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Megaloureter
THE JOURNAL OF UROLOGY
Vol. 75, No. 4, April 1956
Printed in U.S.A.
MEG ALO URETER EVAN L. LEWIS, MAJOR (MC) AND RICHARD
w. CLETSOWAY, CAPT. (MC)
From the Urology Service, Tokyo Army Hospital, 8059th Army Unit, APO 500, San Francisco, Calif.
This article is presented in an attempt to clarify a condition in the lower ureter that has been misinterpreted, misclassified and erroneously treated. E. W. Campbell, M. F. Campbell, Kimbrough, Band and Crabtree have written on this and related subjects. Since the original article in 1952 (Lewis and Kimbrough), Nesbit and Hutch and Carlson have written articles on this condition. The term, megaloureter is being accepted to mean a neurogenic dilatation of the ureter in contradistinction to obstructive uropathy. Unfortunately this term is ambiguous and has been used by too many to mean giant dilated ureters whatever the cause. In 1950 and 1951 a resume of the work done at Walter Reed Army Hospital on this subject was presented by Kimbrough, Lewis and Crompton. Further study has served to bear out our original concepts. This condition is caused by a neurogenic disturbance of the lower end of the ureter, an achalasia so to speak, and manifested by 1) ureteral dilatation, either unilateral or bilateral, 2) no evidence of true obstruction either in ureters, ureterovesical junction or at bladder neck or urethra, 3) pelvis and calyces not dilated in proportion to ureter, 4) peristalsis present in dilated portion, and 5) lack of tortuosity. As seen roentgenologically, the typical picture is that of a dilated ureter without tortuosity. The dilatation is most marked in the lower end of the ureter and diminishes upward. The pelvis and calyces are slightly dilated depending on the amount of infection that has been present. There may or may not be seen an undilated segment at the lower end of the ureters. Most often it is the intramural segment of the ureter which is involved. Cystoscopically the orifices appear normal. A No. 12 Braasch bulb passes with ease. Under the fluoroscope the dilated segment is seen to contract normally but the bolus of dye does not entirely go through the ureterovesical junction. A neurogenic bladder of the hypotonic type may be associated but has not been noted in our last 6 patients. Symptoms depend on several factors. The syndrome may be entirely asymptomatic. Pain is usually of a mild degree and is usually lower abdominal. When infection supervenes the symptoms become more severe and are associated with frequency, urgency, fever and a general lassitude. This syndrome has been compared to achalasia of the cardiac end of the stomach with megaesophagus and with megacolon (Hirschsprung's disease). The pathological lesion in the latter has been demonstrated to be an absence of Auerbach's plexus in the lower undilated segment of bowel. A search for nerve plexi in the removed segment of undilated ureter has failed to reveal any change. The reason for this, of course, is that the ganglion cells lie outside the Accepted for publication September 21, 1955.
643
644
EVAN L. LEWIS AND RICHARD W. CLETSOWAY
wall of the ureter. Dr. A. Pieper in Germany has described a plexus of ganglion cells on the posterior wall of the bladder which supplies the bladder and the lower end of the ureter. His work has not been corroborated but does give a lead which must be followed to get to the definite neurogenic disturbance present in this condition. Hutch, in his article on dilated ureters without demonstrable obstruction, puts the blame on a trabeculated bladder wall. This is very well for the patient who has spinal cord disease or bladder neck obstruction, but in none of the 6 patients in this presentation nor in the 3 previously presented has trabeculation been seen. We believe that Hutch is describing an entirely different syndrome completely unrelated to a megaloureter as we define it. It should be stressed that pyeloscopy-that is, a retrograde study done under the fluoroscope-is an excellent procedure. It is our opinion that more information can be obtained both in this disease and in other cases of uropathology than with single x-ray exposure. If a ureter can be seen to contract forcibly then a good result can be expected and there is no need for such operations as intrapsoas transplant; whereas if a ureter is a tonic, it will not reduce in caliber with relief of obstruction, whatever the cause. In the presentation of the original article on this condition we described a new method of treatment which has given excellent results. This consisted of cutting the ureter in the dilated portion and reimplanting this dilated segment into the bladder. A technique of reimplantation must be used which will prevent stricture and reflux (fig. 1). The technique we use has been 100 per cent successful so far. The bladder wall is penetrated with a clamp rather than incised. The ureter is splinted with a lGF polyethylene tube for 4 days. Approximately one inch of ureter is brought into the bladder and the end is sutured to the opposite bladder wall. This degenerates to leave a well formed nipple of ureter approximately one-fourth inch in diameter. The dilated ureter returns to almost normal size in a matter of 6 to 9 weeks. Infection has not been a problem and all symptoms have been alleviated.
