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Surgical Management of Bladder Stone
THE JOURNAL OF UROLOGY
Vol. 66, No. 2, August 1951 Printed in U.S.A.
SCRGICAL JVIANAGEMENT OF BLADDER STOXE FRANCIS PATTOX TWINEM
AND
BENJAMIN BRUCE LANGDON
Frain the James B11chanan Brady Foundation.for Urology, New York Hospital, New York, N. Y.
In all the :wnals of medical history there is no more fascinating chapter than the surgical treatment of Yesical calculm;. In 1727 James Dougla,s wrote, "Stone in the bladder is a Distemper, which, for ought \\'8 know to the contrary, is as ancient as any other to ,Yhich the humane Body has C"1·er been subject." }\cmong the Egyptians and Hindus, cutting for stone was performed many centuries before Christ. The Hippocratic Oath states, "I will not use the knife either on sufferert> from stone, hut I ffill gi,'e place to such as are craftsmen therein." The first ,Yell recognized operation for bladder stone 1Yas "le pctit appareil," a perinea! lithotomy popularized hy Ammonius of Alexandria in the third century B.C., and requiring only a knife and a hook. This operation remained essentially unchanged until ,1 .bout 1520 A.D., ,Yhen Joannis de Romanis of Cremona deYisecl a better perineal operation Yvhich was described 15 years later by his pupil :Vfariamrn Sanctus and thus became known as the l\!Iarian operation, or "le grand appareil," t>O called because of the more numerous instruments required for its performance. In this operation a grooYed sound ,ms first passed and the bulbom, urethra openC'cl ,,-ith a lithotome. A gorgct ,ms then passed along the groove to ,;teer the forceps into the yesical neck. The stone -was seized with either straight or curved forceps and extracted. If this failed, a dilator was passed and the vesical neck dinilsed sufficiently to permit extraction of the stone. The mortality of this procedure ,ms high and rectal injury ,nts frequent. The next modification was the use of lateral lithotomy in ,1·hich the incision \YaS made just mesial to the left isehium. The originator and chief exponent of this operation ,ms Frere .Jacques, a former French trooper who flourished in the latter part of the seventeenth century and attained a wide reputation as an itinerant lithotomist. He concerned himself but little -with postoperative care, stating, "I have extracted the stone; I leave God to cure the patient." Later, Chesclden ,ms the most skillful lateral lithotomist, and 200 years ago, operated upon 213 patients 11·ith a mortality of 9.3 per cent. lhanco, in 155G, was the first to employ c:uprapubic lithotomy, but this operation was used hut little until the latter part of the last century. Its more general use was retarded by the dm,elopment of lithotripsy which appeared to he a grci,t advance over a cutting operation ,Yithout anesthesia. Crushing calculi by open operation ,ms probably known to Ammonius about 230 B.C. Sanctorius, in lG26, devised a crude instrument for crushing stones without opening the bladder, but it was not until the time of Civiale, in the early nineteenth century, that the operation could be performed with reasonable efficiency and safety. Civiale ,ms involved in many arguments as to priority Read at annual meeting, American -Urological Association, Washington, D. C., Hl50. 201
80,
202
F. P. TWINEM AND B. B. LANGDON
with Leroy d'Etoilles and Heurteloup. Civiale's instrument consisted of two metal tubes, the inner tube having three curved projections by which the stone was grasped and held while a sharp iron rod was used to bore a hole in it. Several treatments were required to pulverize the stone. Weiss invented a curved screw lithotrite in 1824 and Heurteloup designed his curved percussion lithotrite in 1833. It was Bigelow, a Bostonian, who perfected the lithotrite, and in 1878 employed the modern operation of litholapaxy in which the calculus is crushed and the fragments evacuated through a metal tube at the same sitting. Since Bigelow's time little change has occurred in the procedure of litholapaxy except the introduction of the visualizing lithotrite which is preferred by some operators. TABLE
1. Replies of 210 urologists to questionnaire
Visualizing li thotri te preferred. N onvisualizing lithotrite preferred ... Employ both, no special preference. Never employ litholapaxy. Of those using visualizing lithotrites: Prefer Ravich type . Prefer Hendrickson type. No preference. .............................. Few use other types: Lowsley, Young, Wolf, Kirwin. Never use a visualizing li thotri te .................... .
128
64 16 2
73 68 14 14
2. Accidents during litholapaxy (Compiled from questionnaire replies)
TABLE
Total accidents. Breakage of li thotri te. Jamming of jaws of lithotrite. Bending of lithotrite. Rupture of bladder. Separation of parts of instruments with cystotomy.
67 37 18
Accidents requiring cystotomy. Marked urethral trauma; cystotomy not required ....
27
7 4
1
To determine the point of view of urologists throughout the country in the treatment of patients with vesical calculus, a questionnaire was sent out and 210 replies were received (table 1). Although a visualizing type of lithotrite was preferred by 128 urologists, a preference for the nonvisualizing type was expressed by 64. It was noted that the majority of the older urologists preferred a nonvisualizing type. The difference in point of view of various urologists was quite marked. One urologist stated that since we had visualizing lithotrites he considered it akin to malpractice to use a nonvisualizing instrument. Whereas, another urologist said: "Visualizing lithotrites, Phooey!" A third urologist asked why one should use a lithotrite at all when it is so simple to do an open operation. Table 2 shows the various types of accidents reported by those answering the questionnaire.
