- Email: [email protected]
Plastic Surgery of the Renal Pelvis1
PLASTIC SURGERY OF THE RENAL PELVIS 1 ROBERT B. McIVER From the Departments of Urology, St. Vincent's and Duval County Hospitals, Jacksonville, Florida
From the standpoint of treatment, obstructions at the ureteropelvic juncture may be divided into 2 groups: (1) those relieved by cystoscopic dilatation and (2) those requiring open surgery. The latter group may be considered in 4 subgroups: (a) those cases diagnosed early that require division of bands and disposition of polar vessels; (b) later cases that need in addition some type of plastic operation; (c) late cases requiring resection of the extrarenal pelvis including the ureteropelvic juncture with reimplantation of the ureter; and (d) neglected cases that demand nephrectomy. Interest in the conservative surgery of hydronephrosis has received tremendous stimulus from the improved results recently obtained. This in turn has led to a more aggressive diagnosis of early ureteropelvic obstructions, particularly in infants and children. It should be remembered that the most frequent cause of obstruction, namely, aberrant vessels, is a congenital condition although symptoms of it may develop much later. A complete study of the urinary tract is therefore important, not only in adults but in children and particularly in infants. Early diagnosis means less radical surgery and offers greater opportunity to relieve the uretcropelvic obstruction without the division of large polar vessels. The function of the obstructed kidney is usually considerably reduced and may be entirely absent. This condition does not of itself indicate nephrcctomy. If at operation cortical tissue remains in fair amount, good drainage is followed by an increase in the renal function and in some cases it may approach that of the opposite organ. Postoperative serial pyelograms at intervals and studies of renal function have invariably demonstrated this fact in our cases of this type. Follow-up studies and drainage by catheter of the repaired pelvis, important after every pyeloplasty, become increasingly so as the operation approaches the more radical type of resection. Open surgery has a fourfold objective, the relief of obstructions, the preservation of the blood supply, 1 Read before annual meeting, American Urological Association, White Sulphur Springs West Virginia, May 29 to June 1, 1939. 1069
1070
ROBERT B. McIVER
the establishment of dependent urinary drainage and the maintenance of the proper position of the kidney. Nonoperative treatment. In selected cases of obstruction at the ureteropelvic juncture dilatation is effective and may bring permanent relief. This procedure is readily accomplished by the ingenious method described by Dees. A maximum dilating bulb is passed into the pelvis. A ureteral catheter is then passed through the narrowed lumen alongside the bougie shaft, and the bulb is withdrawn. The dilatation obtained is the sum of the diameters of the bulb and the catheter. This group of
FIG. 1
FIG. 2
FIG. 1. Case 1. Ureteropelvic obstruction on right side treated by cystoscopic dilatation. Pyelogram before treatment. FIG. 2. Case 1. Pyelogram after treatment for several months
cases offers the greatest difficulty in diagnosis, and, as there is no open operation, the exact cause of the obstruction is not demonstrated. Indeed, the diagnosis itself is not proved. Typical of the diagnostic iindings and the results of treatment is the following case. Case 1. J. C. D., No. 53354, a white physician, aged 56 years, married, was admitted on September 16, 1938. He complained of recurrent attacks of pain and a sense of "fulness" and aching in the loin and back on the right side. The pain was referred downward at times, but there were no definite symptoms in the lower urinary tract. Examination of the urine, blood and blood chemis-
PLASTIC SURGERY OF THE RENAL PELVIS
1071
try gave normal results. Diagnostic cystoscopy and pyelography revealed residual urine, in amount 35 cc., in the renal pelvis and gave evidence of obstruction at the ureteropelvic juncture on the right side (fig. 1). Over a period of several months this ureteral segment was progressively dilated to No. 12 French. The symptoms were relieved, and a follow-up pyelogram showed a decrease in the hydronephrosis (fig. 2). Our conception of the probable pathological condition the treatment and the result is shown in the line drawings (fig. 3).
FIG. 3. Case 1. Drawings showing probable pathological condition and result of treatment
Operative Treatment. A study of our last SO cases of hydronephrosis treated by open surgery, classified according to the type of operation, is summarized in tables 1 to 3. I. Disposition of polar vessels, bands and adhesions. Complete exposure of the renal pedicle with dissection of the pelvis and vessels well into the renal hilum will not only disclose the obstructing lesion but frequently will also allow the disposition of large polar vessels without their division. The obstructing artery may supply the lower half of the kidney, it may be larger than any other supplying the kidney, or it may constitute the only source of blood supply to the entire organ, as was
1072
ROBERT B. MCIVER
true in one case in this series. As the adhesions between the obstructing vessel and the pelvis are divided, the movement of the pelvis is downward while that of the vessel is upward so that by simple dissection, division of bands and adhesions, the obstruction may be completely relieved. Moreover, the released pelvis contracts almost immediately, its peristalsis becomes visibly more frequent and pronounced and it tends to resume its natural funnel shape. At times the aberrant artery will terminate in 2 or more arteries, and, if division is necessary, sacrifice of the lowest branch may free the ob1
TABLE
I. Disposition of Polar Vessels, Bands and Adhesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II. Plastic Procedures in Addition to I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III. Resection of Extrarenal Pelvis and Ureteropelvic Juncture..................... Total Number of Cases. . . . . ............................................
TABLE
2 SEX
AGE
SIDE AFFECTED
35 10 5 50
TOTAL
Right
Left
37
13
0-15 yrs.
15-50
Over 50
9
32
9
~I 8
TABLE SUBGROUP I
Urinary :fistula ............ Reoperation .............. Nephrectomy ............. Deaths ..................
. . . .