Fw. 1. Cystoscopic view of bladder following bilateral reimplantation of ureters for megaloureter. Note well formed nipples which prevent reflux.
MEG ALO URETER
1\45
Recent articles haYe shown that the interest in this disease i::-: sprea,ding, That othern have not obtained the sarne results as ours is due to their technique of ureteral reimplantation. If reflux occurs, the condition is definitely made worse. Hence a method that prevents reflux must be used. We belieYe !he method we reported, which is a modification of one first described by Jewett, is the best. "\Ve have now done 15 ureters by this method (;3 for other reasons) ,rnd have not had a single case of reflux. H is admitted that not every ease needcJ surgical treatment. U the infection can be cleared up and the patient does not have recurrent attacks of pyelonephritis and is asymptomatic, then surgery may not be indicated. VVe have two such patients. One is a 28-year-old woman on whom a pyelogram was made as part of a routine workup. The megaloureter was an incidental finding and surgery was not advised A. second ('ase was a 5:3-year-old male offirer 1Yho fell in Korea and injured his right kidney enough to cause mild hematuria. A pyelograrn revealed unilateral megaloureter. No infection ensued; he had been asymptomatic all his life-uaturally surgery was not advised. Since publication of our original article, the procedure has been performed in,.six ::i.dditional patients. CASE REPORTS
Case L A 41-year-old white housewife was admitted to vValter H.ecd Army Hospital January 28, 1\l52. She had previously been a patient on the gynecological servi<:e where a uterine fibroid was removed. During the gynecological study a urological consultation 1Yas obtained because of white blood cells in the urine. She was asymptomatic. An excretory urogram reYealed a left megaloureter (fig, 2). On January :H. 1952 the left ureter was reimplantecl into the hlad(for
"Iii o. 2. C:,.se L A, prnopern.tive. B, po8topcrative
f
646
EVAN L. LEWIS AND RICHARD W. CLETSOWAY
approximately one inch above the normal opening. The convalescence was uneventful. At the time of discharge the ureter was back to normal size, the urine was sterile and there was no reflux. The patient is completely asymptomatic. Case 2. A 32-year-old white man was seen in the outpatient clinic at Tokyo Army Hospital because of severe, incapacitating, right lower quadrant pain. He had been treated for 6 months for chronic prostatitis without success. The pain was intermittent in nature lasting two to three days, usually accompanied by chills and fever. Excretory urography revealed bilateral megaloureter, the right side being only slightly larger than normal. The bladder was slightly hypotonic, urine was sterile-there was no reflux. Pyeloscopy revealed good contraction in the dilated portion but no dilatation of the "normal segment." Reimplantation of the right ureter was done on September 24, 1953. The ureter has gradually returned to normal. The urine is sterile, there is no reflux, indigo carmine comes through the new opening in "normal spurts." The patient is now asymptomatic and has not had a single attack of pain since surgery. Case 3. A 24-year-old Greek Private was transferred from a station hospital in Korea where he was admitted because of severe pain in the left flank associated with dysuria and frequency. Past history was negative. He was found to have hematuria and pyuria and temperature of lOlF. He was treated with antibiotics prior to transfer. On admission at Tokyo Army Hospital he was in less pain and his temperature was normal. Urinalysis revealed several red blood cells and white blood cells per high power field. Culture was positive for alpha Streptococcus faecalis. Physical examination revealed only left flank tenderness. Excretory urography revealed marked dilatation of the lower end of both ureters. Excretion was delayed in both sides. There appeared to be a double kidney on the left with the upper half being rudimentary. A retrograde urogram revealed two orifices on the left. The lower half of the left kidney had much better function than the upper half. The ureter to the upper half appeared normal but that to the lower half was quite dilated. A diagnosis of bilateral megaloureter was made. On