Radiographic Evidence of the Association of Ureteral Stricture and Urinary Calculi1

RADIOGRAPHIC EVIDENCE OF THE ASSOCIATION OF URETERAL STRICTURE AND URINARY CALCULI1 GUY L. RUNNER From the Gynecological Department of the Johns Hop kins University and Hospital, Baltimore, Maryland

The presence of a calculus in the kidney or ureter is presumptive evidence of a coexistent ureteral stricture. Ureteral stricture is probably of blood-borne origin; hence, as one would anticipate under such circumstances, we find that it is practically always bilateral. The symptoms and many of the pathological changes which we formerly ascribed to the presence of a stone are probably more often the result of stasis due to the stricture. The foregoing conclusions founded on a fairly large experience help to illuminate several problems that have been the subject of much speculation by urologists and medical men in general. We can now explain in a more logical way such phenomena as "silent" stone, "reno-renal reflex," "calculous anuria" with a stone obstructing on one side only, bilateral stone, the frequent recurrence of stone on the side operated upon, the frequent postoperative development of stone on the opposite side, the recurrence of symptoms soon after operation, the recurrence of symptoms after a ureteral stone has passed, the persistence of a sinus after operation, the problem of emergency operations, the problem of renal and ureteral calculus in the aged,· operations for supposed ureteral stones that cannot be found, and the phenomenon of migrating stone. The so-called "silent" stones are rarely silent. The case is stated more accurately by saying that many stones are silent, but 1 Read at the thirty-seventh annual session of the Southern Surgical Association, Charleston, S. C ., December 9, 1924.

497 THE JOURNAL OF 'C'ROLOGY, VOL , XIII, NO.

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GUY L. RUNNER

that the accompanying ureteral stricture is not often without symptoms. Although the stricture may fail to cause renal colic, it often gives rise to discomfort in the back, in the urinary or in the gastrointestinal tracts sufficient to call for the x-ray examination which to our surprise discloses the presence of the stone (case 1, fig. 1). The so-called "reno-renal reflex" or reference of pain to the side opposite the one bearing a renal or ureteral stone may occur, but this phenomenon of bilateral pain or of pain only on the side without calculus should suggest at once an examination for bilateral stricture. Reflex anuria, heretofore considered a nervous phenomenon, will likewise be found in most instances to be due to bilateral stricture, and to depend on actual physical changes in the narrowed areas of both ureters. We frequently see temporary anuria affecting both sides after we have passed a renal catheter to one kidney. This is probably a nervous phenomenon, and I have seen it last for ten, twenty, or thirty minutes at the most. When complete anuria persists for hours or days, and investigation reveals a stone in one ureter, this usually means, (1) that there is only one kidney and that this is blocked by the stone (see case 2, fig. 2); or, (2) that some influence is at work which has caused edema and closure of bilateral stricture areas (see case 3, figs. 3 to 6). At times this prolonged anuria follows the manipulation of a ureteral stone on one side, and its persistence usually means that our manipulations have changed the position of the stone or caused a surrounding edema which has effected a complete block on that side, and that the traumatic edema has crossed the trigonum and implicated the stricture of the opposite side sufficiently to cause a complete block. We not infrequently see a similar phenomenon in cases without calculus. The patient may have suffered for years with symptoms due to a stricture on one side. After the first investigation of that side the patient may experience the first symptoms she has ever had on the opposite side, and indeed these may overshadow the pain on the investigated side and cause much

URETERAL STRICTURE AND URINARY CALCULI

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apprehension and fear that the surgeon has made some serious error, until the modus operandi has been explained to the patient. The two sides are usually treated with an interval of forty-eight hours, and in cases with this bilateral reaction one finds at the end of this period much traumatic redness and edema about the ureter first catheterized, and not infrequently edema and submucous hemorrhage extending across the entire trigonum and surrounding the orifice of the untreated ureter, which at the first examination may have appeared practically normal. The bilateral character of stricture helps to account for the relatively high incidence of bilateral stone. With unilateral stone the opposite side is seldom normal (case 4, figs. 7 and 8). The side on which there is a calculus either in the kidney or ureter may be doing the best work, whereas the one without calculus may have failed to develop symptoms, and yet may present varying grades of renal destruction. The side with calculus may be practically "dead" and the side without calculus may show a fairly high functional value, which can usually be raised to a considerable degree after the establishment of better drainage by dilatation of the ureteral stricture (case 5, figs. 9 and 10). If both kidneys contain stone and if both show very low function, one of them registering near zero, both can often be markedly improved before operation by instituting better drainage; so that after operation, the kidney previously functioning at about zero, may be found doing more work than was previously being done by both kidneys before operation (case 6, figs. 11 to 15). The etiology of urinary calculus formation has been discussed in previous publications, in which we have weighed the evidence for and against such theories as the chemical, or faulty metabolism, the microbic infection, and the mechanical or urinary stasis theory. We are forced to conclude that no single theory is all-sufficient for the explanation of such a complicated problem as that of calculus formation, but if we can demonstrate the presence of ureteral stricture in approximately 100 per cent of patients with stone in the kidney or ureter, it is evident that those interested in this problem from the etiological viewpoint have a new angle from which bearings may be taken.

