Renal and ureteral calculi

RENAL AND URETERAL SOME PRESENT

DAY SURGICAL

H. G.

HAMER,

CALCULI * PROBLEMS

M.D.

INDIANAPOLIS, IND.

T

HE probIem of deahng with urinary Iithiasis is an ever fruitful subject for discussion. Whether it be the

uretera

caIcuIus

which tarries

out danger of injury to the ureter, the bougies may be removed one at a time. That the use of the simpIe buIbous bougie is not without its dangers is shown by the writer’s experience in diIating a uretera stricture behind which a stone was Iodged. The bougie was passed through the stricture and beyond the stone but upon the attempt to withdraw the bougie the stone was caught under its shouIder and couId not be disengaged. RemovaI of the caIcuIus through an iIiac incision Iiberated the entrapped bougie. The Iength of time in which one is justified in using intrauretera1 measures naturaIIy varies in wide Iimits in different cases. The comparative size of the caIcuIus and that of the ureter as shown by urogram, the shape of the caIcuIus, the history of previous passage of urinary caIcuIi, the impairment of renaI function, evidences of serious infection during attacks of uretera occIusion, and the genera1 physica condition of the patient are the factors for consideration in the individua1 case in deciding upon operation or persistence in intrauretera1 manipuIation. CaIcuIi of unusua1 size Iodged in the Iower ureter near the bIadder aImost aIways require operation, yet there are occasiona exceptions, which the foIIowing case wiI1 iIIustrate.

too Iong in

its passage through the uretera channe1 or massive coral caMi invoIving both kidneys, the individua1 case brings its own diff&uIties which require soIution. That no eminentIy satisfactory method of dealing with smaI1 uretera stones has yet been found is evidenced by the numerous devices which have been invented for the purpose of disIodging retarded stones and speediIy bringing them through a ureter aImost too smaI1 for their passage. To accomplish this, ureter catheter manipuIation is of such common practice that it may be regarded as universa1 and it is credited with an enormous number of successes. Yet, when we take into account the fact that the majority of smaI1 stones wiI1 pass spontaneousIy, the actua1 vaIue of the procedure must be discounted ConsiderabIy. The faiIures of the method furnish the incentive to Iook for more reIiabIe means and an array of diIators, crushing forceps, screws, sIings, buIbs and the Iike is the answer. The suggestion made a few years ago of passing severa uretera bougies past a lodged uretera caIcuIus and withdrawing a11 at once in the hope that these bougies had disposed themseIves aIong different sides of the stone and wouId thus hoId it within their grasp and deIiver it into the bIadder has much to recommend it. By this method the ureter has on two occasions deIivered troubIesome caIcuIi. It has an advantage which the more compIicated devices do not possess, nameIy that, shouId the stone become so tightIy wedged that it cannot be brought out with* Read

before

the UroIogicaI

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of The New

CASE I. A man forty-two years old whose stone-bearing history covered a period of twenty-five years, showed by x-ray examination two large caIculi in the lower right ureter. The shadows were about equa1 in size and measured approximateIy 7 by 15 mm. The uretera orifice was enIarged with cystoscopic scissors, and recta1 massage given in an effort to dislodge the caIculi. ShortIy afterwards one of the stones passed into the bIadder and was removed by IithoIapaxy. In a few days the second stone was passed into the bIadder and it aIso was crushed and removed. York

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EnIargement of the uretera orifice for the reIease of a stone engaged in the intramural portion is more satisfactoriIy accompIished by surgica1 diathermy than by incision as hemorrhage is thus avoided and the sear is Iess. The vaIue of cystoscopic methods in aiding passage of uretera caIcuIi is expressed in a recent report by Squires’ of the CroweII Clinic. Of a tota of 606 cases the caIcuIi were recovered by cystoscopic methods in 528 or 87.13 per cent. Caution must be observed in dealing with a migrating stone, and especiaIIy shouId one not deIay surgica1 remova when there is evidence of advanced pathoIogy in the kidney. The foIlowing case iIIustrates some of the diffrcuIties encountered in deaIing with a migratory caIcuIus and emphasizes the danger of intrauretera1 manipuIations in the presence of stones of this character. CASE II. In a man of fifty-six years, suffering with renaI coIic, the x-ray showed a stone 0.5 cm. in diameter opposite the right transverse process of the fourth Iumbar vertebra. A ureter catheter was obstructed at this point. AIboIene was injected into the ureter and the attack graduaIIy subsided. Ten days later x-ray showed the caIcuIus in the kidney peIvis. Shortly afterwards he had another attack of colic with fever and reduced urinary output. He deveIoped hiccups. x-ray now showed the stone to be about 4 cm. from the bIadder. The ureter was catheterized, Iavage given and the catheter fixed. Hiccups ceased and the genera1 condition improved. UreteraI diIatations were performed at intervaIs of seven to ten days and drainage maintained for brief periods afterwards by indweIIing ureteral catheter. X-ray showed the stone at one time in the ureter and at another in the kidney pelvis. After the fourth treatment he deveIoped fever, rapid heart, rigid abdomen and failed rapidIy and died three days later. Autopsy disclosed acute peritonitis centraIized about the right kidney. The kidney contained multipIe abscesses. No injury couId be demonstrated in the ureter or renaI peIvis. The ureter was dilated except near the bIadder, and contained a smaI1 stone which was freeIy movabIe throughout the length of the ureter.