June 24, 1953 a bilateral ureteroneocystostomy was accomplished. The ureter to the upper half of the left kidney was not bothered. The splints were removed on the seventh postoperative day. Recovery was uneventful. At the time of his transfer to Greece he was asymptomatic, urine was clear but culture was still positive. There was no reflux. Long-term followup will be impossible. Case 4- A 6-year-old white girl was seen in the outpatient clinic because of recurrent left pyelonephritis. She had had two previous reimplantations of the left ureter for megaloureter. Excretory urography revealed good function on both sides. The right kidney and ureter were normal. There was dilatation of the left kidney, pelvis and ureter. Cystogram revealed reflux up the left side. Culture revealed E. coli. It was believed that a third attempt at transplant would be in order although the parents had been told that the child would lose the kidney if the second operation failed. On July 27, 1954 the left ureter was explored. It was removed near the bladder and reimplanted in the dome. A segment was
r
M~]GALOtTHETEH
iH7
left in the bladder but it was not as long as -we usually like to leave. Corwal(iscene,, was conmletely uneventful. The sphnt was removed on the seventh day and the patient wa.s discharged on the tenth postoperative day_ It is nmr 11 months since surgery and she has beeu asymptomatic. Her pediatrician reported that she has had no subi:,equcnt attacks of pyelitis and her general health is excellent. Case 5 A. l -white enlisted man ,rns admitted to Tokyo Army Hospital August 21, 1954- because of pain in the right flank and pyuria. Past history was negative. Ht: had had no previom; attacks of urinary tract infection . This episode had begun several days prior to admission aud had been alleviated with gautrisin and penicillin. Excretory urography revealed hydronephrosis of mild degree ou the right with some
648
EVAN L. LEWIS AND RICHARD W. CLETSOWAY
Fm. 4. Case 6. A, preoperative. B, postoperative
In 1947 the patient had been turned down for admission to West Point because of albuminuria. Excretory urography was done at this time and he was told he had left hydronephrosis (fig. 4). He has been asymptomatic since but on annual physical examination the albuminuria was again noted and another excretory urogram was done. When questioned carefully he admitted to nocturia one to two times and some frequency and urgency of urination. Physical examination on admission was negative. The urinalysis revealed 2 plus albuminuria with 7-10 granular casts; culture was negative. On February 17, 1953 the left ureter was reimplanted according to the previously described technique. In this case, because of the large caliber of the ureter, a segment was removed from the most dilated portion and the splint was allowed to remain for 3 vrneks. The patient had some fever postoperatively but after removal of the splint the fever subsided, the urine cleared and the culture became negative. He is now asymptomatic and has returned to duty. A final urinalysis revealed only a faint trace of albumin, 0-3 white blood cells per high power field and no casts. Excretory urography G weeks later revealed diminution in the size of the hydronephrotic sac and in the ureter. It is believed that surgery will be unnecessary on the right side due to the minimal disease present. Comment: Although this patient was asymptomatic and had not had infection, operation was performed because of persistent albuminuria which would be picked up on each year's annual physical examination. Although we could not assure him that the albuminuria would disappear, we are gratified that only a trace is now present. SUMMARY
Six additional cases are presented demonstrating the new concept for surgery for megaloureter. This syndrome of neurogemc "obstruction" at the lower
MEGALO URETER
649
