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The Removal of Ureteral Stone by Cystoscopy Manipulation
THE REMOVAL OF URETERAL STONE BY CYSTOSCOPIC MANIPULATION A. J. CROWELL The Crowell Clinic of Urology and Dermatology, Charlotte, North Carolina
For the past six years the removal of ureteral stones by cystoscopic manipulation has been our method of choice. During this time 98 such cases have come under our observation. An attempt was made to remove them by cystoscopic manipulation in 95 cases and succeeded in 88. Of the other 7 cases so treated the stones were accidentally pushed back into the kidney pelves in 4; 1 obtained relief following ureteral dilatation and failed to return for further treatment; and 2 ureterolithotomies were performed. N ephrectomies were performed on 2 of the remaining 3 cases in this series not adaptable to this method and 1 was removed through a pyelotomy opening while removing a large stone from the kidney pelvis on the same side. The method by which we have accomplished this ,vork consists of ureteral anesthesia and ureteral dilatation. These are obtained by injecting a solution of one of the local anesthetics into the lumen of the ureter through a ureteral catheter and dilating the ureter by means of the retention catheter and mechanical dilators. We have tried a number of local anesthetics and :find that a 2 per cent solution of procain (Metz novocain) is a very satisfactory one. A 5 per cent solution can be used with perfect safety but if given sufficient time the 2 per cent is ample. The success of the method is largely dependent upon the extent of bladder and ureteral anesthesia. To obtain this one ounce of the above mentioned solution is injected into the bladder through the urethra and retained for ten minutes before :filling the bladder with boric acid solution. The ureteral catheter is then inserted into the ureter until it meets with resistance. 243 THE JOURNAL OF UROLOGY, VOL. VI, NO.
3
244
A. J. CROWELL
At this time procain solution is slowly injected through the catheter and allowed to remain for ten minutes. The catheter can then be passed above the stone without difficulty in most instances and especially is this true if oil is injected during this -manipulation. We have not failed in a single instance to get
FIG. 1.
POSITION OF CATHETER WHILE INJECTING NOVOCAINE.
CATHETER
AGAINST STONE
by the stone in this way but frequently several attempts were necessary to succeed. When the catheter has passed the stone we are master of the situation. It can be fastened in and retained almost indefinitely. The presence of the catheter will allow the kidney's secretion to pass through it as well as dilate the ureter. In this way pressure
REMOVAL OF URETERAL STONE
245
atrophy is prevented. The kidney's functional activity can also be ascertained and decision made as to whether or not the kidney should be removed. If infection be present or should it occur during the course of treatment, the kidney pelvis can readily be lavaged with saline or any of the mild antiseptic solutions.
FIG. 2.
ANOTHER CASE SHOWING CATHETER ABOVE STONES AFTER INJECTION OF NOVOCAIN
If the presence of the catheter should produce undue reaction local anesthetics can be applied through it or morphine given. In twenty-four and every twenty-four hours thereafter the catheter should be removed and a larger one introduced until a no. 11 has been reached. This is the largest size the Brown-
----- -
246
A. J. CROWELL
Berger operating cystoscope will easily admit. A· no. 9 tapered catheter can usually be introduced after the removal of a no. 5 or 6 at the end of the first twenty-four hours. A second, then a third one may be introduced until two no. 11 and one no. 6 have been inserted into the ureter. We have done this
FIG.
3.
SAME CASE AS FIGURE
2;
AND ABOVE THE STONES.
