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New Ureteral Dilators and Catheters1
NEW URETERAL DILATORS AND CATHETERS1 VICTOR COX PEDERSEN New York
In 1921 the author conceived a woven soft ureteral dilator having the same structure and model as the standard ureteral catheters. Owing to cpnditions in France following the war, when the order was given to Eynard the well known maker, the first lot produced were entirely wrong and likewise the second lot. Under date of March 2, 1925, Mr. Charles R. Bard, the agent of Eynard, states that the original order was dated August, 1921, and that the first shipment was received on August 23, 1922, and the second shipment on December 30, 1922. Both these lots were very far from the design, because the shafts of the instruments instead of being uniform in size like the correct model varied with the size of the dilating tip so that the instruments with larger tips had shafts so heavy that their use was impossible. Mr. Bard states that the third lot prepared for the author and approved by Mr. Bard are as given in this contribution for the various styles of instrument described. INSTILLATING URETERAL BOUGIE
Following the details of the sketch: A = standard ureteral catheter shaft 6 F . diameter for all sizes of tip graduated in standard 1 cm. and 5 cm. marks; B = opening of shaft at the apex of the tip of instrument after passing through the tip; C + D = length overall of tip, namely, about 1 cm. for large sizes and 0. 75 cm. for small sizes according to convenience of manufacture; D = distance from the apex to the largest diameter of the tip, namely, about three-quarters of total length of the tip; 1 Presented before the Section on Genito-Urinary Surgery of the New York Academy of Medicine, May 20, 1925, and by title before the American Urological Association, May 23, 1925.
671
672
VICTOR COX PEDERSEN
C = distance from the largest diameter of the tip to the shaft; namely, about one-quarter of total length of the tip; E = largest diameter of the tip. The set consists of 1 pair each of the following sizes: 20 F., 18 F., 16 F., 14 F., 12 F., 10 F., 8 F. The points to note then are that this instument permits instillation of oil or other fluid ahead of its tip to afford lubrication or removal of an obstructing fold of mucosa; uniform taper of the tips to about 6 F. at their points; uniformity of length of tip at 1 cm.; uniformity of taper of the tips to the maximum at 0.75 cm. from the apex; standard graduation in 1 and 5 cm. marks and application of a light stilette where necessary to exert a little more pressure.
A-+
------I I I I
I
I
'*C+l+---D- ---+-t I
I
I I
I
I ___.__i.-1-------------FIG. 1 MULTIPLE-EYE OLIVE-TIP URETERAL CATHETER
Realizing the difficulty of securing uniform drainage through the usual ureteral catheter having one end-eye and two side-eyes, it occurred to the writer that a catheter with five eyes (one in each of the first 5.cm.) might provide better evacuation because the first two eyes could be placed within the pelvis of the kidney while the other three would be within the ureter. Such a position of the catheter would be relatively easy to the average patient by assuming that slight pain in the kidney at or about the 25 cm. mark would indicate that the upper limits of the pelvis had been reached, from which a withdrawal of 2 cm. would restore the instrument to its proper place just above the isthmus. Therefore
673
NEW URETERAL DILATORS AND CATHETERS
along with the instillating ureteral bougies just described the following instruments were ordered. A = standard olive-tip; B = first five standard centimeter markings; C, C', C", D and D' = one opening, standard size and form in each of the first five cm. subdivisions; E = standard shaft graduated throughout with standard 1 cm. and 5 cm. markings; F = cavity in apex to seat stilette if one is used. The set of these instruments consists of 1 pair each 5 F., 6 F., 7 F. and 8 F. of the standard type of catheter and of the x-ray type of catheter. Of the standard type also 4 F ., but this one size cannot be produced in the x-ray type of instrument. In order to try out the instruments the olive-tips were made first because they are somewhat easier to pass and somewhat less apt to irritate the kidney substance by contact. There is now being prepared in France a similar set of instruments with the so-called whistle-tip or open end. ;. ·- -- ------8----------"1 \L _
A
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t I
6 I
I
c,,
l
o,,
i
c,,,
\
\F
FIG. 2