end of the ureter causing dilatation is again presented and described in detail. Diagnosis is based on the pyelographic appearance, lack of obstruction and action of the ureter as seen at fluoroscopy. That others have not been able to achieve the clinical results is not due to the fault of the theories or principle of treatment, but to the technique of surgery. The occurrence of a stricture at the site of reimplantation or reflux up the ureter postoperatively is definitely an operative failure. If such occurs, further surgery is necessary, as in the fourth patient. REFERENCES BAND D.: Discussion on anomalies of the ureter in childhood. Proc. Roy. Soc. Med., 43: 280-281, 1950. CAMPBELL, E.W.: Megalo-ureter. J. Urol., 60: 31-45, 1948. CAMPBELL, M. F.: Ureteral obstruction in children. J. Urol., 41: 660, 1939. CARLSON, H.: The intrapsoas transplant of megalo-ureter. J. Urol., 72: 172-177, 1954. CRABTREE, E. G.: Plastic operation for relief of megalo-ureter. Tr. Am. Genito-Urin. Surg., 30: 342, 1937. HUTCH, J. A.: Nonobstructive dilatation of the upper urinary tract. J. Urol., 71: 412-420, 1954. JEWETT, H. J.: Upper urinary tract obstructions in infants and children: Diagnosis and treatment. Pediatric Clinics of North Amer., 2: 737-754, 1955. KIMBROUGH, J. C., LEWIS, E. L. AND CROMPTON, R. E.: Megaloureter exhibit, Am. Urol. Assn., Washington, D. C., May 28, 1950. LEWIS, E. L. AND KIMBROUGH, J. C.: Megalo-ureter. South M. J., 45: 171-177, 1952. NESBIT, R. M. AND WITHYCOMBE, J. F.: The problem of primary megaloureter. J. Urol., 72: 162-171, 1954. PIEPER, A.: Beitrag zur Nerversorgung des Ureters. Ztschr. f. Urol., 44: 17-23, 1951.
] J ~/,,,/)
w .
_.
Vol. 75, No. 4, April 1956
Printed in U.S.A.
MEG ALO URETER EVAN L. LEWIS, MAJOR (MC) AND RICHARD
w. CLETSOWAY, CAPT. (MC)
From the Urology Service, Tokyo Army Hospital, 8059th Army Unit, APO 500, San Francisco, Calif.
This article is presented in an attempt to clarify a condition in the lower ureter that has been misinterpreted, misclassified and erroneously treated. E. W. Campbell, M. F. Campbell, Kimbrough, Band and Crabtree have written on this and related subjects. Since the original article in 1952 (Lewis and Kimbrough), Nesbit and Hutch and Carlson have written articles on this condition. The term, megaloureter is being accepted to mean a neurogenic dilatation of the ureter in contradistinction to obstructive uropathy. Unfortunately this term is ambiguous and has been used by too many to mean giant dilated ureters whatever the cause. In 1950 and 1951 a resume of the work done at Walter Reed Army Hospital on this subject was presented by Kimbrough, Lewis and Crompton. Further study has served to bear out our original concepts. This condition is caused by a neurogenic disturbance of the lower end of the ureter, an achalasia so to speak, and manifested by 1) ureteral dilatation, either unilateral or bilateral, 2) no evidence of true obstruction either in ureters, ureterovesical junction or at bladder neck or urethra, 3) pelvis and calyces not dilated in proportion to ureter, 4) peristalsis present in dilated portion, and 5) lack of tortuosity. As seen roentgenologically, the typical picture is that of a dilated ureter without tortuosity. The dilatation is most marked in the lower end of the ureter and diminishes upward. The pelvis and calyces are slightly dilated depending on the amount of infection that has been present. There may or may not be seen an undilated segment at the lower end of the ureters. Most often it is the intramural segment of the ureter which is involved. Cystoscopically the orifices appear normal. A No. 12 Braasch bulb passes with ease. Under the fluoroscope the dilated segment is seen to contract normally but the bolus of dye does not entirely go through the ureterovesical junction. A neurogenic bladder of the hypotonic type may be associated but has not been noted in our last 6 patients. Symptoms depend on several factors. The syndrome may be entirely asymptomatic. Pain is usually of a mild degree and is usually lower abdominal. When infection supervenes the symptoms become more severe and are associated with frequency, urgency, fever and a general lassitude. This syndrome has been compared to achalasia of the cardiac end of the stomach with megaesophagus and with megacolon (Hirschsprung's disease). The pathological lesion in the latter has been demonstrated to be an absence of Auerbach's plexus in the lower undilated segment of bowel. A search for nerve plexi in the removed segment of undilated ureter has failed to reveal any change. The reason for this, of course, is that the ganglion cells lie outside the Accepted for publication September 21, 1955.
