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Stricture Formation in the Ureter Following Pyelonephritis of Pregnancy1
STRICTURE FORMATION IN THE URETER FOLLOWING PYELONEPRRITIS OF PREGNANCY1 E. GRANVILLE CRABTREE From the Urological Clinic of the Boston Lying-In Hospital
Ockerblad (1) in a recent article on stricture of the ureter in males, published in the Journal of the American Medical Association, calls attention to the preponderance of clinical findings as the basis of our knowledge of ureteral strictures. To quote his words: "Among urologists there is no longer any controversy over stricture of the ureter as a disease entity. Clinical evidence is not lacking, but more experimental data and much necropsy testimony is needed to write convincingly in this subject and to establish the pathology in this newly recognized disorder." Surgical specimens are even more valuable for study than the terminal lesions of necropsy, but unfortunately not so easily obtainable. There is no excuse to remove by operation a kidney when ureteral dilatation will suffice, nor is excision of a specimen from a stricture for pathological examination possible at operation without jeopardizing the kidney. A combination of pathological changes in a kidney long studied in my clinic have made possible the report of the surgical specimen described below. Ureteral stricture has been described from autopsy by Evart, Galliard, Kroner and Watson from 1879 to 1885, Runner, HH8, and Corson, 1924. Halle (1887) and Morris (1901) expressed the opinion that in pregnant women pressure of the child's head in utero laid the foundation for the preponderance of ureteral strictures in women over men. This opinion has now no more popularity than that fetal pressure alone obstructs the upper ureters in the later months of pregnancy. Runner calls attention to ureteral irregularities, kinks and 1 Read at the Annual Meeting of the American Urological Association; Baltimore, Maryland, May, 1927.
575
576
E. GRANVILLE CRABTREE
strictures of ureters in pregnancy appearing to assign more importance to strictures as a cause of back pressure kidneys in pregnancy than to the unknown factor which is as yet indeterminate. I am convinced that if stricture exists in many of the pregnant women with pyelonephritis in my clinic, it is of very few weeks' duration and recovers spontaneously after delivery. I do not think it is present in the majority of ureteral and pelvic dilatations in pregnancy. The return to normal of such kidneys without treatment suitable for stricture is too rapid and proper drainage measures will relieve the over-distention in the absence of ureteral dilatation. I recognize that such a statement but adds to the controversy over the "clinical" stricture. In our clinic we have demonstrated in postpartem pyelonephritis an area of inflammatory change in one patient sufficient to deform the course of the ureter. Stricture subsequently developed at that area. The severity of inflammatory reaction in the partially closed type of kidney found in the pregnant woman is favorable to stricture formation after delivery as scar tissue formation takes place. In 1 case the stricture developed within a year following pyelographic evidence of its absence prior to that time. The evidence available on the subject of stricture formation in pyelonephritis of pregnancy is extremely meager; speculation almost entirely occupies the field. Rarely is it possible to know the condition of the urinary tract either before or early in preg'." nancy. Pyelography either during or within three months following delivery is unreliable since interpretations made on pyelograms taken before the kidney has recovered from the overdistention present during pregnancy are very misleading and unsafe. Different degrees of distention of such pelves will give entirely different pictures. The slack following over distention has not yet been taken up. It is my experience that stricturing does take place in regions of the ureter where pressure from the fetus is impossible, as a result of inflammatory changes attendant upon pyelonephritis of pregnancy. It is noteworthy that the few strictures which have been observed in the pregnant women of our clinic have not
STRICTURE FORMATION IN URETER
577
produced symptoms immediately after delivery took place, but months afterwards. There has been but 1 patient in whom strictured ureter was diagnosed prior to the onset of pregnancy. The strictured area assumed its part in the ureteral dilatation which took place in the later months of pregnancy, but returned
\. I
FIG. FIG.
1.
1
FIG . 2
PYELOURETEROGRAM OF THE RIGHT KIDNEY (1922) SHOW ING EXTREME
DILATATION OF CALYCES, PELVIS AND URETER TO THE PELVIC BRIM
At cystoscopy residual urine of 165 cc. was found . Phthalein output at this stage was good. FIG.
2.