LEWIS' METALLIC DILATOR PASSED BETWEEN ONE STONE HAS BEEN PUSHED
UP
on several occasions. The third catheter cannot be larger than a no. 6. It is introduced through a no. 15 child's single catheterizing cystoscope. It is necessary to use this small instrument because the ordinary male urethra will not admit two no. 11 ureteral catheters and the Brown-Berger single catheterizing cystoscope at the same time; the female urethra however will
----~
REMOVAL OF URETERAL STONE
247
admit this instrument and at least three no. 11 catheters. The ureter can, in this way, be dilated extensively without danger to the patient. The dilatation can be further extended by using the cable metallic dilator after removing the catheters. In fact, we have used the metallic dilator along side of a no. 11 catheter in the male to further dilate the ureter. This instrument is of special value in assisting the stone to pass through the bladder wall and out of the ureteral opening. In passing the metallic dilator or the stiff bougie, care should be taken that the stone is not pushed back into the kidney pelvis. This accident occurred in four of our recent cases while using the stiff bougie as dilators. It is less liable to occur following the use of the ureteral catheters, because the catheter is not so rigid but sufficiently so to admit the manipulation necessary to force it by the stone following ureteral anesthesia. To prevent this accident, it is well to pass the metallic dilator or stiff bougie, when these instruments are selected, under fluoroscopic vision. This precaution is especially advisable when the stone is located in the upper third of the ureter. The stone may not be visible but the bougie or dilator can be seen and it should be stopped at the level of the stone which has been determined by a radiogram. Should this accident occur, the stone may be dislodged and gotten back into the ureter by distending the kidney pelvis with a saline solution and deep percussion over the kidney while the patient is turned on the opposite side. We have slides in three cases showing the removal of stones from the pelves in this way. Before withdrawing the catheter the kidney pelvis should be filled with normal saline solution and a few drops of sterile oil released in the ureter as the catheter is withdrawn. The saline solution should be injected as hot as the tissues will permit since the heat relaxes the ureter and augments the passage of the stone. The simplicity and safety of this method is very evident. It is simple in that any one reasonably skilled in cystoscopy can do the work in his office or hospital with perfect safety without a general anesthetic or :qiarked suffering on the part of the patient. It is safe because no trauma of consequence is pro-
248
A. J. CROWELL
duced,- and in addition to the kidney's function not beinginhibited, -drainage frequently improves the renal function. In fact, we have seen marked uremic symptoms clear up rapidly following such drainage. Fatalities following this work are unnecessary if ordinary precautions are observed in the technique. This cannot be
FIG.
4.
SAME CASE AS FIGURE
2;
THREE RETENTION CATHETERS
said of the surgical procedures n ecessary for the removal of ureteral stone. If we are to judge from the reports of those who depend largely upon surgery for the relief of this condition, we must conclude that they, like ourselves, have been disappointed in their results. Many deaths have followed ureterotomy and frequently fistulae and kidney infection have persisted for months
- - - - - ~ = ~ - - ~ ~ ~ - ' - - - - - - - - - - - - ' - - - - - - - - - - - - -- ------~------
FIG.
FIG.
6.
5.
SAME CASE AS FIGURE
2;
STONES AFTER REMOVAL BY THIS METHOD
CASE WITH DOUBLE URETER ON RIGHT SIDE WITH TEN STONES IN LOWER END OF ONE OF THE URETERS
249
250
A. J. CROWELL
and occasionally required nephrectomy to perfect a cure. Judd reports only two deaths in 400 cases operated upon at the Mayo Clinic for the removal of ureteral stone but 50 nephrectomies were reported in this series. The only unpleasant results obtained in the cases treated by us since we began the systematic use of local anesthetics and
FIG.
7.
PYELOGRAM OF SAME CASE AS FIGURE 6, SHOWING DOUBLE URETER AND DOUBLE PELVIS
dilatation were the two cases upon whom we did ureterolithotomies. A urinary fistula persisted in one of these for several months and the other case had an unsatisfactory recovery."i in fact the kidney was finally removed on account of the persistence of kidney infection. Do you wonder that we are glad to find a more satisfactory way of handling these cases?
REMOVAL OF URETERAL STONE
251
The fatalities following operation for the relief of ureterai stone range from one-half of 1 to 20 per cent. From 40 to 60 per cent of the cases applying for relief of this condition have been operated upon with no record of an effort having been made to remove them by cystoscopic means. Some claim that 90
FIG.