203
SURGICAL MANAGEMENT OF BLADDER STONE
Fourteen years ago, one of us (F. P. T.) became interested in determining the breaking strength of various types of lithotrites. The Engineering Department of Columbia University was consulted and 5 lithotrites were subjected to increasing force in a manner simulating the conditions of lithotripsy. The exact amount of pressure in pounds required to break each lithotritc was carefully determined. Recently, 4 more lithotrites of different types were similarly tested at Columbia University. The results of these tests are given in table 3. TABLE
3. Breaking strength of lithotrites
(Tests made al Columbia University Laboratory) I
Light-visualizing, foreign make, 22F Movable jaw bent at 140 lbs., broke at 153 lbs.
II
Havich, 19½F l\Iovablc jmv bent at 450 lbs., broke at 490 lbs.
III
Ravi ch, same as II bnt shoulder of movable jaw thicker. Movable jaw bent at 500 lbs., broke at 550 lbs.
IV
Ravich, 22F l\1ovable ja11· bent at 650 lbs., broke at 712 lbs.
V
VI
Ravich 27F Movable jaw broke at 637 lbs. Alcock 27F Bend in tubing at ,150 lbs., shaft broke at 476 lbs.
VII Hendrickson, 27:F Shaft broke at 962 lbs. (5 cm. from distal end)
VIII
IX
TABLE
Bigelow type, 18F ;'\fovable jaw bent at 650 lbs., broke at 762 Jim. Bigelow, 24F Movable jaw bent and broke at shoulder at 315 lbs.
4. Amount of .force applied manually by a man o,r average strength
. 1 J One hand .. avic ~ Two hands Alcock. Bigelm1·, large wheel.
R
I
60-70 110 160 300
lbs. lbs. lbs. lbs.
Table 4 shows amount of force that can be applied manually to the jmrn of the lithotrite by a man of average strength. It is seen from table 4 that if one uses a strong type of lithotrite and the lithotrite is in excellent condition, a man of average strength or even considerably greater than average strength cannot exert enough force manually to break the instrument. One lightly constructed visualizing instrument of foreign make was broken at 153 pounds' pressure. Such an instrument -would be unsafe to use-
204
F. P. TWINEM AND B. B. LANGDON
The numerous accidents reported in table 2 with 37 instances of lithotrite breakage indicate that many of these instruments must not have been in excellent condition or such breakage should not have occurred. Some bladder calculi have been measured, the amount of force required to crush them determined, and the fragments then chemically analyzed. Table 5 gives the result of these tests. The force required to crush these stones was measured under conditions approximating as closely as possible those prevailing during lithotripsy. It is seen from table 5 that the amount of force required to crush some calculi is greater than the breaking strength of a light lithotrite. From the size of the calculi listed, it can be concluded that there are undoubtedly some large, hard calculi which would require a force exceeding 400 pounds to crush. TABLE
5. Force required to crush bladder calculi
COMPOSITION
Calcium oxalate ................................. . Calcium oxalate and calcium phosphate .......... . Calcium oxalate and calcium phosphate .... . Uric acid ........................................ . Uric acid. . ................................... . Uric acid. . .......... . Phosphatic. . . . . ....................... . Phosphatic. . ................. . Phosphatic. . . . . . . ........... . Phosphatic. . . . . . . ........................... . Phosphatic. . ............................ . Phosphatic ............................... . Phosphatic . . . . . ............. . ........ . Phosphatic . . . . . . . . . . . . ........... . Phosphatic ..................................... .
DIAMETER (CM.)
2.0 1.1 2.2 1.6 1.5 1.8 1.1 0.6 0.8 1.0 1.3 1.3 1.1 2.9 3.2
FORCE (LBS.)
49.0 62.0 150.0 52.0 58.0 142.0 18.0 20.0 22.8 26.0 35.0 45.0 81.0 208.0 218.0
Some years ago, tests were made by one of us (F. P. T.) at the Columbia University Testing Laboratory to determine by using a series of artificially constructed spheres of cement and sand, how the required crushing force varies with the diameter of the artificial stone; whether this force varies directly as the diameter-as the square of the diameter-or otherwise. Table 6 shows the results of these tests. The results indicate that for the materials employed compression strength varies approximately as the square of the diameter. However, the materials used in these experiments are somewhat harder than most bladder calculi and previous experiments indicated that for softer materials, the exponent could be nearer 1 than 2. It is therefore highly probable that the compression strength of bladder stones varies as the diameter raised to an exponent which may vary between 1 and 2 depending upon the composition and hardness of the stone. With very hard stones, compression strength probably varies approximately as the square of the diameter, whereas with softer stones, the variation would be more nearly a direct proportion.
205
SURGICAL MANAGEMENT OF BLADDER STONE
A clinical study has been made of the cases of vesical calculus occurring at the New York Hospital during the years 1933-1950. Three hundred and sixty nine cases were thus studied in detail and the more important findings derived from this study are given in the following tables. Of these 369 cases, 349 occurred in males and 20 in females, a ratio of 17 .5 to l
Table 7 gives age distribution by decades and also the percentage of patients with bladder calculi less than 30 years of age at different periods at the :\fpw York Hospital. TABLE
6. Relation between diarneler of stone and compressive strength
-------1-
NUMBER OF TE-STS·---1--l\-'_(E_.x_e_ol\_"E_,,::--;_-T_)
__
Quartz. Silica sand-cement. Phosphate rock-cement. Limestone natural Sand-lime. Average
27 20 27 30 30
;
2.06 1.4 2.13 2.16 2.10
UJ7 (or 2 00)
I
------------------------------------
-·---
W = Kd" = Kd 2 . (W = compression strength-K = a constant-cl = diamet.-n = exponent) Example-A stone 1.4" in diameter has crushing; strength of 150 lbs. What force is required to crush a stone of same m[lterial 2" in di[lmeter, W
-
=
150
K(2.0)2
----:
K(l 4) 2
W
=
306 lbs. TABLE
--;KD 1ST
7. Age distribul"ion by decades
--i--:~--!--4-TI_I___
5_TH _ _ _ _6_TH_~-;~~-l 8TH
---1---1--------- --------,--------
3
2
I
7
\
13
36
82
138
9TIJ
79
I
D
Percentaac of patients with bladder calculi less than 30 years of aqe at di.fferent periods at the New Yark Hospital - - - - - - - - - - - - - - - - - - - - - - - - - - - - - · - - - - - - - - --·--1820-1846
1846-1866
1866-1920
1920-1937
I
1933-1950
I
s.25%
------- - - - - - - - - - - - - - - - ! - - - 83.3%
714%
26.D%
------- -----~--~-----------------------
Table 7 shmvs only 5 patients since 1933 under the age of 20 years. The decreasing incidenee of bladder ealculi in young people from 1820 to the present time is very striking. Whereas in 1820-1846 more than four fifths of the patients were less than 30 years of age, in this study only 3.25 per cent of the patients are in that age group. This finding has also been made in studies in England and else-1Yhere. The mark.eel change in age grouping has undoubtedly been due to jmprovement in the diet of children. In size, the calculi varied from those a little less than a centimeter in diameter to the giant calculus illustrated in figure 1. The essential data concerning this calculus are given in table 8.