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When a caIcuIus obstructs one ureter and anuria occurs, if a singIe manipuIation faiIs to establish drainage immediate surgica1 intervention is usuaIIy indicated. ExceptionaIIy secretion of urine may be reestabIished by stimuIating measures and operation deIayed for a more favorabIe condition of the patient. In one such case, the anuria being of fifty-two hours’ duration, copious secretion of urine foIIowed stimuIating measures and remova of the obstructing caIcuIus was deIayed unti1 the fifth week after the anuria occurred. In the presence of biIatera1 stones, aIthough intrauretera1 measures may resuIt in some downward progress of the stone, sudden compIete occIusion of both ureters may occur, producing a simiIar problem and surgica1 remova of the obstruction becomes imperative. When operation for the remova of a uretera stone is undertaken, damage to the kidney may be so advanced that nephrectomy IS indicated, yet the impairment of function of the other kidney may make the procedure inadvisabIe. In certain instances the repair is remarkabIe in what seemed a hopeIessIy diseased kidney, after drainage has been reestabIished through removal of the stone. Rena1 stones requiring operative remova1 are not suffIcientIy simiIar to permit the adoption of a routine procedure. Most uroIogists prefer pyeIotomy to nephrotomy, especialIy in cases of smaI1 or medium sized stones in the pelvis of the kidney or accessibIe caIices. Stones of considerabIe size, even those having branches into the calices, may be removed by enIarged pyeIotomy” without incurring the dangers which commonIy attend nephrotomy. By corrosion modeIs Deming3 has shown that enIargement of the pyeIotomy incision may be extended straight into the kidney or to the Iower poIe without impairment of the circuIation of the kidney if the retropelvic vessels are conserved. It is not assumed that a11renaI caIcuIi are amenabIe to operation by this method. For the coraI-Iike stone, for the calcuIus

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or the multiple disexcIusiveIy renal, seminated stones deep in the cahces, it is evident that this operation wiII not be sufficient but may need to be augmented by smaI1 nephrotomy incisions to liberate smaI1 stones or fragments Iodged in the caIices. For the stones of the peIvis that are proIonged into the kidney, enIarged pyeIotomy wiI1 often suffice for their delivery. NaturaIIy there should be a radiogram that demonstrates cIearIy the characteristics of the stone and which Ieaves no doubt as to its shape and its direction, but shows equaIIy we11 the absence of fragments situated a IittIe distance away or in totaIly different positions. In cases of biIatera1 renaI caIcuIi of the branched or staghorn or giant type, there is often no pain, the patient suffering from septic absorption. In deciding on operation, one wiI1 consider whether the remova of the caIcuIi invoIves greater destruction of kidney tissue than wiI1 resuIt from the presence of the caIcuIi or whether probabIe improvement folIowing remova of the stones justifies the risk. A stone free in the peIvis, causing intermittent obstruction, may require first consideration. The deveIopment of acute infection may demand immediate action. GeneraIIy the kidney with the better function shouId be operated on first to conserve to a maximum its function before operating upon its fellow. This opinion is best appIied in the case where one kidney is aImost compIeteIy destroyed and the other has fair, or good function. There are many exceptions to the rule. MuItipIe caIcuIi in different parts of the urinary tract may be present in addition to biIatera1 renaI stones, i.e., in the ureters, the bIadder and the urethra. UnIess there are contraindications those stones in the Iowermost position in the urinary tract shouId be removed first. No ruIe can be Iaid down as each case must be handIed according to its individua1 pecuIiarities. Likewise the time of operation calIs for the exercise of good judgment. Postpone-

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ment in one case may give an opportunity for improvement, whereas deIay may resuIt in a hopeIess state that might have been avoided by an early operation. It is important not to undertake too much at one operation. Many of these patients suffer from the of incurabIe infection of the presence urinary tract and the most one can hope for is to minimize the infection and reIieve pain. AIthough many of them are incurabIe they may derive great benefit from a we11 pIanned and carefuIIy executed program of operation and gain several years of comparative comfort. SeveraI Iesions may exist in a singIe kidney giving rise to similar symptoms. We shouId not be content with a seIfevident diagnosis as renal stone, and overIook the presence of coexisting pathoIogy. In a survey of 1817 cases of renaI tubercuIosis at the Mayo CIinic Crenshaw4 found renaI caIcuIus associated with renaI tubercuIosis in 1.8 per cent of the cases. This datum may be taken as indicative of the reIative occurrence of such combined Four cases of renaI stone pathoIogy. associated with renaI tubercuIosis have been observed among our cases. In I case a shadow in the upper poIe was mistaken for caIcification in reading the x-ray. After nephrectomy the specimen was found to be that of a tubercuIous doubIe kidney, the upper peIvis of which contained a caIcuIus.

CASE III. A particularly interesting case was that of a woman (Mrs. G.) forty-eight years of age, who, in a period of twenty-two years, had recurrent attacks of hematuria, numerous attacks of renaI colic, foIlowed by the passage of caIcuIi, nephrotomy for kidney stone, and spontaneous rupture of a Ioin abscess, the sinus persisting many months. She was referred to us by Dr. W. N. TayIor of CoIumbus, Ohio, who had diagnosed Ieft caIcuIous pyonephrosis and exophthaImic goiter. The right kidney was normal. Through a Iumbar incision a Iarge pyonephrotic kidney, containing severa Iarge caIcuIi, was removed with great diffIcuIty, a capsular enucIeation being necessary. The pathoIogist’s report showed, in addition to the genera1 destruction,