The olive-tip instruments in use have done the whole work a great deal better than the usual forms of instrument seen having one end and two side openings only. It may therefore be assumed that the open-end instruments with care will correct some of the difficulties in drainage well known to exist with the closed end of standard olive-, cone- or taper-tip form. WHALEBONE-TIP URETERAL CATHETER
The writer has a patient with stricture of the ureter following removal of a small stone with primary union throughout which up to the present time has refused all efforts at dilatation except with whalebone guides of which only three size 4 F have ever been passed and commonly only two. When he endeavored to purchase new whalebone-tip ureteral catheters, he learned that they are no longer regularly in the market for the reason that many accidents had been ascribed to the whalebone-tips. These must
674
VICTOR COX PEDERSEN
have occurred chiefly because the whalebones were too heavy and sharp, or because undue force had been used. The thought therefore occurred to him that if the whalebones were all of the same size and definitely light and if they possessed a head equal to the head on whalebone guides for the urethra, the element of danger would be practically removed unless due to real carelessness. The following instrument conforms with these points. Experience with them cannot be stated at the present time because they have just arrived from France and treatment of the patient has just begun, but the promise of success is obvious because ordinary whalebone guides have passed the stricture. ~ A
''
£?
~I
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E I c:, I = I:~=------· r
:'
B
:' G
Fm. 3
A = standard ureteral catheter shaft 4 F., 5 F., 6 F., graduated throughout with standard 1 cm. and 5 cm. markings; B = standard cm. and 5 cm. markings; C and C' = one opening standard size and form in each of the first two centimeters; D = standard taper tip; E = whalebone about 1 inch long, 2 F . diameter and 3 F. ball head; G = cavity in the apex to seat a stilette if one is used. In offering fixed designs for these three ureteral instruments of which the maker has the fixed drawings, it is hoped that not only have some of the defects of previous instruments been corrected, but also has provision been secured against variation in manufacture, which sooner or later occurs and is commonly greatly to the annoyance of the user.
In 1921 the author conceived a woven soft ureteral dilator having the same structure and model as the standard ureteral catheters. Owing to cpnditions in France following the war, when the order was given to Eynard the well known maker, the first lot produced were entirely wrong and likewise the second lot. Under date of March 2, 1925, Mr. Charles R. Bard, the agent of Eynard, states that the original order was dated August, 1921, and that the first shipment was received on August 23, 1922, and the second shipment on December 30, 1922. Both these lots were very far from the design, because the shafts of the instruments instead of being uniform in size like the correct model varied with the size of the dilating tip so that the instruments with larger tips had shafts so heavy that their use was impossible. Mr. Bard states that the third lot prepared for the author and approved by Mr. Bard are as given in this contribution for the various styles of instrument described. INSTILLATING URETERAL BOUGIE
Following the details of the sketch: A = standard ureteral catheter shaft 6 F . diameter for all sizes of tip graduated in standard 1 cm. and 5 cm. marks; B = opening of shaft at the apex of the tip of instrument after passing through the tip; C + D = length overall of tip, namely, about 1 cm. for large sizes and 0. 75 cm. for small sizes according to convenience of manufacture; D = distance from the apex to the largest diameter of the tip, namely, about three-quarters of total length of the tip; 1 Presented before the Section on Genito-Urinary Surgery of the New York Academy of Medicine, May 20, 1925, and by title before the American Urological Association, May 23, 1925.
671
672
VICTOR COX PEDERSEN
C = distance from the largest diameter of the tip to the shaft; namely, about one-quarter of total length of the tip; E = largest diameter of the tip. The set consists of 1 pair each of the following sizes: 20 F., 18 F., 16 F., 14 F., 12 F., 10 F., 8 F. The points to note then are that this instument permits instillation of oil or other fluid ahead of its tip to afford lubrication or removal of an obstructing fold of mucosa; uniform taper of the tips to about 6 F. at their points; uniformity of length of tip at 1 cm.; uniformity of taper of the tips to the maximum at 0.75 cm. from the apex; standard graduation in 1 and 5 cm. marks and application of a light stilette where necessary to exert a little more pressure.