206
F. P. TWINEM AND B. B. LANGDON
The man who had this giant calculus was a private pJ.tient of one of us (F. P. T.), and who gave as his chief complaint "I have f,n e,che in my prostate." The calculus was removed without difficulty and 3 weeks later a transurethral prostatic resection was performed. The patient made a very satisfactory
FIG. 1. Giant vesical calculus removed from 63 year old man whose only complaint was "ache in prostate." Three weeks later a transurethral resection was done, and patient made an excellent recovery. TABLE 8. Giant vesical calculus Circumference in two planes 32 cm. and 31. 5 cm. Diameter 12 cm. x 8.5 cm. Weight (after a week of drying) 446 g. Culture from interior of calculus Streptococcus non-hemolyticus and Gram negative bacillus Chemical composition Triple phosphate with traces of urates and calcium oxalate. Removal by cystotomy was followed 3 weeks later by transurethral prostatic resection. Patient did well postoperatively.
recovery. After he,ving dried out fore, period of a week the weight of the calculus was 446 gm. Had the calculus been weighed immediately, the weight would certainly have exceeded 500 gm. Table 9 shows the types of operations performed. Of these, 219 were open operations and 146 were closed. Of the open operations, 168 were simple cys-
SURGICAL MANAGEMENT OF BLADDER STONE
207
tolithotomies. In the other 51 cases, the removal of the calculi was associated with some other operative procedure. TABLE
9. Types of operations
OPEN-219
CLOSED-146
Closed True litholapaxy (stone crushed and washed out) .................................. 104 Unsuccessfully attempted litholapaxies...... ............................... 17 Removal transurethrally without crushing, (rongeur, forceps or irrigation)........ 25 146
Types of Open Operations 1. Simple cystolithotomy. . . . . . . . . . . . . . . . .
2. 3. 4. 5. 6. 7. 8.
. . . . . . . . . . . . . . . . . . . . . . . . . . 168 With one stage suprapubic prostatectomy. . . . . . . . . . . . . . . . . . . . . 33 Perinea! prostatectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 With diverticulectomy. . . . .......................... 2 With transurethral prostatic resection. .................................... 1 With segmental resection of bladder tumor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Retro pubic prostatectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 With suprapubic fulguration of bladder tumor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 219 TABLE
10. Relevant associated conditions
Obstructions to urinary outflow .................................................... 312 Nephrolithiasis.................................................................. 56 Diverticula of bladder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Bladder tumors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Bladder fistulas ....... . 9 Neurological bladder .... . 13 Foreign body in bladder . 4 Radon ulcers ............ . 3 Cystoceles ........ . 2 Parathyroid tumor ..... 1 TABLE
11. Nonfatal complications of cystolithotomy
Pulmonary emboli. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Thrombophlebitis................................................................... Coronary infarction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Septic temperature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wound reopened. . . . . . ...................................................... Postoperative hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Epididymitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lobar pneumonia. . . . . . . . . . . . . . . . . . . . . . . . . . .................... Anuria (for 3 days). . .................. ........................
3 2 1 3 3 3 4 3 1
The various related conditions complicating cystolithiasis are shown in table 10. Of course, the most commonly associated condition was that of obstruction at the bladder neck, which was demonstrable in 312 cases (84 per cent). Stone
208
F. P. TWINEM AND B. B. LANGDON
in the kidney occurred in 56 cases. There was only one case of demonstrable parathyroid tumor. Table 11 shows the various nonfatal complications of the cystolithotomies. TABLE
12. Complications of litholapaxy
Perforated bladder. 3 Perforated urethra. 3 Traumatic bladder ulcer. 2 Excessive bleeding during procedure (operation discontinued) 2 Postoperative hemorrhage. 2 Marked postoperative sepsis (in addition to those having the above traumatic injuries) 2 Epididymitis .................. . l Mortality of litholapaxy ... . 1 (0. 7%) Cause of death, perivesical cellulitis and multiple abscesses (Staph. aureus) TABLE
13. Incomplete litholapaxies
Poor anesthesia (bladder spasms) . Evacuation equipment not available. Hemorrhage. Lithotrite jammed. Impossible to introduce evacuator tube .. Stone too hard to crush (Ravi ch badly bent). No clear explanation, but procedure discontinued and cystolithotomy done. Completed by litholapaxy at later date. Total.
1 1 2
1 1 1 8 2
17 TABLE
14. Composition of calculi
Phosphatic (CaPO,, CaCO,, MgNH.PO.) .. Uric acid Oxalate Oxalate and phosphate .. Phosphate and urate. Oxalate and urate .. Oxalate, urate and phosphate. Cholesterol. . ........... . Phosphate, urate, and sulfate.