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due to pyonephrotic changes, several areas in the remnant of renal parenchyma which contained giant celIs and tubercIes. Operation upon a soIitary kidney is attended by considerabIe apprehension by both the surgeon and the patient. Keyes5 has made the observation that the remova of uncompIicated stone from the peIvis of the soIitary kidney in 6 cases shows that these patients stand operation aImost as we11 as patients with two kidneys. WaIters6 of the Mayo CIinic, found record of 45 cases of solitary kidney in which operation upon the kidney or ureter had been done for the remova of caIcuIi. The mortaIity was 13.3 per cent. Four of the writer’s cases of caIcuIus in soIitary kidney have been treated. One of them was in a young physican who had Iost one kidney by emergency nephrectomy soon after a caIcuIus had been removed by nephrotomy. A year or two Iater he had anuria due to a caIcuIous obstruction of the ureter of his remaining kidney. We succeeded in passing a catheter beyond the caIcuIus and reIieved the retention. ShortIy afterwards the stone was passed. In another case of a young man who had Iost a kidney by operation for caIcuIous pyonephrosis a stone formed in the remaining kidney. This stone was of the migrating type. After severa efforts to cause it to pass by catheter manipuIation, ureter diIatations, etc., operation was undertaken after a catheter had been passed to make sure the stone wouId remain in the kidney during operation. Through a pyeIotomy incision attempts to find the stone faiIed and much effort was expended by way of irrigations to flush it out but did not succeed. FinaIIy, in acknowIedgment of faiIure, a drainage tube was inserted through the cortex and the kidney repIaced. The proIonged operation added too much to his aIready overtaxed kidney and he died, uremic, four or five days Iater. The use of the fluoroscope to Iocate a stone during operation is not aIways feasibIe, as was demonstrated in this case in which a short renaI pedicIe in a fat

subject made unsuccessfu1.

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CASE IV. Mrs. M, a woman of thirty-four, was one of the cases of nephrectomy for caIcuIous disease associated with tuberculosis. Prior to remova of the Ieft kidney in May, 1929, a pyelogram of the right showed it to be normaI. Six months Iater the x-ray showed the right kidney fiIIed with stone. The fiIm was an exact dupIicate of the previous pyelogram. In February, 1930, she was again admitted to the hospita1 with anuria of forty-eight hours’ duration. Efforts to catheterize the right ureter faiIed. Emergency nephrotomy was performed, numerous stones removed and nephrostomy drainage established. In November, 1930, x-ray showed recurrence of caIcuIi. The sinus was diIated and several masses of caIcareous materia1 were removed. Future management of the case wil1 be guided by whatever emergency arises. The outIook is manifestIy far from being hopefu1. Cases in which urinary caIcuIi cannot be demonstrated by x-ray are diminishing in number as x-ray equipment is improved and as our methods of appIying x-ray are modified to intensify shadows or to demonstrate fiIIing defects. Very smaI1 caIcuIi frequentIy do not give a shadow by x-ray and this group furnishes most of the IO or 13 per cent of cases of renaI coIic in which the x-ray examination is negative, though stone is diagnosed by wax tipped catheter. In such a case where the stone does not pass promptIy, more intensive appIication of x-ray study wiI1 usuaIIy show either a shadow or a rarefied area in the urogram. Larger stones occasionaIIy are not demonstrated in the x-ray. Two cases of cystinuria with caIcuIi have come under our observation, both in boys, one eighteen and the other sixteen years of age. In the first no shadows were obtained by x-ray though severa caIcuIi passed spontaneousIy and an accumuIation of smaI1 stones in the Iower Ieft ureter required operative remova1. During convaIescence from the operation coIic occurred on the opposite side accompanied by anuria. UreteroIithotomy was again necessary for

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remova of a stone Iodged in the right Iower ureter. In the second case (C. F.) the stones were aIso biIatera1. From the Iower Ieft ureter a caIcuIus was removed by ureterolithotomy and at a Iater operation the right kidney, a Iarge caIcuIous pyonephrosis was removed. This kidney had been operated upon seven years before for stone. These typic”1 sIightIy transIucent cystine stones gave good shadows to x-ray. CaIcified Iymph gIands in the region of the kidney are occasionaIIy the cause of confusion in diagnosis where stone is suspected. SeveraI cases of renaI caIcuIus are recaIIed in which gaIIstones aIso were present but the position of the gaIIstone shadows in the x-ray gave no cause for doubt as to their identity. Rapid formation of stone in the septic bIadder is a matter of common observation, and the same is aIso true within the kidney. Marked interference with drainage accompanied by infection wouId seem to provide the condition most IikeIy to give rise to rapid accumuIation of caIcareous materia1. The case previousIy mentioned of the woman who had Iost one kidney affected with caIcuIous disease and tubercuIosis, had what seemed to be a norma condition of the opposite kidney at the time the nephrectomy was done, yet within six months the remaining kidney was fiIIed with stones, CASE v. Mr. S. Large branched stones were removed from both kidneys by enIarged pyelotomy. When first observed the concretions were smaI1, not Iarger than a bean in one kidney, and in the other a smaI1 speck of calcified materia1. On one side the ureter was strictured near the ureteropeIvic juncture. In this kidney the stone grew more rapidIy, filling the peIvis in nine months; the other kidney was fiIIed in tweIve months. RemovaI of the stones and diIatation of the stricture of the right ureter, and the cIearing up of foci of infection in teeth and tonsiIs have cured his urinary infection. During the period of a year we observed rapid formation of biIatera1 kidney stones, notwithstanding that the patient was

under cIose observation habits, diet, medication,

and reguIation etc.

