Renal Migration of Ureteral Calculus: Case Report

Renal Migration of Ureteral Calculus: Case Report

RENAL MIGRATION OF URETERAL CALCULUS: CASE REPORT JOHN H. NEFF University, Virginia Miss C. H., graduate nurse, age twenty-four, entered the Universi...

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RENAL MIGRATION OF URETERAL CALCULUS: CASE REPORT JOHN H. NEFF University, Virginia

Miss C. H., graduate nurse, age twenty-four, entered the University of Virginia Hospital, July, 1919, with a diagnosis of right pyelitis. She gave a history of infrequent attacks of right abdominal pain accompanied by chills, temperature, and urinary frequency since 1907. Since April, 1918, these attacks had been more severe, with a maximum temperature of 104.8° and, once, with considerable hematuria. No relief had been obtained from an appendectomy in 1915. Catheterized bladder urine upon admission contained much pus. Cystoscopy, Brown-Buerger, showed a moderate basal cystitis. The left kidney urine gave negative findings, culturally and microscopically. On the right side an impassable obstruction was met 2 cm. above the ureteral orifice. X-ray examination of the u,rinary tract, August 3, 1919, revealed a stone low in the right ureter (fig. 1), no shadows in the kidney region. On second cystoscopy, Kelly, August 4, obstructioll was encountered as before in the right ureter. After cocainizing the low segment, a no. 8' catheter carrying a no. 13 wax bulb was finally passed. Ten cubic centimeters of olive oil were injected above the stone. The wax bulb met much resistance on withdrawal and was deeply grooved on .one side. The kidney urine gave a pure culture of staphylococcus. The patient had a sharp reaction after the treat~ ment, temperature reaching 103°. Patient returned, August 29, for further dilatation. X-ray on that date showed the position of the stone unchanged. The low right ureter was again cocainized, olive oil injected above the calculus, the point of obstruction stretched with the Lewis dilator and, finally, dilatation to about 17F. obtained with a bougie. The reaction following this treatment was violent-repeated chills and temperature as high as 105°. Vaginal examination two days later demonstrated pronounced tenderness and induration at the b!:tse of the right broad ligament. This finding, along with the rather unusual reaction, suggested lll

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JOHN H. NEFF

the possibility of some leakage at the site of dilatation. On the fourth day this area was exposed through a vaginal incision; only a nonsuppurative periureteritis was found . Temperature was normal on the seventh day.

FIG .

1.

Low IN THE RIGHT URETER, AuausT 3, 1919 Kidney plate this date was negative

STONE

Patient was again admitted October 15, 1919, six weeks after the above treatment. In this period she had been practically free from all symptoms and had gained 17 pounds. She had watched her urine carefully and was positive that she had not passed a stone. A picture of the lower urinary tract was made but no evidence of calculus seen. If the patient's statement were correct that the stone had not been

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voided, the remaining possibility was that the stone had ascended the ureter to a point out of range of the low first exposure. A kidney plate was therefore taken, and this located the calculus evidently in the pelvis (fig. 2).

FIG.

2.

STONE rn THE RIGHT PELVIS, OCTOBER 15, 1919 Low ureteral plate this date was negative

Pyelotomy was done the next day and the stone removed from one of the middle calices. The exposed portion of the ureter presented surprisingly slight dilatation. It would have been rather difficult manually to force the stone into the ureter. The stone measured 5x7x 10 mm.

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JOHN H. NEFF COMMENT

This is evidently a case of renal migration of an ureteral calculus. While the possibility of such an occurrence is well recognized, the observed instances seem rare enough to warrant recording; particularly so, since in any such case the chance for serious clinical error is inherent. The final renal position in our patient might well have been overlooked in that only a low picture was first taken on the last admission. The conclusions of Kretschmer 1 that retrograde movement of ureteral calculi is due either to dilatation of the ureter or, lacking this, to reverse peristalsis, seem obvious and logical. In the case above briefly outlined, the migration finds ready explanation on the basis of ureteral dilatation. The violent reaction after treatment and the marked periureteritis found upon exploration through the vagina, would certainly suggest rather complete temporary occlusion of the ureter, this accompanied of course by wide dilatation above. The dislodged stone would thus have an amply large channel for ascent to the kidney and the gravity element was no doubt furnished by the patient tossing about in bed, hips elevated now and then upon pillows or the bedpan. The ureteral instrumentation could not have carried the stone higher than four inches at the most since no instrument was passed to a greater height. 1 Kretschmer, H. L ., The ret,rograde movement of ureteral calculi. A. , lxxi, 1355.

J. A. M.