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The Incidence of Ureteral Stricture*
THE INCIDENCE OF URETERAL STRICTURE* NATHANIEL P. RATHBUN From /.he Urological Service, Brooklyn Hospital, Brooklyn, New York
Received for p ublication June 15, 1925
During the past ten years there have been numerous contributions to the literature on this important subject, most of them, however, made by a relatively small group of observers, notably Runner who first called the attention of the profession to this condition as a clinical entity per se. This paper while presenting little if any thing new is written for the purpose of emphasizing the importance of the subject, illustrating the frequency with which this lesion may be demonstrated if carefully looked for, and stimulating further investigation on the part of a considerable group of observers who have not in my opinion given this subject the careful consideration to which its importance entitles it. There exists a large group of urologists in which I include myself, who feel that stricture of the ureter occurs very commonly, is easily recognized, and is very amenable to treatment. There is I believe another group who feel that the lesion rarely occurs per se, a few of them even going so far as to feel and perhaps state informally that those of us who are enthused over the subject are pursuing a phantom. I believe that the final test of time will demonstrate as usual that the truth lies somewhere between these two extremes. It is of course obvious and freely admitted that so long as there remains a group of workers including in its number some of the best minds in urology, who honestly and frankly question the accuracy of our observations, it behooves those of us who are enthused over the subject to proceed with care and caution, to check up our findings carefully and not allow our enthusiasms to warp judgment. It is however equally fair to say that there has * Read at the annual meeting of the American Association of Genito Urinary Surgeons, May 4 and 5, 1925, Washington, D. C. 403 THE JOURNAL OF UROLOGY, VOL, XIV, NO . 4
404
.NATHANIEL P. RATHBUN
been enough evidence accumulating and presented by a considerable number of workers to entitle the matter to careful consideration and thorough investigation before dismissing it. It seems to me that there have been several factors that have operated to defer a proper appreciation of this subject by the profession in general and by urologists in particular. Paradoxical as it may seem I believe that one of these factors has been the somewhat overzealous enthusiasm of some of the earlier writers whose claims might well have appeared to the conscientious thinker as being too extravagant to warrant serious consideration. Then too the earlier contributions had very little in the way of concrete tangible evidence, such as radiographs. The hang of the large wax bulb was very convincing to Runner and others who were accustomed to using large instruments through a Kelly type of cystoscope, but it meant very little to most of us who were accustomed to using smaller catheters through a fluid medium cystoscope, and for whom the use of even a small wax bulb was attended with considerable technical difficulty. Fortunately some of the more modern instruments have greatly facilitated the employment of wax bulbs in male patients, so that it is now a simple matter to employ this method as a check on other methods of diagnosis and also as a material aid in the treatment. At the present time there are in my opinion two 1;easons why stricture of the ureter is not more frequently recognized. The first and more important is that this condition is too often omitted from the list of possibilities in approaching the diagnosis of obscure cases. In other words we are not able to demonstrate a ureter stricture unless we deliberately look for it. The mere fact that a No. 6 catheter passes readily to the kidney pelvis does not eliminate ureter stricture any more than does the passage of a No. 30 sound into the bladder eliminate urethral stricture. The second reason is that a ureterogram is often omitted from the routine examination of urological problems and often this is made in such a manner as not to produce a true picture of the entire ureter, particularly the lower third. I attribute the frequency with which I have contented myself
INCIDENCE OF URETERAL STRICTURE
405
with a diagnosis of ureteral stricture to a routine procedure which I have followed in my clinic for several years. This briefly is the policy of subjecting every patient in which there is any suspicion of pathology above the bladder to a complete urological survey with the idea of establishing a diagnosis at one sitting. Included in this group there are a considerable number of patients referred to us by the gynecologists and general surgeons for the purpose of excluding any urinary pathology in the absence of
FIG.
1.
Pelvic glands mild infection. dilatation.
UnETEIL\L STHICTURE
Frequency of urination.
Prompt relief from
which the symptoms presented might be attributed to lesions in the tubes, appendix, gall-bladder, etc. This survey includes a careful inspection of the bladder, the passage of radiograph catheters to each kidney pelvis, routine examination of the separated urines, differential renal function tests, a complete x-ray study of the entire urinary tract, with the shadowgraph catheters in position, and a pyelogram and ureterogram of every patient. This is done on the side under suspicion, or if there is no lead pointing
----------
.. 406
NATHAt~IEL P. RATHBUN
to one or the other side, done on both sides at separate sittings. We practically never make bilateral pyelograms at the same sitting. The technique of making the ureterogram is I believe very , important. With the catheter in or near the kidney pelvis, the pelvis is filled with a 15 per cent sodium iodide solution, using a .· small graduated syringe, injecting very slowly and stopping
Fic. 2 FIG.