as to

Hunner’s assertion that renaI caIcuIi are secondary to uretera stricture finds support in the condition of this man’s right kidney, but it cannot be said to be true of the Ieft kidney where stone formation was equaIIy rapid. Braasch’ has suggested that to the various types of urinary caIcuIi described in the Iiterature shouId be added a form of pseudoIithiasis which he caIIs hysterica Iithiasis. This unusua1 manifestation of an abnorma1 psychoIogica1 process is shown by symptoms simuIating those of acute renaI coIic. In order to compIete the deception the patient wiI1 produce a stone shortIy after the coIic, which, to the casua1 obser ver, may be mistaken for urinary caIcuIus. One of our cases, a young woman (Miss D.) described her attack of coIic in a11 of its harrowing detaiIs and produced the resuIt of her travai1, which she had fished from the chamber. It proved to be a fragment of a parched grain of popcorn.

CASE VI. Mr. G.‘s case, thirty-nine years of age, who came to us June 21, 1927, was more diffIcuIt of soIution. He gave a history of attacks of Iumbar pain somewhat resembhng renal coIic and stated that he had passed I I stones, 3 in one month. For ten weeks no stones had passed but there were evidences of one in the bladder which seemed to come down into the urethra and remain there. His physician said that he had displaced it into the bladder by instrumentation but was unabIe to get the urethra suffIcientIy open for the stone to pass. Upon expIoration of the urethra a stone was detected in the buIbomembranous portion. Through an endoscope the stone was caught and extricated with urethra1 forceps. He was urged to go to the hospita1 for compIete uroIogical examination upon the ground that the Iumbar pain which had preceded the passage of each stone suggested the origin of the stones as being renal and that the renaI side of the diagnosis shouId be carefuIIy worked out. He decided to return home. His physician reported by Ietter that he had extracted two more stones, one on June 27 and the other JuIy 2. On August 2, 1927, the doctor wrote, “That

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man stiI1 passes stones and number 21 is now in the deep urethra and I am not able to get it out. Eight have passed since he was at your offIce. But there are no indications that they pass from kidney to bIadder-just through the urethra.” He entered the hospita1 on the afternoon of October 18, 1927 for uroIogica1 examination. The usua1 bIood count, urinaIysis, and kidney function tests were made. The folIowing forenoon he Ieft the hospita1 without permission, but before going he toId one of the doctors that in the morning he feIt the stone drop into his bIadder. He produced a stone but its appearance caused great doubt as to its having originated in his urinary passages. He had no colic while in the hospita1 and received no morphine. On March 12, 1929, he reentered the hospita1 on account of morphinism. The puIse and temperature, bIood pressure, bIood count, phenoIsuIphonthaIein and: urinaIysis_were a11 within norma limits. After severa days’ observation it was decided his condition had improved suffIcientIy to proceed with his uroIogica1 examination. He seemed to sense the significance of certain preparations and quietIy slipped out of the hospita1. We have not seen him since. CASE VII. A middIe-aged woman who had previously been operated upon for renaI came to the IndianapoIis City calculus, HospitaI periodicaIIy for remova of bIadder stones. Some were smaI1 and couId be removed with a stone evacuator without being crushed whiIe others had to be crushed. On one occasion cystoscopic examination showed what appeared to be a flat, dirty white stone lying on the floor of the bladder. Upon prodding it with a uretera catheter deep indentations were made. The whoIe mass was pumped out with the stone evacuator, and the materia1 was sent to the chemist for examination. The chemist reported the materia1 to be composed aImost entireIy of caIcium sulphate. The nurse was instructed to observe if she had visitors and what was brought to her. Within a few days her IittIe daughter brought a paper sack containing white powder which the patient said was tooth powder. It proved to be pIaster-of-Paris. Being thoroughIy frightened over the exposure and the fear of prosecution by the insurance company which had paid weekIy benefits for a Iong time, she toId us how the deception was carried out. At first she

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used a catheter which she wouId fiI1 with the pIaster-of-Paris paste and after inserting the catheter into the bIadder, wouId strip it backwards forcing the paste into the bIadder. At other times when a catheter was not avaiIabIe the same performance was accompIished with a strip of paper roIIed into a tube. CASE VIII. A student nurse (M. McC.) whose uroIogica1 examination was negative and whose attacks of renal coIic suggested

hysteria, was toId it seemed strange that her attacks aIways occurred at night and that none of the stones were recovered. Within a few days she had another attack and this time produced a “stone” for our inspection. It proved to be a smaI1 piece of cinder.

In concIusion, the various topics may be summarized as foIIows : I. DeIayed passage of smaI1 uretera caIcuIi may often be fa.ciIitated by uretera instrumentation, either with the uretera catheter or bougie or speciaIIy devised instruments. Such manipuIations are not whoIIy without danger. The migrating uretera caIcuIus is aIways a cause for worry, being capabIe of seriousIy frustrating efforts for its remova1. CaIcuIi of unusua1 size Iodged in the Iower ureter frequentIy require operative remova either by ureteroIithotomy or uretera meatotomy. UreteraI meatotomy by surgica1 diathermy is preferabIe to that by incision. 2. AI1 uroIogists recognize that biIatera1 renaI caIcuIi usuaIIy manifest a state of advanced renaI infection, seIdom of the same duration in the two kidneys, hence an unequa1 degree of renaI impairment, and present probIems that demand the exercise of trained judgment in the adoption of a program of surgica1 interference. CaIcuIus in the soIitary kidney is cause the risk of operation for apprehension, being dependent upon the function and the degree of infection. The combination of stone and renaI tubercuIosis is rare and it may be inferred that in such instances the stone is the primary Iesion.

