The role of the ureter in diseases of the genitourinary tract

NEW SERIES,

APRIL,

VOL. IV

No. 4

1928

THE ROLE OF THE URETER IN DISEASES OF THE GENITOURINARY THOMASJ.

KIRWIN,

M.D.,

TRACT

P.A.C.S.

From the Department of Urology (James Buchanan Brady Foundation) of the New York Hospital NEW YORK HISTORY

fact that humans have more than one inasmuch as he had credited ureter, EITHER anatomica nor phiIoanimaIs with possessing two. Of the sophica1 consideration of the anatomy and physioIogy of these ducts ureter has a pIace in the history BeIIini has IittIe to say, mereIy noting that of ancient medicine. Hippocwhen the renaI secretion had been eIaborrates doubtIess saw more ated according to his understanding of this than one case of kink, stricture and impacted stone, but unfortunateIy his process, it was conveyed by the ureters to the bIadder. descriptions are not detailed enough to A few years Iater we find Johannis permit us to interpret them correctIy criticizing Casper Bauhinus RioIani today, and as the prejudices of his time because this worthy had stated in his wouId not permit autopsies, he was never “Theatre Anatomicurn”: “It is not generabIe to find out after death that the troubIe aIIy known that the ureters are sometimes had resided in this apparentIy innocuous divided beIow the kidneys into three, IittIe duct. four or even five different branches.” It was not unti1 the MiddIe Ages had RioIani wouId have none of this: it was aImost come to an end that the ureters received any attention from medica writpIainIy contrary to nature as we11 as comers. ApparentIy mon sense. It was not untiI Iong afterward the first anatomica description was pubIished in 1585 by that duplication of the ureters was acknowIAIbertus in his “Tres Orationes Norimedged as a possibiIity, and not unti1 the bergae.” In Laurentius BeIIini’s IittIe immediate present has it been reaIized to voIume, “De Structura Renum,” which Ieft be a reIativeIy common finding. the printer’s hands two hundred and In the eighteenth century we find several sixty-three years ago, I have found a very anatomists giving attention to the quesneat drawing showing a bisection of the tion as to whether or not there are vaIves kidney through the peIvis and ureters, at the vesica1 ends of the ureters. DiIthey with the haIves of the right and Ieft ureters in 1723 had something to say about this, duIy IabeIIed and represented. In the text and van BeeIhoven de Wind made the we find the author expressing wonder that anatomy of the ureters the subject of his his predecessor Highmore, whose name dissertation delivered in 1734. Other has come down to us as an appeIIation of studies were made by Gontard in 1757 and the maxiIIary sinus, had faiIed to note the Guigneux in 1760, while PohI pubIished 355

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some observations at Leipzig in 1772. Anatomy thus received considerabIe attention before the nineteenth century began, but none concerned themselves with the physioIogy of the ureters unti1 the year 1812, when CharIes Be11 caIIed the attention of the members of the MedicaI and ChirurgicaI Society of London to “a set of muscles attached to the orifices of the

FIG. I. Cat

embryo,

7 mm.,

of Ureter

knowIedge concerning the anatomy, physioIogy and pathoIogy of the ureters had been accumuIated. The introduction of surgica1 anesthesia and the discoveries of Pasteur and Lord Lister enabled surgeons to reach the region of the ureters and view them in the Iiving subject, so that not a few points hitherto shrouded in the deepest mystery were expIained and made

showing ureteric bud. Courtesy, University.

ureters and seated in the bIadder, which seem not to have been observed by former anatomists.” It is a bit ironic that these muscIes stiI1 bear ,BeII’s name, aIthough the function he attributed to them has since been proved non-existent. Soon after Be11 announced his discovery, French surgeons, who were even then speciaIizing in uroIogy, began making more detaiIed studies of this particuIar section of the genitourinary tract, so that by the middIe of the century a fair body of

APRIL, 1928

Dr. Elwyn,

Department

of Anatomy,

CoIumbia

to serve in the onward progress of uroIogic technique. This knowIedge has been infinitely extended by the introduction of pyeIography, so that at present the haze of mystery which had heretofore surrounded the ureter and its functions has in a great measure been dispeIIed. EMBRYOLOGY

In a11the higher vertebrates embryoIogicaI deveIopment produces three excretory organs which appear in succession during

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intrauterine Iife. These are the pronephros, mesonepbros and metanephros, which deveIop in the order named, the first and second being temporary structures whiIe the third eventually takes its place as the kidney of complete development:AII three of these organs arise from a series of mesoderma1 ceII-masses, the nephrotomes or primitive segment stalks which extend

U.G

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ney. The persistence of the duct of the pronephros after its early disappearance is the only cIaim which this rudimentary organ has upon embryologic4 interest. As the Wolffran duct this Iater becomes the excretory duct of the mesonephros or, as it is more commonIv termed, the Wolffran body. This organ’is at the height of its development about the fourth or

SI

Od

FIG. 2. Cat embryo,

8.5 mm., showing ureteric bud and urogenital sinus. Courtesy, Anatomy, CoIumbia University.

IongitudinaIIy on either side of the neura1 cana1. As these primitive segment stalks are the components from which the nephrogenic cord is derived, a11 three of the structures just mentioned may be regarded as of mesoderma1 origin. The pronephros is formed very earIy in fetal Iife from the crania1 portion of the nephrogenic cord. Thereafter the cord divides into a mesonephrogenic and a metanephrogenic portion, from the first of which the WolffIan body is derived; the second is destined to form eventuaIIy the secreting portion of the permanent kid-

Dr. Elwyn,

Department

of

fifth week of fetal life, and apparently undergoes atrophy from the eighth week onward. The duct, however, persists when the second organ has disappeared and in the final state of feta1 deveIopment appears as the vas deferens in the maIe and the rudimentary Gaertner’s duct in the female. About the time the embryo has reached a length of 3 mm. the metanephros or permanent kidney makes its appearance as a budding or evagination from the Iower end of the WoIffIan duct cIose to its point of opening into the cIoaca. From this bud there wiII be formed eventuaIIy the

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caIyces and coIIecting tubuIes of the permanent kidney as we11 as the renaI peIvis and its ureter-that is, the entire efferent apparatus. The secreting portion of the kidney has its origin in a mass of mesoder-

FIG. 3. Single kidney and ureter. One of the many reasons for a complete urologicat examination before the remova of a kidney. Courtesy, Dr. ChristeILer, Virchow Krankenhaus, BerIin.

ma1 ceIIs arising from the cauder1 portion of the nephrogenic cord. This mass of ceIIs surrounds the tip of the ureter very soon after its evagination, even before the bud has had time to grow a distance equivalent to the diameter of the WoIffIan duct, so that they come to form a distinct “cap”

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covering the buIbous tip of the uretera bud (Fig. I). This bud grows first toward the vertebra1 coIumn, then turns to grow upward toward the cranium. Its cap accompanies it in the ascent so that when the embryo is no more than 6.6 mm. in length the uretera tip has become buIbous and the primitive peIvis is thus differentiated from the more sIender stalk that now begins to resembIe the organ it is destined to become-the ureter. As the kidney continues its independent deveIopment, changes are taking pIace in the Iower end of this staIk. By a process of diIatation the Iower end of the WoIffIan duct comes to form a portion of what wiI1 in future be the bIadder waI1. This makes it necessary for the ureter to acquire an orifice separate and distinct from the WoIffIan duct. The segment of the common cIoaca previousIy shared by the WoIffIan duct and future ureter disappears, being incorporated into the diIatation of the cIoaca which is Iater to become the bIadder and urogenita1 sinus. Thus the two ducts acquire separate ope’nings, the ureter passing beside the WoIffIan duct and entering what wiI1 in future be the trigone vesicae, whiIe the WoIffIan duct, destined to become the vas deferens, finds its termination further down so that it comes to empty into that portion of the tract destined to become the prostatic urethra. When the embryo has attained a Iength of approximateIy 8 mm., the buIbous tip with which the ureter has been equipped spIits in two, thus indicating the future division into caIyces. This step in the deveIopment of the ureter is of especia1 interest in connection with certain reIativeIy frequent anomaIies. An incomplete doubIe ureter is generaIIy supposed to be due to a premature or exaggerated bifurcation of this tip, the spIit extending down the stalk. If the bud spIits before the primitive renaI peIvis has had a chance to form, the two ureters originating from the bifurcation of the staIk wiI1 ascend paraIIe1 to each other (Fig. 2). FeIix, whose conception this is, designates such anomaIous

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forms as this Iast as “cIeft ureter,” reserving the designation of “double ureter” for those showing compIete separation and separate entrances for each duct through the bIadder waI1.