500

GUY L. RUNNER

The most fruitful aspect of this discovery lies in its bearing on the therapeutics of urinary calculus. Now, if we recognize the symptoms of ureteral stricture in their incipiency we are going at once to institute proper procedures and thus reduce the incidence of stone formation. This early treatment includes thorough dilatation of the stricture with restoration of normal drainage, and the eradication of focal infection areas to prevent a recurrent irritation of the stricture area with its consequent shrinkage and urinary stasis. The care of the focal infection area will also safeguard against future direct injury to the kidney substance and the mucous membranes of the tract which is probably a frequent factor in stone formation. With the knowledge gained from the study of ureteral stricture and the part it plays in the patient's symptoms, in the future we shall seldom operate as an emergency measure on patients who are desperately ill from the alleged effects of a stone in the ureter or kidney. By instituting proper drainage with the ureteral catheter and dilators we can in most instances tide over the emergency and choose our own time for operation, if it should become necessary later on. This temporary or permanent avoidance of operation while we are improving the patient's condition through the restoration of ureteral drainage is very valuable in many conditions other than the acute emergencies just mentioned. In children who are poor operative risks at best, and especially poor risks after months of suffering from the effects of stricture and stone, we can well afford to drain by the ureteral route first and delay operation for weeks or months if they continue to gain in weight, hemoglobin, and general well-being (case 7, figs. 16 to 19). In pregnant women we do not add the risks of a stone operation if ureteral dilatation gives the required relief from serious symptoms (see case 8, figs. 20 to 23). To the man or woman of large business affairs, to the busy professional man, to the farmer in the midst of saving his crops, and indeed to the man or woman in almost any walk of life it may mean a great deal from the economic standpoint, if, instead

URETERAL STRICTURE AND URINARY CALCULI

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of being railroaded to an operation of supposed immediate necessity, they can by ureteral drainage be relieved of symptoms and put in a condition of improving health until they can find a convenient time for their hospital and convalescent period (case 9, figs. 24 to 26). Every surgeon of wide experience knows with what misgivings he reviews the x-ray film of recurring stone (case 10, figs. 27 and 28). Shall he operate again, knowing that another recurrence is practically certain? We now know that the likelihood of recurrence is greatly reduced if before operation we establish good ureteral drainage; and, moreover, experience has demonstrated the value of attention to focal infections as a part of this prophylactic program. Another serious problem confronts the surgeon when he has to decide whether or not to operate in cases of large bilateral stones accompanied by very low kidney function. By first establishing good ureteral drainage one often finds that one or both kidneys have a distinct power for recovery and the question of operation and its extent will vary with the patient's age, the degree to which the kidney recovers after ureteral drainage, and to other details which present themselves in the individual case (case 1, fig. 1). Because of their intense suffering surgeons have been obliged at times to operate for calculus on patients whose advanced age and precarious general health have made the operation extremely hazardous, if not practically hopeless. We know that some of these patients are freed from their pain and show a great improvement in general health after the establishment of ureteral drainage (case 11, figs. 29 and 30). Formerly many useless operations were done for a supposed stone in the ureter on the strength of the symptoms and the demonstration by the x-ray of an opaque shadow in the region of the ureter. We now know that ureteral stricture is far more common than ureteral calculus, that the symptoms of the two conditions are often identical, and that calcified glands and venous phleboliths in the neighborhood of an ureteral stricture are of frequent occurrence. Occasionally the physician is puzzled by the patient who corn-

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GUY L. RUNNER

plains of symptoms very suggestive of ureteral calculus, and in whom the x-ray picture reveals a small shadow in the region of the ureter on the symptomless side. Such a patient should be carefully examined for bilateral stricture, and the wax-tipped and wax-bulbed catheter will settle the question as to whether the shadow on the symptomless side represents a stone inside or outside the ureter (case 12, fig. 31). The much discussed phenomenon of migrating stone finds a logical explanation in the associated presence of ureteral stricture. A stone forming in a stricture area may help to develop sufficient hydraulic pressure to force it downward to another stricture area or to any area in the lower ureter; or it may go through to the bladder. It may help to increase the dilatation of the upper tract already begun by the stasis of the stricture, and this dilatation may affect the upper portion of the stricture area so that the stone is set free and can migrate in the widened tract above. The stone may retain its original size and change position with the varying posture of its host. It may take on new accretions and become trapped in a calyx or in the pelvis; or it may begin a descent and, because of its increased size, it may be stranded in some portion of the ureter above the original site of its formation (case 13, figs. 32 to 36). The illustrations are submitted as visible evidence that ureteral stricture is an associated lesion in most of our cases of calculus in the upper urinary tract. In spite of the skepticism of most urologists we still find that the renal catheter with a wax-bulb is the simplest, most accurate, and most efficient method for the diagnosi::,, study, and treatment of ureteral stricture; but in view of the natural conservatism over the acceptance of a new idea which threatens a revolution in former methods of dealing with an important problem, it becomes necessary to present visible evidence of the truth of our thesis. If space permitted, this evidence could be abundantly duplicated, but it is hoped that these few radiograms are sufficiently convincing at least to excite an investigation. Careful examination of a few patients is certain to convince any surgeon that in most cases radiographic evidence of a cal-

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culus in the urinary tract is no longer the signal for an immediate operation; but is rather a sign that he has on his hands an intricate drainage problem requiring careful study of the bilateral upper urinary tract, with special reference to the condition of the ureters, and that pathological conditions in the ureter may in turn demand an investigation of the possibility of focal infection as the underlying cause. Such a careful bilateral investigation not infrequently reveals the surprising knowledge that the side bearing a renal or ureteral calculus is doing the major work, although the other side may have been symptomless. By establishing good drainage on

FIG.