0 0 0 0
Female
50 50 50
32
3 SUBGROUP II
SUBGROUP III
0 0 0 0
0 0 0
1
struction. We have found that the complete dissection of the pedicle renders the division of large vessels increasingly unnecessary and that fixation of the kidney in elevation with particular attention to the lower pole obviates the division and reanastomosis of the ureter in order to preserve a large artery. In difficult cases the polar vessel may be separated from the pelvis by the interposition of fat or muscle transplant. The pelvis and upper segment of the ureter may be held in position by a nephrostomy-ureterostomy catheter splint. The following case is illustrative.
PLASTIC SURGERY OF THE RENAL PELVIS
1073
Case 2. T. G. B., No. 53284, a white boy, aged 5 years, complained of attacks of colic on the right side when brought to the hospital on September 11, 1938. There was a history of frequent attacks of colic, nausea and vomiting since babyhood. Prior to admission the attacks had recurred more fre-quently, and the pain had centered more definitely in the right side. Ten days previously, when the patient had had an attack of nausea, vomiting and abdominal pain on the right side, an appendectomy had been performed, but 1 week later the colic had recurred in the abdomen and flank on the right side and had persisted at intervals up to the time of admission, becoming progressively more intense, reaching a crisis and then receding. The child had been regarded as delicate and was underweight. On examination, the patient weighed 39 pounds. His temperature was 100.8 F. and the pulse and respiration rates were 120 and 20 respectively. There was tenderness over the abdomen and flank on the right side, most pronounced in the costo-muscle angle. Urinalysis revealed the presence of pus cells and erythrocytes, and examination of the blood showed a total leukocyte count of 12,000 per cu. mm. A roentgen study gave no evidence or urinary calculus. Cystoscopic examination revealed that 14 cc. of residual urine containing pus cells and erythrocytes was present in the pelvis of the right kidney, and a pyelogram demonstrated a considerable degree of obstruction at the upper ureteral segment (fig. 4), as shown by a retouched roentgenogram (fig. 5). The pelvis was drained by and irrigated through an indwelling ureteral catheter for several days. On September 14 the kidney was explored, and the pathological condition indicated in the line drawings (fig. 7) was demonstrated. A small band-like aberrant vessel crossed the uteropelvic juncture posteriorly, and the ureter was bound to the lower renal pole by dense adhesions. These obstructions were divided. Splint-fixation of the ureter was accomplished by the introduction of a Cumming self-retaining nephrostomy tube having a ureteral drain. Convalescence was uncomplicated. Examination at the third postoperative month showed that the boy had gained 10 pounds and was well. Seven months after the operation serial pyelograms of the right side demonstrated a normal condition (fig. 6). II. Plastic procedures in addition to the release of obstructions.
This type of operation has 3 objectives: (1) enlargement of the narrowed lumen; (2) dependent drainage by gradual funneling of the pelvis into the ureter; and (3) elimination of redundant pelvic tissue, obstructing flaps and the high insertion of the ureter in the pelvis. To accomplish these ends a variety of ingenious operations has been described by Kuster, Fenger, Schwyzer and others. Foley called attention to the
1074
ROBERT B. MCIVER
principles of visceral anastomoses, particularly pyloroplasties, as applied to plastic surgery of the ureteropelvic juncture and described his Yplasty. Other procedures and reports of cases have been published by Young and Davis, Braasch, Quinby, Thomas, Herman, Moore, Eisendrath, Herbst and Polkey, Lubash and Madrid, Sargent, Walters and
FIG.4
FIG.5
FIG. 4. Case 2. Hydronephrosis due to obstruction at ureteropelvic juncture on right side in a boy, aged 5 years, subjected to appendectomy 10 days previously under a mistaken diagnosis of appendicitis. Preoperative pyelogram. FIG. 5. Case 2. Roentgenogram retouched to emphasize pathological condition
Braasch, Cabot, Pilcher, Cabot, Walters and Priestley, Ormond, Legueu, von Lichtenberg, Kelly and Burnam, Lower and Nichols, Eliot and a number of other authors in this country and abroad. In this subgroup no single operation was followed routinely but the one selected instead which met the conditions encountered. In 1 case of this series the obstruction developed rapidly and was impassable by uteteral catheterization. The patient was in a decidedly toxic condition
PLASTIC SURGERY OF THE RENAL PELVIS
1075
with high temperature. Prompt drainage by nephrostomy was imperative, but extensive plastic surgery was contraindicated. To com-
FIG.
6. Case 2. Serial pyelograms showing normal condition after operation for relief of obstruction
Seven months a.'fter-
opera.tton
FIG. 7. Case 2. Drawings showing findings at operation and postoperative result
promise this situation and still remedy the ureteropelvic obstruction a longitudinal incision carried through the ureteropelvic juncture was
1076
ROBERT B. MCIVER
allowed to gape open, a splint catheter was placed in position and a "blowout" patch of fat secured in place. Case 3. E. B., No. 55540, a white single woman, a bookkeeper, aged 33 years, was admitted on February 10, 1939, complaining of chills, fever and severe pain in the left loin. Vague bladder discomfort had been present for 2 weeks, she related, and for 24 hours immediately preceding admission she had suffered from colic in the left loin and back, with the pain growing more severe and chills and high fever developing in the last 10 hours.
FIG. 8. Case 3. Practically complete obstruction of ureteropelvic juncture on left side with acute pyonephrosis in a patient operated upon as an emergency case. Preoperative pyelogram showing obstruction and enlarged kidney.