FIG. 4. SingIeIkidney

with

a hypopIastic

of Ureter

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normaI which wouId otherwise have passed compIeteIy unrecognized. Certain maIformations, however, were recognized and sought for Iong before Roentgen made his revoIutionary discovery, and the deveIop-

Ieft kidney with patent Krankenhaus, Berlin.

The frequency of anomaIies of the ureters is becoming more wideIy recognized every day, for the introduction of roentgenographic diagnosis has brought to Iight great numbers of variations from the

American

ureter.

Courtesy,

Dr.

ChristeIIer,

Virchow

ment of cystoscopy with uretera catheterization did much to make uroIogists more or Iess famiIiar with the surprising forms which the renaI ducts may at certain times assume. In 1910, J. and P. DeImas, French surgeons, pubIished the most compIete

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survey of uretera anomahes that, so far as I am aware, had ever been made in any language. Many of the cases which they cite appear to be unique, and so detaiIed is their consideration of these curiosities t’hat no one not thoroughIy famiIiar with the Ianguage wouId ever have the patience to read the entire articIe. The interest of the present day clinician Iies not so much in

-leFf

ureter

! I

ibl

FIG. 5. Non-patent ureters. days, urinating into the Dr. Johnson, Department University.

This chiId Iived sixteen bIadder waII. Courtesy, of Pathology, CoIumbia

the rare and curious cases as in those he is more than IikeIy to encounter in his own daily round. For this reason the consideration of uretera anomaIies recentIy appearing under the names of Eisendrath and Papin has much to recommend it. The cIassification which these authors have made covers the entire subject cIearIy and succinctIy : I. AnomaIies in number.

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2. AnomaIies of calibre and form: (a) congenita1 strictures, (6) congenita1 dilatation, (c) vaIves, (d) spira1 twists and kinks. 3. AnomaIies of origin or termination: (a) abnorma1 modes of origin, (b) ureteroceIe or cystic dilatation of Iower end, (c) bIind-ending ureters (Fig. 4), (d) ectopic termination of the Iower end. 4. DiverticuIa of the ureter. Anomalies in Number. Variations in the number of ureters is by far the most common and, therefore, the most important anomaIy of these organs with which we are caIIed upon to dea1. UreteraI dupIication with doubIe renaI peIvis and kidney occurs more frequentIy than a11 other renaI and uretera anomaIies taken together. Poirer, Bostroem, Huntington, Papin, MotzfeId, Wagner, Robinson and others have variousIy estimated that it is found in from I to 4 per cent of a11 humans, and certain observers pIace the percentage even higher. Byron Robinson found six instances of uretera dupIication in one hundred consecutive autopsies. Four cases of doubIe ureter in 165 dissections were reported by Kerr. In a series of 42 I 5 autopsies, 62 cases of one or more congenita1 defects of the kidneys and ureters were reported on by LowsIey, Kingery and CIarke. Among these biIatera1 partia1 redupIication of the ureters occurred three times, and uniIatera1 partia1 redupIication There was no compIete seven times. biIatera1 doubIing, but compIete one-sided doubIing was found in eight subjects. In two instances there was compIete absence of the ureter, and extreme atrophy in eight others. In a11 there were about 40 cases presenting some uretera anomaIy, or practicaIIy I per cent of the entire series. Most investigators expIain the occurrence of incompIete doubIe ureter as a resuIt of premature or exaggerated bifurcation of the tip of the uretera bud, so that the spIit is not confined to the tip aIone, but extends for some distance downward aIong the uretera staIk. Some authors explain compIete redupIication by the assumption of a separate and secondary

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outbudding upon the uretera stem from the WoIffran duct. As a matter of fact no simpIe embryoIogic theory so far put forward can account for a11 the variations which this anomaIy presents in different individua1 specimens, and we must await further investigation before it wiI1 find an entireIy satisfactory expIanation. (Figs. 3, 4 and s.)

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so that a supernumerary ureter wiI1 have no connection with either kidney or bIadder. More often the bIind end wiI1 be the renaI one, whiIe the opening into the bIadder wiI1 appear norma when viewed through the cystoscope. Ectopic endings are, according to Eisendrath, found most often in connection with double kidneys where ureters and renaI pelves are dupli-

Anomalities of Caliber and Form. Congenital strictures usuaIIy appear at the

norma points of narrowing, that is, where the duct emerges from the Iower poIe of the kidney, about the center of its extent at a point where it comes in contact with the iIiac vesseIs, and at the point of entrance through the waI1 of the bIadder. Congenital dilatations are Iisted by Eisendrath and Papin as tota1, that is, incIuding the entire ureter and its vesica1 orifice: subtota1, being of the entire extent of the ureter but not of the vesical orifice, and finally, partia1, consisting of a series of spindIes. CIoseIy reIated to this Iast form of diIatation are the spiral twists and kinks which are sometimes undoubtedIy of congenita1 origin, and so may justIy be cIaimed as anomaIies. The authors just quoted have found kinks usuaIIy in connection with faulty modes of origin of the ureter from the renaI peIvis, but they also observed them at a number of different IeveIs, doubtIess resuIting either from abnormal motility of the kidney or from redundancv, that is, excessive Iength of the ureter itseIf. Anomalies

of

Origin

or

Termination.

The ureter may take its origin higher up in the renaI peIvis than normaI, and in excessiveIy rare instances has been found to pass a11 around the top of the peIvis before descending toward the bIadder. Such anomalous origins are very uncommon. Greterocele, cystic diIatation of the vesica1 end of the ureter, is at times congenital but at others is undoubtedly acquired, and wiI1 be mentioned again in considering ureteritis cystica. Blind endfound upon anomaIous ings are usuahy ureters; at times both ends may be bIind,

FIG. 6. Megaloureter.

cated. One of the two ureters (usuahy the one ending more distaIIy) opens either at some point considerabIy beIow the opening of the ureter draining the other haIf of the kidney or it opens somewhere outside the bIadder. ANATOMY

The ureters

serve as trunk-Iines

of com-

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munication and transportation between the kidneys and the bIadder. Thus upon their integrity and functiona ability both these supposedIy more important parts of the urinary system are absoIuteIy dependent. If the transportation system

FIG. 7. Ureteritis Virchow

cystica. Courtesy, Dr. Krankenhaus, BerIin.

ChristeIIer,

is disorganized by some disturbance of uretera1 function, such as stiicture, impacted stone or new growth, the kidney wiI1 be seriousIy affected or possibIy compIeteiy destroyed. If the troubIe be’uniIatera1 the bIadder may be abIe to proceed with its particuIar functions as though nothing had happened, but in most instances the bIadder aIso shares in the genera1 disorganization which even a very trifling lesion of the ureter is capabIe of bringing about. The great importance of this seemingIy insignificant duct is thus emphasized, and its inffuence upon every other portion of the genitourinary tract becomes evident. The ureter is a hoIIow tube of muscIe often compared to a goose quiI1 as to its size and shape. The average Iength from kidney to bIadder is 33 centimeters (12 to 14 inches). It has its origin opposite the

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1928

Iower poIe of the kidney, passes downward and inward behind the peritoneum, and eventuaIIy reaches the base of the bIadder into which it opens by passing obIiqueIy through the vesica1 waI1 to a narrow opening caIIed the uretera meatus. Constrictions. Throughout its Iength the ureter presents a diameter of approximateIy 0.3 cm., except at three or occasionaIIy four definite points where its caIiber is greatIy reduced. These normal constrictions occur at the point where the duct emerges from the Iower poIe of the kidney, at a second point near the center of its extent where there is contact with the iliac vessels and finaIIy where the duct enters the bIadder waI1. The mucous Iining of the ureter is continuous with the mucosa of the bladder aIthough it is transitiona in character. The ureter is, however, a structure whoIIy separate from the bIadder, and its fibrous and muscIe coats are quite distinct from those of the bIadder waI1. Histology. The waIIs of the ureter are made up of three Iayers, the histoIogica1 structure of these different strata being important because, together with the nerves which suppIy this section of the urinary cana1, they are directIy concerned with the phenomena of urination. The outer fibrous coat carries the Iarge bIood-vesseIs and nerve trunks which are extensiveIy ramified so as to form a pIexus which reaches a fuIIer deveIopment on the side next the muscIe Iayer. The middIe muscuIar Iayer shows subdivision into three distinct strata at about the center of the ureter’s extent. At the upper end toward the renaI peIvis the muscIe fibers form what Satani has termed a “braided membrane” running irreguIarIy in a11 directions. The isthmus, however, shows a more systematic arrangement, with IongitudinaI fibers within surrounded by a circuIar coat. As the bIadder is approached the IongitudinaI fibers predominate whiIe the number of circuIar fibers becomes Iess and Iess, unti1 they finaIIy disappear entireIy when the duct has passed through

