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The Incidence and Extent of Hydronephrosis in Prostatic Obstruction1
THE INCIDENCE AND EXTENT OF HYDRONEPHROSIS IN PROSTATIC OBSTRUCTION 1 HERMAN L. KRETSCHMER
AND
FAY H. SQUIRE
From the Presbyterian Hospital, Chicago, Ill.
Soon after the introduction of intravenous urography, its routine use incases of prostatic obstruction became an established procedure on the service of one of us (H. L. K.) at the Presbyterian Hospital. Although the subject of hydronephrosis in prostatic obstruction has been known for many years, few figures, if any, are available as to its frequency and extent. This is understandable since routine retrograde pyelograms were not made in cases of prostatic obstruction. This was probably due not only to a lack of interest in its frequency, but more probably due to the fact that in these cases retrograde pyelography was so often followed by severe systemic reactions. In a previous publication2 one of us (H. L. K.) made the statement that as the patients became aware of the treatment of obstruction by transurethral resection with its lower mortality and shorter convalescence, they would seek relief early in the course of the disease and that the incidence of hydronephrosis, stones and diverticula would decline. It has been our impression since the introduction of transurethral resection that the incidence of hydronephrosis has shown a definite decline. This study was undertaken to prove or disprove our impression. It is based on a review of the intravenous urograms of 408 patients and covers the period from 1933 to 1937 and from 1945 to 1947. For purposes of comparison the cases were divided into two groups which we shall designate as group A and Group B. Group A covers the period from 1933 to 1937 and Group B from 1945 to 1947. The ages of the patients are presented in table 1. The educational campaigns directed toward the diagnosis of carcinoma in its early stages, the early recognition of appendicitis, as well as the campaign urging an annual physical examination, might well be extended to the patient with prostatic obstruction. Our studies of the duration of the symptoms before the patient sought relief were most instructive. The average duration of symptoms before seeking medical aid in group A was 60.5 months. In group Bit was 43 months, a difference of 17.5 months or nearly 1½ years. From this evidence the statement is justified that these patients do seek relief at an early period in their illness. Therefore, it is reasonable to assume or to expect that as a result the incidence and degree of hydronephrosis should show a marked reduction in group B as compared with group A. There were 80 cases in group A which presented evidence of hydronephrosis and hydrometers in the intravenous urograms or an incidence of 44.44 per cent. Read at annual meeting, American Urological Association, July 1, 1947. Buffalo, N. Y. Kretschmer, H. L.: Treatment of prostatic obstruction by trans-urethral resection. Illinois M. J., 64: 449, 1933. 1 1
2
2
HERMAN L. KRETSCHMER AND FAY H. SQUIRE
There were 75 cases in group B which showed hydronephrotic changes, an incidence of 33.43 per cent. The result of this study shows that the patients in group B have 11 per cent less evidence of hydronephrosis than the patients in TABLE
1 GROUP :B
GROUP A
30-39 years .................... . 40-49 ..................... . .................... . 50-59 60-69 " .................... . .................... . 70-79 80-89 " 90-99
101
"
4 cases
30-39 years ................... .
8
40---49
"
.................... .
4
27 75 64 7
50-59 60-69 70-79 80-89 90-99
"
.................... . .................... . .................... . ................... .. .................... .
43 93 59 18 1
"
Total........................
222
"
0
"
"
4 cases
"
1
Tci~ .........................
TABLE
1~
2.
Group A. 186 Patients
Dilatation of Calyces Right. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 times Left.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 " Dilatation of Pelvis Right. . . .. . . . . . .. . . . . .. . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . 55 times Left.............. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 " Dilatation of ureter Right. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Left.......................................................................
TABLE
42 times 30
''
3. Group B. 222 Patients
Dilatation of Calyces Right. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 times Left...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 " Dilatation of Pelvis Right. . .. .. . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . . . .. . . . . . . .. . . . . .. . . . . .. . . . 43 times ~~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dilatation of Ureter Right...................................................................... Left.......................................................................
~
42 times 43
''
group A. From these figures it is evident that in the group seeking early relief, there is a corresponding drop in the incidence of hydronephrosis. The incidence of hydronephrosis in group Bis presented in table 3. In evaluating these figures it is to be remembered that in group A there were 186 cases and in group B 222 cases.