643
644
EVAN L. LEWIS AND RICHARD W. CLETSOWAY
wall of the ureter. Dr. A. Pieper in Germany has described a plexus of ganglion cells on the posterior wall of the bladder which supplies the bladder and the lower end of the ureter. His work has not been corroborated but does give a lead which must be followed to get to the definite neurogenic disturbance present in this condition. Hutch, in his article on dilated ureters without demonstrable obstruction, puts the blame on a trabeculated bladder wall. This is very well for the patient who has spinal cord disease or bladder neck obstruction, but in none of the 6 patients in this presentation nor in the 3 previously presented has trabeculation been seen. We believe that Hutch is describing an entirely different syndrome completely unrelated to a megaloureter as we define it. It should be stressed that pyeloscopy-that is, a retrograde study done under the fluoroscope-is an excellent procedure. It is our opinion that more information can be obtained both in this disease and in other cases of uropathology than with single x-ray exposure. If a ureter can be seen to contract forcibly then a good result can be expected and there is no need for such operations as intrapsoas transplant; whereas if a ureter is a tonic, it will not reduce in caliber with relief of obstruction, whatever the cause. In the presentation of the original article on this condition we described a new method of treatment which has given excellent results. This consisted of cutting the ureter in the dilated portion and reimplanting this dilated segment into the bladder. A technique of reimplantation must be used which will prevent stricture and reflux (fig. 1). The technique we use has been 100 per cent successful so far. The bladder wall is penetrated with a clamp rather than incised. The ureter is splinted with a lGF polyethylene tube for 4 days. Approximately one inch of ureter is brought into the bladder and the end is sutured to the opposite bladder wall. This degenerates to leave a well formed nipple of ureter approximately one-fourth inch in diameter. The dilated ureter returns to almost normal size in a matter of 6 to 9 weeks. Infection has not been a problem and all symptoms have been alleviated.
Fw. 1. Cystoscopic view of bladder following bilateral reimplantation of ureters for megaloureter. Note well formed nipples which prevent reflux.