138 55 35
25 12 7 7 1
1 281
No analysis
88 369
Calculi with foreign body nucleus. Hair pin, 1 Prostatic tissue, 1
4
Gauze (absorbable), 1 Silkworm gut, 1
Table 12 shows the complications involved in 146 litholopaxies. These complications were not included in the complications listed previously in the discussion of the questionnaire results. It is seen that serious complications during litholapaxy are not uncommon. This is not surprising when one considers that most of the surgeons who do litholapaxies do them only occasionally. The surgeons in some parts of India who do many hundreds of these procedures and conse-
SURGICAL MANAGEMEN'l' OF BLADDER STO~E
209
quently become more skillful in this type of operation, have proportionally fewer accidents. The one death that occurred in this series of litholapaxies occurred as a result of perivesical cellulitis and multiple abscesses (Staph. aureus). Table 13 lists 17 litholopaxies which were not completed for the reasons specified. Table 14 shows the composition of the removed calculi. As one would expect, phosphatic calculi were by far the most numerous. There were four calculi which had formed around a foreign body nucleus. The nature of the foreign body is stated in the table. Table 15 shows the frequency of various types of infecting organisms. Table 16 lists the mortality in 219 cases of cystolithotomies including 21ssociated operations. The cause of death is given in the table. If one eliminates TABLE
15. Infecting organisms
N onhemolytic streptococcus. Staphylococcus al bus. Bacillus proteus. Bacillus coli. Aerobacter aerogenes . Staphylococcus aureus. Pseudomonas pyocyaneus. Bacillus subtilis . Diphtheroid bacilli .. Hemolytic streptococcus. No culture but over 15 WBC per HPF .. TABLE
38 35 29 27
25 24
20 5 Ei 5
136
16. Deaths: Cystolitholoiny in 219 cases, 21 (9.6%)
General sepsis with Lacteremia. Postoperative hemonhage (prostatectomy) .... Thrombophlebitis and pulmonary emboli. Pneumonia. Acute pulmonary edema. Shock. Uremia. Sudden death (cause?). Intestinal hemorrhage. Anesthetic death (spinal) ..
4. 2 6
3 l
I
those cases in ·which some other major operation accompanied cystolithotomy, one arrives at the figure of 12 deaths in 168 cases of simple eystolithotomy (7.H per cent). CONCLUSIONS AND COMlVUJNT
Choice of the proper type of operation in cases of vesical calculi depends on the age and physical condition of the patient, the size and hardness of the stone, the presence or absence of urethral stricture, prostatic hypertrophy or other associated conditions, and the experience r,nd skill of the operator. A greater degree of skill is required to perform litholapaxy properly than to do a suprapubic lithotomy. Litholapaxy has two advantages over open operation: l) a shorter period of convalescence; 2) a lower mortality. In this series the mortality of
210
F. P. TWINEM AND B. B. LANGDON
litholapaxy was only 0.7 per cent, whereas the mortality of simple cystolithotomy was 7.14 per cent. It is believed that the complications of litholapaxy can be greatly reduced by careful attention to the details of proper technique. Most urologists who do this procedure perform it only occasionally and consequently have a higher percentage of complications than they would with increased experience. The exact amount of force necessary to crush calculi, varying in size and composition, has been determined. The extreme limits of crushing strength of nine lithotrites were determined and are reported in this paper. There are some lightly constructed lithotrites which are not sufficiently strong to crush very hard calculi of even moderately large size. The stronger lithotrites have sufficient strength so that one cannot apply manually enough force to break the lithotrite. (This assumes that the lithotrite is in excellent condition.) In many of the reported accidents, the lithotrite could not have been in first class condition. It has been established that the amount of pressure required to crush vesical calculi of varying size and composition is proportional to the diameter raised to an exponent which varies between 1.2 and 2, depending upon the hardness of the calculus. In general, the visualizing lithotrite is suitable for smaller stones but the nonvisualizing instrument is more satisfactory for the larger ones. The use of a rongeur in handling a stone of any considerable degree of hardness is dangerous and many accidents have been reported from this cause. A decreased incidence of bladder calculi in the young in recent years, as compared with a century ago, is very striking. This is believed to be due to the greatly improved diet of children. A case of giant bladder stone (32 cm. by 31.5 cm.) is reported. A clinical study of 369 cases of bladder calculi is reported. The authors wish to express their appreciation of the very kind assistance given by Professors Krefeld and Ingalls of the Department of Engineering, Columbia University, New York City: vVe also wish to thank Mr. Frederick J. Wallace, president, American Cystoscope Makers, Inc. for his most helpful cooperation.
901 Lexington Ave., New York 21, N. Y. REFERENCES BARNEY, J. D.: History of Urology, American Urological Association. Baltimore: Williams and Wilkins, 1933, vol. 2, chapter 1. CRANCE, A. M.: Removal of a giant vesical calculus with aid of obstetrical forceps. J. U rol., 45: 327, 1941. CRISTOL, D.S. AND GREENE, L. F.: Vesical calculi in women. Surg. Clin. North Am., 25: 987, 1945. PRENTISS, R. J.: Vesical calculus: Clinical study based on 250 cystolithotripsies and 132 cystolithotomies. J. Urol., 47: 664, 1942. RICHES, E.W.: Some landmarks in surgery of stone. Brit. J. Urol., 7: 140, 1938. TwINEM, F. P.: One hundred years of bladder stone surgery at the New York Hospital. Urol. & Cutan. Rev., 42: 313, 1938. TwINEM, F. P.: Surgical removal of vesical calculus: An experimental and clinical study. J. Urol., 41: 360, 1939.