3
EXTENT OF HYDRONEPHROSIS IN PROSTATIC OBSTRUCTION DEGREE AND EXTENT OF HYDRONEPHROSIS
If the incidence of hydronephrosis is less in the cases in which the patients present themselves at an earlier period, the question naturally arises whether or not there will be a difference in the degree of the hydronephrotic changes in these two groups. For purposes of designating the degree of hydronephrosis, the following signs were used: 1+ means a moderate degree of dilatation; 2+ signifies a well developed hydronephrosis; 3+ was used to designate the cases with extreme dilatation. In the following tables are listed the degree of the hydronephrotic changes: PELVIS
CALYCES
Right
Left
URETER
Right
Left
Right
Left
Group A
20 17 13
1+ 12 2+ 16 3+ 12
1+ 26 2+ 16 3+ 13
1+ 16 2+ 18 3+ 12
1+ 23 2+ 11 3+ 8
1+ 24 2+ 16 3+ 7
Total 50
55
55
46
42
47
1+ 2+ 3+
Group B
17 8 12
1+ 18 2+ 10 3+ 10
1+ 22 2+ 9 3+ 12
1+ 15 2+ 11 3+ 11
1+ 24 2+ 7 3+ 11
1+ 26 2+ 10 3+ 7
Total 37
38
43
37
42
43
1+ 2+ 3+
INCIDENCE OF CARCINOMA
The incidence of carcinoma was tabulated for the purpose of determining the incidence of hydronephrosis in cases of carcinoma, as compared with benign obstruction. In group A there were 165 cases of benign obstruction and 20 cases of carcinoma: the incidence was 12.12 per cent. In group B, there were 192 cases of benign obstruction and 25 cases of carcinoma, an incidence of 12.1 per cent. The incidence of carcinoma among these two groups is lower than that in recent publications. Of the 21 cases of carcinoma in group A, 14 had hydronephrosis. Of the 24 cases of carcinoma in group B, 10 had hydronephrosis. In other words, the patients who came in late showed hydronephrosis in 66.66 per cent whereas in the group who came in earlier only 41.66 per cent showed hydronephrosis. CHANGES IN THE COURSE OF THE URETER
Besides dilatation- of the ureter we wish to call attention to other changes in the ureter in this group of cases (fig. 1). In a previous communication3 we 3 Squire, Fay H. and Kretschmer, H. L.: A study of the ureters in bladder neck obstruction. Radiology, 46: 32-36, 1946.
4
HERMAN L. KRETSCHMER AND FAY H. SQUIRE
called attention to the fact that in prostatic enlargement, changes in the course of the ureter are to be seen in the urograms. These changes consist of lateral displacement, angulation and elevation of the ureters at the point of their entrance into the bladder. In the combined series there were 86 cases that showed these changes.
FIG. 1. A, Note fishhook course of left ureter and straight course of right ureter. B, Note right angle course of ureters and high insertion of both ureters. C, Note high insertion of left ureter and fishhook course. D, btraight course of right ureter. High insertion and tortuous course of left ureter.
We also wish at this time to call attention to the fact that similar changes may occur in the course of the ureters in the female (fig. 2). The recognition of these changes in the ureters may be of diagnostic aid or value in some of these cases. BLADDER CHANGES DUE TO OBSTRUCTION
Intimately associated with bladder neck obstruction are changes in the bladder, such as diverticula, cellules and stones. The incidence is presented in the following table:
5
EXTENT OF HYDRONEPHROSIS IN PROSTATIC OBSTRUCTION
GROUP A
GROUP B
~ - - - ~ - ~ ~ I
Diverticula. Cellules. Stones ...
---------------:::::: :I
30
26
~:
2~
On a percentage basis the incidence of diverticula in group A was 16.1 per cent. In group B the incidence was 11.6 per cent. In group A the incidence of cellules was 15.1 per cent; and in group B the incidence was 11.1 per cent.
FIG. 2. Fishhook course and high insertion of left ureter in case of carcinom:1 of bladdre in female.
The percentage of stones in groups A and B, respectively, were 7.5 per cent and 3.1 per cent. PROSTATIC CALCULI
Prostatic calculi were noted in 10 cases in group A or 5.4 per cent, whereas in group B they were found present in 22 cases or 9.8 per cent. BONE INCIDENCE OF CARCINOMA
The incidence of carcinoma in these two groups is lower than any other published series of cases. This may have an effect on the frequency of bone metastases. In group A there were 5 cases of bone metastases and in group B there were 3 cases. PAGET'S DISEASE
We realize the difficulty of differentiating Paget's disease from metastatic carcinoma and that at times errors in reading the films may occur. It is interesting to note that Paget's disease was diagnosed more frequently in group B in which the diagnosis was made 8 times compared with only 2 times in group A.
6
HERMAN L. KRETSCHMER AND FAY H. SQUIRE SUMMARY AND CONCLUSIONS
From our study the following conclusions are justified: The incidence and extent of hydronephrosis are in direct relationship to the duration of the symptoms and the time the patient presents himself for relief. Co-existing bladder disease the result of obstruction, Le. diverticula, cellules and stones are less frequent the earlier the patient seeks relief. Hydronephrosis occurred more frequently in carcinoma than in benign obstruction in our series of cases. Attention is called to changes in the course of the ureter that may be of diagnostic value. An educational campaign urging the patient to seek relief before these changes occur is justified. 122 S. Nlichigan Blvd., Chicago, Ill.