The patient's temperature was 102.4 F., the pulse rate 114 and the respiration rate 18. Shortly thereafter there was a rise in temperature to 104.6 F. and an increase in the pulse and respiration rates to 120 and 20. Urinalysis showed albumin 2 plus, acetone 1 plus, pus cells 2 plus and erythrocytes 1 plus. Examination of the blood revealed a leukocyte count of 10,550, which promptly rose to 15,000, and analysis of the blood chemistry showed urea nitrogen 22 mg. per 100 cc of blood. The patient appeared to be acutely ill and in a highly toxic condition. On the left side there was a painful mass in
PLASTIC SURGERY OF THE RENAL PELVIS
1077
the renal area, and the point of maximum tenderness was in the costo-muscle angle. A complete urinary study gave negative evidence for the bladder and for the kidney and ureter on the right side. On the left side there was an obstruction to the catheter in the upper portion of the urinary tract 25 cm. above the ureteral orifice. The few drops of urine obtained showed many pus cells microscopically. Repeated ureterograms demonstrated an obstruction at the ureteropelvic juncture and showed an enlarged kidney (fig. 8). An emergency nephrostomy was done with division of the aberrant vessels to the tip of the lower renal pole. The stenosed ureteropelvic juncture was incised longitudinally, the incision extending upward into the pelvis 1 cm.
FIG.
9. Case 3. Serial pyelograms 2 months postoperative showing reduced hydronephrosis
and downward into the normal ureter 1 cm. A splint tube was then carried from the pelvis through the gaping wound down into the ureter, and a "blowout." patch of fat, placed over the defect, was tacked in place by several sutures (fig. 10). The patient had an uneventful convalescence with a clinical recovery. Serial pyelograms 2 months postoperative revealed a persistent though reduced hydronephrosis, and the residual urine 20 cc in amount, showed 18 to 20 pus cells to a field (fig. 9). A urologist in another city, checking up on the patient's condition 1 month later, reported: "Passed No. 10 French bulb easily into left renal pelvis; residual urine 10 cc, average 10 pus cells to high power field. Indigo carmen appeared in 7 minutes. Pyelectasis 2 plus. Delay in emptying time." Treatment of this case is being continued.
1078
ROBERT B. McIVER
III. Resection of the extrarenal pelvis and ureteropelvic juncture. The more radical operations are reserved for those cases not amenable to simple surgery, and it is in this subgroup that recent results have shown great improvement. It is believed that some of the poor results here, as in prostatic resection, occur because of failure to remove enough tissue. Our practice is to excise the pelvis to within about 1 cm. of the hilum or so as to leave just enough pelvic border to effect a closure without tension. In advanced cases septa between dilated major calices may obstruct drainage from the upper portion of the kidney. They should be treated by excising an inverted V, or by longitudinal suturing of a transverse mc1s10n in the septum. In closing the pelvis and in Nephro3tomy lube (cro,.,-$ecllon)
Frn. 10. Case 3. Drawings showing findings at operation, emergency procedure to relieve obstruction quickly in a patient critically ill, postoperative result and nephrostomy-ureteral splint devised by author.
anastomosing the upper ureteral segment the following points are observed: (1) Atraumatic sutures of very fine catgut, 00000 to 000, are used; they should not perforate the mucous membrane, should be few in number and should be lightly tied to avoid tension; (2) a nephrostomy tube having a ureteral splint is routinely employed; and (3) nephropexy is done to maintain the position of the anastomosis. The ureteral splint may be removed within a week or 10 days, but nephrostomy drainage should be continued for several weeks, or until the urine is clear and retrograde catheterization of the ureter and pelvis has been accomplished. In our experience this procedure has obviated
PLASTIC SURGERY OF THE RENAL PELVIS
1079
permanent urinary fistulae. We have devised a self-retaining catheter for nephrostomy drainage that has an extension tube for ureteral splinting (fig. 10). It is being constructed by the American Cystoscope Makers, Inc. It is so designed that it may be introduced from either end through a small nephrostomy wound, may be retained by a distensible bag, may be changed without injury to the kidney or pain to the patient and allows continuous irrigation as well as drainage. The follow-up treatment in this subgroup is particularly important. The pelvis should be drained and lavage carried out at regular intervals, beginning weekly, and the ureteropelvic anastomosis should be kept
FIG. 11. Case 4. Advanced hydronephrosis on left side treated by resection of extrarenal pelvis and ureteropelvic juncture. Serial pyelograms showing injection of skiodan and exposures at 0, 5 and 15 minutes.
dilated. Persistence at this stage brings ample reward. case illustrates the upper margin of favorable result.
The following
Case 4. V. R. B., No. 51547, a white schoolgirl, aged 11 years, was admitted May 16, 1938, complaining of pain in the left side. She related that attacks of pain, lasting 18 hours and accompanied by nausea and vomiting, had begun a year previously, recurring 6 months later; for the 3 months prior to admission there had been weekly recurrences of increasing severity with the pain more in the nature of colic. On examination, the child weighed 72 pounds. Analysis of the blood chemistry and examination of the blood gave negative results. Urinalysis
1080
ROBERT B. McIVER
showed pus cells 2 plus. Cystoscopy revealed a normal bladder and upper portion of the urinary tract on the right side. On the left side catheterization of the ureter resulted in the recovery of 45 cc of residual urine from the kidney, showing pus cells 2 plus. Phenosulphonphthalein appeared in 20 minutes with the output reduced 50 per cent. A roentgen study gave no evidence of a calculus in the urinary tract, but a pyelogram revealed hydronephrosis and an obstruction at the ureteropelvic juncture on the left side. Serial pyelograms of this side at the end of 15 minutes (fig. 11) and 60 minutes (fig. 12) showed decided delay in emptying. At operation (May 17) hydronephrosis caused by a small polar vessel was demonstrated. The upper ureteral segment was densely adherent to the
FIG. 12. Case 4. Exposures at 30, 45 and 60 minutes
pelvis and lower pole of the kidney; the extrarenal pelvis was tremendously dilated and there was 60 cc of residual urine. The extrarenal pelvis was excised 1 cm. from the hilum, and the ureter was severed below the obstruction. Closure of the pelvis and anastomosis of the ureter were carried out according to the technique herein described, and the operation was completed by nephropexy (fig. 14). The patient's recovery was uncomplicated. The ureteral splint catheter was removed on the seventh postoperative day. A retrograde ind,wlling ureteral catheter was passed to the pelvis on the eleventh day after the operation, and on the following day the nephrostomy tube was removed. Three weeks after she was operated upon the patient was discharged from the hospital.