8.
URETEROGRAM OF CASE SHOWN IN FIGURE
6;
SACCULAR DILATATION AT
SITE oF SToNEs-ALL oF vVmcH WERE IN O:-iE URETER
to 95 per cent of the stones will pass spontaneously. If this be true, it is evident that we have been operating upon far too many cases for the relief of this condition. There are certain conditions in which cystoscopic methods are not applicable. We can readily understand why the plan would not be practical in such abnormalities as double pelves
_:::..;___-~
__ _
_ .,
252
A. J . CROWELL
with Y-ureters or where the ureter had been completely obstructed sufficiently long to produce complete and permanent anuria without infection or where the kidney had been made worthless by infection and pressure atrophy. In our series a case illustrating a class in which the method should not be
FIG. 9. SAME CASE AS FIGURE 6; DILATING URETER BELOW STONE WITH LEWIS' METALLIC DILATOR
used was one in which the ureter was completely occluded with a large soft stone just above the bladder wall. In addition to this she had a very large stone in each kidney. No effor(was made to remove the one from the ureter by this method bU:t it was broken up and forced into the bladder with a metallic dilator through the pelvic opening when the ~tone was removed from
Fm. 10.
FIG.
11.
SAME CASE AS FIGURE
6,
SHOWIN G DILATO R PASSED ABOVE THE STONE
FRO;;I CASE SHOWN IN STONES REMOVE D Ar,TER THREE TREATM ENTS FIGURE 6
253
-
-
-
---- -------- -
254
------- - - - - - - - --
---- -
A. J. CROWELL
the kidney pelvis. The method is not practical in children where the urethra is too small to admit a catheterizing cystoscope or in men with enlarged prostates or other conditions, such as, bladder tumor, stone, etc., making ureteral catheterization impractical. The removal of ureteral stone by mechanical means is not new but its applicatf,on has largely been limited to those cases in which the stones were lodged in the intravesical portion of the ureter. Local anesthetics have also been mentioned in this connection but, to our knowledge, no large series of consecutive cases have been treated successfully by this plan and we have failed until lately to apply this knowledge in our ureteral work. We believe that pelvic lavage with saline or an antiseptic solution following the removal of stone by any method is very important in order to prevent stone reformation. Certainly this is true where we have kidney infection as a complication. This can be done to greater satisfaction following their removal by cystoscopic manipulation than that following surgical procedure or at least the lavage is begun earlier following their removal by cystoscopic manipulation. To our knowledge we have not had reformation where this procedure has been carried out. CONCLUSIONS
1. Practically all recently impacted ureteral calculi, in the normal ureter, can be removed by cystoscopic methods under local ureteral anesthesia with less fatalities and less injury to the kidney function than that obtained following surgical procedures. 2. The success of the method depends upon the greatest ureteral anesthesia possible and ureteral dilatation, the skill of the operator, and the persistence in his manipulations. 3. An effort should first be made to remove the stone by this method. No harm is done the patient by so doing and surgery can be resorted to at any time necessary. 4. Much time and suffering is saved the patient and a return of the stone less liable to occur following this plan of procedure than that following surgery.
REMOVAL OF URETERAL STONE
REFERENCES {1) BRAASCH AND MooRE: Jour. A. M. A., October 9, 1915. (2) BRANSFORD, LEWIS: New York Med. Jour., November 12, 1912. BRANSFORD, LEWIS: Surgery, Gyn. and Obs., April, 1915. (3) BEVAN AND KRETCHMER: Illinois Med. Jour., November, 1909. (4) KELLY, HowARD: Jour. A. M. A., March, 1900. (5) SHROPSHIRE AND WATTERSTON: Jour. Rec. of Med., September, 1916. (6)' KELLY, How ARD A.: Jour. A. M. A., January, 1900. (7) GERAGHTY: Surgery, Gyn. and Obs., May, 1915. (8) JUDD: Annals of Surgery, February, 1920.