AND
FAY H. SQUIRE
From the Presbyterian Hospital, Chicago, Ill.
Soon after the introduction of intravenous urography, its routine use incases of prostatic obstruction became an established procedure on the service of one of us (H. L. K.) at the Presbyterian Hospital. Although the subject of hydronephrosis in prostatic obstruction has been known for many years, few figures, if any, are available as to its frequency and extent. This is understandable since routine retrograde pyelograms were not made in cases of prostatic obstruction. This was probably due not only to a lack of interest in its frequency, but more probably due to the fact that in these cases retrograde pyelography was so often followed by severe systemic reactions. In a previous publication2 one of us (H. L. K.) made the statement that as the patients became aware of the treatment of obstruction by transurethral resection with its lower mortality and shorter convalescence, they would seek relief early in the course of the disease and that the incidence of hydronephrosis, stones and diverticula would decline. It has been our impression since the introduction of transurethral resection that the incidence of hydronephrosis has shown a definite decline. This study was undertaken to prove or disprove our impression. It is based on a review of the intravenous urograms of 408 patients and covers the period from 1933 to 1937 and from 1945 to 1947. For purposes of comparison the cases were divided into two groups which we shall designate as group A and Group B. Group A covers the period from 1933 to 1937 and Group B from 1945 to 1947. The ages of the patients are presented in table 1. The educational campaigns directed toward the diagnosis of carcinoma in its early stages, the early recognition of appendicitis, as well as the campaign urging an annual physical examination, might well be extended to the patient with prostatic obstruction. Our studies of the duration of the symptoms before the patient sought relief were most instructive. The average duration of symptoms before seeking medical aid in group A was 60.5 months. In group Bit was 43 months, a difference of 17.5 months or nearly 1½ years. From this evidence the statement is justified that these patients do seek relief at an early period in their illness. Therefore, it is reasonable to assume or to expect that as a result the incidence and degree of hydronephrosis should show a marked reduction in group B as compared with group A. There were 80 cases in group A which presented evidence of hydronephrosis and hydrometers in the intravenous urograms or an incidence of 44.44 per cent. Read at annual meeting, American Urological Association, July 1, 1947. Buffalo, N. Y. Kretschmer, H. L.: Treatment of prostatic obstruction by trans-urethral resection. Illinois M. J., 64: 449, 1933. 1 1
2
2
HERMAN L. KRETSCHMER AND FAY H. SQUIRE
There were 75 cases in group B which showed hydronephrotic changes, an incidence of 33.43 per cent. The result of this study shows that the patients in group B have 11 per cent less evidence of hydronephrosis than the patients in TABLE
1 GROUP :B
GROUP A
30-39 years .................... . 40-49 ..................... . .................... . 50-59 60-69 " .................... . .................... . 70-79 80-89 " 90-99
101
"
4 cases
30-39 years ................... .
8
40---49
"
.................... .
4
27 75 64 7
50-59 60-69 70-79 80-89 90-99
"
.................... . .................... . .................... . ................... .. .................... .
43 93 59 18 1
"
Total........................
222
"
0
"
"
4 cases
"
1
Tci~ .........................
TABLE
1~
2.
Group A. 186 Patients
Dilatation of Calyces Right. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 times Left.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 " Dilatation of Pelvis Right. . . .. . . . . . .. . . . . .. . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . 55 times Left.............. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 " Dilatation of ureter Right. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Left.......................................................................
TABLE
42 times 30
''
3. Group B. 222 Patients
Dilatation of Calyces Right. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 times Left...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 " Dilatation of Pelvis Right. . .. .. . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . . . .. . . . . . . .. . . . . .. . . . . .. . . . 43 times ~~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dilatation of Ureter Right...................................................................... Left.......................................................................
~
42 times 43
''
group A. From these figures it is evident that in the group seeking early relief, there is a corresponding drop in the incidence of hydronephrosis. The incidence of hydronephrosis in group Bis presented in table 3. In evaluating these figures it is to be remembered that in group A there were 186 cases and in group B 222 cases.
