Pre- and postoperative ureteral dysfunction

Pre- and postoperative Evaluation

by radioisotope

ALBERT

B.

C.

LARKIN

LINDA

P.

Chicago,

Illinois

GERBIE,

renograms

M.D.

FLANAGAN, WOODBURY,

ureteral dysfunction

M.D. M.D.*

thors whose series revealed incidences oi “major” ureteral injury varying from 0.48 to 2.41 per cent.l This incidence increases sharply when surgical and irradiation procedures for carcinoma are included.“, ‘. !’ Ureteral transection or laceration in many instances is recognized and repaired at the time of occurrence. These injuries may also pass unrecognized until leakage of urine occurs postoperatively. In either case, the diagnosis presents little difficulty. However, unilateral ureteral ligation is notoriously difficult to identify. If a fistula does not develop, it may culminate in a “silent” autonephrect0my.l” Less severe trauma than transection OI ligation may also progress to pyelonephritis, hydroureter, stricture, or even fistu1a.l. I’ In such cases, the “minor” trauma probably exerts its effect by subtle disturbances of ureteral motor activity. These subtle changes may be caused by the following: (1) intcrference with either ureteral blood supply or innervation, (2) ureteral edema, (3) compression of the ureter by a pelvic hematoma or abscess, (4) kinking or constriction of the ureter by a nonligating suture, or (5’) postirradiation reaction.‘, a The resulting dysfunction in instances of “minor” ureteral injury has been extremely difficult to recognize prior to the onset of late complications. Many efforts have been made to determine the frequency of temporary or “minor” ureteral injuries following gynecologic procedures.‘, 2. I2 These studies usually employ

1‘ H E ureters may he involved in gynecologic disease or may be injured in the course of irradiation or operative treatment of the disease. Intravenous pyelograms performed prior to gynecologic operations for benign conditions revealed a surprisingly high incidence of unsuspected ureteral involvementl, ’ The incidence of ureteral dilatation prior to operation was 20 per cent in Solomons’ series and 15 per cent in Morrison’s. They reported that 85 to 90 per cent of these patients with abnormal preoperative findings had normal intravenous pyelograms postoperatively. Ureteral injury has occurred following most types of major gynecologic therapeutic procedures for both benign and malignant diseases.3-7 These injuries may be classified as major (including ureteral transection, laceration, and ligation) or minor. Solomons has summarized the experience of many auFrom the Departments of Obstetrics Gynecology and of Medicine, Northwestern Uuiversity Medical School and Passavant Memorial Hospital.

and

Supported in part by the Lucy and Edwin Kretchmer Fund of Northwestern University, by a grant from the Chicago Heart Association, and by United States Public Health Service Grant H-1890. Presented at the Twentv-ninth Annual Meeting of the Central’Association of Obstetricians and Gynecologists, Cleveland, Ohio, Oct. 5-7, 1961. *Josiah Macy, Jr,, Foundation Fellow.

1138

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83 9

Ureteral

pre- and postoperative intravenous pyelograms. Two and one-half per cent of Solomons’ own patients and 3.7 per cent of Morrison’s patients displayed “ureteral obstruction” following hysterectomy. This obstruction was reported to be mostly minor and temporary. As listed by Morrison, factors involved in the incidence of ureteral injuries in any series include: skill of the operator and anesthesiologist, the type of patient, and the extent and technique of the operation. To these we would add the sensitivity of the method used for investigating and recording these injuries. This paper describes a new method for recognizing them, and reports their incidence in 50 patients. The radioisotope renogram is a rapid, safe, and very sensitive method of evaluating individual renal function. Described in detail originally by Winter in 1956, in a study of unilateral renal disease associated with hypertension,13 it has been adapted as a clinical tool for evaluation of many forms of renal disease.l” We believe that the radioisotope renogram may be an excellent tool for documenting minor ureteral dysfunction following pelvic operations, because it has been found in other instances to be more sensitive than the intravenous pyelogram for recognizing other functional abnormalities of the urinary tract. 14, I5 The test is simple, and it may be done without elaborate preparation or inconvenience to the patient. It is performed by the intravenous injection of a tracer dose of PI-labeled sodium o-iodohip-

purate* followed by continuousmonitoring Over the renal regions. The risk of serial testing is almost nonexistent. Each test involves considerably less irradiation exposure than an intravenous pyelogram.‘6* ” Though the renogram is nonspecific, being an appearance-disappearance curve for a radioactive-labeled substance entering the renal regions, it embodies in its wave pattern much of the information which has been previously obtainable only by excretory *PI-Hippuran, Illinois.