PYELOURETEROGRAM (JANUARY,
1926)
OF THE RIGHT KIDNEY
SHOWING PERMANENT DAMAGE TO KIDNEY AND URETER
Stricture could not be demonstrated cystoscopically. Pelvic residual was 52 cc. Pain in the kidney region had appeared hut phthalein function was unimpaired except for delayed appearance time of seven minutes after intravenous injection.
to its former ureterographic demonstrability some months after delivery. Even then it did not produce symptoms of pain or pelvic dilatation, but showed as a typical, persistent ureteral narrowing. The urine was never found infected during or subsequent to pregnancy. In spite of these somewhat confused findings, I am of the opinion that stricture existed in this ureter, but that it took part in the general ureteral dilatation of the back
578
E. GRANVILLE CRABTREE
pressure kidney of pregnancy. I must confess to insufficient skill with the bulb catheter to insure me against recording the so-called "hang" of strictured ureter in places where pyelography shows wide dilatation and tortuosity. Furthermore, if ureteral stricture is the cause of the pyelonephritis of pregnancy, delivery is sufficient to allow of bacteria-free urine appearing within three weeks to three months without the help of any cystoscopic treatment in most patients. I make the above statements to indicate my experience with strictured ureters complicated by pregnancy. It is my belief that stricture formation may take place as a legacy of severe degrees of pyelonephritis and ureteritis. I am not sure but that previously existing ureteral stricture may take part in the ureterpelvic dilatation commonly found in pregnancy and prove to be of small significance in pyelonephritis until after delivery has taken place. That strictured ureters play an important part in the eventual destruction of the kidney alo'ng with other pathological conditions including obstructing angulations and aberrant vessels needs no comment. A wider experience than many or I may say any urologist now has is necessary to proper evaluation of the significance of ureteral stricture in pregnancy. It is with the hope of adding a little definite data to our present meagre know edge that the following case history and surgical specimen is described : Past history included scarlet fever and diphtheria in childhood without known sequellae. Appendectomy at the age of twenty. There was no history of previous urinary difficulties either in early life or with previous pregnancies. Urines in one previous confinement at this hospital were normal. In 1914, 1915 and 1917 she had been delivered at term of normal babies, 1918, a tubal pregnancy; 1919, a normal delivery. Micturition was not abnormal. Wassermann reaction was negative. Urine was negative. - There was some constipation. December 28, 1921, she appeared at the clinic complaining of left costo-vertebral tenderness and pain. The urine examination showed albumin, s.p.t., sugar 0, sediment moderate number of white blood corpuscles. January 10, 1922, symptoms appeared on the right side.
STRICTURE FORMATION IN URETER
579
January 13 she was admitted to the Peter Bent Brigham Hospital with severe chills where she underwent urological study. Cystoscopic report is as follows: Bladder capacity 300 cc. Right orifice pouty and edematous. Urine report: Left sediment negative. Five per cent function ten minutes. Culture B. coli. Right sediment pus. Nine per cent function ten minutes, Culture no growth. Pyelogram: No stones were found in either kidney. There was markedly dilated right ureter, pelvis and calyces. The patient remained in hospital three weeks. February 1922, the patient was again seen in the out-patient clinic of the Boston Lying-In Hospital. She continued to have pyuria and right renal pain. She was then admitted to the Lying-In Hospital where she was again cystoscoped. The right kidney was then palpable. Pelvic content of the right kidney was 165 cc. Sediment from the right pelvis was pus. From the left bacilli. An inlying catheter was placed in the right ureter, but the patient showed no improvement. March 7, 1922, vaginal Caesarian section was done. After delivery she improved steadily with decrease in pain about the right kidney. She failed to report to the out-patient clinic until October 23, ] 925, when six and one-half months pregnant. The urine still showed pus and bacilli. At this time her blood pressure had risen to 174 mm. and she had had pain about the right kidney for two weeks. Under appropriate treatment the blood pressure dropped to 110 to 120 mn1., the temperature became normal. Phenolsulphonephthalein test 40 per cent in two hours. Albumin v.s.t. She was then admitted to the hospital for toxemia. Cystoscopic findings on admission: Right pelvic content 60 cc. Sediment loaded with pus cocci and bacilli. Function test phthalein four minutes appearance time 14 per cent in 15 minutes. Left: no pelvic residual or dilatation. Sediment: a few white blood cells; many bacilli and cocci. A right pyelogram was done. Markedly dilated pelvis and ureter with dilatation of calyces the tips of which are very blunt. She remained in hospital twelve days. Temperature normal. After returning home she continued to have pain in her right flank. November 29, 1925, readmitted for increasing toxemic symptoms and abdominal Caesarian and sterilization done. Convalescence uneventful. Blood pressure remained below 120 mm. following interruption of pregnancy.