2.
FIG.
3
BILATERAL STRICTURE IN GIRL OF EIGHT YEARS
Infection: colon bacillus. Frequent recurring attacks of acute pyelitis with hyperpyrexia. Entirely relieved by dilatation. FIG.
3.
SAME PATIENT AS FIGURE
3.
LEFT SIDE
immediately at the first suggestion of disoomfort. A picture is now made of the renal pelvis. The catheter is then withdrawn a short distance with the syringe containing the iodide solution still connected, then with the plate in position the catheter is withdrawn entirely from the body, injecting the solution at the same time and a picture made immediately. In this way we obtain a picture of the entire ureter, particularly the pelvic
INCIDENCE OF URE'l'ERAL S'rRICTURE
407
portion. Incidentally one might add that making ureterogrmns in this way we are less apt to miss double pelvis, bifid ureters, and other abnormalities. While this of course is considerably more of an examination that many patients require, yet by doing it as a routine we are less apt to overlook some conditions which might otherwise be readily passed by, including ureteral stricture. I do not hesitate to make pyelograms and ureterograms in all of my cases, and since using sodium iodide as a medium I have never had a single reaction in which I have been the least alarmed. During the year 1924 my assistants and myself made 739 such examinations in my clinic at the Brooklyn Hospital. There were a considerable number in whom our findings were entirely negative, largely among patients referred by the gynecologists and general surgeons. There were however in this group a large percentage in which we were able to demonstrate a urological lesion and many of these patients were spared the danger and discomfort of an unnecessary operation. In this entire group of 739 patients we made a diagnosis of ureter stricture on radiological evidence alone in 92 patients; 48 of these were males; 44 females. Seven of these were tuberculous. Every one is agreed upon the occurrence of this type of stricture, and they are not included in this study. Seventeen cases were complicated by or were a part of urinary lithiasis. Of these calculi were noted in the renal pelvis in 12 cases, in the ureter, 5 cases. It is not unlikely that in some of this latter group the stricture was incidental to and perhaps caused by the presence of the stone. I agree with Runner however that in many of these cases the calculus is secondary to the stricture. At any rate I am very sure that it is of vital importance to consider stricture as a possible factor in the consideration and treatment of any given case. Failure to do this may be and I am sure often does account for the persistence of or recurrence of symptoms following the removal of the calculus. I believe too that the presence of a stricture may be a contributing factor in some of the recurrent stone cases, by means of interfering with the proper drainage and perpetuating infection. Excluding the cases with tuberculosis and calculi and four other
---~· --
---~--
408
NATHANIEL P. RATHBUN
cases (two renal tumors, one complicated by calculus, and two bladder tumors) there remain 63 patients in which we made a diagnosis of primary ureter stricture. In 34 of these the urine was free from pus and sterile. Varying degrees of infection were noted in the remainder, 39. In all cases there was dilatation of the uterer above the stricture and in most of them there were evidences of dilatation of the
Fm. 4 Fm. 4.
FIG.
5
TIGHT STRICTURE OF P EL V I C URETER
Kink lumbar portion, moderate hydro-ureter and hydro-nephrosis. :vioderate infection. Pain and frequency. Relieved by dilatation. FIG. 5. EXTENS I VE STRICTURE OF RIGHT URETER Calculus in left pelvis . Right sided pain and colic. No symptoms left side. May account for some cases "referred pain. " R elieved by left pyelotorny and dilatation right ureter.
renal pelvis, varying from a slight degree to a well marked hydronephrosis. Practically all of this latter group showed varying degrees of infection, a few (3) having gone over to pyonephrosis with a more or less complete destruction of the kidney. While I realize that the problem of hydronephrosis does not entirely center around ureter stricture I do feel that strictures account for a certain number which could be readily relieved if recognized
409
INCIDENCE OF URETERAL STRICTURE
early and which might well go on to renal destruction and nephrectomy if neglected. There were in this~ group 11 cases which were a part of the pyelitis of pregnancy and the puerperium. This I believe is a most importanffield and I am convinced that ureteral strictures play a very prominent part in these cases and that many of them can be promptly and permanently relieved
Fm. 6
Fm. 7
FIG. 6. Two STRICTURES IN PELVIC URETER Another (?) near renal pelvis. Moderate hydronephrosis. uri_nation only symptom. Relieved by dilatation.