Vol. 66, No. 2, August 1951 Printed in U.S.A.
SCRGICAL JVIANAGEMENT OF BLADDER STOXE FRANCIS PATTOX TWINEM
AND
BENJAMIN BRUCE LANGDON
Frain the James B11chanan Brady Foundation.for Urology, New York Hospital, New York, N. Y.
In all the :wnals of medical history there is no more fascinating chapter than the surgical treatment of Yesical calculm;. In 1727 James Dougla,s wrote, "Stone in the bladder is a Distemper, which, for ought \\'8 know to the contrary, is as ancient as any other to ,Yhich the humane Body has C"1·er been subject." }\cmong the Egyptians and Hindus, cutting for stone was performed many centuries before Christ. The Hippocratic Oath states, "I will not use the knife either on sufferert> from stone, hut I ffill gi,'e place to such as are craftsmen therein." The first ,Yell recognized operation for bladder stone 1Yas "le pctit appareil," a perinea! lithotomy popularized hy Ammonius of Alexandria in the third century B.C., and requiring only a knife and a hook. This operation remained essentially unchanged until ,1 .bout 1520 A.D., ,Yhen Joannis de Romanis of Cremona deYisecl a better perineal operation Yvhich was described 15 years later by his pupil :Vfariamrn Sanctus and thus became known as the l\!Iarian operation, or "le grand appareil," t>O called because of the more numerous instruments required for its performance. In this operation a grooYed sound ,ms first passed and the bulbom, urethra openC'cl ,,-ith a lithotome. A gorgct ,ms then passed along the groove to ,;teer the forceps into the yesical neck. The stone -was seized with either straight or curved forceps and extracted. If this failed, a dilator was passed and the vesical neck dinilsed sufficiently to permit extraction of the stone. The mortality of this procedure ,ms high and rectal injury ,nts frequent. The next modification was the use of lateral lithotomy in ,1·hich the incision \YaS made just mesial to the left isehium. The originator and chief exponent of this operation ,ms Frere .Jacques, a former French trooper who flourished in the latter part of the seventeenth century and attained a wide reputation as an itinerant lithotomist. He concerned himself but little -with postoperative care, stating, "I have extracted the stone; I leave God to cure the patient." Later, Chesclden ,ms the most skillful lateral lithotomist, and 200 years ago, operated upon 213 patients 11·ith a mortality of 9.3 per cent. lhanco, in 155G, was the first to employ c:uprapubic lithotomy, but this operation was used hut little until the latter part of the last century. Its more general use was retarded by the dm,elopment of lithotripsy which appeared to he a grci,t advance over a cutting operation ,Yithout anesthesia. Crushing calculi by open operation ,ms probably known to Ammonius about 230 B.C. Sanctorius, in lG26, devised a crude instrument for crushing stones without opening the bladder, but it was not until the time of Civiale, in the early nineteenth century, that the operation could be performed with reasonable efficiency and safety. Civiale ,ms involved in many arguments as to priority Read at annual meeting, American -Urological Association, Washington, D. C., Hl50. 201
80,
202
F. P. TWINEM AND B. B. LANGDON
with Leroy d'Etoilles and Heurteloup. Civiale's instrument consisted of two metal tubes, the inner tube having three curved projections by which the stone was grasped and held while a sharp iron rod was used to bore a hole in it. Several treatments were required to pulverize the stone. Weiss invented a curved screw lithotrite in 1824 and Heurteloup designed his curved percussion lithotrite in 1833. It was Bigelow, a Bostonian, who perfected the lithotrite, and in 1878 employed the modern operation of litholapaxy in which the calculus is crushed and the fragments evacuated through a metal tube at the same sitting. Since Bigelow's time little change has occurred in the procedure of litholapaxy except the introduction of the visualizing lithotrite which is preferred by some operators. TABLE
1. Replies of 210 urologists to questionnaire
Visualizing li thotri te preferred. N onvisualizing lithotrite preferred ... Employ both, no special preference. Never employ litholapaxy. Of those using visualizing lithotrites: Prefer Ravich type . Prefer Hendrickson type. No preference. .............................. Few use other types: Lowsley, Young, Wolf, Kirwin. Never use a visualizing li thotri te .................... .
128
64 16 2
73 68 14 14
2. Accidents during litholapaxy (Compiled from questionnaire replies)
TABLE
Total accidents. Breakage of li thotri te. Jamming of jaws of lithotrite. Bending of lithotrite. Rupture of bladder. Separation of parts of instruments with cystotomy.
67 37 18
Accidents requiring cystotomy. Marked urethral trauma; cystotomy not required ....
27
7 4
1
To determine the point of view of urologists throughout the country in the treatment of patients with vesical calculus, a questionnaire was sent out and 210 replies were received (table 1). Although a visualizing type of lithotrite was preferred by 128 urologists, a preference for the nonvisualizing type was expressed by 64. It was noted that the majority of the older urologists preferred a nonvisualizing type. The difference in point of view of various urologists was quite marked. One urologist stated that since we had visualizing lithotrites he considered it akin to malpractice to use a nonvisualizing instrument. Whereas, another urologist said: "Visualizing lithotrites, Phooey!" A third urologist asked why one should use a lithotrite at all when it is so simple to do an open operation. Table 2 shows the various types of accidents reported by those answering the questionnaire.
203
SURGICAL MANAGEMENT OF BLADDER STONE
Fourteen years ago, one of us (F. P. T.) became interested in determining the breaking strength of various types of lithotrites. The Engineering Department of Columbia University was consulted and 5 lithotrites were subjected to increasing force in a manner simulating the conditions of lithotripsy. The exact amount of pressure in pounds required to break each lithotritc was carefully determined. Recently, 4 more lithotrites of different types were similarly tested at Columbia University. The results of these tests are given in table 3. TABLE
3. Breaking strength of lithotrites
(Tests made al Columbia University Laboratory) I
Light-visualizing, foreign make, 22F Movable jaw bent at 140 lbs., broke at 153 lbs.