580
E. GRANVILLE CRABTREE
January 8, 1926, she reappeared in the out-patient clinic complaining of pain, of recent recurrence, in the region of the right kidney. The
Fro. 4
FIG. 3 FIG. 3. FIG.
4.
LOWER PORTIONS OF URETER AT THE SAME DATE AS FIGURE PYELOURETEROGRAM (MARCH,
1927)
2
OF RIGHT KIDNEY SHOWING
FURTHER DECREA S E IN SIZE OF PELVIS AND DEFINITE STRICTURE FORMATION IN THE UPPER URETER
Repeated ureteral dilatations had been done. Phthalein excretion had almost entirely disappeared,-there was only a trace excreted in fifteen minutes. The above stricture must have formed between January, 1926, and March, 1927. Functional damage in this kidney took palce rapidly on the development of stricture.
right kidney was palpable. The bladder urme showed much pus. Blood pressure had risen to 200 mm.
STRICTURE FORMATION IN URETER
581
Cystoscopic findings: Right sediment: much pus. Pelvic residual 52 cc. Function test seven minutes appearance time, 15 per cent in ten minutes. Left sediment : negative. Pelvic residual 0. Function test four minutes appearance time. Eighteen per cent in fifteen minutes. There was no evidence of ureteral narrowing made out. Right pyelogram still shows considerable dilatation of the pelvis and ureter without any evidence of obstruction noted. Right nephrectomy was advised but not done because of steadily increasing blood pressure which was thought to be due to previous toxemic condition. From March until December the patient was carried by the toxemia clinic, spending most of hertime at home in bed on account of renal pain. Blood pressure ranging from 200 to 210 mm. From December, 1926, to February, 1927, 5 cystoscopic treatments were given. At each sitting the right ureter was dilated with size 11 or 12 F. catheters or bougies. The longest period of relief from symptoms was four days . On February 4, a No . 14 F. bulb was passed without relief. Operation was then decided upon in spite of hypertension. Cystoscopic examination was repeated just prior to the operation on March 11, 1927. The findings were as follows : Bladder urine very cloudy. The bladder mucous membrane is dulled from a chronic inflammation . Both ureters are easily catheterized. Right urine cloudy. Left urine clear. Function test : On the right there is a very slight trace of color in twenty minutes. On the left there is a function of 45 per cent (dilution of 250 cc.) in fifteen minutes. Dr. S. L . Morrison's x-ray interpretation is as follows : The left kidney is about normal in size and position and there are no shadows of stones seen in the kidneys, course of ureters, or in the bladder. The lumbar spine is about normal. A pyelogram of the right kidney shows the ureter to be dilated irregularly. There is a narrowing opposite the transverse process of the third lumbar vertebra. At the uretero-pelvic junction it appears dilated. The infundibula are dilated, the pelvis is dilated, and the calyces are dilated and blunted. The cortex of the kidney seems very thin and narrow. Conclusions: We believe there is a destroyed kidney with considerable hydronephrosis. Preoperative diagnosis : Right pyonephrosis; ureteral stricture. At operation the kidney was adherent to the fatty capsule with some periureteral fat induration throughout the course of the ureter. This was quite marked about the upper third of the ureter. The ureter was dilated throughout its course. About 2 inches below the pelvis it was 0
582
E. GRANVILLE CRABTREE
markedly thickened. The periureteral tissues were veryadherentaboµt this area. There was a flattened red area occupying the upper pole suggestive of infarct. There was very active peristaltic movements of a thick walled dilated pelvis. The ureter was thick walled and dilated below the strictured area as far as the bladder. Ureter was removed to a point about 2, inches below the pelvic brim. At the end of the operation it was noted that peristaltic waves were still in motion over the pelvis and could be stimulated by pinching with forceps for some minutes afterwards in all for a total of probably more than ten minutes from the time the kidney was removed. Dr. Tracy Mallory's report on the gross and microscopical examination of the specimen is as follows: "April 7, 1927. Right kidney (nephrectomy following pyelitis of pregnancy). Weight 130 grams. Dimensions 10 by 5.5 by 4 cm. The kidney is shrunken, firm and decolorized by the fixative. The capsules seem to have stripped readily, leaving a smooth, somewhat mottled surface. At the upper pole there is an irregularly shrunken, puckered area, darker in color, suggesting a previous inflammatory process. Several smaller puckered areas, about 1 cm. square, are seen on the outer border of the kidney. "The renal pelvis and upper ureter are dilated and about 4 cm. below the pelvis there is a definite ureteral stricture extending for about 3 cm. In this area the walls are hypertrophied three or four times the normal, and the ureter below this point still appears somewhat dilated. "On cut section the calyces are dilated and the walls of the pelvis thickened. The renal parenchyma appears fairly normal. There is no gross evidence of inflammation or necrosis. Sections taken as follows: 1. Kidney through shrunken area described _above. 2. Kidney apparently normal, at the upper pole. 3. Kidney, apparently normal, lower pole. 1. Ureter below stricture. 2. Uireter through stricture. 3. Ureter above stricture. "Microscopic examination of sections through unscarred areas of cortex and pyramids show that the glomeruli are uniformly slightly distended. In many instances the capsular space is obliterated, in others the narrowed space is filled with albuminous material. One or two capillaries of the glomerular tuft in almost every instance are occluded by masses of endothelial cells. Occasionally a polymorphonuclear leukocyte is present. In general the lining cells of Bowman's capsules are entirely involved in the process. Occasionally a desquamated cell is seen in the capillary space. The convoluted tubules
STRICTURE FORMATION IN URETER
Fm. 5 Fm .
