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The Value and Limitations of Uroselectan as an Aid in Urological Diagnosis1
THE VALUE AND LIMITATIONS OF UROSELECTAN AS AN AID IN UROLOGICAL DIAGNOSIS 1 HENRY G. BUGBEE
AND
ARTHUR J. MURPHY
New York, N. Y.
From time to time, a new instrument or agent is added to our armamentarium, opening up new vistas and elucidating old problems. Thus we look back upon the advent of the roentgen ray, the cystoscope, x-ray ureteral catheters, high frequency and radium therapy, urography, and functional kidney tests-to mention a few outstanding points in urological progress. As each new discovery has been brought forward, there has been an outburst of enthusiasm, which has often led to an overestimation of the possibilities of its field of usefulness; an employment of the instrument or technique involved, by those not versed in the ground work, and incompetent to master the technique, as well as to correctly interpret the findings; old and tried methods are temporarily side-tracked, neglected, or forgotten; but, with the passing of time, the limitations, as well as the usefulness of each new discovery, are demonstrated, and the sum total is progress. One must not lose sight of the great field of usefulness of the cystoscope, making possible the visual inspection of the bladder and the ureteral orifices, the separation of the urine from each kidney, a study of the separate kidney function, intra-vesical and intra-ureteral manipulations, and the added knowledge to be gained by urography; yet there has been a tendency for urography to dim the light shed by the cystoscopic examination, whereas it should be the climax of an investigation of the urinary tract. Now we have, apparently, a method of outlining the urinary tract, which is free from instrumentation, seems to cause very 1 Read as part of a symposium on Intravenous Urography before the American Urological Association, New York City, June 12, 1930.
275 THE JOURNAL OF UROLOGY, VOL. XXY, NO.
3
276
H. G. BUGBEE AND A. J, MURPHY
slight constitutional reaction, and no local irritation. What will be the natural reaction? The drug will be widely advertised and there"will be a rush to employ it by the profession at largeespecially those with free access to an x-ray apparatus'. ManY, general practitioners, who have looked upon cystoscopy as a procedure to be avoided if possible, will give the intravenous
Fm. 1.
SHADOWS OF POSSIBLE URINARY CALCULI
injection, and the roentgenologist will do the rest; many lesions will be overlooked, and others incorrectly diagnosed. Urologists will easily fall into the habit of making a diagnosis by means of intravenous urography, unless we continue to keep the old and tried methods ever present in mind. These points have been forced upon me, even with my limited experience with uroselectan. An excellent internist sent a patient to me with the instruction that he wished a diagnosis in a case that
UROSELECTAN IN UROLOGICAL DIAGNOSIS
277
had shown definite attacks of apparent biliary colic and right renal colic. A plain x-ray film (fig. 1) showed a shadow high up on the right side, between the eleventh and twelfth ribs, and a second at the level of the fourth lumbar vertebra. He did not wish to have the patient subjected to a cystoscopic examination, but wished him to have an x-ray after an injection of uroselectan.
FIG.
2.
BOTH SHADOWS APPARENTLY INCLUDED IN OUTLINE OF URINARY TRACT FOLLOWING ADMINISTRATION OF UROSELECTAN
This was done. The film shows a dilatation of the upper calyx of each kidney, and the shadow overlying the upper calyx of the right kidney. The lower shadow is apparently in line with the course of the ureter (fig. 2). The urine contained both bile and calcium oxalate crystals. I could not make a diagnosis in this case, without a cystoscopic examination-giving me an analysis of the separate urines and the functional tests-a pyelogram
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3.
PYELOURETEROGRAM-WHICH
INCLUDES
FJG.
4.
STEREOSCOPIC
FILM, WHICH EXCLUDES
SHADOW OF RENAL CALCULUS AND APPAR-
'IHE LOWER SHADOW AS A POSSIBLE
ENTLY EXCLUDES URETERAL CALCULUS
URETERAL CALCULUS
Figures 3 and 4 demonstrate distinct advantage of :pyelogram and stereoscopic films over Uroselectan as a means of diagnosis in this case.
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MuLTIPLE SHADows IN BoTH KIDNEY REGIONS IN CASE OF INFANT
FIG. 6.
SHADOWS DEMONSTRATED AS CAST BY
RENAL CALCULI AFTER UROSELECTAN INJECTION
t--:)
--1
co
280
H. G. BUGBEE AND A. J. MURPHY
(fig. 3), and possibly stereoscopic films (fig. 4). This procedure has subsequently been carried out, and both renal and biliary lesions found to exist. A second case of a child of six years, showing pyuria, was given an injection of uroselectan. The resulting films (figs. 5 and 6) revealed a calculus in the right kidney and many calculi in a
FIG.