II
Havich, 19½F l\Iovablc jmv bent at 450 lbs., broke at 490 lbs.
III
Ravi ch, same as II bnt shoulder of movable jaw thicker. Movable jaw bent at 500 lbs., broke at 550 lbs.
IV
Ravich, 22F l\1ovable ja11· bent at 650 lbs., broke at 712 lbs.
V
VI
Ravich 27F Movable jaw broke at 637 lbs. Alcock 27F Bend in tubing at ,150 lbs., shaft broke at 476 lbs.
VII Hendrickson, 27:F Shaft broke at 962 lbs. (5 cm. from distal end)
VIII
IX
TABLE
Bigelow type, 18F ;'\fovable jaw bent at 650 lbs., broke at 762 Jim. Bigelow, 24F Movable jaw bent and broke at shoulder at 315 lbs.
4. Amount of .force applied manually by a man o,r average strength
. 1 J One hand .. avic ~ Two hands Alcock. Bigelm1·, large wheel.
R
I
60-70 110 160 300
lbs. lbs. lbs. lbs.
Table 4 shows amount of force that can be applied manually to the jmrn of the lithotrite by a man of average strength. It is seen from table 4 that if one uses a strong type of lithotrite and the lithotrite is in excellent condition, a man of average strength or even considerably greater than average strength cannot exert enough force manually to break the instrument. One lightly constructed visualizing instrument of foreign make was broken at 153 pounds' pressure. Such an instrument -would be unsafe to use-
204
F. P. TWINEM AND B. B. LANGDON
The numerous accidents reported in table 2 with 37 instances of lithotrite breakage indicate that many of these instruments must not have been in excellent condition or such breakage should not have occurred. Some bladder calculi have been measured, the amount of force required to crush them determined, and the fragments then chemically analyzed. Table 5 gives the result of these tests. The force required to crush these stones was measured under conditions approximating as closely as possible those prevailing during lithotripsy. It is seen from table 5 that the amount of force required to crush some calculi is greater than the breaking strength of a light lithotrite. From the size of the calculi listed, it can be concluded that there are undoubtedly some large, hard calculi which would require a force exceeding 400 pounds to crush. TABLE
5. Force required to crush bladder calculi
COMPOSITION
Calcium oxalate ................................. . Calcium oxalate and calcium phosphate .......... . Calcium oxalate and calcium phosphate .... . Uric acid ........................................ . Uric acid. . ................................... . Uric acid. . .......... . Phosphatic. . . . . ....................... . Phosphatic. . ................. . Phosphatic. . . . . . . ........... . Phosphatic. . . . . . . ........................... . Phosphatic. . ............................ . Phosphatic ............................... . Phosphatic . . . . . ............. . ........ . Phosphatic . . . . . . . . . . . . ........... . Phosphatic ..................................... .
DIAMETER (CM.)
2.0 1.1 2.2 1.6 1.5 1.8 1.1 0.6 0.8 1.0 1.3 1.3 1.1 2.9 3.2
FORCE (LBS.)
49.0 62.0 150.0 52.0 58.0 142.0 18.0 20.0 22.8 26.0 35.0 45.0 81.0 208.0 218.0
Some years ago, tests were made by one of us (F. P. T.) at the Columbia University Testing Laboratory to determine by using a series of artificially constructed spheres of cement and sand, how the required crushing force varies with the diameter of the artificial stone; whether this force varies directly as the diameter-as the square of the diameter-or otherwise. Table 6 shows the results of these tests. The results indicate that for the materials employed compression strength varies approximately as the square of the diameter. However, the materials used in these experiments are somewhat harder than most bladder calculi and previous experiments indicated that for softer materials, the exponent could be nearer 1 than 2. It is therefore highly probable that the compression strength of bladder stones varies as the diameter raised to an exponent which may vary between 1 and 2 depending upon the composition and hardness of the stone. With very hard stones, compression strength probably varies approximately as the square of the diameter, whereas with softer stones, the variation would be more nearly a direct proportion.
205
SURGICAL MANAGEMENT OF BLADDER STONE
A clinical study has been made of the cases of vesical calculus occurring at the New York Hospital during the years 1933-1950. Three hundred and sixty nine cases were thus studied in detail and the more important findings derived from this study are given in the following tables. Of these 369 cases, 349 occurred in males and 20 in females, a ratio of 17 .5 to l
Table 7 gives age distribution by decades and also the percentage of patients with bladder calculi less than 30 years of age at different periods at the :\fpw York Hospital. TABLE
6. Relation between diarneler of stone and compressive strength
-------1-
NUMBER OF TE-STS·---1--l\-'_(E_.x_e_ol\_"E_,,::--;_-T_)
__
Quartz. Silica sand-cement. Phosphate rock-cement. Limestone natural Sand-lime. Average
27 20 27 30 30
;
2.06 1.4 2.13 2.16 2.10
UJ7 (or 2 00)
I
------------------------------------
-·---
W = Kd" = Kd 2 . (W = compression strength-K = a constant-cl = diamet.-n = exponent) Example-A stone 1.4" in diameter has crushing; strength of 150 lbs. What force is required to crush a stone of same m[lterial 2" in di[lmeter, W
-
=
150
K(2.0)2
----:
K(l 4) 2
W
=
306 lbs. TABLE
--;KD 1ST
7. Age distribul"ion by decades
--i--:~--!--4-TI_I___
5_TH _ _ _ _6_TH_~-;~~-l 8TH
---1---1--------- --------,--------
3
2
I
7
\
13
36
82
138
9TIJ
79
I
D
Percentaac of patients with bladder calculi less than 30 years of aqe at di.fferent periods at the New Yark Hospital - - - - - - - - - - - - - - - - - - - - - - - - - - - - - · - - - - - - - - --·--1820-1846
1846-1866
1866-1920
1920-1937
I
1933-1950
I
s.25%
------- - - - - - - - - - - - - - - - ! - - - 83.3%
714%
26.D%
------- -----~--~-----------------------
Table 7 shmvs only 5 patients since 1933 under the age of 20 years. The decreasing incidenee of bladder ealculi in young people from 1820 to the present time is very striking. Whereas in 1820-1846 more than four fifths of the patients were less than 30 years of age, in this study only 3.25 per cent of the patients are in that age group. This finding has also been made in studies in England and else-1Yhere. The mark.eel change in age grouping has undoubtedly been due to jmprovement in the diet of children. In size, the calculi varied from those a little less than a centimeter in diameter to the giant calculus illustrated in figure 1. The essential data concerning this calculus are given in table 8.