Abbott

Laboratories,

North

Chicago,

dysfunction

1139

RmnKIDmx

mm

Fig. 1. Normal bilateral radioisotope renogram using 1131 sodium o-iodohippurate. The graphs read from right to left. The abscissa is time. From mark I to mark 2, each division is 33/4 minutes. After 2, each division is 7% minutes. The components of a normal renogram are labeled (V) vascular spike, (A) accumulation phase, (X) excretory phase and (E) phase of equilibrium. Differences in the magnitude of the graphs without alterations of the wave form are probably not significant. The sharp downstroke following the equilibrium phase occurs when the probes are removed from the renal regions at the completion of the test (C).

urography ization.ls,

or by bilateral

ureteral

catheter-

Is

Technique

of radioisotope

renogram

A detailed exposition of our renographic equipment, technique, and interpretation was included in a preliminary report of this work.=O All renograms were recorded with the patient in the sitting position. The probes were pointed to the center of the renal pelvis and were parallel to the floor. Measurements of renal the

position midspinous

were line

made and

with the

reference twelfth

to rib

on

either side from the erect film of an intravenous pyelogram or from an erect scout film of the abdomen. P1 sodium o-iodohip1 pc per 5 kilograms body weight, purate, was

injected

No

“carrier”

rapidly

into

substancezl

an antecubital was

ing injection, the positions were rechecked during the

vein.

Followof the probes early stage of given.

1140

Gerbie,

lppTI(IDMTY

Flanagan,

and

May 1: 1962 Am. J. Obst. g: Gynec.

Woodbury

Rmn

-uolm

Kmm

BM-

Fig. 2. Bilaterally abnormal renogram. The vascular spikes are normal bilaterally; accumulation (A) is prolonged and high. Excretion (X) does not take place on the left, and is only slightly evident on the right. This renogram suggests relatively complete outflow obstruction on the left and high grade partial obstruction on the right.

Fig. 4. Apparently abnormal renogram bilaterally. After normal vascular spikes, initially there is little evidence of an accumulation phase on either side. Moving the probes 3 cm. (indicated by the arrows) resulted in a sharp increase in radioactivity followed by the prompt excretion (X) phase. A repeat renogram (Fig. 8A), after proper probe placement, was bilaterally normal.

Customarily, the measurement of renal radioactivity was continued for 20 to 25 minutes, during which time 50 to 75 pchr cent of the injected radioactive material had been excreted.22

spike

(v);

graph

indicates

recording.

Interpretation

The renogram four components

was arbitrariIy divided into (Fig. 1) : ( 1) the vascular

(2)

the accumulation phase (secretory phase of Taplinz3) (A); (3) the excretory phase (X); and (4) the cquilibrium phase (E), at which time the curve has become almost asymptotic with the base line. All graphs read from right to left. The rapid downstroke (C) at the left end of each removal

of

the

probes

from

patient’s back. The ~~nscular spike is the initial rapid upswing. It is of short duration and of marked variability in magnitude. Its durathe

tion is difficult to measure by our recording

lanuom

RIcmrmm

Fig. 3. Bilaterally abnormal renogram. The vascular spike (V) is adequate on the left and very low on the right. Accumulation (A) is slightly prolonged on the left and almost absent on the right. Excretion (X) is deIayed and stepwise on the left and absent on the right. This renogram shows evidence of partial outflow obstruction on the left and marked impairment of function on the right. Both kidneys were visualized by intravenous pyelogram.

technique: I it is not possible ds frequently to recognize the transition from vascular spikes to accumulation phase. 1%‘~ have been \mable to equate this phase with any cornmanly known parameter of renal function. A low vascular spike followed by a plateau throughout the period of observation (Fig. 3, right kidney) is indicative of lack of function or absence of the kidney.“” The accumulation phase extends from the end of the vascular spike to the peak ‘of the curve and is apparently related to active removal of isotope from the blood by renal tubular epithelial cells.23 Our present data suggest that an injection-to-peak time greater than 5 minutes is definitely abnormal. More