FIG. 13. Case 4. Serial pyelograms 11 months after operation showing small pelvis, wide ureteropelvic juncture and rapid emptying time.
Eleven months attet"
opera'llon
FrG. 14. Case 4. Drawings demonstrating operative steps, suture technique and post-
operative result.
1081
1082
ROBERT B. McIVER
Serial pyelographic studies at the second, fifth and eleventh (fig. 13) postoperative months showed a wide ureteropelvic juncture, a reduction of the hydronephrosis and excellent emptying of the pelvis. There was a return to normal in the renal function, and the patient's weight increased to 105 pounds, a gain of 33 pounds. SUMMARY AND CONCLUSIONS
A complete urologic study of all cases of recurrent abdominal pain will result in the early diagnosis of obstructions at the ureteropelvic juncture. Complete exposure of the renal pedicle and high dissection of the pelvis and vessels will frequently relieve the obstruction. Plastic procedures correctly applied give a high percentage of good results with a very low mortality. A series of 50 consecutive cases of operation for ureteropelvic obstruction, with no nephrectomies and one death, is here reported.
Suite 1108-14, Greenleaf Bldg., Jacksonville, Fla. REFERENCES BRAASCH, W. F.: Clinical notes on hydronephrosis. Interstate M. J., 21: 1180-1188, 1914. CABOT, HUGH: Modern Urology in Original Contributions by American Authors. Lea and Febiger, Philadelphia, 1936, ed. 3, vol. 2, pp. 414-416. - - - - , WALTERS, w., AND PRIESTLEY, J. T.: Operative results in non-calculus hydronephrosis, results in 71 plastic operations. J. Urol., 38: 688-693, 1937. DEES, JOHN E.: New method for instrumental dilation of the ureter. J. Urol., 40: 24-26, 1938. ErsENDRATH, D. N.: Inlying ureteral catheter in treatment of pyelonephritis and other renal conditions. J. A. M. A., 89: 2170-2173, 1927. ELIOT, E.: An unusual case of hydronephrosis. Ann. Surg., 61: 474, 1915. FENGER, CHRISTIAN: Operation for the relief of valve-formation and stricture of the ureter in hydro- or pyonephrosis. J. A. M.A., 22: 335-343, 1894. FOLEY, F. E. B.: New plastic operation for stricture at the uretero-pelvic juncture; report of 20 operations. J. Urol., 38: 643-672, 1937. HERBST, ROBERT H., AND POLKEY, HUGH J.: Fenger's uretero-pyelo-plastic operation. J. Urol., 23: 23-31, 1930. HERMAN, LEON: Practice of urology. W. B. Saunders Co., Philadelphia, 1938, chap. 13. KELLY, H. A., AND BURNAM, C. F.: Diseases of the kidneys, ureters and bladder. D. Appleton and Co., New York, 1922, vol. 1, chap. 17. KusTER, E.: Ein fall von resection des ureter. Arch. f. klin. Chir., 44: 852, 1892. LEGUEU, F.: De l'hydronephrose traumatique. Bull. med., Par., 23: 389-391, 1909. - - - - ; Les hydronephroses traumatiques. Rev. gen. de din. et de therap., Par., 28: 100-102, 1914. LOWER, WM. E., AND NrcHOLS, B. H.: Roentgenographic studies of the urinary system. Mosby, 1933, pp. 34-36, 426-473. LUBASH, S., AND MADRID, A.: Uretero-pyeloneostomy for hydronephrosis, with case and experimental reports. J. Urol., 38: 634-642, 1937. MooRE, THOMAS D.: Discussion of Quinby "Plastic surgery of the renal pelvis." J. A. M.A., 89: 843, 1927. ORMOND, J. K.: Unsuccessful plastic operations for hydronephrosis. J. Urol., 36: 512-531, 1936. - - - : Plastic surgery of the ureter. J. Urol., 25: 117-143, 1931.
PLASTIC SURGERY OF THE RENAL PELVIS
1083
PILCHER, F., JR.: Treatment of bilateral congenital hydronephrosis. Proc. Staff. Meet. Mayo Clin., 12: 279-283, May 5, 1937. QUINBY, WM. C.: Plastic surgery of the renal pelvis. J, A. M.A., 89: 841-844, 1927. - - - - : Clinical picture of hydronephrosis in children and young adults. South. M. J., 23: 328-337, 1930. - - - - : Factors influencing operative procedure in hydronephrosis. J. Urol., 38: 673679, 1937. SARGENT, JAMES C.: Conservative surgery in hydronephrosis. J. Urol., 38: 680-687, 1937. - - - - : Hydronephrosis, clinical study of structural involution that follows surgical release of obstruction. J. Urol., 37: 631-638, 1937. ScHWYZER, A.: New pyeloureteral plastic for hydronephrosis. Surg. Clin. N. Am., 3: 14411448, 1923. THOMAS, G. J.: Discussion of Quinby "Plastic surgery of the renal pelvis." J. A. M. A., 89: 843, 1927. VON LICHTENBERG, ALEXANDER: Plastic surgery of the renal pelvis and ureter. J. A. M.A., 93: 1706-1708, 1929. WALTERS, W. AND BRAASCH, W. F.: Urinary obstruction and hydronephrosis; resection of the renal pelvis, the kidney and the ureter; report of 9 cases. J. A. M. A., 93: 1710-1716, 1929. YOUNG, H. H., AND DAVIS, D. M.: Young's practice of urology. W. B. Saunders Co., 1926, vol. 2, chap. 2.