206
F. P. TWINEM AND B. B. LANGDON
The man who had this giant calculus was a private pJ.tient of one of us (F. P. T.), and who gave as his chief complaint "I have f,n e,che in my prostate." The calculus was removed without difficulty and 3 weeks later a transurethral prostatic resection was performed. The patient made a very satisfactory
FIG. 1. Giant vesical calculus removed from 63 year old man whose only complaint was "ache in prostate." Three weeks later a transurethral resection was done, and patient made an excellent recovery. TABLE 8. Giant vesical calculus Circumference in two planes 32 cm. and 31. 5 cm. Diameter 12 cm. x 8.5 cm. Weight (after a week of drying) 446 g. Culture from interior of calculus Streptococcus non-hemolyticus and Gram negative bacillus Chemical composition Triple phosphate with traces of urates and calcium oxalate. Removal by cystotomy was followed 3 weeks later by transurethral prostatic resection. Patient did well postoperatively.
recovery. After he,ving dried out fore, period of a week the weight of the calculus was 446 gm. Had the calculus been weighed immediately, the weight would certainly have exceeded 500 gm. Table 9 shows the types of operations performed. Of these, 219 were open operations and 146 were closed. Of the open operations, 168 were simple cys-
SURGICAL MANAGEMENT OF BLADDER STONE
207
tolithotomies. In the other 51 cases, the removal of the calculi was associated with some other operative procedure. TABLE
9. Types of operations
OPEN-219
CLOSED-146
Closed True litholapaxy (stone crushed and washed out) .................................. 104 Unsuccessfully attempted litholapaxies...... ............................... 17 Removal transurethrally without crushing, (rongeur, forceps or irrigation)........ 25 146
Types of Open Operations 1. Simple cystolithotomy. . . . . . . . . . . . . . . . .
2. 3. 4. 5. 6. 7. 8.
. . . . . . . . . . . . . . . . . . . . . . . . . . 168 With one stage suprapubic prostatectomy. . . . . . . . . . . . . . . . . . . . . 33 Perinea! prostatectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 With diverticulectomy. . . . .......................... 2 With transurethral prostatic resection. .................................... 1 With segmental resection of bladder tumor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Retro pubic prostatectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 With suprapubic fulguration of bladder tumor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 219 TABLE
10. Relevant associated conditions
Obstructions to urinary outflow .................................................... 312 Nephrolithiasis.................................................................. 56 Diverticula of bladder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Bladder tumors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Bladder fistulas ....... . 9 Neurological bladder .... . 13 Foreign body in bladder . 4 Radon ulcers ............ . 3 Cystoceles ........ . 2 Parathyroid tumor ..... 1 TABLE
11. Nonfatal complications of cystolithotomy
Pulmonary emboli. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Thrombophlebitis................................................................... Coronary infarction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Septic temperature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wound reopened. . . . . . ...................................................... Postoperative hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Epididymitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lobar pneumonia. . . . . . . . . . . . . . . . . . . . . . . . . . .................... Anuria (for 3 days). . .................. ........................
3 2 1 3 3 3 4 3 1
The various related conditions complicating cystolithiasis are shown in table 10. Of course, the most commonly associated condition was that of obstruction at the bladder neck, which was demonstrable in 312 cases (84 per cent). Stone
208
F. P. TWINEM AND B. B. LANGDON
in the kidney occurred in 56 cases. There was only one case of demonstrable parathyroid tumor. Table 11 shows the various nonfatal complications of the cystolithotomies. TABLE
12. Complications of litholapaxy
Perforated bladder. 3 Perforated urethra. 3 Traumatic bladder ulcer. 2 Excessive bleeding during procedure (operation discontinued) 2 Postoperative hemorrhage. 2 Marked postoperative sepsis (in addition to those having the above traumatic injuries) 2 Epididymitis .................. . l Mortality of litholapaxy ... . 1 (0. 7%) Cause of death, perivesical cellulitis and multiple abscesses (Staph. aureus) TABLE
13. Incomplete litholapaxies
Poor anesthesia (bladder spasms) . Evacuation equipment not available. Hemorrhage. Lithotrite jammed. Impossible to introduce evacuator tube .. Stone too hard to crush (Ravi ch badly bent). No clear explanation, but procedure discontinued and cystolithotomy done. Completed by litholapaxy at later date. Total.
1 1 2
1 1 1 8 2
17 TABLE
14. Composition of calculi
Phosphatic (CaPO,, CaCO,, MgNH.PO.) .. Uric acid Oxalate Oxalate and phosphate .. Phosphate and urate. Oxalate and urate .. Oxalate, urate and phosphate. Cholesterol. . ........... . Phosphate, urate, and sulfate.