255
For the past six years the removal of ureteral stones by cystoscopic manipulation has been our method of choice. During this time 98 such cases have come under our observation. An attempt was made to remove them by cystoscopic manipulation in 95 cases and succeeded in 88. Of the other 7 cases so treated the stones were accidentally pushed back into the kidney pelves in 4; 1 obtained relief following ureteral dilatation and failed to return for further treatment; and 2 ureterolithotomies were performed. N ephrectomies were performed on 2 of the remaining 3 cases in this series not adaptable to this method and 1 was removed through a pyelotomy opening while removing a large stone from the kidney pelvis on the same side. The method by which we have accomplished this ,vork consists of ureteral anesthesia and ureteral dilatation. These are obtained by injecting a solution of one of the local anesthetics into the lumen of the ureter through a ureteral catheter and dilating the ureter by means of the retention catheter and mechanical dilators. We have tried a number of local anesthetics and :find that a 2 per cent solution of procain (Metz novocain) is a very satisfactory one. A 5 per cent solution can be used with perfect safety but if given sufficient time the 2 per cent is ample. The success of the method is largely dependent upon the extent of bladder and ureteral anesthesia. To obtain this one ounce of the above mentioned solution is injected into the bladder through the urethra and retained for ten minutes before :filling the bladder with boric acid solution. The ureteral catheter is then inserted into the ureter until it meets with resistance. 243 THE JOURNAL OF UROLOGY, VOL. VI, NO.
3
244
A. J. CROWELL
At this time procain solution is slowly injected through the catheter and allowed to remain for ten minutes. The catheter can then be passed above the stone without difficulty in most instances and especially is this true if oil is injected during this -manipulation. We have not failed in a single instance to get
FIG. 1.
POSITION OF CATHETER WHILE INJECTING NOVOCAINE.
CATHETER
AGAINST STONE
by the stone in this way but frequently several attempts were necessary to succeed. When the catheter has passed the stone we are master of the situation. It can be fastened in and retained almost indefinitely. The presence of the catheter will allow the kidney's secretion to pass through it as well as dilate the ureter. In this way pressure
REMOVAL OF URETERAL STONE
245
atrophy is prevented. The kidney's functional activity can also be ascertained and decision made as to whether or not the kidney should be removed. If infection be present or should it occur during the course of treatment, the kidney pelvis can readily be lavaged with saline or any of the mild antiseptic solutions.
FIG. 2.
ANOTHER CASE SHOWING CATHETER ABOVE STONES AFTER INJECTION OF NOVOCAIN
If the presence of the catheter should produce undue reaction local anesthetics can be applied through it or morphine given. In twenty-four and every twenty-four hours thereafter the catheter should be removed and a larger one introduced until a no. 11 has been reached. This is the largest size the Brown-
----- -
246
A. J. CROWELL
Berger operating cystoscope will easily admit. A· no. 9 tapered catheter can usually be introduced after the removal of a no. 5 or 6 at the end of the first twenty-four hours. A second, then a third one may be introduced until two no. 11 and one no. 6 have been inserted into the ureter. We have done this
FIG.
3.
SAME CASE AS FIGURE
2;
AND ABOVE THE STONES.