5.
583
Fm. 6
DRAWING MADE FROM SURGICAL SPECIMEN OF RIGHT KIDNEY SHOWING
DESTRUCTIVE PROCESS IN UPPER POLE, PELVIC THICKENING AND DILATATION, DILATATION OF URETER ABOVE AND BELOW THE STRICTURE, AND A CYLINDRICAL STRICTURE FORMED IN THE UPPER THIRD OF THE URETER FIG.
6.
THE SAME SPECIMEN AS IN FIGURE
5,
WITH THE URETER
OPENED TO SHOW THE STRICTURE
584
E. GRANVILLE CRABTREE
are filled with albuminous material. The fixation is too poor to permit an accurate decision as to vacuolization or albuminous degeneration. "Sections through a large scarred region show a wedge-shaped area with apex towards the pyramid. The tubules have almost entirely disappeared and a dense infiltration with lymphocytes and plasma cells replaces them. The tissue is shrunken and the larger blood vessels are drawn closely together. Many of them show considerable thickening of the intima. The glomeruli in this area are to a large extent completely sclerosed. The remainder show marked capsular thickening and adhesions between tuft and capsule. "Sections of the ureter above and below the point of stricture show moderate thickening of the wall, a normal mucous membrane and a slight degree of infiltration with lymphocytes and plasma cells. Section at the point of stricture shows a marked chronic inflammatory process. There is dense infiltration with lymphocytes and plasma cells of submucosa and muscularis, and considerable increase in fibrous tissue, bands of which run between and split widely apart the muscle bundles of the muscularis. The mucous membrane over this area is less regularly stratified than elsewhere and shows small papillomatous projections. "Diagnosis: Chronic pyelonephritis, subacute glomerulonephritis, inflammatory stricture of ureter.-(Signed) Tracy B. Mallory.'' It is now two months since operation. The blood pressure has fallen from 200 to 210 mm. to 124 to 140 mm. since two weeks after operation, and has remained low in spite of the patient's resumption of the care of a house and 6 children. This case seems to me extremely important in that from long close observation the date of stricture formation is known. It is known to have followed closely upon a pyelonephritis of pregnancy. After stricture development took place, the kidney's value as an excretory organ as shown by phthalein excretion was soon lost. The relation of the rise in blood pressure to the lesion and its rapid and complete subsidence after nephrectomy is to me unexplainable, particularly since more than half of the patient's time for months previous to operation had been spent in bed which should have favored lowered pressure. This phenomenon has cast a great deal of doubt on the original diagnosis of toxaemia which was made during her last pregnancy. From the illus-
STRICTURE FORMATION IN URETER
585
tration and from the pathological report it seems logical that attempts at dilatation of this stricture should have failed. REFERENCES (1) OcKERBLAD, NELSE F.: Stricture of the ureter in males. Jour. Amer. Med. Assoc., 1927, lxxxviii, 544-547. (2) HALLE: Ureterite et Pyelite. Paris, 1887. (3) MoRRis, HENRY: Surgical Distention of the Kidney and Ureters, 1901, vol. ii. (4) HuNNER, GUY L.: Bull. Johns Hopkins Hosp., 1918, xxix. HuNNER, Guy L.: Modern Urology, 1924, ii. HuNNER, GUY L.: Conservative renal surgery associated with ureteral strictures. Jour. Urol., 1923, ix, no. 2.