138 55 35
25 12 7 7 1
1 281
No analysis
88 369
Calculi with foreign body nucleus. Hair pin, 1 Prostatic tissue, 1
4
Gauze (absorbable), 1 Silkworm gut, 1
Table 12 shows the complications involved in 146 litholopaxies. These complications were not included in the complications listed previously in the discussion of the questionnaire results. It is seen that serious complications during litholapaxy are not uncommon. This is not surprising when one considers that most of the surgeons who do litholapaxies do them only occasionally. The surgeons in some parts of India who do many hundreds of these procedures and conse-
SURGICAL MANAGEMEN'l' OF BLADDER STO~E
209
quently become more skillful in this type of operation, have proportionally fewer accidents. The one death that occurred in this series of litholapaxies occurred as a result of perivesical cellulitis and multiple abscesses (Staph. aureus). Table 13 lists 17 litholopaxies which were not completed for the reasons specified. Table 14 shows the composition of the removed calculi. As one would expect, phosphatic calculi were by far the most numerous. There were four calculi which had formed around a foreign body nucleus. The nature of the foreign body is stated in the table. Table 15 shows the frequency of various types of infecting organisms. Table 16 lists the mortality in 219 cases of cystolithotomies including 21ssociated operations. The cause of death is given in the table. If one eliminates TABLE
15. Infecting organisms
N onhemolytic streptococcus. Staphylococcus al bus. Bacillus proteus. Bacillus coli. Aerobacter aerogenes . Staphylococcus aureus. Pseudomonas pyocyaneus. Bacillus subtilis . Diphtheroid bacilli .. Hemolytic streptococcus. No culture but over 15 WBC per HPF .. TABLE
38 35 29 27
25 24
20 5 Ei 5
136
16. Deaths: Cystolitholoiny in 219 cases, 21 (9.6%)
General sepsis with Lacteremia. Postoperative hemonhage (prostatectomy) .... Thrombophlebitis and pulmonary emboli. Pneumonia. Acute pulmonary edema. Shock. Uremia. Sudden death (cause?). Intestinal hemorrhage. Anesthetic death (spinal) ..
4. 2 6
3 l
I
those cases in ·which some other major operation accompanied cystolithotomy, one arrives at the figure of 12 deaths in 168 cases of simple eystolithotomy (7.H per cent). CONCLUSIONS AND COMlVUJNT
Choice of the proper type of operation in cases of vesical calculi depends on the age and physical condition of the patient, the size and hardness of the stone, the presence or absence of urethral stricture, prostatic hypertrophy or other associated conditions, and the experience r,nd skill of the operator. A greater degree of skill is required to perform litholapaxy properly than to do a suprapubic lithotomy. Litholapaxy has two advantages over open operation: l) a shorter period of convalescence; 2) a lower mortality. In this series the mortality of
210
F. P. TWINEM AND B. B. LANGDON
litholapaxy was only 0.7 per cent, whereas the mortality of simple cystolithotomy was 7.14 per cent. It is believed that the complications of litholapaxy can be greatly reduced by careful attention to the details of proper technique. Most urologists who do this procedure perform it only occasionally and consequently have a higher percentage of complications than they would with increased experience. The exact amount of force necessary to crush calculi, varying in size and composition, has been determined. The extreme limits of crushing strength of nine lithotrites were determined and are reported in this paper. There are some lightly constructed lithotrites which are not sufficiently strong to crush very hard calculi of even moderately large size. The stronger lithotrites have sufficient strength so that one cannot apply manually enough force to break the lithotrite. (This assumes that the lithotrite is in excellent condition.) In many of the reported accidents, the lithotrite could not have been in first class condition. It has been established that the amount of pressure required to crush vesical calculi of varying size and composition is proportional to the diameter raised to an exponent which varies between 1.2 and 2, depending upon the hardness of the calculus. In general, the visualizing lithotrite is suitable for smaller stones but the nonvisualizing instrument is more satisfactory for the larger ones. The use of a rongeur in handling a stone of any considerable degree of hardness is dangerous and many accidents have been reported from this cause. A decreased incidence of bladder calculi in the young in recent years, as compared with a century ago, is very striking. This is believed to be due to the greatly improved diet of children. A case of giant bladder stone (32 cm. by 31.5 cm.) is reported. A clinical study of 369 cases of bladder calculi is reported. The authors wish to express their appreciation of the very kind assistance given by Professors Krefeld and Ingalls of the Department of Engineering, Columbia University, New York City: vVe also wish to thank Mr. Frederick J. Wallace, president, American Cystoscope Makers, Inc. for his most helpful cooperation.
901 Lexington Ave., New York 21, N. Y. REFERENCES BARNEY, J. D.: History of Urology, American Urological Association. Baltimore: Williams and Wilkins, 1933, vol. 2, chapter 1. CRANCE, A. M.: Removal of a giant vesical calculus with aid of obstetrical forceps. J. U rol., 45: 327, 1941. CRISTOL, D.S. AND GREENE, L. F.: Vesical calculi in women. Surg. Clin. North Am., 25: 987, 1945. PRENTISS, R. J.: Vesical calculus: Clinical study based on 250 cystolithotripsies and 132 cystolithotomies. J. Urol., 47: 664, 1942. RICHES, E.W.: Some landmarks in surgery of stone. Brit. J. Urol., 7: 140, 1938. TwINEM, F. P.: One hundred years of bladder stone surgery at the New York Hospital. Urol. & Cutan. Rev., 42: 313, 1938. TwINEM, F. P.: Surgical removal of vesical calculus: An experimental and clinical study. J. Urol., 41: 360, 1939.