Ureteral

or less complete ureteral obstructionZ4 is indicated by prolonged uninterrupted accumulation of isotope in the kidney (Fig. 2). \Yhen the rate at which isotope is being accumulated in the renal area is exceeded by the rate at which it leaves that region, the excretory phase begins and the curve starts downward. A plateau at the top of the renogram is formed when an exact balance exists between accumulation and excretion for a prolonged period. Normally this plateau does not exceed 2 minutes. We believe that in the present study, prolonged plateaus are indicative of partial obstruction or atony of the ureter. The entire excretory phase normally is less than 15 minutes. A common abnormality, occurring during this phase in our patients, is a stepwise and prolonged excretory downstroke (Fig. 3, left kidney). Abnormal ureteral motility, secondary to surgical trauma, seems the most probable explanation for this abnormal excretory pattern. Technical

factors

affecting

the

dysfunction

1141

accumulated in the liver. There is little irradiation hazard, because the isotope is rapidly cleared from the blood, having a biologic half-life of approximately 20 minutes.2” That all the isotope must be given intravenously cannot be overemphasized. A curve characteristic of ureteral obstruction or of renal dysfunction may be obtained if extravasation occurs.” The effects of drugs on the renogram are not well understood. In our experience, chlorothiazide and its derivatives have not affected the pattern significantly. Material

Radioisotope renograms were performed preoperatively on 50 patients scheduled for major gynecologic procedures (Table I) .

Table

I. Preoperative

renograms

Total No. of patients Normal renograms Abnormal renograms Technically inadequate renograms

38 10

50 (37 operated) ( 9 operated)

2

renogram

The three most important factors influencing radioisotope renogram reliability and reproducibility were probe placement, the test substance, and injection technique. The most common source of technically inadequate tracings was improper probe position (Fig. 4) _ We found x-ray films taken in the supine position to be inadequate for positioning the probes when the renogram was recorded in the sitting position.20, ” Early work13. ‘3 with radioisotope renograms employed II”‘-labeled iodopyracet.* This substance was unsatisfactory because of its appreciable uptake by the liver, which gave rise to deceptive patterns recorded from the right kidney region.131 21 To date, the most satisfactory medium for the isotope renogram is sodium o-iodohippurate (Fig. 1). 22, ZBvH This is a nearly ideal test agent, since it is stable, easily prepared, and is not *P’-Diodrast, Illinois.

Ahbott

Laboratories,

North

Chicago,

Table

II.

Operations

Total No. of procedures Abdominal Vaginal Private Clinic

patients patients

46 33 13 29 17

The following operations were performed upon 46 patients: 22, total abdominal hysterectomy (with salpingo-ovariectomy; unilateral 6, bilateral 12) ; 3, radical hysterectomy with lymph node dissection; 9, vaginal hysterectomy (with cystocele and rectocele repair 6) ; 2, myomectomy; 1, abdominal hysterotomy with tubal ligation; 1, therapeutic abortion (vaginally) ; 1, bilateral ovarian resection; 2, ovariectomy (with myomectomy 1) ; 1, manchester repair; 2 radium insertion for carcinoma of the cervix; 1, lysis of adhesions to left ovary and sigmoid resection: and 1: bilateral adrenalectomy and ovariectomy.

1142

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Flanagan,

and

May 1: 1962 .4m. J. Obst. & Gynec.

Woodbury

Of the 46 patients who underwent operation, 29 were private and the remainder were clinic patients (Table II). One of the remaining 4 patients was not operated upon, one had a pyeloplasty and 2 were eliminated from our series because unsatisfactory renograms were obtained because of technical factors. Procedure

General history and physical examination and laboratory studies, including urinaIysis, blood urea nitrogen determination, and urine culture, were obtained on all patients and pyelograms performed on many. A preoperative renogram was obtained to determine “baseline” patterns. A repeat radioisotope renogram was recorded on approximately the fifth postoperative day. Repeat studies were done subsequently at intervals on all patients in whom the first postoperative renogram showed a change toward abnormal when compared to the preoperativr tracings. If the first postoperative renogram did not change from normal to abnormal. no further observations were made. Results

Of 9 patients with an abnormal preoperative radioisotope renogram, 3 had a norTable

III.

Preoperative

Postoperative abnormal

Postoperative Postoperative Preoperative

normal

Postoperative Postoperative --not

renograms

(10

normal abnormal

6

renograms

had

a pyeloplasty

iOne

not

operated

patients*)

3 (33%) (38

normal abnormal

“One patient included. patient

renograms

patients?)