1.

CASE

1.

BILATERAL URETERAL STlUCTlIRE.

BILATERAL "SILENT"

STONES

Note the immense kidney stone shadows, the two large ureternl stones near the kidney on the left and the large stone in the right ureter above the pelvic brim.

both sides we get the patient in much better condition for operation, we know something about the possibilities of recovery of function in each kidney, a valuable guide as to what should be done at the operation; and, furthermore, ,ve greatly lessen the danger of recurring stone on the side operated upon, and of future development of stone on the opposite side. Case 1. (Fig. 1.) Illustrates the occurrence of silent stones, and the advantages of conservative treatment in some extreme cases. Mrs. B. was first seen in 1912 when she was twenty-six years of age. She had suffered from backache and renal colics for seven years, having

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GUY L. RUNNER

passed a urinary calculus four years previously, and another calculus during a severe left side colic attack eighteen months before she came to us. Investigation revealed in the right ureter a renal calculus, about 2 cm. long by 15 mm. in diameter, in a stricture area 3 cm. below the pelvic brim. At operation another stricture area, situated about 3 cm. below the stone, was found to be so massive and dense that it was cut into to exclude the presence of a stone. The right kidney held 100 cc. and the left kidney was hydronephrotic. This was before the use of the wax bulb and stricture was not diagnosed on the left, although the previous history of a stone passing from this side with our present knowledge would suggest stricture. The patient was warned to report at once if she again developed backache or colics. She returned to the dispensary eight years later, in 1920, complaining of gastro-intestinal symptoms and the routine examination revealed the immense calculus shadows seen in figure 1. Thorough dilatation of stricture areas in the lower portion of the ureters resulted in considerable improvement in her general health, in her phthalein output, and in the gastro-intestinal symptoms. A few months later the patient was operated upon at another hospital and died soon after. Case 2. (Fig. 2.) Illustrates complete anuria of fifty-five hours' duration, due to complete block by stricture and stone in a monorenal patient. It also illustrates that stricture may be present and cause typical symptoms of calculus many years before a stone forms. Mrs. S., aged forty-two, admitted to the Hebrew Hospital February 10, 1920, after twenty-four hours of complete anuria. The roentgenogram (fig. 2) shows a small stone in the right ureter just below the pelvic brim. The family refused operation and took the patient home. The following day the patient entered the Woman's Hospital with terrific headaches, slow mental reaction, svyollen face with some general anasarca, urinous breath, and a blood pressure of only 128. She was operated upon after fifty-five hours of anuria. The stone could not be dislodged upward until the musculature in t he stricture area had been incised down to the submucosa. The stone was t hen massaged upward out of t he stricture area to the dilated portion at the pelvic brim, fixed between the thumb and finger, and delivered through a small incision. The urine was under such tension that it spurted up out of the abdominal wound and apparently there was an escape of several ounces. Dilating bougies up to 18 Fr. were t hen passed into the bladder

URETERAL STRICTURE AND URINARY CALCULI

505

dilating the stricture which held the stone, and a second lower stricture in the broad ligament region. The ureteral incision was left open for drainage. Within four days most of the urine was passing through the bladder, and the patient's mental and physical condition had returned to practically normal. Dr. Howard A. Keliy had operated on this patient in 1907, removing a large stone transvesically from the lower end of the left ureter. Such thick purulent urine came down from the dilated upper ureter that he decided on an immediate left nephrectomy. About two months later

Fm. 2. CASE 2. MoNORENAL CAsE, TOTAL ANURIA FIFTY-FIVE HouRs Note the si:nall stone shadow just below the right pelvic brim. Note phle· bolith in broad ligament, where a second stricture was demonstrated at operation.

the patient was admitted to the hospital with an attack of acute renal accompanied by hematuria. It was thought she colic on the right must have a stone in the right ureter but x-rays and the passage of a catheter gave negative findings. Vlax bulbs for the detection of stricture were not being used at that time. Case 3. 3 to 6.) Illustrates reflex anuria after disturbance of the non-calculous ureter. It also illustrates "silent" stone in the right kidney and marked destruction of this without pain in the renal

Fm. 3 Fm. 3.

Fm. 4

3.

SHOWING CATHETER IN RIGHT SIDE, WITHDRAWN 1JNTIL THE

BULB, PLACED

10 CM. BACK OF THE END, HAD JUMPED THROUGH SEVERAL

CASE

STRICTURE AREAS AND WAS HANGING IN AN AREA SLIGHTLY DILATED URETER ABOVE THE

2.5

PELVIC

STONE SHADOWS IN LOWER LEFT URETER.

C1I. ABOVE THE BLADDER.

BRIM.

SEVERAL

Two

CONTIGUOUS

PHLEBOLITHS IN THE

LEFT BROAD LIGAMEC'fT REGION

Fm. 4.