From the standpoint of treatment, obstructions at the ureteropelvic juncture may be divided into 2 groups: (1) those relieved by cystoscopic dilatation and (2) those requiring open surgery. The latter group may be considered in 4 subgroups: (a) those cases diagnosed early that require division of bands and disposition of polar vessels; (b) later cases that need in addition some type of plastic operation; (c) late cases requiring resection of the extrarenal pelvis including the ureteropelvic juncture with reimplantation of the ureter; and (d) neglected cases that demand nephrectomy. Interest in the conservative surgery of hydronephrosis has received tremendous stimulus from the improved results recently obtained. This in turn has led to a more aggressive diagnosis of early ureteropelvic obstructions, particularly in infants and children. It should be remembered that the most frequent cause of obstruction, namely, aberrant vessels, is a congenital condition although symptoms of it may develop much later. A complete study of the urinary tract is therefore important, not only in adults but in children and particularly in infants. Early diagnosis means less radical surgery and offers greater opportunity to relieve the uretcropelvic obstruction without the division of large polar vessels. The function of the obstructed kidney is usually considerably reduced and may be entirely absent. This condition does not of itself indicate nephrcctomy. If at operation cortical tissue remains in fair amount, good drainage is followed by an increase in the renal function and in some cases it may approach that of the opposite organ. Postoperative serial pyelograms at intervals and studies of renal function have invariably demonstrated this fact in our cases of this type. Follow-up studies and drainage by catheter of the repaired pelvis, important after every pyeloplasty, become increasingly so as the operation approaches the more radical type of resection. Open surgery has a fourfold objective, the relief of obstructions, the preservation of the blood supply, 1 Read before annual meeting, American Urological Association, White Sulphur Springs West Virginia, May 29 to June 1, 1939. 1069
1070
ROBERT B. McIVER
the establishment of dependent urinary drainage and the maintenance of the proper position of the kidney. Nonoperative treatment. In selected cases of obstruction at the ureteropelvic juncture dilatation is effective and may bring permanent relief. This procedure is readily accomplished by the ingenious method described by Dees. A maximum dilating bulb is passed into the pelvis. A ureteral catheter is then passed through the narrowed lumen alongside the bougie shaft, and the bulb is withdrawn. The dilatation obtained is the sum of the diameters of the bulb and the catheter. This group of
FIG. 1
FIG. 2
FIG. 1. Case 1. Ureteropelvic obstruction on right side treated by cystoscopic dilatation. Pyelogram before treatment. FIG. 2. Case 1. Pyelogram after treatment for several months
cases offers the greatest difficulty in diagnosis, and, as there is no open operation, the exact cause of the obstruction is not demonstrated. Indeed, the diagnosis itself is not proved. Typical of the diagnostic iindings and the results of treatment is the following case. Case 1. J. C. D., No. 53354, a white physician, aged 56 years, married, was admitted on September 16, 1938. He complained of recurrent attacks of pain and a sense of "fulness" and aching in the loin and back on the right side. The pain was referred downward at times, but there were no definite symptoms in the lower urinary tract. Examination of the urine, blood and blood chemis-
PLASTIC SURGERY OF THE RENAL PELVIS
1071
try gave normal results. Diagnostic cystoscopy and pyelography revealed residual urine, in amount 35 cc., in the renal pelvis and gave evidence of obstruction at the ureteropelvic juncture on the right side (fig. 1). Over a period of several months this ureteral segment was progressively dilated to No. 12 French. The symptoms were relieved, and a follow-up pyelogram showed a decrease in the hydronephrosis (fig. 2). Our conception of the probable pathological condition the treatment and the result is shown in the line drawings (fig. 3).
FIG. 3. Case 1. Drawings showing probable pathological condition and result of treatment
Operative Treatment. A study of our last SO cases of hydronephrosis treated by open surgery, classified according to the type of operation, is summarized in tables 1 to 3. I. Disposition of polar vessels, bands and adhesions. Complete exposure of the renal pedicle with dissection of the pelvis and vessels well into the renal hilum will not only disclose the obstructing lesion but frequently will also allow the disposition of large polar vessels without their division. The obstructing artery may supply the lower half of the kidney, it may be larger than any other supplying the kidney, or it may constitute the only source of blood supply to the entire organ, as was
1072
ROBERT B. MCIVER
true in one case in this series. As the adhesions between the obstructing vessel and the pelvis are divided, the movement of the pelvis is downward while that of the vessel is upward so that by simple dissection, division of bands and adhesions, the obstruction may be completely relieved. Moreover, the released pelvis contracts almost immediately, its peristalsis becomes visibly more frequent and pronounced and it tends to resume its natural funnel shape. At times the aberrant artery will terminate in 2 or more arteries, and, if division is necessary, sacrifice of the lowest branch may free the ob1
TABLE
I. Disposition of Polar Vessels, Bands and Adhesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II. Plastic Procedures in Addition to I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III. Resection of Extrarenal Pelvis and Ureteropelvic Juncture..................... Total Number of Cases. . . . . ............................................
TABLE
2 SEX
AGE
SIDE AFFECTED
35 10 5 50
TOTAL
Right
Left
37
13
0-15 yrs.
15-50
Over 50
9
32
9
~I 8
TABLE SUBGROUP I
Urinary :fistula ............ Reoperation .............. Nephrectomy ............. Deaths ..................
. . . .