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the Madder waI1. The IongitudinaI fibers, ho1 vever, can be traced on the outer side as far as the IeveI of the ureterovesica1 orif ice. No definite lJreteronesical Sphincter. SPhIincter was found by Satani, acting to

FIG. 8. FIG s. 8 and

9. TubercuIosis

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important part in the mechanism I;hus referred to. The inner mucous coating of the uret ;eraI waI1 is suppIied with a fine networl C of nerve fibers, while singIe nerve ceIIs are to be found in abundance. It is notewol rthy

FIG. 9.

of ureter and kidney, resuIting diIatation of ureter ragged and irregular contour of ureter and kidney.

shut off the ureter from the bIadder cavity. He did, h owever, observe that “certain structures form a mechanism to prevent a reffux of the bIadder content.” Two we11 deveIoped nerve pIexuses envelope the middIe muscular Iayer of the uretera walI, and these probabIy pIay an

Journal

and

pyonephrosis.

Note

that the mucous surface contains no secreting gIands. Lymphoid tissue exists in considerabIe proportion throughout the three strata which compose the waI1 of the ureter. Anatomical Relations. The course of the ureter after it leaves the kidney peIvis

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is obIiqueIy downward beneath the peritoneum, resting upon the psoas muscIe. The right ureter is in cIose reIation to the inferior vena cava with the iIiac arteries above, the sigmoid ffexure to the Ieft and the iIium to the right. The peIvic portion of both ureters passes in front of the sacroiIiac joint in attaining the pIace of

FIG. FIGS. IO and

I I. Stricture.

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histoIogy, we find as the chief points of interest, (I) it is highIy distensibIe; (2) it has natura1 points of constriction often accentuated under pathoIogic conditions and (3) there is a mechanism of some sort at its point of entrance in the bladder waI1 which acts to prevent regurgitation from the bIadder.

IO.

Exposures

FIG. at different

times showing constriction.

entrance through the bIadder waI1. The reIations of the right ureter are especiaIIy important in differentia1 diagnosis, for the most recent investigations into the pathoIogy of the ureter have shown that a number of conditions may arise there which produce symptoms that are frequentIy attributed to disease of the appendix. Summarizing the ureter’s anatomy and

1928

constancy

and

II.

similarity

of Iength

and

size of

PHYSIOLOGY

Ureteral Peristalsis. The physioIogy of the ureter has been investigated chieffy in reIation to urination. When the ureter has been subjected to specia1 scrutiny the purpose has been to ascertain whether or not it is concerned in the production of urine. Some years ago considerabIe work was done on ureter pressure. Henderson of the University of Toronto concIuded that

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what we term ureter pressure depends not upon secretion but upon renaI bIood pressure. The minimum difference between biood pressure and urete.r pressure wiI1 vary both with the rate of urinary production and the protein constitution of the plasma. The norma peristaItic movements of the ureters were studied by Lucas of

pyramid which projects into it. An increased flow of urine caIIs forth a more eflicient peristalsis and therefore does not produce an increase of pressure. Lucas also noted that in the Iower end of the ureter, contractions are smaIIer but occur more frequently than in the middIe section. It is a reasonabIe supposition that

FIG. 12. Stricture of ureter. Dilatation below stricture. Moth-eaten appearance of ureter typical of tubcrculosis. Diagnosis: tuberculosis of kidney and ureter.

FIG. 13. Stricture at ureteropeIvic junction, resulting compfete destruction of kidney.

the RockefeIIer Institute who found that a suction foIIowed the peristaItic wave, while at the same time a force was exerted on the fluid in front of the wave. In the norma ureter the pressure remains Iow in the renaI peIvis because of an anatomica arrangement which prevents the peIvis from coIIapsing under negative pressure; that is, there exists a rhythmic movement of the peIvis which brings about a “miIking action ” upon that portion of the

in

these contractions have some inffuence in preventing regurgitation. Resemblance to Intestinal Peristalsis. The rate of the uretera peristaItic waves varies in rate in proportion to the extent of the kidney’s activity. The waves begin at the pelvis and are discernibIe a11 the way to the vesica1 opening of the ureter. As has been pointed out by Quinby, the fact that they are initiated by an area of high metabolic rate in the renaI peIvis and pass to one of Iower rate below, is

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cIoseIy anaIogous to peristaIsis as exempIified in the intestine. It differs, however, in a very important particuIar. No evidence has ever been adduced to show that reverse peristaIsis ever takes pIace in the ureter whereas this phenomenon is we11 established in the intestine. There has been observed, nevertheIess, especiaIIy in

FIG.

14. Kinks;

nephrosis.

dilatated ureter with resulting hydroCaIcuIus present in mid-ureter.

experiments upon rabbits, that reflux of the bIadder content into the ureter occasionaIIy takes place. Regurgitation from the Bladder: “Bladder Rejlux.” The question as to whether a vesicorena1 reffux can exist under norma conditions, and the possibiIity of the existence of a demonstrabIe sphincter at the vesica1 end of the ureter, have been under investigation and discussion at

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intervaIs since the opening of the present century. As far back as Igo it was found by Barringer that in diseased conditions of the ureter the vesica1 orifices may be rigid at a time when contractions are taking pIace in other portions of the duct. If urine were being excreted into the bIadder at the same time, regurgitation wouId thus become possibIe. Yet, if the intravesicaI’portion of the ureter is norma no such reffux of urine can occur. WhiIe some carefu1 investigators have denied the possibiIity of reffux under any conditions from the human bIadder, a survey of the evidence points strongIy to the contrary. It was noted by WisIocki and O’Conor that when a moderate retention was produced in a rabbit’s bIadder which possessed good muscIe tone, the ureterovesica1 sphincter was occasionaIIy prevented from cIosing as it shouId normaIIy do after each gush of urine. When this occurred the intravesica1 pressure projected a coIumn of ffuid into the ureters. If peristaIsis was not going on, the reffux couId not be readiIy induced, but when peristaIsis couId be stimuIated, providing a moderate degree of intravesica1 pressure existed, the bIadder content was aImost aIways regurgitated. These investigators finaIIy concIuded that aIthough regurgitation can be readiIy produced in the rabbit and Iess frequentIy in the dog, further observation wouId have to be made before one wouId be abIe to say whether a comparabIe phenomenon occurs in man. If it ever does occur, ascending infection couId be readiIy accounted for. Nothing in their to the observations gave any weight theory of the existence of antiperistaIsis in the ureter. Under pathoIogic conditions, with Ioss of muscIe tone and aIterations in the mechanism which normaIIy prevents it, reffux of urine undoubtedIy couId occur in man. Permanent Ureteral Dilatation. From the CIinic de Necker, Paris, in 1914, Legueu and Papin put out a carefu1 review of previous work on the subject of permanent uretera dilatation, and the

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possibility of vesicorena1 reff ux under conditions of disease. They considered e.speciaIIy the investigations of Sampson and Hagner in the United States, and assented to the conclusions of these American authors that the pathoIogic states which permit gaping of the uretera mouths and regurgitation of urine from the bIadder into the

Under pathoIogic conditions such a reffux is shown (I) when the vesica1 content can be emptied through a uretera catheter, as happened in five of the cases which they detai1; (2) when an injection of opaque ffuid into the bIadder can be shown by roentgenography to ffow into the upper urinary tract, fiIIing not onIy

FIG.

FIG. 16. s-shaped kink in ureter with constant pain over McBurney’s point, resuIting in an appendectomy. Note the ptosed kidney. This roentgenogram wiII be particuIarIy instructive to those uroIogists who beIieve kinks pIay no roIe in uretera pathology.