3.

CAsE

STONE IN THE LEFT URETER ROLLED BY THE CATHETER

FROM !TS BED IN THE BROAD LIGAMENT REGION UP TO A POINT NEAR THE KIDNEY.

SHADOW OF UNSUSPECTED STONE

IN THE RIGHT KIDNEY

Fm. 5.

Fm. 5 3. BrFID

CASE

Fm. 6 TYPE OF LEFT KIDNEY PELVIS WITH MODERATELY

DILATED PELVIS AND UPPER URE'J'ER HOLDING

24 cc.

STONE

IN RIGHT KIDNEY

Fm. 6.

CASE

3.

IMMENSE RIGHT KIDNEY PELVIS AND ENLARGED UPPER

URETER HOLDING

140

CC.

No

PAIN IN RIGHT KIDNEY REGION IS

SPITE OF THIS H YDRONEPHROSIS AND

506

l TS

CONTAINED STO.'sE

URETERAL STRICTURE AND URINARY CALCULI

507

Mrs. P., aged forty-five years, at intervals for about two years has noticed a pain in the lower right quadrant just within the anterior superior spine. A pain began ten days ago in the lower left quadrant exactly like that on the right side, but much more severe, and working up into the posterior left flank. There has never been any pain in the upper right flank. No bladder symptoms. The patient brought an x-ray report stating that there was a fairly large shadow located in the region of the lower end of the right ureter. The urine was negative except for an occasional leukocyte. Because of the x-ray report I investigated the right side first. There were no scratch marks on the wax tip or bulb, but the bulb located multiple infiltration areas in the lower portion of the right ureter. The kidney pelvis held 140 cc. of fluid (see figure 6, taken later). The first plate (fig. 3) showed the shadow of two contiguous stones in the lower left ureteral region and several smaller shadows (phleboliths) in the broad ligament region. After this examination the patient had total anuria for thirty-six hours. Eight days later the left side was examined. The entering catheter was felt to displace a stone and a distinct jumping sensation was felt as the catheter rolled the stone toward the upper ureter (fig. 4). Because of the tendency to anuria, and the evidence that the left side was probably doing most of the work, I did not think it wise to attempt to get the left ureteral stones to pass. These were removed September 21, 1922. On October 10 the two-hour intramuscular phthalein test yielded 14 per cent. On October 31, a half-hour intravenous test with a catheter in the left kidney yielded: LEFT

Appearance time ....... . :First 15 minutes ... . Second 15 minutes.

15 minutes 25 per cent 12 per cent

RIGH'I

(TRAKSVESICAL)

19 minutes 5 per cent 10 per cent

Case 4. (Figs. 7 and 8.) Illustrates bilateral stricture with ureteral stone on the left side. There was bilateral hydronephrosis of fairly marked degree with remarkably few characteristic symptoms. Mrs. H., aged thirty-one, referred in February, 1922, by Dr. "W. S. Robertson of Charleston, W. Va., who sent the x-ray film (fig. 7). From the tortuous course of the catheter in the right ureter I predicted that stricture and hydronephrosis would be found on that side, although Dr. Robertson reported the easy passage of his x-ray catheter. After the patient returned home Dr. Robertson took the bilateral pyelo-

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GUY L. RUNNER

ureterogram (fig. 8), and dilated the stricture on the right side. The patient thinks she had one symptomless attack of hematuria before her third pregnancy. With this pregnancy, five years ago, she had five or six periods of hematuria, each beginning and ceasing suddenly and each lasting one to two days with entire absence of pain or bladder symptoms. During her fourth pregnancy in the summer of 1921 she

FIG. 7

FIG. 8 FIG. 7. CASE 4 Note t he calculus in the lower end of the left ureter, and the dense infiltration area immediately above the calculus almost obliterating the ureteral lumen. Note the enlarged ureter above the stricture, and the left kidney pelvis with a capacity of about 40 cc. FIG. 8.

CASE

4.

PYELOURETEROGRAM NINE WEEKS AFTER LEFT U RETERO-

LITHOTOMY WITH THOROUGH DILATATION OF THE STRICTURE AREA

Note the more normal contour of the left pelvis and calices due to good draina.ge. Compare figure 7. Note the larger kidney pelvis on t he right side where there h ad b een no symptoms.

again had about six att acks of hematuria like those of t he previous pregnancy except that the later ones were accompanied by some pain. Since the childbirth, four months ago, the patient has not had hematuria but in the past three weeks she has suffered with four renal colic attacks, the pain being located entirely in t he left kidney region, not radiating downward and not accompanied by bladder symptoms.

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509

Case 5. (Figs. 9 and 10.) Illustrates bilateral stricture, a large hydronephrosis on right, sterile, symptomless; large calculi on the left, sterile. She had had left renal colics for ten years. Ureteral dilatations for one month relieved all symptoms, and resulted in an increase of phthalein output on the right side from 40 to 65 per cent, but the left kidney remained stationary, with an output of only a trace. Left nephrectomy.

Frn. 9

Fm.IO FIG. 9. CASE 5 Note the multiple calculi in the left kidney. Note the right ureteral stricture about 3 cm. above the bladder, and the dilated ureter and kidney pelvis holding 55 cc., but never presenting symptoms. FIG. 10. CASE 5 Note the left stricture in an area symmetrical with that on the right side (see figure 9) and the dilated ureter above this point.

