: 325-:331 ]95:3. ScrnYAHTZ, .L VV., HE,HTT, C, AND GrnsoN, T. E.: H,,droncphrosis: Evaluation uf pyeloplas(y in the trnaLment of urcleropelvic obstructions. Arch. Surg., 65: 894--905, 1!J52, Il G, AXD HEND,:m,ON, J. H.: (Tretera! regcrn,raliow Experiment,:il all(] clinical. ,J. 72: '.l50