13. Peculiar angulation, ureteropelvic junction, and L-shaped kink in ureter (erect posture).

ureters are of more common occurrence than is generaIIy believed. Their concIusions from reviewing the Iiterature and their own exhaustiveIy investigated cases were that though this reffux exists in animaIs in norma heaIth, in man it has not been demonstrated, though theoretically it is not impossibIe.

the ureter but the caIyces as weI1, and (3) when there is a reffux of urine from the opposite kidney by a nephrectomy wound. Conditions producing retention are we11 understood to make reffux possibIe; it is Iess we11 known that primary atony of

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the ureter and compIete congenita1 diIatation of the duct may have Iike resuIts. Very recentIy, at the ItaIian UroIogic Congress, Ravasini of Trieste presented a paper on this subject wherein he asserted that vesicorena1 reflux may be readiIy produced by either primary congenita1 diIatation of the ureters, or by such

FIG. 17. Angdation

of ureter, rare.

pathoIogica1 conditions as uretera tuberculosis, scIerosing periureteritis or ureteritis, or by bIadder conditions such as distention and inflammation due to caustic action, or the presence of vesica1 diverticulum or new growths. Other conditions which he beIieves capabIe of inducing this reffux are trauma from stone or iII-advised instrumentation, prostatic hypertrophy or abscess or new growth of this gIand, disease of the nervous system, and pregnancy. Treatment of Bladder Rejlux. Though much has been written concerning the mechanism and prevaIence of vesicorena1

of Ureter refIux, there is IittIe or no record of any measures which have been adopted to overcome or neutralize it. More than five years ago Quinby of Boston in a discussion of kidney affections gave it as his opinion that the so-caIIed “uretera chiI1” was dependent in most instances upon regurgitation into the ureters. He feIt justified in assuming that when the bIadder had been kept quiescent for a considerabIe period, as after a prostatectomy, it became hypertonic and on first resuming its function of expuIsion of urine caused the refIux to appear, with the resuIt of upward transfer of infected materia1 to the kidney. Treatment then must be directed toward combatting the renaI infection, and this he feIt couId be best accompIished by the administration of Iarge quantities of water, by mouth if possibIe, or under some conditions by hypodermocIysis. The onIy drugs worth anything in Quinby’s opinion are saIo1 and hexamethyIenamine* and “either of these is at best but feebIe.” Some other cIinicians have had good resuIts by proceeding as though obstruction had been positiveIy demonstrated at the vesica1 neck, even though many cases are not capabIe of offering any such demonstration. Where the reffux is due to Ioss of tone of the bladder muscIes, treatment directed toward its restoration wiI1 often O’Conor of Chicago, in prove effective. discussing a paper read before the UroIogic Section of the American MedicaI Association in 1923, pointed out that antisyphilitic treatment might accomplish this, and a return to norma tone of the bIadder muscuIature wouId abolish the reffux. He had frequentry seen the same resuIt in eIiminating residual urine in the bIadder by active systemic treatment, when a11 IocaI treatment had, for some reason, to be avoided. Ureteral Dilatation. As has aIready been mentioned in discussing anomaIies, the ureter may be congenitaIIy diIated. Most commonIy, however, such diIatation *In the author’s present opinion, hexylresorcino1 more effective for some types of infection.

is

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is a pathoIogica1 condition but may be due to a variety of causes. The designation “megaloureter was coined by CauIk to fit a singIe case which he reported, wherein there was a primary anatomical alteration in the uretera waI1. This is undoubtedly a very rare anomaIy. The term, however, has IateIy been more Ioosely appIied to

FIG. 18. Corkscrew

ureter,

resulting

in pyonephrosis.

those conditions in which the orifice at the vesica1 end of the ureter gaps wide open; “permanent diIatation of the uretera the French have termed it, orifice,” because no stricture or other obstruction can be postulated to account for it. The condition shown by these patients is such

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that if we were to turn them upside down when their bladders were fuI1, the urine wouId flow back to the kidneys just as readily as it flowed from the kidneys to the bIadder when the patient’s head was uppermost. An interesting contribution to the subject of ureteral dilatation was recentIy

FIG. 19. TypicaI corkscrew ureter, resuIting in hydropyonephrosis (tuberculous kidney).

made by Carson, who found in 183 consecutive autopsies upon maIes that 23 showed some degree of this abnormaIity. In fourteen both ureters were diIated, five showed it upon the right onIy, and four upon the left onIy. UreteraI diIatation was accom-

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panied by hydronephrosis in thirty-one cases and was evidentIy due to intravesica1 obstruction in eIeven cases. Five subjects were found to present uretera stricture also, and of these strictures four were of inflammatory origin and one, in an infant

FIG.

20.

APRIL, 1gz.8

of Ureter

of the ureters. In the exampIe offered to us by CauIk, the affected duct was repeatedIy drained and irrigated with antiseptics without, however, having any permanent effect upon the septic condition persisting as a resuIt of urinary infection. CauIk

FIG. 21.

FIGS. 20 and 21. Spasm of ureter. Note Iength of constriction. Note diIatation where constriction (Not constant nor persistent and longer than a definite stricture.)

who died on the sixth day, was unquestionabIy congenita1. Treatment of Megaloureter. What has just been said in regard to handIing cases presenting a vesicouretera1 refIux appIies with equa1 force to permanent diIatations

was present.

himseIf considered remova of the kidney notwithstanding the fact that it was sound, and in this Kretschmer, who aIso saw the concurred. The Iess grave interpatient, vention of sIitting the uretera orifice with cystoscopic scissors was first tried and had

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a temporary beneficia1 effect, enabhng the patient to empty the ureter down to 2 to 4 ounces. But it was not unti1 a far more extensive incision had been made with a speciahy devised instrument that any permanent benefit resuhed. Thereafter the patient couId empty the ureter under ordinary conditions but as soon as the bIadder became at a11 distended its contents immediateIy backed up into the diIated duct and retention again occurred. (Fig. 6.) Others have enIarged the uretera orifice by fmguration, notably Gayet and Rousset in France and PetiIIo of this city. Geisinger of Virginia found all irrigations and IocaI treatment absoIuteIy ineffectua1 and finahy took out the kidney, the patient immediateIy recovering and remaining in normaI heaIth thereafter. The French operators just mentioned aIso found it necessary to remove the kidney in severa cases. DiIIon of San Francisco treated two patients with diIated ureters attended by vesicorena1 reffux by means of irrigations with boric sohrtion very gentIy injected, fohowing this by instihation of 2 per cent mercurochrome. He found that under this regimen they made much better progress than with kidney Iavage. The hips were eIevated and the patients instructed to hoId the sohrtion as Iong as possibIe. Free drainage must be estabIished without fail, and with proper attention to this, together with suitabIe antiseptics to combat the infection, it wouId seem that except in the most severeIy infected cases it wouId hardIy be necessary to remove a usefu1 kidney. URETERAL

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That the majority of strictures are congenita1 in origin is the contention of C. K. Smith of Kansas City, who beIieves that if these cases couId be seen in their earlier phases, which at present very seIdom happens, it wouId be shown that congenitaI

probe in low' er :ef:ureier

norma ureter and hydro22. Hydronephrosis; ureter on left kidney; ureteroceIe. Courtesy, Dr. Christeller, Virchow Krankenhaus, BerIin.

FIG.