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3. DiffIcuIty of diagnosis of renaI and ureteral stones by x-ray is most common when the stones are very small, and especiaIIy when composed of uric acid. Cystine stones are sometimes transparent t,o x-ray. The urogram wiI1 often make visibIe a stone transparent to unaided x-ray. The “staining” quaIity of certain media, such as sodium bromide, sodium iodide, uroseIectan and skiadan, has been found heIpfu1. Extrarena shadows may usuaIly be differentiated by the IateraI x-ray and pyelogram and stereoscopy. DISCUSSION DR.

CLARENCE G.

of renaI and uretera frequentIy,

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OF PAPERS

BANDLER:

WhiIe

I.

SQUIRES, C. B. Disposition of ureteral calculi at the Crowell Clinic from 1915 to March 31, 1930.

J. Ural., 24: 4G1, 1930.

2.

3. 4. 5. 6. 7.

HAMER, H. G. Enlarged pyeIotomy. Boston M. Ed S. J., 197: 819, 1927. DEMING, C. L. Renal circulation foIIowing various types of elongations of pyelotomy incisions. J. Ural., 20: 713, 1928. CRENSHAW, J. L. Renal tubercuIosis with caIcification. J. Ural., 23: 515, 1930. KEYES, E. L. Operation on the singIe kidney. J. A. M. A., 94: 152, 1930. WALTERS, W., and WRIGHT W. Operations on solitary kidneys and ureters. Surg. Gynec. Obsf., 5 I : 836, 1930. BRAASCH, W. F. UnusuaI types of urinary lithiasis.

J. Sol.,

BY DRS.

cases

23: I, 1930.

LUBASH AND HAMER

changed

by

intrauretera1

beIieve that ureterectomy

caIcuIi are not encountered

one hopes to find a case having

REFERENCES

a

separate bIood supply to the affected portion of kidney, such as Dr. Lubash demonstrated. Just today, in our department at the PostGraduate, we encountered the second case in a few months, of uretera and renaI peIvic dupIication, with but a singIe uretera orifice, in which the patient presented the picture of with pyohydronephrosis. Of hydroureters course, in this case, nephrectomy with ureterectomy is indicated. Dr. Hamer has given us a very compIete and interesting resume of ureteral and renal Iithiasis, in which he shows that these probIems in Indiana, in no way differ from simiIar problems eIsewhere. In reference to smaI1 stones in the ureters, it is a we11 known fact that about 70 per cent wiI1 pass spontaneousIy, or assisted by some form of intrauretera1 manipulation. Dr. Hamer’s quotation from the statistics of the CroweII CIinic, whereby they obtained caIcuIi by uretera manipulation in 87 per cent of their cases, is extremeIy interesting, and amply iIIustrates the reward of patience. I beIieve a11 of us have employed multipIe catheters, uretera spindles, wire corkscrew manipuIators, diIating bougies, uretera bags and numerous other devices with some success; however, I am convinced that uretera catheters and buIbous bougies are more frequentIy usefu1 in manipuIating stones out of the ureter through diIatation, than other types of ureteral instruments. If uretera caIcuIi are apparently fixed in their positon, and even their axes cannot be

rather

than

manipuIation,

I

shouId be performed

aIIow these stones

to remain

fixed

so Iong that irreparabIe renaI damage may occur. It is surprising how readiIy some very Iarge caIcuIi may be manipuIated from the Iower end of the ureter. No doubt, most of you recaI1 a case presented before the uroIogica1 section Iast year, by Dr. Dourmashkin, in which, with his diIating bag, he was successfu1 in manipuIating a caIcuIus, 134 in. Iong, out of the Iower end of the ureter. You may aIso recaI1 that at the same meeting, another gentIeman presented a caIcuIus fuIIy 235 in. in length, and irreguIar in shape, which aIso had been manipuIated out of the Iower end of the ureter. In patrents with biIatera1 uretera caIcuIi, one cannot afford to spend so much time in manipuIation as with uniIatera1 cases. If there is not a reasonabIy prompt response to intrauretera1 manipulation, surgica1 intervention is indicated. Dr. Hamer’s reference to extensive biIatera1 renaI caIcuIi, and his enunciation of the principIe that it is usuaIIy preferabIe to operate upon the better functionating kidney first, are reasonably tenabIe. However, the apparent faciIity of remova of such stones shouId have greater weight in influencing our judgment. With this in mind, we not infrequentIy operate upon the poorer functioning kidney first, with more satisfactory surgical resuIts. I am convinced that some patients with muItipIe or Iarge branched caIcuIi in each kidney, Iive Ionger if no surgery is performed, than if they were subjected to the great risk of surgica1 intervention.