Ockerblad (1) in a recent article on stricture of the ureter in males, published in the Journal of the American Medical Association, calls attention to the preponderance of clinical findings as the basis of our knowledge of ureteral strictures. To quote his words: "Among urologists there is no longer any controversy over stricture of the ureter as a disease entity. Clinical evidence is not lacking, but more experimental data and much necropsy testimony is needed to write convincingly in this subject and to establish the pathology in this newly recognized disorder." Surgical specimens are even more valuable for study than the terminal lesions of necropsy, but unfortunately not so easily obtainable. There is no excuse to remove by operation a kidney when ureteral dilatation will suffice, nor is excision of a specimen from a stricture for pathological examination possible at operation without jeopardizing the kidney. A combination of pathological changes in a kidney long studied in my clinic have made possible the report of the surgical specimen described below. Ureteral stricture has been described from autopsy by Evart, Galliard, Kroner and Watson from 1879 to 1885, Runner, HH8, and Corson, 1924. Halle (1887) and Morris (1901) expressed the opinion that in pregnant women pressure of the child's head in utero laid the foundation for the preponderance of ureteral strictures in women over men. This opinion has now no more popularity than that fetal pressure alone obstructs the upper ureters in the later months of pregnancy. Runner calls attention to ureteral irregularities, kinks and 1 Read at the Annual Meeting of the American Urological Association; Baltimore, Maryland, May, 1927.
575
576
E. GRANVILLE CRABTREE
strictures of ureters in pregnancy appearing to assign more importance to strictures as a cause of back pressure kidneys in pregnancy than to the unknown factor which is as yet indeterminate. I am convinced that if stricture exists in many of the pregnant women with pyelonephritis in my clinic, it is of very few weeks' duration and recovers spontaneously after delivery. I do not think it is present in the majority of ureteral and pelvic dilatations in pregnancy. The return to normal of such kidneys without treatment suitable for stricture is too rapid and proper drainage measures will relieve the over-distention in the absence of ureteral dilatation. I recognize that such a statement but adds to the controversy over the "clinical" stricture. In our clinic we have demonstrated in postpartem pyelonephritis an area of inflammatory change in one patient sufficient to deform the course of the ureter. Stricture subsequently developed at that area. The severity of inflammatory reaction in the partially closed type of kidney found in the pregnant woman is favorable to stricture formation after delivery as scar tissue formation takes place. In 1 case the stricture developed within a year following pyelographic evidence of its absence prior to that time. The evidence available on the subject of stricture formation in pyelonephritis of pregnancy is extremely meager; speculation almost entirely occupies the field. Rarely is it possible to know the condition of the urinary tract either before or early in preg'." nancy. Pyelography either during or within three months following delivery is unreliable since interpretations made on pyelograms taken before the kidney has recovered from the overdistention present during pregnancy are very misleading and unsafe. Different degrees of distention of such pelves will give entirely different pictures. The slack following over distention has not yet been taken up. It is my experience that stricturing does take place in regions of the ureter where pressure from the fetus is impossible, as a result of inflammatory changes attendant upon pyelonephritis of pregnancy. It is noteworthy that the few strictures which have been observed in the pregnant women of our clinic have not
STRICTURE FORMATION IN URETER
577
produced symptoms immediately after delivery took place, but months afterwards. There has been but 1 patient in whom strictured ureter was diagnosed prior to the onset of pregnancy. The strictured area assumed its part in the ureteral dilatation which took place in the later months of pregnancy, but returned
\. I
FIG. FIG.
1.
1
FIG . 2
PYELOURETEROGRAM OF THE RIGHT KIDNEY (1922) SHOW ING EXTREME
DILATATION OF CALYCES, PELVIS AND URETER TO THE PELVIC BRIM
At cystoscopy residual urine of 165 cc. was found . Phthalein output at this stage was good. FIG.
2.