INFECTIONS

Infection within the ureter is so cIoseIy aIIied with strictures and other obstructions that one can hardIy be considered apart from the other. It is the opinion of Hunner, to whom we owe much of our present knowIedge regarding uretera stricthat these Iesions are in most ture, instances originahy due to foca1 infection, often quite remote from the urinary tract.

malformation with disturbed uretera function and stasis is the primary factor which decides the place where involvement begins, and that this may very we11 resuIt in the formation of connective tissue with inevitabIe greater decrease in the size of the ureter’s Iumen. The researches of Hunner have aIso gone to show that when a ureteral caIcuIus is found in a denseIy strictured

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area, the encapsuIating scar tissue is not so much due to the irritation induced by the stone’s presence, as is the deposit of the stone in that particuIar place due to the previous existence of the stricture. breteritis. Primary inff ammation of the airophied

Kidney

/A

:

’

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been found that some of the most extreme cases of dysuria in women couId be traced to this cause. The infection may be either a Iymphatic extension or may be secondary to a distant focus. PossibIy obstruction and urinary stasis may contribute in some

hydra nepnro3ls m

I-ure

t et-

2

FIG. 24. Showing

FIG. 23. Calculus, resuIting in compIete destruction of kidney. Courtesy, Dr. ChristeIIer, Virchow Krankenhaus, BerIin.

ureter is probabIy a rare occurrence. In my own experience I have seen but one case. This patient showed absoIuteIy nothing pathoIogica1 in the renaI peIvis or parenchyma, but the attached ureter was compIeteIy fiIIed with granulations which suggested tubercuIosis. This infection was compIeteIy ruIed out, however, so that we couId not but concIude that the inflammation was primary to the duct itseIf. Inflammation, in the Iower section of the ureter especiaIIy, is probabIy responsibIe for a great dea1 of peIvic pain which is reguIarIy referred to other causes. It has

corkscrew diIator above process of remova1.

caIcuIus

in

degree but this wiI1 not account for the cases of megaIoureter of which mention was made previously. In these infection is aIways present yet no obstruction can be demonstrated. Focal Infection. If we accept the contention of Hunner, uretera stricture or simpIe chronic ureteritis may be the outcome of diseased conditions in the throat or mouth, Iess often in the sinuses, and possibIy occasionaIIy in the Iower part of the aIimentary tract. The origina infection may perhaps be first arrested by the Iymph gIands in the region of the ureter, the causative organisms then being taken up by the waIIs of the duct, with resuIting inflammation and infiItration. In many cases of ureteritis, the infection wiI1 descend so far as to invoIve the trigone, thus

NEW SERIES VOL. IV, No.

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producing highlv distressing vesical symptoms, all of which subside as soon as the ureteral condition is controlled, even if nothing whatever has been done in the bladder. A v-cry- rare form Ureteritis Cvstica.

FIG. 25. Calculus

with resulting

dilatation.

of uretera inff ammation which has received practically no attention in uroIogic textbooks is ureteritis cystica. This affection is characterized by muhiple minute cysts of the mucosa1 Iining, usuaIIy of the vesicaI end of the ureter. Microscopicahy they are shown to be inchrsion cysts of the

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lining epithehum. A very interesting specimen of this affection was shown by Bond Stow before the New York Pathologica Society some twenty years ago, and so far as I have been able to discover, no adeqrate discussion of the condition has since

FIG. 26. Calculus in lower end of ureter with resulting dilatation of ureter and hydronephrosis. Stone removed, ureterat diIatation and irrigation. UneventfuI recovery.

appeared in the Iiterature. In 1924 Aschner reported having seen four cases in Beer’s service at Mount Sinai HospitaI, New York. The remarkabIe feature of Stow’s case was that it presented compIete

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biIatera1 dupIication of the ureters, though each pair of ureters united outside the vesica1 waII and entered through the normaI opening as a singIe duct. Each one of the four ureters from its origin to within 4 cm. of its entrance into the bIadder was thickly studded with cysts, varying from the size of a miIIet seed to that of an

Papilloma

FIG. 28. PapiIIoma FIG. 29. Papilloma

the renaI peIvis, but the bIadder was entireIy free from them. AI1 of the cases reported by Aschner had bIadder invoIvement; indeed, the Iesions appeared to have originated in the bIadder and progressed to the ureters secondariIy. More recentIy a case has been reported from AustraIia; it was there reIated, but mereIy in theory

/?9..+$ FIG. ~8.

FIG. 27. FIG. 27.

of Ureter

FIG. 29.

hydronephrosis). Courtesy, Civiale, Dr. Ma .rion, Service _ .. . . -. LarIboIsrere, I’arIs. of ureter. Courtesy, Dr. Marion, Service Civiale, HopitaI Lariboisiere, Paris. Dr. Legeau, Museum Felix of base of ureter and of uretera meatus. Courtesy, HopitaI Necker, Paris. of

ureter

(slight

ordinary pea. Some cysts were isoIated, whiIe others appeared in groups; some were transparent and contained a cIear serous Auid; others were opaque and grayishyeIIow in coIor, fiIIed with a ropy coIIoid materia1; stiI1 others were much harder than the majority, their contents being resinous and of a gIue-Iike consistency. SimiIar cysts were scattered throughout

HopitaI

Guyon,

without bioIogic or histoIogic proof, to a disease prevaIent among cattIe in certain sections of the country known popuIarIy as “ red water. ” Autopsy upon some of these animaIs showed no extensive urinary tract Iesions other than minute cysts scattered over the mucosa of bIadder and ureters and occasionaIIy found aIso in the kidneys. The Iatest case reports on ure-

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teritis cystica I have been abIe to find are the three German ones pubhshed by Knack in 1926. (Fig. 7.) Venereal Injeckons of tbe Ureter. Gonorrhea and syphihs are apparentIy onIy secondary invasions of the ureter. UreteraI syphiIis is not mentioned in any Iiterature that has come to my notice, and secondary infection with the gonococcus is evidentIy an extremeIy rare finding. The possibiIity of vesica1 syphiIis extending to the ureter is, however, perfectIy evident to anyone at a11 famiIiar with urinary tract pathoIogy, but in common with other infections it is doubtfu1 if it couId ascend so Long as the mechanism which prevents reffux into the ureters remained in norma condition. The characteristic Iuetic bIadder uIcer is more IikeIy to appear about the uretera orifices than anywhere eIse, and where diIatation has previousIy taken pIace invasion of the uretera Iumen wiI1 be a very IikeIy seque1. We have it on the authority of Thomson, the EngIish writer, that gonorrhea1 cystitis may extend to the ureters, the renaI peIves and even occasionaIIy to the kidneys themseIves. The opponents of the theory that ascending infection may be heId responsibIe for such an occurrence can attribute this onIy to bIood-borne origin, but I am incIined to beIieve that preceding megaIoureter or even a miId degree of uretera diIatation it must in the majority of cases be the deciding factor. Any such infection is IikeIy to be chronic rather than acute, and very frequentIy the patient wiI1 present no symptoms which can be in any way referred to a venerea1 infection in this part of the urinary tract. The symptoms of uretera gonorrhea are by no means characteristic. There may be a sIight rise of temperature, and pressure on the angIe formed by the Iowest rib and the erector spinae muscIe may eIicit some sIight tenderness. There may be intermittent pyuria or pus wiI1 appear continuaIIy, with easy demonstration of the specific organism on urinaIysis. The fina diagnosis wiI1 rest upon the observations

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made through the cystoscope. The uretera orifices wiI1 appear red and patuIous, often with pus oozing from them. and anaIvsis of thk specimens obtained by ure&aI catheterization wiI1 confirm the visibIe symptomatoIogy. Tuberculosis of the Ureter. Infection by continuity is probabIy the manner in

FIG. 30.

FIG. 31. FIGS. 30 Marion,

AND

31. PoIyps of the ureter.

Service

CiviaIe,

Courtesy, Dr. HopitaI Lariboisiere, Paris.

which most cases of uretera tubercuIosis arise. It is now quite we11 estabIished that vesica1 tubercuIosis is practicaIIy aIways secondary to an earIier focus in the kidney and it wouId be highIy probabIe that the ureter wouId become invoIved even earIier than the bIadder. As a matter of cIinica1 experience, however, many patients are seen with extensive Jesions in both kidney and bIadder, but with a whoIIy norma

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ureter communicating between them. No doubt hematogenic infection as we11 as extension through the lymphatics may occasionaIIy take pIace but descending infection from the kidney is very evidently the etioIogic factor in most cases of uretera tubercuIosis. TubercuIosis of the ureter is especiaIIy

FIG. 32. Cancer of the ureter. Courtesy, Dr. Legeau, Museum FeIix Guyon, Hopital Necker, Paris.

important in reIation to stricture, for a heaIed focus might readily account for such a Iesion which couId not be traced to any other source. To the surgeon operating for the removal of a tuberculous kidney the compIete remova of an infected ureter is essentia1, for faiIure to cIear away this source of infection may continue

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and aggravate a vesica1 condition which wouId otherwise subside and probabIy cIear up entireIy, foIlowing remova of the origina focus in the kidney. (Figs. 8 and 9,) URETERAL