NEW SERIES

With

VOL.XIII,

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conservative how

many

Hamer-CaIcuIi

No. r

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kidneys

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tendency it

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these

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or no renaI

func-

tion, as measured by dye output, wiI1 frequentIy return to a moderate and usefu1 degree of renaI activity. Dr. Hamer has referred to the coincident existence of Iithiasis in cases of renaI tuberculosis, and has quoted Crenshaw’s statistics of I .8 per cent of such cases in a Iarge series at the Mayo Clinic. I do not beIieve renaI caIcuIus in these cases offers a separate surgica1 problem, but that the surgery indicated for the renaI tubercuIosis shouId aIso be that of the Iithiasis. For instance, I doubt if in biIatera1 renaI tubercuIosis with a coincident caIcuIus in one kidney that there wouId be any separate surgica1 indication for the treatment of the caIcuIus. DR. HOWARD S. JECK: Dr. Lubash stated that he regretted not having removed the ureter corresponding to the kidney peIvis in his heminephrectomy for fear that the ureter might Iater give rise to trouble. I believe, in this connection, he has Iittle or nothing to worry about for the great majority of cases of empyemas of the uretera stump occur in cases where stones have been Ieft in the ureter or where there is some other form of obstruction. His case apparentIy had no uretera stone and as far as I couId teI1 from the urogram, there was no obstruction beIow. Dr. Hamer referred to methods of removing uretera stones by means of various devices, some of which actuaIIy grasp the stone. I we11 remember my experience with the flexible bougie that had a sort of a corkscrew at the end. The stone is supposed to be entangIed in the coiIs of the corkscrew. The first time I used this instrument, I had beginner’s Iuck. Within two minutes after I had started, I removed the instrument together with the stone and said, “What a bright boy am I. ” But the next time I tried the same instrument I thought I was going to remove the whoIe Iining

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of the urethra before I couId puI1 the instrument out and I have therefore never used it since. Some years ago at BeIIevue, in another stone case, one of our men passed up the ureter a fIexibIe metaIIic instrument with a head shaped a great dea1 Iike a spermatozoan. When the instrument was removed, the head remained in the ureter as was beautifuIIy demonstrated by the x-ray. However, this particuIar foreign body passed out spontaneously within a few days. Concerning operations for biIatera1 renaI caIcuIi, Dr. Hamer quoted the ruIe, which is usuaIIy foIIowed, of operating on the better kidney first. Dr. BandIer aIso substantiated Dr. Hamer’s remarks. We a11 agree that there are exceptions to this ruIe and one of the most striking exceptions I think is ‘we11 iIIustrated by a patient on whom I recentIy operated at BeIIevue. There were stones in both kidneys, the function of which was very poor. However, the Ieft kidney was functioning somewhat better than the right. In this case I chose for the first operation the kidney with the poorer function (right) on the ground that had I operated upon the Ieft kidney first and had nephrectomy become necessary, the right kidney probabIy couId not have sustained Iife. And I doubt very much if the patient wouId have Iived had onIy a nephrotomy on the right side been necessary. IncidentIy, as it turned out, the kidney and ureter were so friable that in trying to remove the stone, the ureter was accidentIy puIIed in two at its junction with the renaI peIvis. But fortunateIy an anastomosis between the ureter and kidney peIvis performed immediateIy after the stone was removed saved the day as we11 as the kidney. In operating on a singIe kidney containing a stone, I think the point brought out by Dr. Keyes in his recent articIe on the subject was very we11 taken, nameIy, that we can probabIy operate successfuIIy on more of these cases than we do. He ascribes his success to being more carefu1 than when the patient is possessed of two kidneys and aIso to the fact that such a kidney being aIready infected, there is Iess IikeIihood that a severe acute infection wiI1 ensue. Another of Dr. Hamer’s points that I think is worthy of emphasis is the fact that every renaI or uretera stone case, particuIarIy the Iatter, shouId be x-rayed immediateIy before the operation. Ureteral stones have a habit of changing their position on short notice and to

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my sorrow I have operated upon at Ieast 2 patients in whom the stone was in the kidney peIvis at the time of the operation when it was shown to be we11 down in the ureter bv an x-ray taken a day or two before the operation. In operating for kidney or uretera caIcuIi, particuIarIy the Iatter, I think it is of the greatest importance to try to open the ureter immediateIy over the stone. It is diffrcuIt to fish a stone out through a uretera wound which is made severa centimeters above or beIow the point where the stone Iies. A good ruIe to foIIow is that once having gotten your fmgers around a urinary stone, not to turn Ioose unti1 you actuaIIy have the stone out. DR. C. R. Q’CROWLEY: In regard to heminephrectomy: When Dr. Papin of Paris was here Iast June, at the cIose of the UroIogicaI Meeting in New York, I gave an operative cIinic at the Newark City HospitaI, at which Dr. Papin did a heminephrectomy and I assisted him. The patient was a woman twentyfour years old with a doubIe peIvis kidney with two ureters that bifurcated about 6 in. below the kidney. The Iower portion of the kidney had a smaI1 abscess cavity containing a smaI1 caIcuIus. He did a beautifu1 resection in this case by removing a Iarge wedge-shaped portion of the Iower pole and then sewed with number zero catgut a smaI1 opening into a caIyx. A fat pad was pIaced in the wound and the kidney and capsule cIosed over it. The operative wound was closed without drainage. A few days following operation she had a chiI1 with rise of temperature and it was necessary to open the wound sIightIy, let out some pus and insert a drain. She drained pus and then urine for some time and IinaIIy the wound cIosed. She Ieft the hospita1 and a few weeks after the wound opened up again and she returned to the hospital at which time we treated her the same way and at the same time did a uroseIectan study of that kidney. It showed that a smaI1 portion of that Iower calyx was stiI1 there and was communicating both to the middIe calyx and through the Iower pole. I beIieve eventuaIIy the kidney wiI1 have to come out. This is not a hazardous operation and I think more of such operations ought to be done in idea1 cases. Those of us who have had a Iarge experience in nephrolithiasis have come to some very definite ideas which are not very far removed from those stated by Dr. Hamer. It is true