Frequency of
Fm. 7. STRICTURE IN PELVIC URETER Another (not well shown) in intramural portion. Pyonephrosis. tomy. Late case.
Nephrec-
by ureter dilatations. It is interesting to note that practically without exception this entire group of 63 cases were relieved or improved by a line of treatment based on the diagnosis of ureteral stricture. This to my mind is one of the most convincing arguments in the whole matter. Many of these patients have gone the rounds, have submitted to all sorts of treatments, have had
410
NATHANIEL P. RATHBUN
various innocent organs removed, one after the other with no relief, and were promptly relieved by a few ·dilatations of the ureter. Not a few of them volunteer the information after a simple dilatation that they feel better than they have felt for years. With these facts in mind we can be ·forgiven · a certain amount of enthusiasm on the subject. I have gone a bit further than the radiological evidence would warrant, and have in a few cases ,made a diagnosis of ureteral stricture in the absence of radiolo~ical finding;;;, basing the diagnosis on the symptoms and by careful exclusion -of other possible factors in the problem. Sorne of these have been cases of pyelitis which we have treated with various forms of instillations, taking care however to use a large catheter as a part of the treatment. In others in which there was no evidence of infection we have dilated somewhat expectantly and in many cases with· entire relief of symptoms. To my mind this latter item ·is the most cogent argument of all. The fact that so many of these patients presenting a great variety of symptoms which have resisted all sorts of treatment, operative and otherwise, are relieved ·by a few dilatations of the ureter, is very convmcmg. · The hang of a wax bulb and variations in t he caliber of the ureter as shown by ureterograms may be a matter of interpretation and variously construed but the relief iof symptoms following ure- · ter dilatations is a-matter of fact. In conclusion :- While we lay no claim to infallibility and while it is not unlikely that we ,have erred-in some, perhaps many of our diagnoses, , this .paper is written for.· the purpose of placing 011 record the relative frequency · of this diagnosis in one clinic·, hoping to interest ether -observer-s- to the -extent that they may approaeh ·this problem with· an open mind and look carefully for ureteral stricture as a part of the diagnostic survey.
Received for p ublication June 15, 1925
During the past ten years there have been numerous contributions to the literature on this important subject, most of them, however, made by a relatively small group of observers, notably Runner who first called the attention of the profession to this condition as a clinical entity per se. This paper while presenting little if any thing new is written for the purpose of emphasizing the importance of the subject, illustrating the frequency with which this lesion may be demonstrated if carefully looked for, and stimulating further investigation on the part of a considerable group of observers who have not in my opinion given this subject the careful consideration to which its importance entitles it. There exists a large group of urologists in which I include myself, who feel that stricture of the ureter occurs very commonly, is easily recognized, and is very amenable to treatment. There is I believe another group who feel that the lesion rarely occurs per se, a few of them even going so far as to feel and perhaps state informally that those of us who are enthused over the subject are pursuing a phantom. I believe that the final test of time will demonstrate as usual that the truth lies somewhere between these two extremes. It is of course obvious and freely admitted that so long as there remains a group of workers including in its number some of the best minds in urology, who honestly and frankly question the accuracy of our observations, it behooves those of us who are enthused over the subject to proceed with care and caution, to check up our findings carefully and not allow our enthusiasms to warp judgment. It is however equally fair to say that there has * Read at the annual meeting of the American Association of Genito Urinary Surgeons, May 4 and 5, 1925, Washington, D. C. 403 THE JOURNAL OF UROLOGY, VOL, XIV, NO . 4
404
.NATHANIEL P. RATHBUN
been enough evidence accumulating and presented by a considerable number of workers to entitle the matter to careful consideration and thorough investigation before dismissing it. It seems to me that there have been several factors that have operated to defer a proper appreciation of this subject by the profession in general and by urologists in particular. Paradoxical as it may seem I believe that one of these factors has been the somewhat overzealous enthusiasm of some of the earlier writers whose claims might well have appeared to the conscientious thinker as being too extravagant to warrant serious consideration. Then too the earlier contributions had very little in the way of concrete tangible evidence, such as radiographs. The hang of the large wax bulb was very convincing to Runner and others who were accustomed to using large instruments through a Kelly type of cystoscope, but it meant very little to most of us who were accustomed to using smaller catheters through a fluid medium cystoscope, and for whom the use of even a small wax bulb was attended with considerable technical difficulty. Fortunately some of the more modern instruments have greatly facilitated the employment of wax bulbs in male patients, so that it is now a simple matter to employ this method as a check on other methods of diagnosis and also as a material aid in the treatment. At the present time there are in my opinion two 1;easons why stricture of the ureter is not more frequently recognized. The first and more important is that this condition is too often omitted from the list of possibilities in approaching the diagnosis of obscure cases. In other words we are not able to demonstrate a ureter stricture unless we deliberately look for it. The mere fact that a No. 6 catheter passes readily to the kidney pelvis does not eliminate ureter stricture any more than does the passage of a No. 30 sound into the bladder eliminate urethral stricture. The second reason is that a ureterogram is often omitted from the routine examination of urological problems and often this is made in such a manner as not to produce a true picture of the entire ureter, particularly the lower third. I attribute the frequency with which I have contented myself