OBSTRUCTION

Mention has aIready been made of the indebtedness of the medica profession in genera1 and uroIogists in particuIar to Hunner for the work which he has done in regard to uretera stricture. Before he made known the resuIts of his researches medica men generaIIy knew IittIe about this Iesion and probabIy cared even Iess. It was many years before the BaItimore uroIogist’s views were accepted but at present there are very few who now his concIusions, dispute even if they refuse to believe that uretera stricture is so common an occurrence as he maintains it to be. It shouId be borne in mind, however, that the ureter is subject to considerabIe variation in caliber even in perfectIy norma individuaIs, and the normal constrictions may be some distance away from the positions usuaIIy assigned to them, so that an expIoring bougie might easiIy impinge upon one of the& in an area which even a good anatomist wouId consider free from any congenita1 narrowing. In the interpretation of pyeIoit behooves us to be carefu1 grams not to mistake a temporary IocaI spasm, perhaps induced by the presence of the foreign opaque medium, for a permanent constriction; neither shouId we jump at the concIusion that an inflammatory diIatation is mechanica1. Stricture of the ureter is very IikeIy to be biIatera1, according to Hunner, and when the Iesion has been estabIished in one ureter it is we11 aIways to make careful examination of the opposite side. The Iesion undoubtedIy pIays a very important part in genitourinary pathology. Without stopping to discuss whether the congenita1 or the acquired type is the more frequent, it is evident that when infIammation has once been set up, if it chances to occur near one of the natura1 narrowings of the

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urinary duct, obstruction will take place sooner than if the lesion were Iocated in an area where the lumen is wider. As tubercuIosis is one of the most frequent causes of inflammation in all parts of the urinary tract, the ureter naturaIIy does not escape; yet exampIes of tubercuIar uretera strictures are not very numerous as yet. Al1

/I FIG. 33. 1Xver

r ‘.YM-

.ticuIa of

ureter.

American Journal 01 Surgery

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with an anomaly. Some years ago the Californians, Hale and von GeIdern, found a diverticulum some IO cm. above the vesicaI orifice with a structure just beIow the diverticulum. UreteraI diverticuIum is as rare as stricture of the same duct is common; the one shown in Figure 33 is a decidedly unusua1 finding.

HA?7 Courtesy,

Dr.

AMarion, Service

types, however, are being encountered with ever-increasing frequency as our methods of diagnosis, especiaIIy the roentgenoIogic ones, improve and achieve greater exactness and clarity. This does not mean that there are actuaIIy any more strictures; we are now more IikeIy to demonstrate their existence. In any case where some pathologic condition in the upper urinary tract is obscure and defies discovery by routine examination, stricture of the ureter, either partial or compIete, may be at fat&, and this possibiIity shouId never be forgotten. It is we11 to remember that stricture may very readiIy exist in conjunction with other Iesions, or be present together

Civinie,

HopitaI

La] -ibloisiere,

Paris.

The latest pubIished studies on uretera stricture, reports of which were made a few months ago by Schreiber, list as prime etioIogica1 factors in the pathogeneisis of this Iesion : (a) congenitally accentuated narrowing of a congenita1 physioIogicaIIy narrow site; (b) extension of inflammatory processes into the uretera waI1 from adnexal disease with and without thrombophIebitis, and advanced chronic cystitis; (c) the occIuding kinking power of crossing anatomical structures, namely, the vas deferens in the male and the uterine artery in the female. This investigator thus restricts considerabIy the etioIogic factors previously postulated by Hunner, though

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he takes a broader viewpoint than some of the men with whom he has been cIoseIy associated, notabIy Edwin Beer, who recently put himself on record* as remaining unconvinced that uretera stricture is a common lesion, that it is usuaIIy biIatera1, that it is due to focal infection, or that Hunner’s method of diagnosis by the wax bulb is perfectIy reIiabIe. It is my persona1 opinion, however, that Schrei- .

withdraw the catheter beIow the upper limit of the bony peIvis so as to be abIe to take a picture when the ureter no Ionger contained anything firm enough to straighten it out and stiffen it, we doubtIess missed a great many kinks which doubIed up again as soon as the catheter was withdrawn. Yet the fact that we no Ionger miss them as we used to do is no reason for our regarding them as being of Iess impor-

FIG. 34. CongenitaI short ureter with congenita1 ptosed

FIG. 35. Double ureter and doubIe kidney on right side, with single ureter on left.

kidney and pyonephrosis.

ber’s work, based upon IOO consecutive autopsies, is in Iarge measure a confirmation of Hunner’s contentions, and that our present cIinica1 procedure wiI1 be successful onIy in the measure that we are wiIIing to proceed aIong the Iines he has marked out for us. Ureteral Kinks. The demonstration of kinks of the ureter requires carefu1 pyeIography. So often do they appear in the pyeIogram that the finding may be regarded as a mere accident and its significance underestimated. Before we Iearned to *AM. J. SURG., 1927, iii, 59.

They undoubtedIy account for tance. much otherwise unexpIained abdomina1 pain, and by obstruction of the ureter set up pyeIitis and induce various forms of renaI pathoIogy which are whoIIy unassociated with movabIe kidney, the condition in connection with which we are most apt to think of kinked ureter. (Figs. 14 to 17.) On the other hand it is possibIe to produce a kink artificiaIIy, as has been pointed out by Eisendrath. In injecting media for pyeIography the catheter may

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be pushed up cIose to the kidney, and a picture taken at this time wiI1 show the ureter kinked between the peIvis and the end of the catheter. If a second exposure be made after the catheter is withdrawn there wiII be no kink visibIe. This iIIustrates the unwisdom of depending upon a singIe exposure. At Spastic Obstruction of the Ureter. of the times instrumenta exploration

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and a short interva1 of time aIIowed to eIapse before it is reinserted, the secretion of urine wiII have resumed and the tip pass the point where it was previousIy obstructed without any troubIe whatsoever. It may be said here, as wiI1 be much more strongIy emphasized when we consider the remova of uretera calcuIi, that in no part of the body is more patience and thoroughness required of him who

FIG. 36. Author’s case of compIete double ureter and doubIe peIves on right and Ieft side, with a pyonephrosis due to kink on right side. Catheterization of both ureters, catheters (No. 7) Ieft in situ; irrigation with I : IOOO acriflavine for 72 hours. UneventfuI recovery.

ureter may be found impossibIe and the impression be gained that we are deaIing with an impassabIe stricture. It must be remembered, however, that if secretion by the kidney is for any reason temporariIy suspended, as is IikeIy to happen from the psychic effect of the examination aIone, the unmoistened Iining mucosa of the ureter wiII offer effective resistence to the passage of the catheter. If the apparent obstruction is at the ureterovesica1 vaIve, the existence of spasm shouId be strongIy suspected. (Figs. 20 and 2 I .) A pyeIogram made after the faiIure of the instrument to pass often shows nothing obstructive at the point where its progress was arrested. Sometimes if the catheter is withdrawn

undertakes irreguIarities ureter.

to

expIore and correct and diseases than in

its the

Ureterocele. Cystic diIatation of the vesica1 end of the ureter has been generaIIy Iooked upon as a congenita1 anomaIy. Its occurrence in aduIts, however, and the greater frequency of its appearance now that pyeIography and other diagnostic measures have reached their present usefuIness, has tended to indicate that the condition is more often acquired than congenita1. PetiIIo has attributed the condition to two factors: (I) a Iesion at the end of the extramura1 portion of the ureter, acting upon the nervous or muscuIar eIements so as to diminish or aItogether aboIish uretera

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peristalsis in the dista1 portion of the duct, thus paraIyzing the intramura1 portion; continuous pressure from above wouId tend to dilate this atonic portion; (2) a narrowed uretera orifice wouId have to exist in addition to the Iesion; otherwise the entire ureter wouId be more IikeIy to undergo diIatation. UreteroceIe wouId be produced in inverse proportion to the size of the meatus; a narrow orifice wouId produce a larger ureteroceIe than a more generous one. The diagnosis can be made onIy by cystoscopy. As Damon A. Brown has said: “The ghstening cystic tumor Iocated at one or the other uretera orifice and baIIooning and retracting, according to the influx of urine, couId not be mistaken for any other condition.” Various kinds of treatment have been instituted by different writers upon this condition but the greatest success seems to have attended fuIguration. In a few cases manipuIation with the catheter and systematic diIatation have served to reduce the cystic condition but destruction is IikeIy to prove most satisfactory in the Iong run. Prolapse of the Ureter. Cystic diIatation of the vesica1 end of the ureter has been mentioned as probabIy in most instances a congenita1 anomaIy. In the few cases of proIapse of this portion of the duct which have been put on record, the condition has usuaIIy been mistaken for some type of cystic diIatation. A year or more ago Mercier coIIected six cases of uretera proIapse, to which he added one which had been seen in Marion’s cIinic in Paris. According to the histoIogic and cIinica1 observations of this writer, proIapse may sometimes be due to over-vioIent contractions of the ureter, but a predisposing weakness in the structure of the waI1 must be present to make such an occurrence possible. A certain amount of redundancy, such as was postuIated as a frequent cause of kinks which have no pathoIogica1 significance, wouId aIso seem a reasonabIe accompaniment to conditions inducing proIapse. Mercier even goes so far as to