MEG ALO URETER
1\45
Recent articles haYe shown that the interest in this disease i::-: sprea,ding, That othern have not obtained the sarne results as ours is due to their technique of ureteral reimplantation. If reflux occurs, the condition is definitely made worse. Hence a method that prevents reflux must be used. We belieYe !he method we reported, which is a modification of one first described by Jewett, is the best. "\Ve have now done 15 ureters by this method (;3 for other reasons) ,rnd have not had a single case of reflux. H is admitted that not every ease needcJ surgical treatment. U the infection can be cleared up and the patient does not have recurrent attacks of pyelonephritis and is asymptomatic, then surgery may not be indicated. VVe have two such patients. One is a 28-year-old woman on whom a pyelogram was made as part of a routine workup. The megaloureter was an incidental finding and surgery was not advised A. second ('ase was a 5:3-year-old male offirer 1Yho fell in Korea and injured his right kidney enough to cause mild hematuria. A pyelograrn revealed unilateral megaloureter. No infection ensued; he had been asymptomatic all his life-uaturally surgery was not advised. Since publication of our original article, the procedure has been performed in,.six ::i.dditional patients. CASE REPORTS
Case L A 41-year-old white housewife was admitted to vValter H.ecd Army Hospital January 28, 1\l52. She had previously been a patient on the gynecological servi<:e where a uterine fibroid was removed. During the gynecological study a urological consultation 1Yas obtained because of white blood cells in the urine. She was asymptomatic. An excretory urogram reYealed a left megaloureter (fig, 2). On January :H. 1952 the left ureter was reimplantecl into the hlad(for
"Iii o. 2. C:,.se L A, prnopern.tive. B, po8topcrative
f
646
EVAN L. LEWIS AND RICHARD W. CLETSOWAY
approximately one inch above the normal opening. The convalescence was uneventful. At the time of discharge the ureter was back to normal size, the urine was sterile and there was no reflux. The patient is completely asymptomatic. Case 2. A 32-year-old white man was seen in the outpatient clinic at Tokyo Army Hospital because of severe, incapacitating, right lower quadrant pain. He had been treated for 6 months for chronic prostatitis without success. The pain was intermittent in nature lasting two to three days, usually accompanied by chills and fever. Excretory urography revealed bilateral megaloureter, the right side being only slightly larger than normal. The bladder was slightly hypotonic, urine was sterile-there was no reflux. Pyeloscopy revealed good contraction in the dilated portion but no dilatation of the "normal segment." Reimplantation of the right ureter was done on September 24, 1953. The ureter has gradually returned to normal. The urine is sterile, there is no reflux, indigo carmine comes through the new opening in "normal spurts." The patient is now asymptomatic and has not had a single attack of pain since surgery. Case 3. A 24-year-old Greek Private was transferred from a station hospital in Korea where he was admitted because of severe pain in the left flank associated with dysuria and frequency. Past history was negative. He was found to have hematuria and pyuria and temperature of lOlF. He was treated with antibiotics prior to transfer. On admission at Tokyo Army Hospital he was in less pain and his temperature was normal. Urinalysis revealed several red blood cells and white blood cells per high power field. Culture was positive for alpha Streptococcus faecalis. Physical examination revealed only left flank tenderness. Excretory urography revealed marked dilatation of the lower end of both ureters. Excretion was delayed in both sides. There appeared to be a double kidney on the left with the upper half being rudimentary. A retrograde urogram revealed two orifices on the left. The lower half of the left kidney had much better function than the upper half. The ureter to the upper half appeared normal but that to the lower half was quite dilated. A diagnosis of bilateral megaloureter was made. On June 24, 1953 a bilateral ureteroneocystostomy was accomplished. The ureter to the upper half of the left kidney was not bothered. The splints were removed on the seventh postoperative day. Recovery was uneventful. At the time of his transfer to Greece he was asymptomatic, urine was clear but culture was still positive. There was no reflux. Long-term followup will be impossible. Case 4- A 6-year-old white girl was seen in the outpatient clinic because of recurrent left pyelonephritis. She had had two previous reimplantations of the left ureter for megaloureter. Excretory urography revealed good function on both sides. The right kidney and ureter were normal. There was dilatation of the left kidney, pelvis and ureter. Cystogram revealed reflux up the left side. Culture revealed E. coli. It was believed that a third attempt at transplant would be in order although the parents had been told that the child would lose the kidney if the second operation failed. On July 27, 1954 the left ureter was explored. It was removed near the bladder and reimplanted in the dome. A segment was