0 0 0 0
Female
50 50 50
32
3 SUBGROUP II
SUBGROUP III
0 0 0 0
0 0 0
1
struction. We have found that the complete dissection of the pedicle renders the division of large vessels increasingly unnecessary and that fixation of the kidney in elevation with particular attention to the lower pole obviates the division and reanastomosis of the ureter in order to preserve a large artery. In difficult cases the polar vessel may be separated from the pelvis by the interposition of fat or muscle transplant. The pelvis and upper segment of the ureter may be held in position by a nephrostomy-ureterostomy catheter splint. The following case is illustrative.
PLASTIC SURGERY OF THE RENAL PELVIS
1073
Case 2. T. G. B., No. 53284, a white boy, aged 5 years, complained of attacks of colic on the right side when brought to the hospital on September 11, 1938. There was a history of frequent attacks of colic, nausea and vomiting since babyhood. Prior to admission the attacks had recurred more fre-quently, and the pain had centered more definitely in the right side. Ten days previously, when the patient had had an attack of nausea, vomiting and abdominal pain on the right side, an appendectomy had been performed, but 1 week later the colic had recurred in the abdomen and flank on the right side and had persisted at intervals up to the time of admission, becoming progressively more intense, reaching a crisis and then receding. The child had been regarded as delicate and was underweight. On examination, the patient weighed 39 pounds. His temperature was 100.8 F. and the pulse and respiration rates were 120 and 20 respectively. There was tenderness over the abdomen and flank on the right side, most pronounced in the costo-muscle angle. Urinalysis revealed the presence of pus cells and erythrocytes, and examination of the blood showed a total leukocyte count of 12,000 per cu. mm. A roentgen study gave no evidence or urinary calculus. Cystoscopic examination revealed that 14 cc. of residual urine containing pus cells and erythrocytes was present in the pelvis of the right kidney, and a pyelogram demonstrated a considerable degree of obstruction at the upper ureteral segment (fig. 4), as shown by a retouched roentgenogram (fig. 5). The pelvis was drained by and irrigated through an indwelling ureteral catheter for several days. On September 14 the kidney was explored, and the pathological condition indicated in the line drawings (fig. 7) was demonstrated. A small band-like aberrant vessel crossed the uteropelvic juncture posteriorly, and the ureter was bound to the lower renal pole by dense adhesions. These obstructions were divided. Splint-fixation of the ureter was accomplished by the introduction of a Cumming self-retaining nephrostomy tube having a ureteral drain. Convalescence was uncomplicated. Examination at the third postoperative month showed that the boy had gained 10 pounds and was well. Seven months after the operation serial pyelograms of the right side demonstrated a normal condition (fig. 6). II. Plastic procedures in addition to the release of obstructions.
This type of operation has 3 objectives: (1) enlargement of the narrowed lumen; (2) dependent drainage by gradual funneling of the pelvis into the ureter; and (3) elimination of redundant pelvic tissue, obstructing flaps and the high insertion of the ureter in the pelvis. To accomplish these ends a variety of ingenious operations has been described by Kuster, Fenger, Schwyzer and others. Foley called attention to the
1074
ROBERT B. MCIVER
principles of visceral anastomoses, particularly pyloroplasties, as applied to plastic surgery of the ureteropelvic juncture and described his Yplasty. Other procedures and reports of cases have been published by Young and Davis, Braasch, Quinby, Thomas, Herman, Moore, Eisendrath, Herbst and Polkey, Lubash and Madrid, Sargent, Walters and
FIG.4
FIG.5
FIG. 4. Case 2. Hydronephrosis due to obstruction at ureteropelvic juncture on right side in a boy, aged 5 years, subjected to appendectomy 10 days previously under a mistaken diagnosis of appendicitis. Preoperative pyelogram. FIG. 5. Case 2. Roentgenogram retouched to emphasize pathological condition
Braasch, Cabot, Pilcher, Cabot, Walters and Priestley, Ormond, Legueu, von Lichtenberg, Kelly and Burnam, Lower and Nichols, Eliot and a number of other authors in this country and abroad. In this subgroup no single operation was followed routinely but the one selected instead which met the conditions encountered. In 1 case of this series the obstruction developed rapidly and was impassable by uteteral catheterization. The patient was in a decidedly toxic condition
PLASTIC SURGERY OF THE RENAL PELVIS
1075
with high temperature. Prompt drainage by nephrostomy was imperative, but extensive plastic surgery was contraindicated. To com-
FIG.
6. Case 2. Serial pyelograms showing normal condition after operation for relief of obstruction
Seven months a.'fter-
opera.tton
FIG. 7. Case 2. Drawings showing findings at operation and postoperative result
promise this situation and still remedy the ureteropelvic obstruction a longitudinal incision carried through the ureteropelvic juncture was
1076
ROBERT B. MCIVER
allowed to gape open, a splint catheter was placed in position and a "blowout" patch of fat secured in place. Case 3. E. B., No. 55540, a white single woman, a bookkeeper, aged 33 years, was admitted on February 10, 1939, complaining of chills, fever and severe pain in the left loin. Vague bladder discomfort had been present for 2 weeks, she related, and for 24 hours immediately preceding admission she had suffered from colic in the left loin and back, with the pain growing more severe and chills and high fever developing in the last 10 hours.
FIG. 8. Case 3. Practically complete obstruction of ureteropelvic juncture on left side with acute pyonephrosis in a patient operated upon as an emergency case. Preoperative pyelogram showing obstruction and enlarged kidney.