Miss P., aged nineteen years, entered the obstetrical department at the Johns Hopkins Hospital in February, 1924, and had an uneventful delivery of a full-term child. She entered the gynecological department in September, 1924, complaining of a more or less continuous dull pain in the left upper abdominal quadrant and of intermittent sharp attacks of pain in the left kidney region which she had had for ten years. She had never had bladder symptoms except some frequency during her pregnancy. She had noticed pus in the urine for several years, but had never seen any blood.

-- ------------- --

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Case 6. (Figs. 11 to 15.) Illustrates bilateral stricture, stone in the bladder wall portion of the right ureter, bilateral renal calcareous masses. A two-hour phthalein output on admission was only 7 per cent, all being secreted by the left side. On dismissal the output in one hour was: Right side 7 per cent; left side 28 per cent. Mrs. G., aged twenty-six years, has suffered with soreness through the upper abdomen as long as she can remember. For several years has had agonizing pain in the upper right quadrant and a nagging

FIG . 11. CASE 6 Note the large ureteral stone near the bladder on the right side. This was first removed through the Kelly cystoscope. Note the multiple phleboliths or calcified lymph glands in both broad ligament regions. Note the large mucocalcareous masses in both kidneys.

burning raw feeling, which was thought to be an ovarian pain, in the lower left quadrant. Nine months ago passed three small stones during agonizing attacks on the left side. There has been considerable loss in weight. The patient has grown dependent on morphin. After removal of the right ureteral stone and the dilatation of stricture areas in both ureters the pain and soreness almost disappeared from the right kidney region, but the nagging soreness in the region of the lower left ureter persisted. The preoperative dilatations occupied one month after which the two-hour phthalein output had risen to 14 per cent,

FIG.

Fm. 12 Fm. 13 12. CASE 6.- PLAIN FILM THREE WEEKS AFTER LEFT PYELOLITHOTOMY Note absence of stones in left kidney, and large masses in right kidney

Fm.

·rn.

CAsE

6.

LEFT PYELouRETEROGRAM SHoWING STRICTURE AREA

IN BROAD LIGAMENT REGION, SLIGHTLY DILATED URETER ONLY PARTIALLY FILLED, AND LARGE PELVIS AND CALICES

Note lumbar drainage tube still present in right kidney and several calcareous particles in the lower pelviA and calices.

Frn.M

~G.ffi

14. CASE 6. PLAIN FILM FouR WEEKS AFTER FrnuRE 13 Note one small stone particle in lower calyx. With each of several dilatations the large wax bulb had brought away several stone particles which had descended from the pelvis to the stricture area. Fm. 15. CASE 6 Taken same day as figure 14. Note stricture area at iliac gland region, and dilated upper ureter and pelvis. Note small stone shadow in lower calyx. Urine had become clear from both kidneys and this right kidney formerly at zero was secreting in one hour 7 per cent of phthalein, or as much as both kidneys were secreting in two hours on patient's admission. Fm.

511

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GUY L. RUNNER

the -right side still secreting only a trace. The left kidney was first operated on and one month later the right kidney. The patient was under observation and treatment five months, and was discharged quite free from pain, freed from the morphin habit, and with normal weight. Case 7. (Figs. 16 to 19.) Illustrates the advantage in children of establishing ureteral drainage and waiting to build up the general health before operating. Baby W., aged two years and nine months, was admitted to the Harriet Lane Home in January, 1924. The patient had been very ill for eighteen months with a constant fever around 100° to 101°, with higher exacerbations, marked gastro-intestinal disturbance and pyuria. No bladder symptoms. On admission she was markedly under weight, hemoglobin 47 per cent, leukocytes 20,000, temperature reaching 101 ° daily. The radiogram (fig. 16) revealed a large stone with smaller shadows in each kidney. Investigation of the left side with a renal catheter and an 8 Fr. bulb revealed a definite scar tissue hang of the bulb at a point estimated to be between one and two centimeters above the ureter al orifice. The differential functional test showed 5 per cent of phthalein in fifteen minutes from the left kidney, and only a trace transvesically from the right side. I advised dilatation of the right ureter to be followed by an interval of a few weeks for the child to improve before operation, but the anxious parents being averse to further anesthesias for mere preliminary treatments, I was obliged to take the risks of an early operation. I did this the more readily because of the position and shape of the large stone on the right side indicating that it was probably acting as a ball-valve in the upper ureter, and, if so, the dilatation of the lower ureter would probably not be of great value. Through a pyelotomy incision over the large stone this was removed and the small stone in the lower calyx was easily found and removed, but the medium-sized stone in the upper kidney could not be located, in spite of three counter openings made through thin areas in the cortex by plunging small forceps from within the pelvis. The precarious condition of the patient did not warrant a prolonged search. Before draining I passed two No. 6 catheters loaded with wax bulbs of sizes respectively 10 and 12 Fr., placed near the tip of the catheter, from the pelvic opening down into the bladder. There was a firm hang of each bulb coming back at a point 10 cm. below the kidney pelvis which I estimated to be in or near the vesical portion of the ureter. Four weeks after operation the child was again anesthetized and a 13 Fr. bulb was passed

Fm.