7.
DEMONSTRATION OF FUNCTIONLESS KIDNEY AFTER NEPHROTOMY WITH
NORMAL FUNCTION IN OPPOSITE KIDNEY• (UROSELECTAN I N J ECTION )
dilated left kidney pelvis. One could not outline an operative procedure without knowing the exact condition of each kidney. In the first case, a complete cystoscopic investigation was necessary, and with the data so obtained, uroselectan would not have been necessary. In the sec.and case of the child, the use of uroselectan does not give all the data necessary. On the other h and, uroselectan films supply information of
UROSELECTAN IN UROLOGICAL DIAGNOSIS
281
great value in many cases; it may be the only specific information obtainable, or a corroboration of facts previously obtained. To briefly cite 16 of the cases in our series of 26, in addition to the above 2 cases mentioned: first, I would state that the method has been employed only in cases in which it was thought that information of real value could be obtained, or where additional
Fm.
8.
UROSELECTAN INJECTION DEMONSTRATING FUNCTIONLESS KIDNEY WITH
NORMAL
FUNCTION
IN
OPPOSITE
KIDNEY.
URETERAL
CATHETERIZATION
IMPOSSIBLE
data, besides that obtained through cystoscopic methods, was to be desired. Case 3. Large left pyonephrosis. No urine obtained from left kidney. Right kidney, good function, urine negative. Uroselectan injection shows no injection of the left kidney. Right pyelo-ureterogram normal. Patient too sick for nephrectomy. Nephrotomy,
282
H. G. BUGBEE AND A. J. MURPHY
one quart of thick foul pus evacuated. Second injection of uroselectan, one month later, shows improved function of right kidney and functionless left kidney (fig. 7). Case 4. Branching calculus filling pelvis of left kidney. Equal kidney function, no infection. Uroselectan injection shows no distortion of either pelvis. Patient still under observation. Case 5. Woman, aged thirty-eight. , Radium treatment for carcinoma of the cervix in 1928-intestinal obstruction, necessitating operation six months later-followed by ureterovaginal fistula. Cystoscopic investigation showed a healthy left kidney, while a catheter on the right side came out through the fistulous opening into the vagina. Uroselectan films show a normal left pyelo-ureterogram, while there is no elimination from the right kidney (fig. 8). The right kidney was removed, showing marked pyonephrosis. Case 6. Male, thirty-two years of age, large irregular mass in right kidney region. Pyelogram shows horse-shoe kidney. No left ureteral orifice found. Uroselectan films show no left kidney shadow. Case 7. Male, aged fifty-six, cystoscopy showed a healthy right kidney with no flow from the left kidney, on several attempts. Uroselectan films show a normal pyelo-ureterogram on the right side, with no elimination on the left. Left kidney removed and found entirely destroyed; secondary to a calculus wedged into the ureter at its junction with the kidney pelvis. Case 8. Male, aged thirty-two cystoscopic examination followed by uremia in 1928, necessitating hospital treatment for six weeks. Since then, several attacks of renal colic. Further cystoscopic investigation not attempted. Uroselectan films show calculi in both kidneys and in the lower right ureter. Kidney function does not warrant operation at this time. Case 9. Male aged sixty, right epididymitis, large congested prostate, advanced periurethritis. Cystoscopic examination inadvisable.
UlWSELECTAN IN UROLOGICAL DIAGNOSIS
283
Uroselectan films show large mass of prostatic calculi, with bladder and upper urinary tract negative. Case 10. Girl, aged four, developed frequency, dysuria and malaise following measles. Cystoscopic examination impossible owing to large vesical calculus. Films show large vesical calculus, also a large calculus in right ureter, with dilatation of upper ureter and kidney pelvis. Both calculi removed separately, owing to poor kidney function. Removal of ureteral calculus simplified by dilatation of ureter, which was demonstrated by uroselectan films. An incision was made at the brim of the pelvis, the calculus grasped with forceps and withdrawn. Case 11. Male, aged thirty-six symptoms of colic in both lumbar regions. Plain x-ray shows multiple shadows on both sides, which, with Uroselectan films, are proved to be cast by calcareous nodes. Case 12. A girl, aged six, had pyuria for three years. Plain x-rays negative. Uroselectan films show a sharp angulation of the ureter on each side, at the ureteropelvic junction (fig. 9). The kink on the right side is more pronounced, and elimination, as shown by subsequent films, is delayed. Case 13. Female, aged sixty-six, diagnosis elsewhere of bilateral ureteral stricture. Uroselectan films show no dilatation of kidney pelves or ureters, and rapid elimination from each. Case 14. Male aged forty-seven, cystoscopic examination, even under parasacral anesthesia, was unsatisfactory, owing to a contracted bladder and great tenesmus. Uroselectan films show a functionless right kidney. Case 15. Female, aged forty-one, right ureter cannot be catheterized. Films show the right kidney destroyed by large masses of calculi (fig. 10). Case 16. Stricture of left ureter following operation for ectopic (fig. 11). Films show a normal right pyelo-ureterogram with no excretion from the left side (fig. 12). Left nephroureterectomy showed complete destruction of kidney with ureteral dilatation to point of constriction.