PYELOURETEROGRAM (JANUARY,
1926)
OF THE RIGHT KIDNEY
SHOWING PERMANENT DAMAGE TO KIDNEY AND URETER
Stricture could not be demonstrated cystoscopically. Pelvic residual was 52 cc. Pain in the kidney region had appeared hut phthalein function was unimpaired except for delayed appearance time of seven minutes after intravenous injection.
to its former ureterographic demonstrability some months after delivery. Even then it did not produce symptoms of pain or pelvic dilatation, but showed as a typical, persistent ureteral narrowing. The urine was never found infected during or subsequent to pregnancy. In spite of these somewhat confused findings, I am of the opinion that stricture existed in this ureter, but that it took part in the general ureteral dilatation of the back
578
E. GRANVILLE CRABTREE
pressure kidney of pregnancy. I must confess to insufficient skill with the bulb catheter to insure me against recording the so-called "hang" of strictured ureter in places where pyelography shows wide dilatation and tortuosity. Furthermore, if ureteral stricture is the cause of the pyelonephritis of pregnancy, delivery is sufficient to allow of bacteria-free urine appearing within three weeks to three months without the help of any cystoscopic treatment in most patients. I make the above statements to indicate my experience with strictured ureters complicated by pregnancy. It is my belief that stricture formation may take place as a legacy of severe degrees of pyelonephritis and ureteritis. I am not sure but that previously existing ureteral stricture may take part in the ureterpelvic dilatation commonly found in pregnancy and prove to be of small significance in pyelonephritis until after delivery has taken place. That strictured ureters play an important part in the eventual destruction of the kidney alo'ng with other pathological conditions including obstructing angulations and aberrant vessels needs no comment. A wider experience than many or I may say any urologist now has is necessary to proper evaluation of the significance of ureteral stricture in pregnancy. It is with the hope of adding a little definite data to our present meagre know edge that the following case history and surgical specimen is described : Past history included scarlet fever and diphtheria in childhood without known sequellae. Appendectomy at the age of twenty. There was no history of previous urinary difficulties either in early life or with previous pregnancies. Urines in one previous confinement at this hospital were normal. In 1914, 1915 and 1917 she had been delivered at term of normal babies, 1918, a tubal pregnancy; 1919, a normal delivery. Micturition was not abnormal. Wassermann reaction was negative. Urine was negative. - There was some constipation. December 28, 1921, she appeared at the clinic complaining of left costo-vertebral tenderness and pain. The urine examination showed albumin, s.p.t., sugar 0, sediment moderate number of white blood corpuscles. January 10, 1922, symptoms appeared on the right side.
STRICTURE FORMATION IN URETER
579
January 13 she was admitted to the Peter Bent Brigham Hospital with severe chills where she underwent urological study. Cystoscopic report is as follows: Bladder capacity 300 cc. Right orifice pouty and edematous. Urine report: Left sediment negative. Five per cent function ten minutes. Culture B. coli. Right sediment pus. Nine per cent function ten minutes, Culture no growth. Pyelogram: No stones were found in either kidney. There was markedly dilated right ureter, pelvis and calyces. The patient remained in hospital three weeks. February 1922, the patient was again seen in the out-patient clinic of the Boston Lying-In Hospital. She continued to have pyuria and right renal pain. She was then admitted to the Lying-In Hospital where she was again cystoscoped. The right kidney was then palpable. Pelvic content of the right kidney was 165 cc. Sediment from the right pelvis was pus. From the left bacilli. An inlying catheter was placed in the right ureter, but the patient showed no improvement. March 7, 1922, vaginal Caesarian section was done. After delivery she improved steadily with decrease in pain about the right kidney. She failed to report to the out-patient clinic until October 23, ] 925, when six and one-half months pregnant. The urine still showed pus and bacilli. At this time her blood pressure had risen to 174 mm. and she had had pain about the right kidney for two weeks. Under appropriate treatment the blood pressure dropped to 110 to 120 mn1., the temperature became normal. Phenolsulphonephthalein test 40 per cent in two hours. Albumin v.s.t. She was then admitted to the hospital for toxemia. Cystoscopic findings on admission: Right pelvic content 60 cc. Sediment loaded with pus cocci and bacilli. Function test phthalein four minutes appearance time 14 per cent in 15 minutes. Left: no pelvic residual or dilatation. Sediment: a few white blood cells; many bacilli and cocci. A right pyelogram was done. Markedly dilated pelvis and ureter with dilatation of calyces the tips of which are very blunt. She remained in hospital twelve days. Temperature normal. After returning home she continued to have pain in her right flank. November 29, 1925, readmitted for increasing toxemic symptoms and abdominal Caesarian and sterilization done. Convalescence uneventful. Blood pressure remained below 120 mm. following interruption of pregnancy.