16.

Frn.16 7. PLAIN

CASE

Fm.

17

FILM SHOWING ONE LARGE AND Two SMALLER

CALCULI IN EACH KIDNEY OF A CHILD Two YEARS AND NINE MONTHS OLD FIG.

17.

CASE

7.

PYELOURETER'OGRAM LEFT SIDE, SHOWING STRICTURE

AREA IN BROAD LIGAMENT REGION, AND IMMENSELY DILATED LEFT URETER

Note medium-sized calculus in upper right kidney not found at operation.

Frn.18 Fm.

18.

CASE

Frn.19 7.

PLAIN FILM TAKEN TEN MONTHS AFTER RIGHT PYELOLITHOTOMY

Note extension of prongs of stone in left kidney. in size of stone left in right kidney. Fm.

19.

CASE

7.

No appreciable increase

RIGHT PYELOURETEROGRAM SHOWING STRICTURE AREA

IN BROAD LIGAMENT REGION AND DILATED URETER AND KIDNEY PELVIS

Note stone particles left in calices of left kidney

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GUY L . RUNNER

on the right side and had a definite hang in the broad ligament region. One week later the left side was dilated with a bulb of 11 Fr. size and the pyeloureterogram, shown in figure 17, was taken. The patient was then sent home to recuperate and to return for operation on the left side in the fall . During the summer she had but one renal colic, and this was synchronous with an attack of mumps. At this time she developed fever, pain and tenderness in the left kidney region and intermittent hematuria of a few days' duration. On her return in November her weight was within one pound of the normal ideal, the hemoglobin was 60 per cent, and the two-hour phthalein output was 66 per cent. The stone which we had missed on the right side had not grown appreciably, and the large stone on the left had apparently extended its prongs slightly (see fig. 18). At the operation the large stone was carefully removed through a pyelotomy incision, and some small particles were located and removed. Fearing that some of the prong tips had been left, I made two counter openings through thin areas in the cortex and a thorough salt solution irrigation was made, but figure 19 shows that some particles were left. The parents have been advised to return with the child for annual investigations with x-ray, functional tests, etc., and for dilatation of each ureter if this seems indicated. Case 8. (Figs. 20 to 23.) Illustrates the advantages in pregnancy of establishing good ureteral drainage and deferring the stone operation. Mrs. D., aged thirty-one years, seen in consultation with Dr. Lazenby, February 2, 1921, because of symptoms of an acute pyelitis developing in the third month of her fourth pregnancy. Soon after her marriage Dr. Lazenpy had operated for an acute appendicitis, and at this time he discove}ed acute gonorrheal pus tubes which were stripped and left in situ. Her first child was born within one year. Two years ago she had her first kidney symptoms, passing a small stone from the right ureter. She soon became pregnant, and in the fifth month she developed symptoms of pyelitis on the left side. Investigation with a wax-tipped and wax-bulbed catheter revealed a left colon bacillus pyelitis; and the bulb had a hang as from stricture, and both wax bulb and tip were scratched, showing the presence of a stone in the ureter. The patient was so weak that the pregnancy was terminated, and when she sat up after the delivery a large left ureteral stone was passed, in January, 1920. In December, 1920, she developed a severe pyelitis on the right side and investigation revealed bilateral stricture, with bilateral pyelitis

20 Fm. 21 20. CAsE 8. THREE MoNTHS PREGNANCY Pyelitis symptoms left side. Left pyeloureterogram February 2, 1921, showing stricture in broad ligament region, and upper tract holding 15 cc. Note calculus in right kidney. Bilateral colon bacillus infection. Fm. 21. CASE 8. PLAIN FILM, AuGusT 17, 1922 Compare figure 20, taken eighteen months previously Fm.

Fm.

FIG. FIG.

22.

CASE

8.

22

Fm.

23

PYELOURETEROGRAM, SHOWING RIGHT URETERAL STRIC-

TURE AND MucH DILATED URETER, WITH THE So-CALLED URETERAL KINKS IN ABDOMINAL PORTION

A pyeloureterogram taken one month after operation duplicated these ureteral ''kinks.'' FIG. 23. CASE 8. RIGHT PYELOURETEROGRAM TAKEN THREE MONTHS

r

I

AFTER OPERATION

Note absence of ureteral "kinks" after the patient had gained 20 pounds in weight and thus replaced her kidney. Compare figure 22. 515

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GUY L. RUNNER

and a stone in the right kidney. After two dilatations on each side the pyelitis symptoms ceased, to reappear on the left side two months later when it was discovered that she was nearly three months pregnant. I first saw the patient at this time and obtained the pyeloureterogram shown in figure 20. As the patient had but one living child and was anxious to carry to term, we made wide dilatations of each ureter, after which the symptoms of pyelitis promptly disappeared. At seven and one-half months mild uremic symptoms developed and Dr. Lazenby promptly performed Caesarian, _section with a successful outcome for the mother, but the child living only six hours. The patient seemed to progress favorably for a year, and then began to complain of dizziness, nausea, chills, and night sweats, and soon developed tenderness

FIG.

24.

CASE

9.