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CONGENITAL
OBSTRUCTIO:'<
AT
URE-
TERO-PELVIC JUNCTION (BILATERAL) IN CHILD OF
4 YEARS (UROSELECTAN INJECTION)
Fm.
10.
KIDNEY
DEMONSTRATION CONTAINING
OF
FUNCTIONLESS
MULTIPLE
CALCULI,
WITH NORMAL FUNCTION IN OPPOSITE KIDNEY (UROSELECTAN INJECTION)
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COMPLETE STRICTURE OF URETER
Fm. 12.
UROSELECTAN INJECTION DEMONSTRAT-
ING FUNCTIONLESS KIDNEY ON SIDE OF STRICTURE WITH SIDE
K ORMAL
KIDNEY
ON
OPPOSITE
G:)
00
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286
H. G. BUGBEE AND A. J. MURPHY
In a limited series of 26 cases, valuable data have been obtained through the use of uroselectan. The following might be mentioned as lesions demonstrated: the absence of a kidney; in 2 cases, the presence of a non-functionating kidney; in 4 instances, marked destruction of kidney tissue in pyonephrosis; nephrolithiasis without kidney destruction; extra-urinary shadows; and outline of the upper tract in cases in which a cystoscopic examination could not be made; the presence and absence of ureteral stricture; valuable data in children where cystoscopy might be avoided; guidance in outlining operative procedures; interesting facts regarding the dynamics of kidney and ureters. On the other hand, only in those cases in which a cystoscopic examination was mechanically impossible, and in one child in whom the symptoms do not warrant surgery at this time, has the information obtained by this method been sufficient without c-ystoscopic confirmation; so that I feel very strongly that, while a remarkable addition has been made to the field of urology through the painstaking work of the pioneers in this technique, yet it is primarily a method of corroboration, to be employed as a supplement to our present known methods of urological diagnosis - except in the-very limited number of cases in which cystoscopic manipulation is impossible. Here it gives much valuable data otherwise unavailable, but when such data are unsupported by cystoscopic information, the interpretations must be made with extreme care and conservatism. 40 East 41 st Street, New York , N. Y .
AND
ARTHUR J. MURPHY
New York, N. Y.
From time to time, a new instrument or agent is added to our armamentarium, opening up new vistas and elucidating old problems. Thus we look back upon the advent of the roentgen ray, the cystoscope, x-ray ureteral catheters, high frequency and radium therapy, urography, and functional kidney tests-to mention a few outstanding points in urological progress. As each new discovery has been brought forward, there has been an outburst of enthusiasm, which has often led to an overestimation of the possibilities of its field of usefulness; an employment of the instrument or technique involved, by those not versed in the ground work, and incompetent to master the technique, as well as to correctly interpret the findings; old and tried methods are temporarily side-tracked, neglected, or forgotten; but, with the passing of time, the limitations, as well as the usefulness of each new discovery, are demonstrated, and the sum total is progress. One must not lose sight of the great field of usefulness of the cystoscope, making possible the visual inspection of the bladder and the ureteral orifices, the separation of the urine from each kidney, a study of the separate kidney function, intra-vesical and intra-ureteral manipulations, and the added knowledge to be gained by urography; yet there has been a tendency for urography to dim the light shed by the cystoscopic examination, whereas it should be the climax of an investigation of the urinary tract. Now we have, apparently, a method of outlining the urinary tract, which is free from instrumentation, seems to cause very 1 Read as part of a symposium on Intravenous Urography before the American Urological Association, New York City, June 12, 1930.