580
E. GRANVILLE CRABTREE
January 8, 1926, she reappeared in the out-patient clinic complaining of pain, of recent recurrence, in the region of the right kidney. The
Fro. 4
FIG. 3 FIG. 3. FIG.
4.
LOWER PORTIONS OF URETER AT THE SAME DATE AS FIGURE PYELOURETEROGRAM (MARCH,
1927)
2
OF RIGHT KIDNEY SHOWING
FURTHER DECREA S E IN SIZE OF PELVIS AND DEFINITE STRICTURE FORMATION IN THE UPPER URETER
Repeated ureteral dilatations had been done. Phthalein excretion had almost entirely disappeared,-there was only a trace excreted in fifteen minutes. The above stricture must have formed between January, 1926, and March, 1927. Functional damage in this kidney took palce rapidly on the development of stricture.
right kidney was palpable. The bladder urme showed much pus. Blood pressure had risen to 200 mm.
STRICTURE FORMATION IN URETER
581
Cystoscopic findings: Right sediment: much pus. Pelvic residual 52 cc. Function test seven minutes appearance time, 15 per cent in ten minutes. Left sediment : negative. Pelvic residual 0. Function test four minutes appearance time. Eighteen per cent in fifteen minutes. There was no evidence of ureteral narrowing made out. Right pyelogram still shows considerable dilatation of the pelvis and ureter without any evidence of obstruction noted. Right nephrectomy was advised but not done because of steadily increasing blood pressure which was thought to be due to previous toxemic condition. From March until December the patient was carried by the toxemia clinic, spending most of hertime at home in bed on account of renal pain. Blood pressure ranging from 200 to 210 mm. From December, 1926, to February, 1927, 5 cystoscopic treatments were given. At each sitting the right ureter was dilated with size 11 or 12 F. catheters or bougies. The longest period of relief from symptoms was four days . On February 4, a No . 14 F. bulb was passed without relief. Operation was then decided upon in spite of hypertension. Cystoscopic examination was repeated just prior to the operation on March 11, 1927. The findings were as follows : Bladder urine very cloudy. The bladder mucous membrane is dulled from a chronic inflammation . Both ureters are easily catheterized. Right urine cloudy. Left urine clear. Function test : On the right there is a very slight trace of color in twenty minutes. On the left there is a function of 45 per cent (dilution of 250 cc.) in fifteen minutes. Dr. S. L . Morrison's x-ray interpretation is as follows : The left kidney is about normal in size and position and there are no shadows of stones seen in the kidneys, course of ureters, or in the bladder. The lumbar spine is about normal. A pyelogram of the right kidney shows the ureter to be dilated irregularly. There is a narrowing opposite the transverse process of the third lumbar vertebra. At the uretero-pelvic junction it appears dilated. The infundibula are dilated, the pelvis is dilated, and the calyces are dilated and blunted. The cortex of the kidney seems very thin and narrow. Conclusions: We believe there is a destroyed kidney with considerable hydronephrosis. Preoperative diagnosis : Right pyonephrosis; ureteral stricture. At operation the kidney was adherent to the fatty capsule with some periureteral fat induration throughout the course of the ureter. This was quite marked about the upper third of the ureter. The ureter was dilated throughout its course. About 2 inches below the pelvis it was 0
582
E. GRANVILLE CRABTREE
markedly thickened. The periureteral tissues were veryadherentaboµt this area. There was a flattened red area occupying the upper pole suggestive of infarct. There was very active peristaltic movements of a thick walled dilated pelvis. The ureter was thick walled and dilated below the strictured area as far as the bladder. Ureter was removed to a point about 2, inches below the pelvic brim. At the end of the operation it was noted that peristaltic waves were still in motion over the pelvis and could be stimulated by pinching with forceps for some minutes afterwards in all for a total of probably more than ten minutes from the time the kidney was removed. Dr. Tracy Mallory's report on the gross and microscopical examination of the specimen is as follows: "April 7, 1927. Right kidney (nephrectomy following pyelitis of pregnancy). Weight 130 grams. Dimensions 10 by 5.5 by 4 cm. The kidney is shrunken, firm and decolorized by the fixative. The capsules seem to have stripped readily, leaving a smooth, somewhat mottled surface. At the upper pole there is an irregularly shrunken, puckered area, darker in color, suggesting a previous inflammatory process. Several smaller puckered areas, about 1 cm. square, are seen on the outer border of the kidney. "The renal pelvis and upper ureter are dilated and about 4 cm. below the pelvis there is a definite ureteral stricture extending for about 3 cm. In this area the walls are hypertrophied three or four times the normal, and the ureter below this point still appears somewhat dilated. "On cut section the calyces are dilated and the walls of the pelvis thickened. The renal parenchyma appears fairly normal. There is no gross evidence of inflammation or necrosis. Sections taken as follows: 1. Kidney through shrunken area described _above. 2. Kidney apparently normal, at the upper pole. 3. Kidney, apparently normal, lower pole. 1. Ureter below stricture. 2. Uireter through stricture. 3. Ureter above stricture. "Microscopic examination of sections through unscarred areas of cortex and pyramids show that the glomeruli are uniformly slightly distended. In many instances the capsular space is obliterated, in others the narrowed space is filled with albuminous material. One or two capillaries of the glomerular tuft in almost every instance are occluded by masses of endothelial cells. Occasionally a polymorphonuclear leukocyte is present. In general the lining cells of Bowman's capsules are entirely involved in the process. Occasionally a desquamated cell is seen in the capillary space. The convoluted tubules
STRICTURE FORMATION IN URETER
Fm. 5 Fm .