The patient's temperature was 102.4 F., the pulse rate 114 and the respiration rate 18. Shortly thereafter there was a rise in temperature to 104.6 F. and an increase in the pulse and respiration rates to 120 and 20. Urinalysis showed albumin 2 plus, acetone 1 plus, pus cells 2 plus and erythrocytes 1 plus. Examination of the blood revealed a leukocyte count of 10,550, which promptly rose to 15,000, and analysis of the blood chemistry showed urea nitrogen 22 mg. per 100 cc of blood. The patient appeared to be acutely ill and in a highly toxic condition. On the left side there was a painful mass in
PLASTIC SURGERY OF THE RENAL PELVIS
1077
the renal area, and the point of maximum tenderness was in the costo-muscle angle. A complete urinary study gave negative evidence for the bladder and for the kidney and ureter on the right side. On the left side there was an obstruction to the catheter in the upper portion of the urinary tract 25 cm. above the ureteral orifice. The few drops of urine obtained showed many pus cells microscopically. Repeated ureterograms demonstrated an obstruction at the ureteropelvic juncture and showed an enlarged kidney (fig. 8). An emergency nephrostomy was done with division of the aberrant vessels to the tip of the lower renal pole. The stenosed ureteropelvic juncture was incised longitudinally, the incision extending upward into the pelvis 1 cm.
FIG.
9. Case 3. Serial pyelograms 2 months postoperative showing reduced hydronephrosis
and downward into the normal ureter 1 cm. A splint tube was then carried from the pelvis through the gaping wound down into the ureter, and a "blowout." patch of fat, placed over the defect, was tacked in place by several sutures (fig. 10). The patient had an uneventful convalescence with a clinical recovery. Serial pyelograms 2 months postoperative revealed a persistent though reduced hydronephrosis, and the residual urine 20 cc in amount, showed 18 to 20 pus cells to a field (fig. 9). A urologist in another city, checking up on the patient's condition 1 month later, reported: "Passed No. 10 French bulb easily into left renal pelvis; residual urine 10 cc, average 10 pus cells to high power field. Indigo carmen appeared in 7 minutes. Pyelectasis 2 plus. Delay in emptying time." Treatment of this case is being continued.
1078
ROBERT B. McIVER
III. Resection of the extrarenal pelvis and ureteropelvic juncture. The more radical operations are reserved for those cases not amenable to simple surgery, and it is in this subgroup that recent results have shown great improvement. It is believed that some of the poor results here, as in prostatic resection, occur because of failure to remove enough tissue. Our practice is to excise the pelvis to within about 1 cm. of the hilum or so as to leave just enough pelvic border to effect a closure without tension. In advanced cases septa between dilated major calices may obstruct drainage from the upper portion of the kidney. They should be treated by excising an inverted V, or by longitudinal suturing of a transverse mc1s10n in the septum. In closing the pelvis and in Nephro3tomy lube (cro,.,-$ecllon)
Frn. 10. Case 3. Drawings showing findings at operation, emergency procedure to relieve obstruction quickly in a patient critically ill, postoperative result and nephrostomy-ureteral splint devised by author.
anastomosing the upper ureteral segment the following points are observed: (1) Atraumatic sutures of very fine catgut, 00000 to 000, are used; they should not perforate the mucous membrane, should be few in number and should be lightly tied to avoid tension; (2) a nephrostomy tube having a ureteral splint is routinely employed; and (3) nephropexy is done to maintain the position of the anastomosis. The ureteral splint may be removed within a week or 10 days, but nephrostomy drainage should be continued for several weeks, or until the urine is clear and retrograde catheterization of the ureter and pelvis has been accomplished. In our experience this procedure has obviated
PLASTIC SURGERY OF THE RENAL PELVIS
1079
permanent urinary fistulae. We have devised a self-retaining catheter for nephrostomy drainage that has an extension tube for ureteral splinting (fig. 10). It is being constructed by the American Cystoscope Makers, Inc. It is so designed that it may be introduced from either end through a small nephrostomy wound, may be retained by a distensible bag, may be changed without injury to the kidney or pain to the patient and allows continuous irrigation as well as drainage. The follow-up treatment in this subgroup is particularly important. The pelvis should be drained and lavage carried out at regular intervals, beginning weekly, and the ureteropelvic anastomosis should be kept
FIG. 11. Case 4. Advanced hydronephrosis on left side treated by resection of extrarenal pelvis and ureteropelvic juncture. Serial pyelograms showing injection of skiodan and exposures at 0, 5 and 15 minutes.
dilated. Persistence at this stage brings ample reward. case illustrates the upper margin of favorable result.
The following
Case 4. V. R. B., No. 51547, a white schoolgirl, aged 11 years, was admitted May 16, 1938, complaining of pain in the left side. She related that attacks of pain, lasting 18 hours and accompanied by nausea and vomiting, had begun a year previously, recurring 6 months later; for the 3 months prior to admission there had been weekly recurrences of increasing severity with the pain more in the nature of colic. On examination, the child weighed 72 pounds. Analysis of the blood chemistry and examination of the blood gave negative results. Urinalysis
1080
ROBERT B. McIVER
showed pus cells 2 plus. Cystoscopy revealed a normal bladder and upper portion of the urinary tract on the right side. On the left side catheterization of the ureter resulted in the recovery of 45 cc of residual urine from the kidney, showing pus cells 2 plus. Phenosulphonphthalein appeared in 20 minutes with the output reduced 50 per cent. A roentgen study gave no evidence of a calculus in the urinary tract, but a pyelogram revealed hydronephrosis and an obstruction at the ureteropelvic juncture on the left side. Serial pyelograms of this side at the end of 15 minutes (fig. 11) and 60 minutes (fig. 12) showed decided delay in emptying. At operation (May 17) hydronephrosis caused by a small polar vessel was demonstrated. The upper ureteral segment was densely adherent to the
FIG. 12. Case 4. Exposures at 30, 45 and 60 minutes
pelvis and lower pole of the kidney; the extrarenal pelvis was tremendously dilated and there was 60 cc of residual urine. The extrarenal pelvis was excised 1 cm. from the hilum, and the ureter was severed below the obstruction. Closure of the pelvis and anastomosis of the ureter were carried out according to the technique herein described, and the operation was completed by nephropexy (fig. 14). The patient's recovery was uncomplicated. The ureteral splint catheter was removed on the seventh postoperative day. A retrograde ind,wlling ureteral catheter was passed to the pelvis on the eleventh day after the operation, and on the following day the nephrostomy tube was removed. Three weeks after she was operated upon the patient was discharged from the hospital.