LEWIS' METALLIC DILATOR PASSED BETWEEN ONE STONE HAS BEEN PUSHED
UP
on several occasions. The third catheter cannot be larger than a no. 6. It is introduced through a no. 15 child's single catheterizing cystoscope. It is necessary to use this small instrument because the ordinary male urethra will not admit two no. 11 ureteral catheters and the Brown-Berger single catheterizing cystoscope at the same time; the female urethra however will
----~
REMOVAL OF URETERAL STONE
247
admit this instrument and at least three no. 11 catheters. The ureter can, in this way, be dilated extensively without danger to the patient. The dilatation can be further extended by using the cable metallic dilator after removing the catheters. In fact, we have used the metallic dilator along side of a no. 11 catheter in the male to further dilate the ureter. This instrument is of special value in assisting the stone to pass through the bladder wall and out of the ureteral opening. In passing the metallic dilator or the stiff bougie, care should be taken that the stone is not pushed back into the kidney pelvis. This accident occurred in four of our recent cases while using the stiff bougie as dilators. It is less liable to occur following the use of the ureteral catheters, because the catheter is not so rigid but sufficiently so to admit the manipulation necessary to force it by the stone following ureteral anesthesia. To prevent this accident, it is well to pass the metallic dilator or stiff bougie, when these instruments are selected, under fluoroscopic vision. This precaution is especially advisable when the stone is located in the upper third of the ureter. The stone may not be visible but the bougie or dilator can be seen and it should be stopped at the level of the stone which has been determined by a radiogram. Should this accident occur, the stone may be dislodged and gotten back into the ureter by distending the kidney pelvis with a saline solution and deep percussion over the kidney while the patient is turned on the opposite side. We have slides in three cases showing the removal of stones from the pelves in this way. Before withdrawing the catheter the kidney pelvis should be filled with normal saline solution and a few drops of sterile oil released in the ureter as the catheter is withdrawn. The saline solution should be injected as hot as the tissues will permit since the heat relaxes the ureter and augments the passage of the stone. The simplicity and safety of this method is very evident. It is simple in that any one reasonably skilled in cystoscopy can do the work in his office or hospital with perfect safety without a general anesthetic or :qiarked suffering on the part of the patient. It is safe because no trauma of consequence is pro-
248
A. J. CROWELL
duced,- and in addition to the kidney's function not beinginhibited, -drainage frequently improves the renal function. In fact, we have seen marked uremic symptoms clear up rapidly following such drainage. Fatalities following this work are unnecessary if ordinary precautions are observed in the technique. This cannot be
FIG.
4.
SAME CASE AS FIGURE
2;
THREE RETENTION CATHETERS
said of the surgical procedures n ecessary for the removal of ureteral stone. If we are to judge from the reports of those who depend largely upon surgery for the relief of this condition, we must conclude that they, like ourselves, have been disappointed in their results. Many deaths have followed ureterotomy and frequently fistulae and kidney infection have persisted for months
- - - - - ~ = ~ - - ~ ~ ~ - ' - - - - - - - - - - - - ' - - - - - - - - - - - - -- ------~------
FIG.
FIG.
6.
5.
SAME CASE AS FIGURE
2;
STONES AFTER REMOVAL BY THIS METHOD
CASE WITH DOUBLE URETER ON RIGHT SIDE WITH TEN STONES IN LOWER END OF ONE OF THE URETERS
249
250
A. J. CROWELL
and occasionally required nephrectomy to perfect a cure. Judd reports only two deaths in 400 cases operated upon at the Mayo Clinic for the removal of ureteral stone but 50 nephrectomies were reported in this series. The only unpleasant results obtained in the cases treated by us since we began the systematic use of local anesthetics and
FIG.
7.
PYELOGRAM OF SAME CASE AS FIGURE 6, SHOWING DOUBLE URETER AND DOUBLE PELVIS
dilatation were the two cases upon whom we did ureterolithotomies. A urinary fistula persisted in one of these for several months and the other case had an unsatisfactory recovery."i in fact the kidney was finally removed on account of the persistence of kidney infection. Do you wonder that we are glad to find a more satisfactory way of handling these cases?
REMOVAL OF URETERAL STONE
251
The fatalities following operation for the relief of ureterai stone range from one-half of 1 to 20 per cent. From 40 to 60 per cent of the cases applying for relief of this condition have been operated upon with no record of an effort having been made to remove them by cystoscopic means. Some claim that 90
FIG.
8.