20 17 (46%) for

ureteropelvic

ma1 postoperative renogram, an improvcment rate of 33 per cent (Table III). Of 37 patients with normal preoperative radioisotope renograms who underwent major operations, 17, or 46 per cent, had an abnormal postoperative radioisotope renogram 5 to 6 days postoperatively (Table III). Six of these tracings indicated bilateral abnormality and 11 unilateral (7 right: 4 left) abnormality. Subsequent renograms to date revealed that 13 ha\:c% reverted to normal. ‘I’he other 4 arc bein,q followed. In ;tt least 1 patient, the renogram pattern has continued to be abnormal 9 months aftet thca operative procedure. Tablr IV indicates that the renographic abnormalitirs following operation most frequently consisted of either a prolonged accumulation phase or a prolonged and stepwise excretion phase or both. A plateau at the top of the curve was also common. These findings were interpreted as suggesting partial and/or intermittent ureteral obstruction. Such abnormalities have not been encountered in the few patients studied renographically after abdominal sur,gical proccdurcs in which the pel\-it ureters were not in the operative field. The abnormal postoperative radioisotope renograms were distributed proportionately between private and “clinic” patients. Ten were private and 7 were service patients. Following the 33 abdominal procedures. 10 patients had abnormal renograms whereas 13 vaginal operations led to 7. We are not aware of ureteral ligation. laceration, or transection having occurred in this series.

stenosis

Case

upon.

Table IV. Renographic abnormalities associated with gynecologic operations Prolonged accumulation phase only Prolonged accumulation plus prolonged excretion Prolonged excretion only Stepwise excretion Plateau longer than ? minutes at top of curve

3 9 1 5 3

reports

1. The patient, aged 34, gravida 0, was admitted with a preoperative diagnosis of a large left ovarian cyst. Intravenous pyelograrn revealed a pelvic soft tissue shadow, larger on the right. Obstruction of the uretrr was not evident pyelographically on either side. A rndioiqotopc renogram revealed normal function on the left and prolonged accumulation followed by very slow excretion on the right (Fig. 5A). Thus. the left rrnogram was normal and t?lr Case

Volume Number

right

83 9

Ureteral

suggested

partial

outflow

obstruction.

dysfunction

1143

Left

salpingoovariectomy and myomectomy were done with removal of a left ovarian mutinous cystadenoma (which measured 28 by 40 cm. and weighed more than 4,500 grams) and a 2 cm. uterine fibroid. The postoperative course was normal. A radioisotope renogram on the fifth postoperative day revealed a normal renogram bilaterally (Fig. 5B). The ureteral dysfunction, demonstrated by renogram but not by pyelogram, has apparently been relieved. Case 2. The patient, aged 53, gravida 0, was admitted with a preoperative diagnosis of multiple uterine fibroids, one of which was in the right broad ligament. Intravenous pyelogram revealed a 12 cm. soft tissue density in the midline of the pelvis, pressing on the roof of the I>ladder and displacing both ureters slightly laterally. Neither the pyelogram nor the renogram suggested ureteral dysfunction preoperatively (Fig. GA ) Curettage and total abdominal hysterectomy and bilateral salpingoovariectomy were pertermed. During removal of the large right intraligamrntous fibroid, the right ureter was dissected and its entire course traced. No apparent injury was present. The postoperative course was complicated on the third day by a minor urinary tract infection (Escherichia coli) which responded promptly to nitrofurantoin. A radioisotope rcnogram on the fifth postoperative day revealed normal left kidney function. The right rcnogram revealed a normal accumulation phasr I(,ading to a prolonged plateau and followed by :I delayed excretion phase, characterized by a sudden stepwise drop. We interpreted this c,hange as indicating partial, intermittent outflow obstruction on the right (Fig. 6B). The radioisotope renogram 43 days postoperatively was once again normal bilaterally (Fig. 6C). In this case, the urinary tract was normal preoperatively. right ureter

The probably

trauma of dissection caused a motor

of thr disturb-

ance which was evident in the rcnogram. This disturbance disappeared without treatment. Case 3. The patient, aged 40, gravida iv, para iv, was admitted with a preoperative diagnosis of Stage Ia squamous cell carcinoma of thr t.ervis, diagnosed at a previous admission by cervical conization. Review of the pathologic material revealed squamous cell carcinoma of the cervix with minimal tissue invasion. Intra\renous

pyelogram

revealed

no

abnormality.

A

=-CKICNEY

RBxrKIDNm

Fig. 5A. Patient 1. Abnormal right rcnogram. preoperatively. Accumulation (A) is normal on the left and prolonged on the right. Excretion (X) is prompt on the left and very slow on the right. Left renogram is normal, the right renogram indicates partial ureteral obstruction with wellpreserved parenchymal function.

ISTKIDNEX

Fig. 5B. tive day. bilaterally.