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suggest the existence of an abnorma1 vaIve at the uretera meatus which shuts off the flow of urine intermittentIy and thus stimuIates the ureter to abnorma1 peristaIsis. But when we come to consider how many conditions can occur to cause bIockage at the vesica1 orifice without going to the troubIe of imagining anomaIous structures such as “vaIves,” this hardIy seems necessary. A perfectIy norma ureter wiI1 hardIy proIapse, no matter how much disturbance in its performance of function may be induced by blockading its outIet. The previous existence of stricture with subsequent diIatation, of caIcuIus formation with resuIting trauma and stretching of the uretera waI1, wouId certainIy provide definite etioIogic factors suflicient to account for those few instances where proIapse of the ureter has taken pIace. As a ruIe such an accident causes no symptoms, and it is only on cystoscopic examination for something eIse that its existence may be discovered. It is easiIy differentiated from congenita1 cystic diIatation because it is easiIy reduced by the catheter, and when the Iesion which was instrumenta in producing it has been suitabIy treated and aboIished, the proIapse is IikeIy to be cured at the same time. It may possibIy be necessary to treat it in the same manner as the proIapsing femaIe urethra is handIed: destruction of the proIapsing portion and enIargement of the orifice if this seems to be necessary. Ureteral Calculus. In considering stone of the ureter we must differentiate between those which originate in the duct itseIf and those which form in the kidney and are Iater forced into the ureter by the outflow of urine. The majority of stones first recognized in the ureter probabIy originate in the kidney, but it was demonstrated many years ago by Rovsing, and that constriction and Iater by Hunner, obstruction of the ureter offer favorabIe conditions for the production of caIcuIi directIy at the site of the Iesion. Stricture and stone formation are the

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forms of uretera pathoIogy which most often give rise to symptoms which are wrongly attributed to other organs, the appendix and gaII-bIadder most frequently. Their roIe not onIy in diseases of the urinary tract but in abdomina1 affections generally thus becomes a very important one, and differentia1 diagnosis at times is a highIy diffIcuIt matter. PyeIography wiI1 in most cases estabIish the existence of the uretera stone and, together with obstruction to the passage of the catheter, may be regarded as concIusive evidence, but in many instances the patient does not come into the hands of the uroIogist unti1 the internist and genera1 surgeon have exhausted their resources, and may have undergone several operations in a vain effort to ease his sufferings. On the other hand stones may often Iie in the ureter for years without causing any symptoms whatever. Many, when removed, show a deep groove at one side, through which the urine freeIy passed, and it was onIy when something occurred to aIter its position so that the ureter’s Iumen was occIuded that the stone caused obstruction with the production of renaI colic or even eventua1 destruction of the kidney. The remova of uretera stones offers a very nice problem to the surgeon and caIIs for the exercise of his best judgment and critica faculties. Ureterotomy is a very serious procedure and shouId onIy be undertaken when a11 hope of removing the caIcuIus by any other means has had to be abandoned. By the empIoyment of modern expedients and the exercise of unIimited patience and perseverance, most stones can be made to pass. Sometimes uretera catheterization aIone wiI1 reIieve the symptoms and diIate the ureter beIow the point of impaction of the stone suffrcientIy to make it move downward to the bladder where it can be easiIy grasped and extracted. At others, repeated diIatations, sometimes extending over many months, have been necessary before the caIcuIus fmally appeared.

of Ureter Various methods of manipulation of caIcuIi intraureteraIIy are empIoyed, but I think the experience in most cIinics has been simiIar to ours; no one method is appIicabIe to a11 cases. CroweII has for a number of years used and warmIy advocated a combination of uretera anesthesia with diIatation by means of instruments. OiI is sometimes injected to aid in the passage of the catheter beyond the stone, and in different cases fIuorscopy may be brought into pIay to give information as to the progress of meta diIators and prevent accidental pushing of the stone back into the kidney peIvis. As far back as 1918, Bugbee reported the successfu1 extraction of a Iarge caIcuIus Iodged in the Iower portion of the ureter, which was effected by twisting a soft catheter in the fingers unti1 it coiIed in a Ioop about the stone which was then drawn out as in a sling. The catheter is rendered soft by boiling. Several roentgenograms were pubIished showing the catheter coiIed about the stone in the uretera lumen. Wax-tipped catheters and bougies are usefu1 in the types of stone which do not cast definite shadows in the roentgenogram and may otherwise remain unsuspected, but once the diagnosis is estabIished patience on the part of everyone concerned wiI1 usuaIIy be the deciding factor. It requires not a IittIe persuasion to induce a patient to submit time after time to cystoscopy, but often the thought that he is avoiding a serious and possibIy fata operation may keep him steadfast in the face of repeated faiIures to disIodge a stone. (Figs. 23 to 26.) TUMORS

OF

THE

URETER

NeopIasms of the ureter are very rare findings. CuIver who made a search of the Iiterature in 192 I couId find but sixteen cases of uretera papiIIoma, whiIe Aschner the foIIowing year coIIected onIy fortyseven ureteral new growths of a11 types. In the Iatest pubIication I have seen on this subject, that of R. LesIie Stewart of Edinburgh, five more cases were added, making with Stewart’s own case but fifty-three

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known cases of tumors primary to the ureter. Papilloma. Benign growths appear to be even more uncommon than mahgnant ones but this may very we11 be because al1 uretera neopIasms tend toward maIignancy and probabIy do not produce correctIy appreciated symptoms unti1 they have ceased to be benign. PapiIIoma deveIoping in the ureter is in every way simiIar to Iike growths in the bIadder or renaI peIvis. It presents a vascuIar stroma, branching typicaIIy, covered with muItipIe layers of transitiona epitheIia1 ceIIs which are in marked contrast to the underIying connective tissue. SmaII round ceIIs are often found in this underIying connective tissue, suggesting a preceding inff ammation due to irritation which may possibIy be indicative of some irritative factor in the production of the neopIasm. Commenting on the Iiterature, CuIver teIIs us that in three of these cases caIcuIus was intimateIy associated with the neopIasm; one had a partia1 uretera dupIication, one a diverticulum at the site of the tumor and one a duodena1 renaI peIvic fistuIa, presumabIy caused by stone. It is a question, however, whether these associations had an influence on the occurrence of the neopIasm or whether some of them at Ieast were not caused by the neopIasm and had arisen subsequent to its formation. The reported cases show that uretera papiIIomata may be located in any one of three positions. In the first the entire ureter may be invoIved, and the renaI peIvis and bIadder at the same time. In the second the renaI end of the ureter onIy wiIl be affected, with part or a11 of the renaI peIvis. Again it may be that in addition to the second situation the Iast inch or so of the duct may be affected, with the portion which Iies between the two areas of papiIIoma apparentry normaI. According to Stewart, if these tumors occur at the Iower end they may be extruded through the uretera orifice and be engrafted on the adjacent vesica1 waI1. Marion has reported a case where it was necessary to remove

of Ureter the ureter because of a profuse papiIIomatosis, five years after the corresponding kidney had been taken out for a simiIar condition. Between these two major operations fuIguration of simiIar growths in the bIadder had been severa times carried out. (Figs. 27 to 29.) Malignant Neoplasms of the Ureter. The few cases of primary maIignant growths of the ureter gave symptoms practicaIIy identica1 with simiIar tumors arising in the kidney. Hematuria is often the onIy indication, but if the bIeeding is excessive the passage of cIots may cause the most intense pain. The cIots are frequentIy aImost compIete casts of the ureter, and may even be voided in Iong strings Iooking Iike “ angIeworms. ” Less definite hematuria is the ruIe, however, and because the symptoms are not in any way pecuIiar to uretera Iocation of the lesion, differentia1 diagnosis is IikeIy to be diffIcuIt. Like other maIignant growths, cancer of the ureter aImost aIways appears Iate in Iife, so it may be the more readiIy distinguished from renaI tubercuIosis which produces some of the same symptoms but is found among younger patients. In the same way we may be abIe to ruIe out stricture and stone, but if there is any reason to beIieve that maIignancy may be existent, a11 instrumentation shouId be appIied with great caution. CompIete ureterectomy and nephrectomy offer the onIy certain means of remova1, but in patients advanced in years or greatIy depIeted by excessive bIeeding such measures may be out of the question. SeveraI patients so treated have survived for years and finaIIy died of something eIse. A few authors aIso report good resuIts from fuIguration of growths cIose to the vesica1 meatus. This, however, wouId be of IittIe avai1 in cases of estabIished maIignancy. (Figs. 30 and 3 I.) In the course of a number of years devoted to cIinica1 observation upon the urinary tract I have become convinced that what Saint James said of the tongue may be appIied with equa1 truth to the