PLAIN FILM SHOWING LARGE POROUS STONE IN LE FT

PELVIS AND SMALLER STONE PARTICL ES IN LOWER CALICES

over the right kidney. Investigation showed that t he right kidney stone had about doubled in size in the previous eighteen months (compare figs. 20 and 21). A differential functional test (figures unfort unately lost) showed the right kidney to be doing the best work. A two-hour functional test showed an output of 45 per cent. The right kidney stone was removed through an incision in t he pelvis extending through the kidney cortex into the lower calices (see post-operative fig. 23). Case 9. (Figs. 24 to 26.) Illustrates the advantages, in certain cases formerly considered as surgical emergencies, of being able to allow t he patient to choose a conveni ent time for the operation.

URETERAL STRICTURE AND URINARY CALCULI

517

Miss W., aged sixty, holding an important position in a girls' finishing school in Washington, was taken suddenly in September, 1922, with an attack of left renal colic with chills, high fever and pyuria. Her school year was to begin in about ten days and from her past history we suggested that her attack might be due to stone and that she might require an operation. When she pictured what this would mean to her and to her school organization we promised to investigate and, if possible, allow her to defer the decision as to radical treatment until the end of the school year.

Fm. 26 F10. 25 FIG. 25. CASE 9. PLAIN FILM SEVEN WEEKS AFTER OPERATION Note two stone particles left in lower calyx. Urine normal FIG.

26.

CASE

9.

LEFT PYEL0URETER0GRAM TAKEN SAME DAY AS

FIGURE 25 Another pyeloureterogram taken at this time duplicated the two stricture areas in the lower ureter with the slight dilatation between the strictures.

Investigation showed definite multiple strictures on the right side with no evidence of inflammation in that kidney. The left kidney urine yielded pus, no scratch marks on the wax tip, and no appreciable hang of the 4 mm. wax bulb. In spite of the negative wax bulb test on the left the pyelitis on that side and the definite evidence of strictures on the right side made it probable that a larger bulb would show infiltration areas on the left. After these tests her condition improved rapidly, she took up her school duties on time, and on her return for a

518

GUY L . RUNNER

complete investigation in June, 1923, she said she felt like a fool for coming back to the hospital after enjoying for nine months t he best health she had experienced for several years. H er previous history included four severe colic attacks on the left side, one in about 1893 when she was supposed to have passed a stone, one in 1900, and two in 1914. The att~cks subsequent to the first were supposed to be "intestinal or mucous colitis spells." Pus was found in the urine in a routine medical examination before she sailed for Europe in 1921. She had noticed for some months before her 1922 attack that her mind seemed to function slowly. The complete examination, in June, 1923, revealed bilateral ureteral stricture, with calcareous masses in the left kidney (fig. 24). Her post-operative recovery was rapid and unevent ful. Her two-hour phthalein test before operation showed 32 per cent, two weeks after operation 38 per cent, and twenty-four days after operation 45 per cent. The blood pressure before operation was 160/ 85 and twentyfour days after operation 118/ 65. Five weeks after operation the urine was free from pus and negative to culture, in spite of the two tiny stone particles left in the lower calyx (figs. 25 and 26). Case 10. (Figs. 27 and 28.) Illustrates recurring renal calculi (bilateral); bilateral ureteral stricture; recurring ureteral calculi during treatment; complete relief from symptoms and marked gain in weight and general health after ureteral dilatations. She still retains her renal calculi after a period of five years. Miss F., aged sixteen years, seen with Dr. George Walker in April, 1921. She had had stones removed from one kidney in June, 1920, and from the other in September, 1920. In December, 1920, she had a very severe attack of pain in the left side, with a t emperature of 105°F., and passed five stones. In March, 1921, she again developed general malaise and fever and was in bed three weeks before consulting Dr. Walker. Both Dr. Walker and I feel t hat in such a young person the kidney stones should be removed because of their possible damage to the kidney substance, but t he patient is enjoying excellent health and refuses operation. Case 11. (Figs. 29 and 30.) Illustrates the value of ureteral drainage in the aged and infirm. Mrs. N ., aged sixty-four, first seen in April, 1922, complaining chiefly of severe lumbar backache, dysentery (mucous colitis), and a feeling of pressure and sagging in t he pelvis. She had never had bladder symp-

------·- - - - - - - - - - - - - - - - ~

URETERAL STRICTURE AND URINARY CALCULI

519

toms. At about thirty-five years of age she had inflammatory articular rheumatism for about three years and at that time she was having much dental trouble. The pelvic organs were removed at forty-five because of profuse bleeding for seven or eight years previously. The patient was extremely emaciated and weak and she was living on a markedly deficient diet. There was general visceroptosis, the left kidney was not palpable, but she was tender in that region, and quite tender over the palpable right kidney. Both ureters were.· tender at the pelvic brim, and ureteral palpation in the broad ligament regions elicited much tenderness, and her old sensation of prolapse of the pelvic organs and rectal pressure. The urine showed much albumin, and an occasional

FIG.

27

FIG. Fm.

27.

CASE

28

10

A preliminary plain plate showed two large stone masses lying rather far apart in each kidney. FIG.

28.

CASE

10.