INCIDENCE OF URETERAL STRICTURE
405
with a diagnosis of ureteral stricture to a routine procedure which I have followed in my clinic for several years. This briefly is the policy of subjecting every patient in which there is any suspicion of pathology above the bladder to a complete urological survey with the idea of establishing a diagnosis at one sitting. Included in this group there are a considerable number of patients referred to us by the gynecologists and general surgeons for the purpose of excluding any urinary pathology in the absence of
FIG.
1.
Pelvic glands mild infection. dilatation.
UnETEIL\L STHICTURE
Frequency of urination.
Prompt relief from
which the symptoms presented might be attributed to lesions in the tubes, appendix, gall-bladder, etc. This survey includes a careful inspection of the bladder, the passage of radiograph catheters to each kidney pelvis, routine examination of the separated urines, differential renal function tests, a complete x-ray study of the entire urinary tract, with the shadowgraph catheters in position, and a pyelogram and ureterogram of every patient. This is done on the side under suspicion, or if there is no lead pointing
----------
.. 406
NATHAt~IEL P. RATHBUN
to one or the other side, done on both sides at separate sittings. We practically never make bilateral pyelograms at the same sitting. The technique of making the ureterogram is I believe very , important. With the catheter in or near the kidney pelvis, the pelvis is filled with a 15 per cent sodium iodide solution, using a .· small graduated syringe, injecting very slowly and stopping
Fic. 2 FIG.
2.
FIG.
3
BILATERAL STRICTURE IN GIRL OF EIGHT YEARS
Infection: colon bacillus. Frequent recurring attacks of acute pyelitis with hyperpyrexia. Entirely relieved by dilatation. FIG.
3.
SAME PATIENT AS FIGURE
3.
LEFT SIDE
immediately at the first suggestion of disoomfort. A picture is now made of the renal pelvis. The catheter is then withdrawn a short distance with the syringe containing the iodide solution still connected, then with the plate in position the catheter is withdrawn entirely from the body, injecting the solution at the same time and a picture made immediately. In this way we obtain a picture of the entire ureter, particularly the pelvic
INCIDENCE OF URE'l'ERAL S'rRICTURE
407
portion. Incidentally one might add that making ureterogrmns in this way we are less apt to miss double pelvis, bifid ureters, and other abnormalities. While this of course is considerably more of an examination that many patients require, yet by doing it as a routine we are less apt to overlook some conditions which might otherwise be readily passed by, including ureteral stricture. I do not hesitate to make pyelograms and ureterograms in all of my cases, and since using sodium iodide as a medium I have never had a single reaction in which I have been the least alarmed. During the year 1924 my assistants and myself made 739 such examinations in my clinic at the Brooklyn Hospital. There were a considerable number in whom our findings were entirely negative, largely among patients referred by the gynecologists and general surgeons. There were however in this group a large percentage in which we were able to demonstrate a urological lesion and many of these patients were spared the danger and discomfort of an unnecessary operation. In this entire group of 739 patients we made a diagnosis of ureter stricture on radiological evidence alone in 92 patients; 48 of these were males; 44 females. Seven of these were tuberculous. Every one is agreed upon the occurrence of this type of stricture, and they are not included in this study. Seventeen cases were complicated by or were a part of urinary lithiasis. Of these calculi were noted in the renal pelvis in 12 cases, in the ureter, 5 cases. It is not unlikely that in some of this latter group the stricture was incidental to and perhaps caused by the presence of the stone. I agree with Runner however that in many of these cases the calculus is secondary to the stricture. At any rate I am very sure that it is of vital importance to consider stricture as a possible factor in the consideration and treatment of any given case. Failure to do this may be and I am sure often does account for the persistence of or recurrence of symptoms following the removal of the calculus. I believe too that the presence of a stricture may be a contributing factor in some of the recurrent stone cases, by means of interfering with the proper drainage and perpetuating infection. Excluding the cases with tuberculosis and calculi and four other
---~· --
---~--
408
NATHANIEL P. RATHBUN
cases (two renal tumors, one complicated by calculus, and two bladder tumors) there remain 63 patients in which we made a diagnosis of primary ureter stricture. In 34 of these the urine was free from pus and sterile. Varying degrees of infection were noted in the remainder, 39. In all cases there was dilatation of the uterer above the stricture and in most of them there were evidences of dilatation of the
Fm. 4 Fm. 4.