that a very Iarge percentage of stones pass of themseIves and that the remaining percentage can aImost always be encouraged to move by the various methods of intrauretera1 manipuIations we are accustomed to, but I beIieve that a11 of these manipulations should show some resuIt and that operation in some cases shouId not be put off too long, particularly, in those cases where we can demonstrate that manipulations, coIics, and a11 forms of treatment have failed. It is my opinion that in cases with caIcuIi in both kidneys, it is wiser to operate upon the better kidney at first in order to raise its standard in case you operate later on the opposite side and may be compeIIed to do a nephrectomy. DR. J. STURDIVANT READ: I agree with Dr. Hamer that the removal of uretera stones can generaIIy be accompIished by manipulations with a uretera catheter. Stones in the ureter which wiI1,aIIow the passage of a catheter aIongside them can be assisted in their passage by aIIowing the catheter to remain in situ one or two days. In my own clinic, we are impressed by the mechanical ingenuity of some of the instruments advocated for the remova of ureteral stones. FrequentIy we think their advocates forget the deIicacy of the mucous membrane and the smaI1 caliber of the ureter. I must say that most of these mechanica contrivances are now museum specimens. Fifty per cent of uretera stones wiI1 be passed spontaneousIy and this should be taken into account in discussing the remova of stones by various manipulations. The subject of cIosing the skin wound after nephrectomies has been mentioned. I have never seen any such wound deIayed in healing up by putting in a drain, and I think it best that a drain shouId be used in every case. Where this is not done, there are about 2 per cent in which when the skin wound has heaIed, pus would accumuIate in the bed of the wound and burrow in the wrong direction and not be discovered for a long period. Sometimes it necessitates a real operative procedure for its relief. Records from our clinic at the Long IsIand CoIIege HospitaI of 102 successive stone cases, show that there were 47 per cent right, 38 per cent Ieft, biIatera1 I I per cent. Of this, 70 per cent were in males, 31 per cent in femaIes. Of these 102 cases, 58 came to operation; 28 nephrectomies, 23 pyelotomy, I pyelonephrot-

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omy, 3 nephrostomies. The necessity for the suspension of the kidney after pyeIotomy was thought to be indicated in 3 of these cases onIy.

FIG.

I.

The routine suspension of kidneys after pyeIotomy is unnecessary. In the analysis of 13 cases of biIatera1 stone, 3 were nephrectomies on one side and Iater a pyeIotomy was done. There were no deaths. The 3 nephrostomy cases were a11 in women, ranging in age from fortyeight to sixty-three, in which there were Iarge branching caIcuIi of each side. Pain was so great and sepsis so profound, that reIief was sought. One died the fifteenth day postoperative of interstitia1 nephritis. The second died the same day, and the third, aged forty-eight, made a remarkabIe recovery though at the time the picture was one of intense pain and profound systemic retention. Yet she is now vigorous and we11 after six months’ period. GeneraIIy it is wise in cases of Iarge branching doubIe caIcuIi not to operate except for severe pain or great sepsis. I beIieve that reguIar diIatation of the ureters and Iavage of the kidney peIvis retard the rate of progress of kidney destruction. When to save a badly infected kidney in which there is a Iarge branching caIcuIus or many Iarge caIcuIi must aIways be a matter of

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individua1 judgment of the specific case. The damaged kidney may be improved for one to two years, but generaIIy a secondary operation

FIG.

2.

because of surgica1 difFicuIties is a much greater hazard. AIso in our experience there is apt to be a recurrence of caIcuIi in one to two years, so that if either kidney is undamaged except for the presence of a singIe smaI1 stone, we prefer nephrectomy. A case in point is a man, aged forty-nine, in whom eIeven years ago 3 Iarge phosphatic caIcuIi were removed from the kidney. It was necessary to injure the kidney parenchyma whiIe doing this. After two years, x-ray shows recurrence of this phosphatic caIcuIi. There has been a permanent renaI fistuIa which at times cIoses and produces systemic symptoms. After four years the Ieft ureter became blocked by fibrotic and caIcareous materia1 at the junction of the ureter and peIvis. This has been a constant source of damage and has made the man a semi-invaIid. The smaI1 caIcuIus on the other side has not increased in size during these eIeven years, and has given no pain or hematuria, though there is a moderate number of pus ceIIs aIways. This kidney has been Iavaged once in four months reguIarIy. The second case is that of a man now aged

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Iifty, with doubIe caIculi, who was seen nineteen years ago and has been under constant observation since. There were 2 large phosphatic

FIG. 3.

caIcuIi on the Ieft side and a nephrectomy was done. Two years later a pyeIotomy was done on the remaining kidney. There was no postoperative shock. There has never been any recurrence. The patient has been in perfect heaIth. This man is Iavaged once in six months reguIarIy. We doubt if there is such a thing as a siIent stone. AI1 of these patients have some sort of pain at some time, mostIy a duI1 backache to which they become so accustomed that unless a very carefu1 history is taken, they wiI1 state that they never had any pain in the affected side. In the presence of reguIarIy appearing smaI1 amounts of pus ceIIs, and clear urine which has been secured by catheter, separate kidney urines shouId be secured, and if the pus shouId prove to be consistently from one side only, the presence of stone shouId be diagnosed even if x-ray findings are negative. This does not necessariIy mean surgica1 procedures, but it does mean dietetic measures, occasiona urinary antiseptics, and bi-yearly diIatation of the ureter with Iavage of the peIvis. DR. EDWARD L. KEYES: The fundamenta1 physiologica fact in relation to uretera stone