Rzxr

Km

Renogram recorded on fifth postoperaThe renogram is within normal limits

radioisotope renogram was normal bilaterally (Fig. 7A). Radical hysterectomy, bilateral salpingoovariectomy and bilateral pelvic lymph node dissection were performed. Pathologic diagnosis was carcinoma in situ of the cervix and hyperplasia of lymph nodes. The postoperative course was relatively uneventful. Results of preand postoperative radioisotope blood volume studich were normal. A radioisotope renogram on the fifth postoperative day was grossly abnormal bilaterally, suggestive of partial bilateral outflow obstruction more marked on the right (Fig. 7B). A repeat renogram on the thirteenth postoperative day continued to show bilateral dysfunction (partial outflow obstruction) with some improvement on the left. Intravenous pyelogram

1144

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Flanagan,

and

Woodbury

RImI I(IMm

rarxmm

Fig. 6.4. Patient 2. I’reopcrative bilaterally.

*

KIDrn

rrnogram;

R&m

normnl

KIDNEX

Fig. 6B. Unilaterally

abnormal renogram on the fifth postoperative day. Left renograrn is normal, right renogram sug-grsts partial outflow obstruction with a normal accumulation (A) phase, a prolonged plateau, and a delayed stepwise L’Ycretion (X) phase on the right.

KIDINFY

Fig.

6C.

renogram

RIGIn

Forty-three days postoperatively, is again normal bilaterally.

KIDNEY

the,

on the fourteenth postopcrativc day showed “no signs of ollstruction or displacement.” The radioisotope renogram approximately one month postoperatively (Fig. 7C) was interpreted as normal on the left and frankly abnormal on the right, accumulation being markedly pruton,qed and cxrrction very slow. The radioisotope rrnograrn was within normJ limits bilateratl~ 72 days postoperatively (Fig. 70). Thll:. a radical hysterectomy resulted in a r~~lativc~t>- severe degree of bilateral urinary tract tlylogram failed to rc%cord thiq tl) sflul(.tion. After one month. one ureter 1~x1 ;tppar~~ntly reverted to normal function xvhilc lh~ 0011.r had not. Case 4. The patient, aged 39, para xiii, was ;~tlmittcd \\pith rhe preoperative diagnosis of ( )-stoc-cl{*, urethrocele, and rectocele, and second dqrcc tlterine proiapse. Preoperative renogram IVX within normal limits bilaterally (Fig. 8A). \*aginal hysterectomy and vaginal repair were performed. On the fifth postoperative day &, patient hecame acutely ill, developed fever of I O’l.tj“ F., gcneralizcd abdominal tcnderucs<: and Sf’\‘PI‘i co.~tovertcbral angle trnderness bitatcrally. fntnkt: and olltput wrc normal through<~ut. A radioisotope renogram (Fig. 8B? 1 \\~hich had to bc discontinu(xd before completion I)~~auqt> of sc\‘crc abdominal and costovertt:hral arql~ pail], revealed that the renal parcnchyma xvns f~mctioning but that bilateral r)bstruc.tic~rr 10 outflow from the renal regions was preq‘nl. Intravenous pyclogram then showrd bilateral cxlycctasis and dilatation of the ureters due to partial Ilrctcral obstruction near the uretcrnvcsical junctions. A peritoneal mass posterior to chc bladder was suggested hy the forward position and irrrgular outline of the bladder. The clinical diagnosis was pelvic ccltulitis and the paticlnt \vas given antibiotics and supportivr care. On the tenth postoperative day an excluisitel) tcndcr pelvic mass associated lvith s(avrrc abdominal pain was palpable. Incisioll and draina,ge of a peIvic afxcess was don<, vnginally. This rcsutted in some clinical imprr~vcmt~nt. Howc\.er, right-sided pain, fever, and tcrtkocytosis persisted. The patient again Ixcamca x.utely ill on the seventeenth postopflrativp day. X-ray examination of the abdomen tlcmonst rnrtxd elevation of the right diaphragm :~nd d
Ureteral

dysfunction

1145

I UlTF.LV%l

IEFTKILWEY

RIGErr KIDNm

Fig. 7A. Patient 3. The preoperative shows normal function bilaterally.

Fmm

~KIonn

renogram

steadily and was discharged on the thirtieth postoperative day. A radioisotope renogram (Fig. 8C) on the twenty-second posthysterectomy day (12 days after drainage of the pelvic abscess and 4 days after abdominal drainage) was normal bilaterally. In the present instance, the pyelogram and rcnogram agreed that a bilateral ureteral obstructive lesion was present. The renogram reverted to normal promptly, though residue of the widespread pyogenic process undoubtedly some time junction

in the as well

Fig. 7B. Bilaterally abnormal rcnogram on the fifth postoperative day. Accumulation (A) is very high and prolonged on each side. Excretion (X) is delayed on each side, more so on the right than on the left. Renogram shows dysfunction which is suggestive of bilateral partial outflow obstruction. The sharp downward deflection (D) seen is where the sensitivity was momentarily cut to return the writer to the writing surface.