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ureter: It is “a IittIe member” but is capable of kindIing “a great fire, ” and the importance of its roIe in a great majority of urinary tract diseases is even yet not so fuIIy appreciated as it shouId be. SUMMARY I. The history of urinary surgery indicates that comparativeIy IittIe attention was given to the anatomica importance of the ureter unti1 very recent times. The introduction of safe methods of pyeIography has done more to famiIiarize the surgeon with this duct and its pathoIogy than any other singIe factor. 2. EmbryoIogicaIIy the ureter takes its origin as a bud from the Iower end of the WoIffIan duct, cIose to its point of opening into the cloaca. When the cIoaca disappears in the process of deveIopment, the ureter acquires a separate opening and a buIbous tip which Iater spIits in two indicating future division into caIyces. Incomplete or doubIe ureter probabIy comes from a premature bifurcation of this tip, or an abnorma1 spIit which incIudes the stalk. Most anomalies of number and form probabIy arise at this point in feta1 deveIopment. Huntingdon contends that double ureters have separate buds. 3. The most important points in the anatomy of the ureter are its areas of narrowing and the arrangement of muscIe fibers at its vesica1 end which serve to prevent regurgitation from the bIadder. The exact nature of this mechanism is not we11 understood but it is the present writer’s opinion that there is a definite arrangement of nerves and muscIes which serves the purpose of a sphincter. Regurgitation is very IikeIy aided aIso by uretera peristaIsis. Under conditions of disease diIatation of the ureter undoubtedly occurs and the condition known as megaloureter is estabIished, wherein rise of pressure within the vesica1 cavity may force the contained urine back into the ureters even entireIy to the renaI peIvis. 1. Stricture of the ureter is a definite clinica entity, occurring somewhat fre-

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quentIy in uroIogic practice though perhaps not quite as often as some enthusiasts would have us believe. PathoIogic stricture is more IikeIy to take pIace at the points of anatomica narrowing, and caIcuIus formation is undoubtedIy favored by the existence of infection in these strictured areas, the stone being a resuIt rather than a cause of the stricture as has been generaIIy beIieved. 3. Ureteritis cystica is a rare form of uretera inffammation to which IittIe or no attention has been given in textbooks. The condition is not pecuIiar to the ureter but may be present in bIadder and renaI pelvis as weI1. UreteroceIe, or cystic diIatation of the Iower end of the ureter, shouId not be confused with ureteritis cystica. This may possibIy be congenita1 in a few instances but is much more reasonabIy regarded as a graduaIIy progressive condition acquired through many years. Ureteral prolapse is a separate entity. 6. Primary infections of the ureter are not very common; whiIe the ureter may be infected by venerea1 diseases, tubercuIosis and so forth, this is usuaIIy onIy an extension from kidney or bIadder. TubercuIosis is undoubtedIy a frequent cause of uretera stricture and obstruction. ;. UreteraI caIcuIi may have formed in the kidney and descend to the ureter, or they may originate in strictures or from other causes in the ureter itseIf. They shouId be removed by intravesica1 manipuIations if possibIe. Patience and perseverence wiI1 usuaIIy accompIish this, and surgery shouId be only a Iast resort, 8. Tumors of the ureter are a rare finding. PoIyps are occasionaIIy encountered, and benign papiIIoma has been reported in a few instances. MaIignant neopIasms piimary to the ureter are very seIdom seen. CompIete remova of any neopIasm shouId b e promptIy undertaken, as a11 benign growths tend rapidIy to become malignant. I wish to thank Dr. 0. S. Lowsley, Director of the Brady UroIogicaI Foundation, for his courtesy in extending to me the priviIeges of his department.

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BIBLIOGRAPHY ALBARRAN. Trait& de Medecine operatoire de I’Appareil urinaire. Paris, Masson et Cie, 1906. ASCHNER, P. W. Primary tumors of the ureter. Surg. Gynec. @ Obst., 1922, xxxv, 749. BARRINGER, B. S., Observations on the physioIogy and pathoIogy of the uretera function. Folia Urologica, 1908, ii, 468. BARNEY, J. D. Observations on the kinks of the ureters. J. urol., 1923, ix, 81. CARSON, W. .I. DiIatation of the ureter in the male. AM. J. SURG., 1927, iii, 541. CAULK, J. R. MegaIoureter; the importance of the ureterovesica1 vaIve. J. Ural., 1923, ix, 315. CLELAND, J. B. Ureteritis cystica. M. J. Australia, 1926, xiii, 13. CROWELL, A. J. Removal of uretera stone by cystoscopic manipuration. J. Ural., 1921, vi, 243. DOURMASHKIN, R. L. A dew procedure in the roeutgen-ray diagnosis of ureteral caIcuIi. Read before N. Y. Academy of Medicine, Jan. 18, 1928. EISENDRATH, D. N. CongenitaI strictures and spira1 twists of the ureters. Ann. Surg., 1917, Ixv, 552. EISENDRATH, D. N. UreteraI strictures, kinks and abnorma1 inserts. Surg., Gynec. @ Obst., 1925, xii, 557. GUYON ET ALBARRAN. Retention d’urine. Arch. de med. . exper., II, 1924. HAILES, W. A. and BURNEL, F. M. A case of cystitis cystica associated with severe hematuria. M. J. Australia, 1925, xii, 285. HENDERSON, V. E. The factors of ureter pressure. Jour. Pbysiol., 1905, xxxiii, 175.

HEPBURN, T. N. Obstructions at the ureterovesicat valve. Surg., Gynec. @ Obst., 1923, xxxvi, 368. HUNNER, G. L. UreteraI stricture. J. A. M. A., 1922, Ixxix, 731; and 1924, Ixxxii, Tog. KNACK, A. V. Ueber ureteritis cystica. Dermat. Wcbnschr., Ixxxii, 85. LUCAS, D. R. On intrauretera1 pressure and its reIations to the peristaltic movements of the ureter. hoc. Sot. Exper. Biol. &+Med., 1904-5, ii, 61. LUCAS, D. R. On the abnorma1 peristaltic movements of the ureter. Proc. Sot. Exper. Biol. ti Med., 1906, iv, 6. LEGUEU, F. ET PAPIN, E. De la dilatation permanente des orifices ureteraux et du reflex vesico-renal. Arch. Ural. de la Clin. Necker, 1913, i, 377. MERCIER, 0. Le proIapsus intravesical de I’extremiti: inferieure de I’uretere. J. d’urol., med. et cbir., 1925, xix, 402. QUINBY, W. C. Observations on the physiology and pathoIogy of the ureter. J. Ural., 1922, vii, 259. SATANI, Y. Histologic study of the ureter. J. Ural., 1919, . .. In, 247. SCHREIBER, M. UreteraI stricture; its anatomical and pathologica background; based upon the findings in IOO consective autopsies. Surg. G.ynec. @ Obst., 1927, xiv, 423. STOW, B. Ureteritis cystica. Proc. Path. Sot. N. Y., 1907, vii, I. WISLOCKI, G. B. and O’CONOR, V. J. Experimental observations upon the ureters, with specia1 reference to peristalsis and antiperistalsis. Johns Hopkins Hosp. Bull., Igzo, xxxi, 197.