RIGHT PYELOURETEROGRAM

Note the upper stricture area located just below the pelvic brim and the widely dilated ureter and kidney pelvis above. Note the two stone shadows, one in the upper stricture and one below. These two stones passed after the first dilatation. After each of the succeeding two dilatations of this ureter a small calculus passed. These may have been ureteral calculi forming in the stricture areas between treatments or particles descending from the kidney.

520

GUY L. RUNNER

leukocyte; the culture was negative. Urological investigation showed bilateral ureteral stricture, the left pelvis holding 15 cc. and the right containing two stone shadows (fig. 29). Gastro-intestinal investigation by Dr. Thomas R. Brown showed marked hyperchlorhydria and a true mucous colitis, but without occult blood. Dr. Brown placed her on antacid treatment and a more liberal but carefully selected diet. Each

Fm. 29 .

CASE

11.

BILATERAL URETERAL STRICTURE

Urine-a few leukocytes, negative to culture. Two stone shadows in right kidney . Left pyeloureterogram, no appreciable dilatation left ureter, left hydronephrosis of 15 cc . Fm . 30.

CASE

11

Taken one year after figure 28. Right pyeloureterogram, showing stricture area in right broad ligament region, with slight dilatation of the ureter. A plain film showed no increase in size of stones. Note phleboliths in both broad ligament regions .

of the early ureteral dilatations were very prostrating and markedly stirred up her mucous colitis. In spite of this she improved steadily. On her second visit in January, 1923, the differential functional test showed an appearance time from each side, after intravenous injection of phthalein, of seven minutes, with a half-hour test showing from

URETERAL STRICTURE AND URINARY CALCULI

521

the right side 7.5 per cent and from the left 10 per cent. On her third visit in January, 1924, the test showed appearance time, each side three minutes, right 11.5 per cent, left 20 per cent. She was free from backache, able to take a more liberal diet, and to do far more physically. She still had some of the pelvic pressure feeling at times and at times this was accompanied by mucous colitis.

Case 12. (Fig. 31.) Illustrates bilateral stricture with the chief symptoms on the left side, and an impassable obstruction in the lower right ureter with a large x-ray shadow in this region.

FIG. FIG.

31.

31

FIG.

CASE

12.

32

CHIEF SYMPTOMS LEFT KIDNEY REGION

Note No. 8 X-ray catheter which entered left ureter without obstruction. Right ureter would not take a catheter. Note large calcified gland near right ureter. Demonstration of bilateral ureteral stricture. FIG.

32.

CASE

13.

RIGHT KIDNEY AND URETER HOLDING

50 cc.

Note the so-called ureteral kinks, with the dilated ureter below these angulations showing that there must be some lower point of obstruction.

Miss R., aged fifty, seen with Dr. Walker, April, 22, 1924. The patient had suffered for several years with bilateral renal symptoms referred chiefly to the left side, and she had recently been forced to give up her position because of this pain. Dr. Walker had passed a No. 8 renal x-ray catheter to the left kidney without finding any appreciable

Fm. 33

Fm. 34

Fm. 33. CASE 13 Note the sm all st one shadow beneath the last rib FIG. 34. C AS E 13 Note the migration of the sm a ll bean sha ped stone to a point n ear t h e fourth lumbar vertebra.

F m. 35

Fm. 36

Fm. 35. C ASE 13 Note a larger stone sh adow in t h e lower uret er region F m . 36 . CASE 13 The lower larger stone has b een displaced from t he stricture area, and apparent ly both stones are near t he catheter t ip at t he pelvic br im region . At operation b oth stones were found in the stricture region, t he sm aller stone free, a nd t he larger one again engaged in t he st r icture .

522

URETERAL STRICTURE AND URINARY CALCULI

523

obstruction. He could not introduce a catheter in the right ureter beyond 1 or 2 cm., and an x-ray picture (fig. 31) showed a large shadow in the region of the right ureter. Dr. Walker interpreted thisasaright ureteral calculus which he thought might be removed through the bladder by means of the Kelly cystoscope. We were able to pass whalebone filiforms, and finally a wax-tipped and wax-bulbed renal catheter demonstrated the absence of a calculus in the ureter and the presence of ureteral stricture. Dr. Walker, by using a bulb, later demonstrated stricture on the left side which had taken his original No. 8 blunt-end catheter without obstruction, and his patient was soon able to take up her business position again. Case 13. (Figs. 32 to 36.) The patient had bilateral ureteral stricture, bilateral hydronephrosis, multiple ureteral calculi, right, one migrating and one fixed in the stricture area. She was four months pregnant. Mrs. T., aged thirty-one years, admitted February 15, 1921. She has had recurring attacks of renal pain in the left side for four years, on the right side for three years. The right-side attacks have recently required morphin. Attacks of hematuria lasting one to seven days began two and one-half years ago immediately after her second childbirth. She is now four months pregnant. Examination revealed bilateral stricture, bilateral hydronephrosis, the left side holding 20 cc. of fluid, and secreting normal sterile urine, the right side holding 50 cc., and the urine showed a few leukocytes and a colon bacillus infection. Roentgenograms taken at various periods demonstrated two calculi on the right side, a small one migrating and a larger one lying in the stricture area. A half-hour differential functional test after intravenous administration, showed before the operation 12 per cent output from the left side, and 4 per cent from the right. After thorough dilatation of both sides and ureterolithotomy on the right, the test showed 17 per cent from each side.