Km

Fig. 7C. Unilaterally abnormal renogram, approximately one month postoperative. The left renogram is within normal limits, showing definite improvement over the previous tracing. The right kidney exhibits a markedly prolonged accumuiation phase (A) and a slow excretion phase (X), being frankly abnormal and continuing to suggest partial outflow obstruction.

persisted for ureterovesical coneally.

RmtI rm

region of the as intraperi-

FL.,.

Imr

KILNEI

Rrcm

KIDNEr

Fig. 7D. Seventy-two days postoperatively, radioisotope renogram is normal on the left, probably within normal limits on the right.

the and

Comment

Ureteral complications of gynecologic diseases as well as ureteral injuries from gynecologic procedures are relatively common. In Solomons’ series’ a pyelographic diagwas made in 25 nosis of “hydronephrosis” per cent of the patients preoperatively. In Morrison’s patients this incidence was 14.5 Postoperatively 85 per cent of per cent.’ these patients had intravenous pyelograms which had reverted to normal. Three, or 33 per cent, of the 9 patients in our series who had abnormal preoperative renograms had normal patterns postoperatively.

1146

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fEpIur4m

Flanagan,

and

May 1, 1962 Am. J. Obst. & Gym.

Woodbury

T

RMIpiiJIWI

Fig. 8A. Patient 4. The renogram is normal bilaterally, despite the asymmetry of the curves. The changes since the previous tracing (Fig. 4) are the result of better probe placement.

L?m KDNEY Fig. 8C. The renogram days postoperatively.

modalities

of

ureteral

-i is

normal

Amm xmm bilaterally,

dysfunction

must

22

oc-

cur more often. Previous

LhTT KIDNSY

rim

KIIbvtiy

Fig. 8B. Bilaterally abnormal renogram on the fifth postoperative day. The vascular spikes are normal bilaterally. Accumulation (A) is extremely high and prolonged on each side. There is no excretory phase on either side. The sharp downward deflection (D) seen on the left is where the sensitivity was decreased for three minutes. Both tracings indicate a high degree of excretory dysfunction, presumably due to complete obstruction.

Because of the positions of the pelvic portions of the ureters, they are vulnerable to gynecologic disease and to injury during gynecologic operation.28 Consideration of this relationship led us to believe that, although “major” ureteral injury has been found to occur infrequently,l* 2 more subtle

investigations

to discover

the

true

incidence of silent ureteral injury following pelvic operations have utilized insensitive methods such as the intravenous pyelovisualization of gram I, p* Z!’ or cystoscopic the ureteral orifices following indigo carmine given intravenous1y.l” The incidence of clinically unrecognizable ureteral injury rcported by these methods ranged from 1 to 3 per cent. In Freda’s series of 310 patients,” a total of 31 failed to excrete indigo carmine to the level of the ureteral orifices in 15 minutes (the prescribed normal interval) . In 4 of these patients (1.3 per cent of the total series) ligated ureters were demonstrated by intravenous pyelogram. The pyelogram was normal in the remaining 27. Thus, Freda interpreted the rate of “silent” ureteral injury following pelvic surgery to be quite low. We wonder if his incidence of ureteral injury should not have been interpreted as 10 per cent, with the 27 patients having normal pyelograms in actuality suffering from ureteral dysfunction of a nature less severe than ligation. This dysfunction in Freda’s group was probably manifested by delayed excretion of dye, but was not evident in the intravenous pyelogram. In the present series, the incidence of urinary tract abnormality developing after op-