3
EXTENT OF HYDRONEPHROSIS IN PROSTATIC OBSTRUCTION DEGREE AND EXTENT OF HYDRONEPHROSIS
If the incidence of hydronephrosis is less in the cases in which the patients present themselves at an earlier period, the question naturally arises whether or not there will be a difference in the degree of the hydronephrotic changes in these two groups. For purposes of designating the degree of hydronephrosis, the following signs were used: 1+ means a moderate degree of dilatation; 2+ signifies a well developed hydronephrosis; 3+ was used to designate the cases with extreme dilatation. In the following tables are listed the degree of the hydronephrotic changes: PELVIS
CALYCES
Right
Left
URETER
Right
Left
Right
Left
Group A
20 17 13
1+ 12 2+ 16 3+ 12
1+ 26 2+ 16 3+ 13
1+ 16 2+ 18 3+ 12
1+ 23 2+ 11 3+ 8
1+ 24 2+ 16 3+ 7
Total 50
55
55
46
42
47
1+ 2+ 3+
Group B
17 8 12
1+ 18 2+ 10 3+ 10
1+ 22 2+ 9 3+ 12
1+ 15 2+ 11 3+ 11
1+ 24 2+ 7 3+ 11
1+ 26 2+ 10 3+ 7
Total 37
38
43
37
42
43
1+ 2+ 3+
INCIDENCE OF CARCINOMA
The incidence of carcinoma was tabulated for the purpose of determining the incidence of hydronephrosis in cases of carcinoma, as compared with benign obstruction. In group A there were 165 cases of benign obstruction and 20 cases of carcinoma: the incidence was 12.12 per cent. In group B, there were 192 cases of benign obstruction and 25 cases of carcinoma, an incidence of 12.1 per cent. The incidence of carcinoma among these two groups is lower than that in recent publications. Of the 21 cases of carcinoma in group A, 14 had hydronephrosis. Of the 24 cases of carcinoma in group B, 10 had hydronephrosis. In other words, the patients who came in late showed hydronephrosis in 66.66 per cent whereas in the group who came in earlier only 41.66 per cent showed hydronephrosis. CHANGES IN THE COURSE OF THE URETER
Besides dilatation- of the ureter we wish to call attention to other changes in the ureter in this group of cases (fig. 1). In a previous communication3 we 3 Squire, Fay H. and Kretschmer, H. L.: A study of the ureters in bladder neck obstruction. Radiology, 46: 32-36, 1946.
4
HERMAN L. KRETSCHMER AND FAY H. SQUIRE
called attention to the fact that in prostatic enlargement, changes in the course of the ureter are to be seen in the urograms. These changes consist of lateral displacement, angulation and elevation of the ureters at the point of their entrance into the bladder. In the combined series there were 86 cases that showed these changes.
FIG. 1. A, Note fishhook course of left ureter and straight course of right ureter. B, Note right angle course of ureters and high insertion of both ureters. C, Note high insertion of left ureter and fishhook course. D, btraight course of right ureter. High insertion and tortuous course of left ureter.
We also wish at this time to call attention to the fact that similar changes may occur in the course of the ureters in the female (fig. 2). The recognition of these changes in the ureters may be of diagnostic aid or value in some of these cases. BLADDER CHANGES DUE TO OBSTRUCTION
Intimately associated with bladder neck obstruction are changes in the bladder, such as diverticula, cellules and stones. The incidence is presented in the following table:
5
EXTENT OF HYDRONEPHROSIS IN PROSTATIC OBSTRUCTION
GROUP A
GROUP B
~ - - - ~ - ~ ~ I
Diverticula. Cellules. Stones ...
---------------:::::: :I
30
26
~:
2~
On a percentage basis the incidence of diverticula in group A was 16.1 per cent. In group B the incidence was 11.6 per cent. In group A the incidence of cellules was 15.1 per cent; and in group B the incidence was 11.1 per cent.
FIG. 2. Fishhook course and high insertion of left ureter in case of carcinom:1 of bladdre in female.
The percentage of stones in groups A and B, respectively, were 7.5 per cent and 3.1 per cent. PROSTATIC CALCULI
Prostatic calculi were noted in 10 cases in group A or 5.4 per cent, whereas in group B they were found present in 22 cases or 9.8 per cent. BONE INCIDENCE OF CARCINOMA
The incidence of carcinoma in these two groups is lower than any other published series of cases. This may have an effect on the frequency of bone metastases. In group A there were 5 cases of bone metastases and in group B there were 3 cases. PAGET'S DISEASE
We realize the difficulty of differentiating Paget's disease from metastatic carcinoma and that at times errors in reading the films may occur. It is interesting to note that Paget's disease was diagnosed more frequently in group B in which the diagnosis was made 8 times compared with only 2 times in group A.
6
HERMAN L. KRETSCHMER AND FAY H. SQUIRE SUMMARY AND CONCLUSIONS
From our study the following conclusions are justified: The incidence and extent of hydronephrosis are in direct relationship to the duration of the symptoms and the time the patient presents himself for relief. Co-existing bladder disease the result of obstruction, Le. diverticula, cellules and stones are less frequent the earlier the patient seeks relief. Hydronephrosis occurred more frequently in carcinoma than in benign obstruction in our series of cases. Attention is called to changes in the course of the ureter that may be of diagnostic value. An educational campaign urging the patient to seek relief before these changes occur is justified. 122 S. Nlichigan Blvd., Chicago, Ill.