5.
583
Fm. 6
DRAWING MADE FROM SURGICAL SPECIMEN OF RIGHT KIDNEY SHOWING
DESTRUCTIVE PROCESS IN UPPER POLE, PELVIC THICKENING AND DILATATION, DILATATION OF URETER ABOVE AND BELOW THE STRICTURE, AND A CYLINDRICAL STRICTURE FORMED IN THE UPPER THIRD OF THE URETER FIG.
6.
THE SAME SPECIMEN AS IN FIGURE
5,
WITH THE URETER
OPENED TO SHOW THE STRICTURE
584
E. GRANVILLE CRABTREE
are filled with albuminous material. The fixation is too poor to permit an accurate decision as to vacuolization or albuminous degeneration. "Sections through a large scarred region show a wedge-shaped area with apex towards the pyramid. The tubules have almost entirely disappeared and a dense infiltration with lymphocytes and plasma cells replaces them. The tissue is shrunken and the larger blood vessels are drawn closely together. Many of them show considerable thickening of the intima. The glomeruli in this area are to a large extent completely sclerosed. The remainder show marked capsular thickening and adhesions between tuft and capsule. "Sections of the ureter above and below the point of stricture show moderate thickening of the wall, a normal mucous membrane and a slight degree of infiltration with lymphocytes and plasma cells. Section at the point of stricture shows a marked chronic inflammatory process. There is dense infiltration with lymphocytes and plasma cells of submucosa and muscularis, and considerable increase in fibrous tissue, bands of which run between and split widely apart the muscle bundles of the muscularis. The mucous membrane over this area is less regularly stratified than elsewhere and shows small papillomatous projections. "Diagnosis: Chronic pyelonephritis, subacute glomerulonephritis, inflammatory stricture of ureter.-(Signed) Tracy B. Mallory.'' It is now two months since operation. The blood pressure has fallen from 200 to 210 mm. to 124 to 140 mm. since two weeks after operation, and has remained low in spite of the patient's resumption of the care of a house and 6 children. This case seems to me extremely important in that from long close observation the date of stricture formation is known. It is known to have followed closely upon a pyelonephritis of pregnancy. After stricture development took place, the kidney's value as an excretory organ as shown by phthalein excretion was soon lost. The relation of the rise in blood pressure to the lesion and its rapid and complete subsidence after nephrectomy is to me unexplainable, particularly since more than half of the patient's time for months previous to operation had been spent in bed which should have favored lowered pressure. This phenomenon has cast a great deal of doubt on the original diagnosis of toxaemia which was made during her last pregnancy. From the illus-
STRICTURE FORMATION IN URETER
585
tration and from the pathological report it seems logical that attempts at dilatation of this stricture should have failed. REFERENCES (1) OcKERBLAD, NELSE F.: Stricture of the ureter in males. Jour. Amer. Med. Assoc., 1927, lxxxviii, 544-547. (2) HALLE: Ureterite et Pyelite. Paris, 1887. (3) MoRRis, HENRY: Surgical Distention of the Kidney and Ureters, 1901, vol. ii. (4) HuNNER, GUY L.: Bull. Johns Hopkins Hosp., 1918, xxix. HuNNER, Guy L.: Modern Urology, 1924, ii. HuNNER, GUY L.: Conservative renal surgery associated with ureteral strictures. Jour. Urol., 1923, ix, no. 2.