is that

JULY,,931 the stone advances

onIy during periods

when there is no coIic or pain. These symptoms mean retention,

and the most certain

way to

make a11 uretera stones pass wouId be to perform biIatera1 pyeIostomy. The reIief of back pressure, when this operation is performed for the reIief of caIcuIous anuria, permits the siIent passage of extraordinariIy Iarge stones. ConverseIy manipuIation caIcuIated to irritate the ureter wiI1, if anything, deIay the passage of the stone. ObviousIy not a11 stones that pass after uretera manipuIation can be credited to the manipuIation. I have had no Iuck with the passage of severa catheters up the ureter to expedite passage of stone. A singIe catheter seems to do as weI1. Indeed in most instances, there is no need to interfere at aI1. DR. MEREDITH F. CAMPBELL: I have here the urograms in 2 cases which I thought might be of interest in connection with the first paper. The patients were both infants. I wiI1 not go into the detaiIs of the cases. The first urogram (Fig. I) is in a patient six months of age with a history of pyuria since birth. This is a “cystogram.” It is obvious that an anomaIous condition exists. It was found that the catheter entered a ureteral orihce on the fIoor of the mid-urethra. The second urogram (Fig. 2) shows the right peIvis injected and normal. The Iower Ieft renal peIvis is injected and norma and the catheter in the ectopic ureter shows a hydroureter and hydropyonephrosis of the upper peIvis. The urine from this upper left pelvis was milky with pus and functional tests indicated a dead kidney segment. The Iower haIf and right side were normal. Heminephrectomy of the upper Ieft kidney with ureterectomy down to about an inch from the urethra1 opening was successfuIIy carried out (Fig. 3). The chiId’s urine is now cIear and sparkling and pyeIogram taken one year postoperatively indicates a norma Iower kidney peIvis. The second case is that of a child first seen at the age of five weeks with a history of pyuria since birth. The urine was grossly puruIent and at the age of six weeks the chiId was cystoscoped and it was determined that a congenital stricture of the left ureterovesical junction existed with infected hydroureter and nephrosis above. The kidney was functionaIIy dead. On the right side there was a compIete redupIication of the urinary tract with ureterovesica1 junction stricture and diIatation of the

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ureter0 to the Iower pelvis, normaI function and urine. Repeated search for a second uretera1 orifice on the Ieft side was fruitIess tiI1 two years later. In the meantime conservative dilatation of the stricture by passing of muItipIe catheters served to restore partiaI kidney function and diminished infection. There were, however, periodic attacks of so-caIIed “acute pyelitis.” With the finding of the two uretera orifices on the Ieft side and the determining of a good functional upper Ieft kidney half, ureteroheminephrectomy of the Iower segment was successfuIIy carried out (Fig. 4). The chiId is now cured except for a persistent urinary infection originating in the Iower haIf of the right kidney. DR. S. LUBASH (closing): As to Dr. O’CrowIey’s remarks regarding the heminephrectomy that was performed at his institution by Dr. Papin, I shouId Iike to point out that in Dr. Papin’s recent talk before the American UroIogic Association on conservative surgery he made mention of the fact that it was better to remove not only the diseased portion of the kidney, but to go beyond into norma areas rather than Ieave any of the infected materia1 behind which wouId cause troubIe in heaIing. This was aIso brought out by Judd in his very memorabIe work reported back in 1915. DR. HAMER, (closing): The discussion has brought out severa points in regard to the spontaneous passage of uretera caIcuIi. DoubtIess many of the patients who have been subjected to uretera catheter manipuIations wouId have passed their stones had no instrumentation been done. Yet there is ampIe evidence that the measure is entitIed to much credit. Dr. Squire had record of 606 patients of whom 528 passed their stones foIIowing uretera manipuIations; 44 were operated on and 34 did not return. If Dr. Squire had been Iess modest he couId have said that of the 572 patients treated 92 per cent passed their stones after uretera manipuIations. Dr. Read’s observation concerning fixation of the kidney after remova of a stone recaIIs an experience I recentIy had. After removal of a caIcuIus by pyeIotomy we were unabIe to find the uretera outlet, and it developed that the ureter was anguIated and bound down by adhesions. When these were broken up the ureter was freeIy open. I did not regard it as

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necessary to anchor the kidney. It was not so much the position of the kidney as the adhesions which caused the obstruction of the

FIG. 4. ureter. Maintaining the kidney in the norma position during convaIescence probabIy accompIishes the same resuIts as fixation. However, fixation shouId be done when indicated. Conservatism in surgery of the kidney in biIatera1 stone is receiving much discussion at the present time. We are often in doubt whether pyeIotomy, nephrotomy or nephrectomy shouId be done. The case of a young man with a Iarge stone Iodged in the mid-ureter of the right side and severa Iarge stones in the Ieft kidney, iIIustrates this uncertainty. We removed the stone from the right ureter and drained the kidney by a smaI1 tube through the cortex. There was no urine from the bIadder for several days and we were in doubt as to whether the Ieft kidney had suficient functiona abiIity Ieft to justify remova of its stones or whether it shouId be sacrificed. The left ureter was catheterized and it was found the kidney had some abiIity to excrete phthaIein. The stones were removed and the kidney drained through a nephrostomy tube. The infection cleared up and the patient made a pretty good recovery but he has had a recurrence of stone on that side. Perhaps it wouId have been better to have removed his Ieft kidney.