r
M~]GALOtTHETEH
iH7
left in the bladder but it was not as long as -we usually like to leave. Corwal(iscene,, was conmletely uneventful. The sphnt was removed on the seventh day and the patient wa.s discharged on the tenth postoperative day_ It is nmr 11 months since surgery and she has beeu asymptomatic. Her pediatrician reported that she has had no subi:,equcnt attacks of pyelitis and her general health is excellent. Case 5 A. l -white enlisted man ,rns admitted to Tokyo Army Hospital August 21, 1954- because of pain in the right flank and pyuria. Past history was negative. Ht: had had no previom; attacks of urinary tract infection . This episode had begun several days prior to admission aud had been alleviated with gautrisin and penicillin. Excretory urography revealed hydronephrosis of mild degree ou the right with some
648
EVAN L. LEWIS AND RICHARD W. CLETSOWAY
Fm. 4. Case 6. A, preoperative. B, postoperative
In 1947 the patient had been turned down for admission to West Point because of albuminuria. Excretory urography was done at this time and he was told he had left hydronephrosis (fig. 4). He has been asymptomatic since but on annual physical examination the albuminuria was again noted and another excretory urogram was done. When questioned carefully he admitted to nocturia one to two times and some frequency and urgency of urination. Physical examination on admission was negative. The urinalysis revealed 2 plus albuminuria with 7-10 granular casts; culture was negative. On February 17, 1953 the left ureter was reimplanted according to the previously described technique. In this case, because of the large caliber of the ureter, a segment was removed from the most dilated portion and the splint was allowed to remain for 3 vrneks. The patient had some fever postoperatively but after removal of the splint the fever subsided, the urine cleared and the culture became negative. He is now asymptomatic and has returned to duty. A final urinalysis revealed only a faint trace of albumin, 0-3 white blood cells per high power field and no casts. Excretory urography G weeks later revealed diminution in the size of the hydronephrotic sac and in the ureter. It is believed that surgery will be unnecessary on the right side due to the minimal disease present. Comment: Although this patient was asymptomatic and had not had infection, operation was performed because of persistent albuminuria which would be picked up on each year's annual physical examination. Although we could not assure him that the albuminuria would disappear, we are gratified that only a trace is now present. SUMMARY
Six additional cases are presented demonstrating the new concept for surgery for megaloureter. This syndrome of neurogemc "obstruction" at the lower
MEGALO URETER
649
end of the ureter causing dilatation is again presented and described in detail. Diagnosis is based on the pyelographic appearance, lack of obstruction and action of the ureter as seen at fluoroscopy. That others have not been able to achieve the clinical results is not due to the fault of the theories or principle of treatment, but to the technique of surgery. The occurrence of a stricture at the site of reimplantation or reflux up the ureter postoperatively is definitely an operative failure. If such occurs, further surgery is necessary, as in the fourth patient. REFERENCES BAND D.: Discussion on anomalies of the ureter in childhood. Proc. Roy. Soc. Med., 43: 280-281, 1950. CAMPBELL, E.W.: Megalo-ureter. J. Urol., 60: 31-45, 1948. CAMPBELL, M. F.: Ureteral obstruction in children. J. Urol., 41: 660, 1939. CARLSON, H.: The intrapsoas transplant of megalo-ureter. J. Urol., 72: 172-177, 1954. CRABTREE, E. G.: Plastic operation for relief of megalo-ureter. Tr. Am. Genito-Urin. Surg., 30: 342, 1937. HUTCH, J. A.: Nonobstructive dilatation of the upper urinary tract. J. Urol., 71: 412-420, 1954. JEWETT, H. J.: Upper urinary tract obstructions in infants and children: Diagnosis and treatment. Pediatric Clinics of North Amer., 2: 737-754, 1955. KIMBROUGH, J. C., LEWIS, E. L. AND CROMPTON, R. E.: Megaloureter exhibit, Am. Urol. Assn., Washington, D. C., May 28, 1950. LEWIS, E. L. AND KIMBROUGH, J. C.: Megalo-ureter. South M. J., 45: 171-177, 1952. NESBIT, R. M. AND WITHYCOMBE, J. F.: The problem of primary megaloureter. J. Urol., 72: 162-171, 1954. PIEPER, A.: Beitrag zur Nerversorgung des Ureters. Ztschr. f. Urol., 44: 17-23, 1951.
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_.