URETEROGRAM OF CASE SHOWN IN FIGURE
6;
SACCULAR DILATATION AT
SITE oF SToNEs-ALL oF vVmcH WERE IN O:-iE URETER
to 95 per cent of the stones will pass spontaneously. If this be true, it is evident that we have been operating upon far too many cases for the relief of this condition. There are certain conditions in which cystoscopic methods are not applicable. We can readily understand why the plan would not be practical in such abnormalities as double pelves
_:::..;___-~
__ _
_ .,
252
A. J . CROWELL
with Y-ureters or where the ureter had been completely obstructed sufficiently long to produce complete and permanent anuria without infection or where the kidney had been made worthless by infection and pressure atrophy. In our series a case illustrating a class in which the method should not be
FIG. 9. SAME CASE AS FIGURE 6; DILATING URETER BELOW STONE WITH LEWIS' METALLIC DILATOR
used was one in which the ureter was completely occluded with a large soft stone just above the bladder wall. In addition to this she had a very large stone in each kidney. No effor(was made to remove the one from the ureter by this method bU:t it was broken up and forced into the bladder with a metallic dilator through the pelvic opening when the ~tone was removed from
Fm. 10.
FIG.
11.
SAME CASE AS FIGURE
6,
SHOWIN G DILATO R PASSED ABOVE THE STONE
FRO;;I CASE SHOWN IN STONES REMOVE D Ar,TER THREE TREATM ENTS FIGURE 6
253
-
-
-
---- -------- -
254
------- - - - - - - - --
---- -
A. J. CROWELL
the kidney pelvis. The method is not practical in children where the urethra is too small to admit a catheterizing cystoscope or in men with enlarged prostates or other conditions, such as, bladder tumor, stone, etc., making ureteral catheterization impractical. The removal of ureteral stone by mechanical means is not new but its applicatf,on has largely been limited to those cases in which the stones were lodged in the intravesical portion of the ureter. Local anesthetics have also been mentioned in this connection but, to our knowledge, no large series of consecutive cases have been treated successfully by this plan and we have failed until lately to apply this knowledge in our ureteral work. We believe that pelvic lavage with saline or an antiseptic solution following the removal of stone by any method is very important in order to prevent stone reformation. Certainly this is true where we have kidney infection as a complication. This can be done to greater satisfaction following their removal by cystoscopic manipulation than that following surgical procedure or at least the lavage is begun earlier following their removal by cystoscopic manipulation. To our knowledge we have not had reformation where this procedure has been carried out. CONCLUSIONS
1. Practically all recently impacted ureteral calculi, in the normal ureter, can be removed by cystoscopic methods under local ureteral anesthesia with less fatalities and less injury to the kidney function than that obtained following surgical procedures. 2. The success of the method depends upon the greatest ureteral anesthesia possible and ureteral dilatation, the skill of the operator, and the persistence in his manipulations. 3. An effort should first be made to remove the stone by this method. No harm is done the patient by so doing and surgery can be resorted to at any time necessary. 4. Much time and suffering is saved the patient and a return of the stone less liable to occur following this plan of procedure than that following surgery.
REMOVAL OF URETERAL STONE
REFERENCES {1) BRAASCH AND MooRE: Jour. A. M. A., October 9, 1915. (2) BRANSFORD, LEWIS: New York Med. Jour., November 12, 1912. BRANSFORD, LEWIS: Surgery, Gyn. and Obs., April, 1915. (3) BEVAN AND KRETCHMER: Illinois Med. Jour., November, 1909. (4) KELLY, HowARD: Jour. A. M. A., March, 1900. (5) SHROPSHIRE AND WATTERSTON: Jour. Rec. of Med., September, 1916. (6)' KELLY, How ARD A.: Jour. A. M. A., January, 1900. (7) GERAGHTY: Surgery, Gyn. and Obs., May, 1915. (8) JUDD: Annals of Surgery, February, 1920.
255