A-+
------I I I I
I
I
'*C+l+---D- ---+-t I
I
I I
I
I ___.__i.-1-------------FIG. 1 MULTIPLE-EYE OLIVE-TIP URETERAL CATHETER
Realizing the difficulty of securing uniform drainage through the usual ureteral catheter having one end-eye and two side-eyes, it occurred to the writer that a catheter with five eyes (one in each of the first 5.cm.) might provide better evacuation because the first two eyes could be placed within the pelvis of the kidney while the other three would be within the ureter. Such a position of the catheter would be relatively easy to the average patient by assuming that slight pain in the kidney at or about the 25 cm. mark would indicate that the upper limits of the pelvis had been reached, from which a withdrawal of 2 cm. would restore the instrument to its proper place just above the isthmus. Therefore
673
NEW URETERAL DILATORS AND CATHETERS
along with the instillating ureteral bougies just described the following instruments were ordered. A = standard olive-tip; B = first five standard centimeter markings; C, C', C", D and D' = one opening, standard size and form in each of the first five cm. subdivisions; E = standard shaft graduated throughout with standard 1 cm. and 5 cm. markings; F = cavity in apex to seat stilette if one is used. The set of these instruments consists of 1 pair each 5 F., 6 F., 7 F. and 8 F. of the standard type of catheter and of the x-ray type of catheter. Of the standard type also 4 F ., but this one size cannot be produced in the x-ray type of instrument. In order to try out the instruments the olive-tips were made first because they are somewhat easier to pass and somewhat less apt to irritate the kidney substance by contact. There is now being prepared in France a similar set of instruments with the so-called whistle-tip or open end. ;. ·- -- ------8----------"1 \L _
A
__::E:....___ _ _ _-1.l..:::i.:;::,:.....r..::f:_:;:..;--=--_ _ :::::)
t I
6 I
I
c,,
l
o,,
i
c,,,
\
\F
FIG. 2
The olive-tip instruments in use have done the whole work a great deal better than the usual forms of instrument seen having one end and two side openings only. It may therefore be assumed that the open-end instruments with care will correct some of the difficulties in drainage well known to exist with the closed end of standard olive-, cone- or taper-tip form. WHALEBONE-TIP URETERAL CATHETER
The writer has a patient with stricture of the ureter following removal of a small stone with primary union throughout which up to the present time has refused all efforts at dilatation except with whalebone guides of which only three size 4 F have ever been passed and commonly only two. When he endeavored to purchase new whalebone-tip ureteral catheters, he learned that they are no longer regularly in the market for the reason that many accidents had been ascribed to the whalebone-tips. These must
674
VICTOR COX PEDERSEN
have occurred chiefly because the whalebones were too heavy and sharp, or because undue force had been used. The thought therefore occurred to him that if the whalebones were all of the same size and definitely light and if they possessed a head equal to the head on whalebone guides for the urethra, the element of danger would be practically removed unless due to real carelessness. The following instrument conforms with these points. Experience with them cannot be stated at the present time because they have just arrived from France and treatment of the patient has just begun, but the promise of success is obvious because ordinary whalebone guides have passed the stricture. ~ A
''
£?
~I
'''
'' I
E I c:, I = I:~=------· r
:'
B
:' G
Fm. 3
A = standard ureteral catheter shaft 4 F., 5 F., 6 F., graduated throughout with standard 1 cm. and 5 cm. markings; B = standard cm. and 5 cm. markings; C and C' = one opening standard size and form in each of the first two centimeters; D = standard taper tip; E = whalebone about 1 inch long, 2 F . diameter and 3 F. ball head; G = cavity in the apex to seat a stilette if one is used. In offering fixed designs for these three ureteral instruments of which the maker has the fixed drawings, it is hoped that not only have some of the defects of previous instruments been corrected, but also has provision been secured against variation in manufacture, which sooner or later occurs and is commonly greatly to the annoyance of the user.