Volume Number

83 9

Ureteral

eration is 46 per cent. The renographic abnormalities which we noted were suggestive of intermittent and/or partial ureteral “obstruction.” This “obstruction” may be due to extrinsic pressure from abscess, hematoma, or suture. It may be intrinsic, due to ureteral edema or spasm. Denervation of the ureter as well as interruption of its blood and lymphatic vessels may play important roles, by producing ureteral atony. In all of the series noted thus far, including our own, the surgically induced injuries were for the most part temporary, with reversion to normal in the follow-up studies. However, caution is indicated in interpretation of this reversion to normal. It is not justified at present to presume that permanent changes are absent simply because they are not demonstrated by present techniques. Proportionately, there were more abnormal renograms following vaginal procedures than abdominal (7 followed 13 vaginal procedures as compared to 10 following 33 abdominal). This could well be related to the downward angulation of the ureters associated with uterine prolapse,3o which makes these structures more vulnerable to surgical trauma. In addition, there seems little doubt that vaginal procedures, while sparing the peritoneum and manipulation of the abdominal contents, sacrifice clear visualization of the course of the ureters. Twenty-one of our patients had preoperative intravenous pyelograms. Four, or 19 per cent, were abnormal. All 4 of these patients had abnormal renograms. Three other patients who had abnormal renograms had normal pyelograms. Thus, our results agree with those of others14, I53 31 that the radioisotope renogram is more sensitive than the intravenous pyelogram for the detection of renal functional abnormality. However, the

dysfunction

1147

range of “normal “variation” of renograms remains to be completely explored. There are many other uses for the radioisotope renogram in gynecology. These include evaluation and management of patients with malignancy, postoperative anuria,32 and ureteral obstruction resulting from pelvic disease.14 These will be subjects of future studies rising this new clinical and research tool. Summary

and

conclusions

1. Radioisotope renogram studies have been done on 50 gynecologic patients. Preand postoperative renograms were obtained in 46. 2. Abnormal preoperative renograms were detected in 9 patients who were later operated upon. In 3, the renogram reverted to normal in the postoperative period. 3. Ureteral dysfunction, suggestive of partial and/or intermittent obstruction and usually temporary, was found in 46 per cent of the patients in the postoperative period. 4. The radioisotope renogram provides a dynamic picture of the function of each kidney and ureter. It is a useful procedure in the evaluation of ureteral and renal dysfunction as related to gynecologic procedures. We wish to thank technical assistance

Mrs. Jolanta in this study.

Munch

for her

Addendum. Since this paper was presented, Wax and McDonald (J. A. M. A. 179: 140, 1962) have presented convincing evidence that the term “vascular spike” is a misnomer. These authors point out that part of the initial upupon functional activity of swing is dependent the kidney. Their observations do not appear to effect materially our interpretation of the graphs presented in this paper where ureteral function is the primary concern.

REFERENCES

1. 2. 3.

Solomons, 111: 41, Morrison, Emp. 67: Brack, C. Obst. &

E., et al.: Surg. Gynec. & Obst. 1960. J. I<.: J. Obst. & Gynaec. Brit. 66, 1960. B., Everett, H. S., and Dickson, R.: Gynec. 7: 196, 1956.

4. 5. 6.

Burns, B. C., Everett, H. S., and Brack, C. B.: AM. J. OBST. & GYNEC. 80: 997, 1960. Everett, H. S.: AM. J. OBST. & GYNEC. 38: 889, 1939. Everett, H. S., and Mattingly, R. F.: AM. J. OBST. & GYNEC. 71: 502, 1956.

1148

7. 8. 9. 10. 11. 12. 13. 14.

15. 16. 17.

18. 19. 20.

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Flanagan,

and

May 1, 1962 Am. J. Ohst. & Gynec.

Woodbury

Johnson, C. G., MOB, C. F.. and Post, L.: Anr. 1. OBST. & GYNEC. 71: 515. 1956. Bru&chwig, A., and Frick, H. C.: AM. J. OBST. Sr GYNEC. 72: 479, 1956. Liu, W., and Meigs, J. V.: A&r. J. OBST. & GYNEC. 69: 1, 1955. Falk, H. C., and Bunkin, I. A.: Obst. & Gynec. 4: 4, 1954. Thornton, W. N.: AM. J. OBST. & GYNEC. 67: 867, 1954. Freda, V. C., and Tacchi, D.: AM. J. ORST. & GY~c. 8i: 406, 1962. Winter. C. C.: T. Ural. 76: 182. 1956. Serratto, M., G;ayhack, J. T.,’ and Earle, D. P.: A. M. A. Arch. Int. Med. 103: 851, 1959. Straffon, R. A., and Garcia, A. M.: J. Ural. 83: 774, 1960. Miller, J, E., and Swindell, G. E.: J. ‘4. M. A. 170: 761, 1959. Quimby, E. H., Feitelberg, S., and Silver, S.: Radioisotopes in Clinical Practice, Philadelphia, 1958, Lea & Febiger. Winter. C. C.: 1. Ural. 78: 107. 1957. Flanagan, C. L.: Unpublished data. Gerbie, A. B., Flanagan, C. L., and Woodbury, I,.: Obst. & Gyncc. 18: 44, 1961.

31. ',', _-. :! 3 21. '5. 26. 27.