FIG.
5
TIGHT STRICTURE OF P EL V I C URETER
Kink lumbar portion, moderate hydro-ureter and hydro-nephrosis. :vioderate infection. Pain and frequency. Relieved by dilatation. FIG. 5. EXTENS I VE STRICTURE OF RIGHT URETER Calculus in left pelvis . Right sided pain and colic. No symptoms left side. May account for some cases "referred pain. " R elieved by left pyelotorny and dilatation right ureter.
renal pelvis, varying from a slight degree to a well marked hydronephrosis. Practically all of this latter group showed varying degrees of infection, a few (3) having gone over to pyonephrosis with a more or less complete destruction of the kidney. While I realize that the problem of hydronephrosis does not entirely center around ureter stricture I do feel that strictures account for a certain number which could be readily relieved if recognized
409
INCIDENCE OF URETERAL STRICTURE
early and which might well go on to renal destruction and nephrectomy if neglected. There were in this~ group 11 cases which were a part of the pyelitis of pregnancy and the puerperium. This I believe is a most importanffield and I am convinced that ureteral strictures play a very prominent part in these cases and that many of them can be promptly and permanently relieved
Fm. 6
Fm. 7
FIG. 6. Two STRICTURES IN PELVIC URETER Another (?) near renal pelvis. Moderate hydronephrosis. uri_nation only symptom. Relieved by dilatation.
Frequency of
Fm. 7. STRICTURE IN PELVIC URETER Another (not well shown) in intramural portion. Pyonephrosis. tomy. Late case.
Nephrec-
by ureter dilatations. It is interesting to note that practically without exception this entire group of 63 cases were relieved or improved by a line of treatment based on the diagnosis of ureteral stricture. This to my mind is one of the most convincing arguments in the whole matter. Many of these patients have gone the rounds, have submitted to all sorts of treatments, have had
410
NATHANIEL P. RATHBUN
various innocent organs removed, one after the other with no relief, and were promptly relieved by a few ·dilatations of the ureter. Not a few of them volunteer the information after a simple dilatation that they feel better than they have felt for years. With these facts in mind we can be ·forgiven · a certain amount of enthusiasm on the subject. I have gone a bit further than the radiological evidence would warrant, and have in a few cases ,made a diagnosis of ureteral stricture in the absence of radiolo~ical finding;;;, basing the diagnosis on the symptoms and by careful exclusion -of other possible factors in the problem. Sorne of these have been cases of pyelitis which we have treated with various forms of instillations, taking care however to use a large catheter as a part of the treatment. In others in which there was no evidence of infection we have dilated somewhat expectantly and in many cases with· entire relief of symptoms. To my mind this latter item ·is the most cogent argument of all. The fact that so many of these patients presenting a great variety of symptoms which have resisted all sorts of treatment, operative and otherwise, are relieved ·by a few dilatations of the ureter, is very convmcmg. · The hang of a wax bulb and variations in t he caliber of the ureter as shown by ureterograms may be a matter of interpretation and variously construed but the relief iof symptoms following ure- · ter dilatations is a-matter of fact. In conclusion :- While we lay no claim to infallibility and while it is not unlikely that we ,have erred-in some, perhaps many of our diagnoses, , this .paper is written for.· the purpose of placing 011 record the relative frequency · of this diagnosis in one clinic·, hoping to interest ether -observer-s- to the -extent that they may approaeh ·this problem with· an open mind and look carefully for ureteral stricture as a part of the diagnostic survey.