FIG. 13. Case 4. Serial pyelograms 11 months after operation showing small pelvis, wide ureteropelvic juncture and rapid emptying time.
Eleven months attet"
opera'llon
FrG. 14. Case 4. Drawings demonstrating operative steps, suture technique and post-
operative result.
1081
1082
ROBERT B. McIVER
Serial pyelographic studies at the second, fifth and eleventh (fig. 13) postoperative months showed a wide ureteropelvic juncture, a reduction of the hydronephrosis and excellent emptying of the pelvis. There was a return to normal in the renal function, and the patient's weight increased to 105 pounds, a gain of 33 pounds. SUMMARY AND CONCLUSIONS
A complete urologic study of all cases of recurrent abdominal pain will result in the early diagnosis of obstructions at the ureteropelvic juncture. Complete exposure of the renal pedicle and high dissection of the pelvis and vessels will frequently relieve the obstruction. Plastic procedures correctly applied give a high percentage of good results with a very low mortality. A series of 50 consecutive cases of operation for ureteropelvic obstruction, with no nephrectomies and one death, is here reported.
Suite 1108-14, Greenleaf Bldg., Jacksonville, Fla. REFERENCES BRAASCH, W. F.: Clinical notes on hydronephrosis. Interstate M. J., 21: 1180-1188, 1914. CABOT, HUGH: Modern Urology in Original Contributions by American Authors. Lea and Febiger, Philadelphia, 1936, ed. 3, vol. 2, pp. 414-416. - - - - , WALTERS, w., AND PRIESTLEY, J. T.: Operative results in non-calculus hydronephrosis, results in 71 plastic operations. J. Urol., 38: 688-693, 1937. DEES, JOHN E.: New method for instrumental dilation of the ureter. J. Urol., 40: 24-26, 1938. ErsENDRATH, D. N.: Inlying ureteral catheter in treatment of pyelonephritis and other renal conditions. J. A. M. A., 89: 2170-2173, 1927. ELIOT, E.: An unusual case of hydronephrosis. Ann. Surg., 61: 474, 1915. FENGER, CHRISTIAN: Operation for the relief of valve-formation and stricture of the ureter in hydro- or pyonephrosis. J. A. M.A., 22: 335-343, 1894. FOLEY, F. E. B.: New plastic operation for stricture at the uretero-pelvic juncture; report of 20 operations. J. Urol., 38: 643-672, 1937. HERBST, ROBERT H., AND POLKEY, HUGH J.: Fenger's uretero-pyelo-plastic operation. J. Urol., 23: 23-31, 1930. HERMAN, LEON: Practice of urology. W. B. Saunders Co., Philadelphia, 1938, chap. 13. KELLY, H. A., AND BURNAM, C. F.: Diseases of the kidneys, ureters and bladder. D. Appleton and Co., New York, 1922, vol. 1, chap. 17. KusTER, E.: Ein fall von resection des ureter. Arch. f. klin. Chir., 44: 852, 1892. LEGUEU, F.: De l'hydronephrose traumatique. Bull. med., Par., 23: 389-391, 1909. - - - - ; Les hydronephroses traumatiques. Rev. gen. de din. et de therap., Par., 28: 100-102, 1914. LOWER, WM. E., AND NrcHOLS, B. H.: Roentgenographic studies of the urinary system. Mosby, 1933, pp. 34-36, 426-473. LUBASH, S., AND MADRID, A.: Uretero-pyeloneostomy for hydronephrosis, with case and experimental reports. J. Urol., 38: 634-642, 1937. MooRE, THOMAS D.: Discussion of Quinby "Plastic surgery of the renal pelvis." J. A. M.A., 89: 843, 1927. ORMOND, J. K.: Unsuccessful plastic operations for hydronephrosis. J. Urol., 36: 512-531, 1936. - - - : Plastic surgery of the ureter. J. Urol., 25: 117-143, 1931.
PLASTIC SURGERY OF THE RENAL PELVIS
1083
PILCHER, F., JR.: Treatment of bilateral congenital hydronephrosis. Proc. Staff. Meet. Mayo Clin., 12: 279-283, May 5, 1937. QUINBY, WM. C.: Plastic surgery of the renal pelvis. J, A. M.A., 89: 841-844, 1927. - - - - : Clinical picture of hydronephrosis in children and young adults. South. M. J., 23: 328-337, 1930. - - - - : Factors influencing operative procedure in hydronephrosis. J. Urol., 38: 673679, 1937. SARGENT, JAMES C.: Conservative surgery in hydronephrosis. J. Urol., 38: 680-687, 1937. - - - - : Hydronephrosis, clinical study of structural involution that follows surgical release of obstruction. J. Urol., 37: 631-638, 1937. ScHWYZER, A.: New pyeloureteral plastic for hydronephrosis. Surg. Clin. N. Am., 3: 14411448, 1923. THOMAS, G. J.: Discussion of Quinby "Plastic surgery of the renal pelvis." J. A. M. A., 89: 843, 1927. VON LICHTENBERG, ALEXANDER: Plastic surgery of the renal pelvis and ureter. J. A. M.A., 93: 1706-1708, 1929. WALTERS, W. AND BRAASCH, W. F.: Urinary obstruction and hydronephrosis; resection of the renal pelvis, the kidney and the ureter; report of 9 cases. J. A. M. A., 93: 1710-1716, 1929. YOUNG, H. H., AND DAVIS, D. M.: Young's practice of urology. W. B. Saunders Co., 1926, vol. 2, chap. 2.