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3'.

Block. J. B., Hine, 0. J., and Burrows, B. A.: 1. Lab. & Clin. Med. 56: 110, 1960. Win&, C. C., Nordyke, R. .4.. and Tubis, M.: 1. Urol. 85: 92. 1961. Tap&r, G. V., et al.: J. Lab. Rr Clin. Med. 48: 886, 1956. Winter, C. C., and Taplin. G. ‘I’.: J, Ural. 79: 573, 1958. Saterborg, N-E: Acta radiol. 53: 433, 1960. Nordyke, R. A., Tubis, M., and Blahd, W. F.: J. Lab. & Clin. Med. 56: 438, 1960. Tubis, M., Posnick, E., and Nordyke, R. A.: Proc. Sot. Exper. Biol. Pr Med. 103: 497. 1960. Wharton, L. R.: Gynecology Including Frmale Urology, Philadelphia, 1947, W. 1~. Saunders Company. Conger, K., Beecham, C. T., and Horrax, ‘1. M.: Obst. & Gyncc. 3: 343, 1954. Lieberthal, F.. and Frankenthal, I,., Jr.: Surg. Gynec. & Obst. 73: 828, 1941. Winter. C. C., Maxwell, M. H., Richney. R. E.. and Kleeman, C. R.: J. Urol. 82: 674. 1959. O’Conor, V. J.. Jr., Libretti. J. V., and Grayhack, ,J. T.: ,J. Ural. 86: 276, 1961.

Discussion DR. CHARLES H. HENDRICKS, Cleveland, Ohio. The authors have reminded us once again that gynecologic surgery often is hazardous to the urinary drainage tracts, but also that all ureteral dysfunction is not produced by gynecologic surgery. Many of the lesions for which the gynecologist operates have already compromised the effectivrncss of the drainage systenI to some degree. To mention only a few examples, ovarian tumors, myomas, uterine dccervical carcinoma, and, rarely endocensus, metriosis, may damage ureteral function. The authors also have said, in sum, that the surgeon, by an operative procedure, may relieve me-existing ureteral malfunction, or may produce a malfunction at the time of operation. Finally, they have cautiously observed that, when a previously damaged ureter is shown by an> method now available to have been returned to supposedly “normal” function, there is still no assurance that complete recovery has actually taken place. It sounds at first paradoxical that this study on ureteral dysfunction should have been made by conducting a series of what are primarily renal function tests. Upon further reflection, however, we realize that currently, in cases in which ureteral pathology is suspected, the

amount of dysfunction is quantitated in somtdegree by tests of kidney fmlction. The radioisotope renogram has already provided helpful information. It would be even more valuable if it could be modified to permit the study to be done with the patient in the supine position (as has been tried by the authors and other workers with limited success), since it would become more feasible to study patients much earlier in the postoperative period. Thr method also needs to be further clarified in tht area of interpretation, as stated by the authors. One would be safe in predicting that it will be some time before this study technique is unequivocably accepted by all the hospitals which are at present doing intravenous pyelography. Furthermore, there appears little likelihood that this method, no matter how completely developed, will ever entirely replace intravenous pyelography. While awaiting acceptance of this new method in everyday practice, the technique can continur to serve a$ a useful investigative tool. If the posture problem can be solved, and if nror-c’ subtle indications for interpretation of the curvea can be evolved, this technique. even while being used only in a few institutions, can provide data of interest and value to all obstetricians arrd

Volume Number

83 9

Ureteral

gynecologists. We could hope to see demonstrations of the effect of posture on renal function, and whether any observed alterations were unilateral or bilateral. We could anticipate demonstrations of the acute effects of anesthesia upon renal function. We might learn the pattern of spontaneous variability of renal function in the partially dysfunctional ureter, and the pattern of recovery aftrr urcteral injury, or after an operation which has relieved some pre-existing ureteral obstruction.

DR.

position portable

(Closing). The remark about in part is solved because we use a machine. We can move it to the pa-

GEKBIE

dysfunction

1149

tient’s room. It is a bit cumbersome yet, bllt we can have the patient sit up in bed for the renogram. Although many do the renograms with the patient in the supine position, we have not found that the results are quite as reproducible. The other work that is being done on this particular problem is in dogs, particularly with both surgical ligation of the ureters and chemical induction of lowrr nephron nephrosis in making the differential diagnosis. It must be emphasized, as Dr. Hendricks has said, that the full normal range in the renogram is still to be determined. It should be considered just a laboratory test and an aid in the clinical diagnosis for whatever lesion is being studied.