275 THE JOURNAL OF UROLOGY, VOL. XXY, NO.
3
276
H. G. BUGBEE AND A. J, MURPHY
slight constitutional reaction, and no local irritation. What will be the natural reaction? The drug will be widely advertised and there"will be a rush to employ it by the profession at largeespecially those with free access to an x-ray apparatus'. ManY, general practitioners, who have looked upon cystoscopy as a procedure to be avoided if possible, will give the intravenous
Fm. 1.
SHADOWS OF POSSIBLE URINARY CALCULI
injection, and the roentgenologist will do the rest; many lesions will be overlooked, and others incorrectly diagnosed. Urologists will easily fall into the habit of making a diagnosis by means of intravenous urography, unless we continue to keep the old and tried methods ever present in mind. These points have been forced upon me, even with my limited experience with uroselectan. An excellent internist sent a patient to me with the instruction that he wished a diagnosis in a case that
UROSELECTAN IN UROLOGICAL DIAGNOSIS
277
had shown definite attacks of apparent biliary colic and right renal colic. A plain x-ray film (fig. 1) showed a shadow high up on the right side, between the eleventh and twelfth ribs, and a second at the level of the fourth lumbar vertebra. He did not wish to have the patient subjected to a cystoscopic examination, but wished him to have an x-ray after an injection of uroselectan.
FIG.
2.
BOTH SHADOWS APPARENTLY INCLUDED IN OUTLINE OF URINARY TRACT FOLLOWING ADMINISTRATION OF UROSELECTAN
This was done. The film shows a dilatation of the upper calyx of each kidney, and the shadow overlying the upper calyx of the right kidney. The lower shadow is apparently in line with the course of the ureter (fig. 2). The urine contained both bile and calcium oxalate crystals. I could not make a diagnosis in this case, without a cystoscopic examination-giving me an analysis of the separate urines and the functional tests-a pyelogram
tv
---:i 00
~
a td
q a
td
t,,J t,,J
;,,
z
l;;I
;,, '-'
~
q
::d '"d ~
>-<\
FJG.
3.
PYELOURETEROGRAM-WHICH
INCLUDES
FJG.
4.
STEREOSCOPIC
FILM, WHICH EXCLUDES
SHADOW OF RENAL CALCULUS AND APPAR-
'IHE LOWER SHADOW AS A POSSIBLE
ENTLY EXCLUDES URETERAL CALCULUS
URETERAL CALCULUS
Figures 3 and 4 demonstrate distinct advantage of :pyelogram and stereoscopic films over Uroselectan as a means of diagnosis in this case.
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z~
z ~
0
t<
0 Q
>-<
[; t<
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00 00
Fm. 5.
MuLTIPLE SHADows IN BoTH KIDNEY REGIONS IN CASE OF INFANT
FIG. 6.
SHADOWS DEMONSTRATED AS CAST BY
RENAL CALCULI AFTER UROSELECTAN INJECTION
t--:)
--1
co
280
H. G. BUGBEE AND A. J. MURPHY
(fig. 3), and possibly stereoscopic films (fig. 4). This procedure has subsequently been carried out, and both renal and biliary lesions found to exist. A second case of a child of six years, showing pyuria, was given an injection of uroselectan. The resulting films (figs. 5 and 6) revealed a calculus in the right kidney and many calculi in a
FIG.
7.
DEMONSTRATION OF FUNCTIONLESS KIDNEY AFTER NEPHROTOMY WITH
NORMAL FUNCTION IN OPPOSITE KIDNEY• (UROSELECTAN I N J ECTION )
dilated left kidney pelvis. One could not outline an operative procedure without knowing the exact condition of each kidney. In the first case, a complete cystoscopic investigation was necessary, and with the data so obtained, uroselectan would not have been necessary. In the sec.and case of the child, the use of uroselectan does not give all the data necessary. On the other h and, uroselectan films supply information of
UROSELECTAN IN UROLOGICAL DIAGNOSIS
281
great value in many cases; it may be the only specific information obtainable, or a corroboration of facts previously obtained. To briefly cite 16 of the cases in our series of 26, in addition to the above 2 cases mentioned: first, I would state that the method has been employed only in cases in which it was thought that information of real value could be obtained, or where additional
Fm.
8.
UROSELECTAN INJECTION DEMONSTRATING FUNCTIONLESS KIDNEY WITH
NORMAL
FUNCTION
IN
OPPOSITE
KIDNEY.
URETERAL
CATHETERIZATION
IMPOSSIBLE
data, besides that obtained through cystoscopic methods, was to be desired. Case 3. Large left pyonephrosis. No urine obtained from left kidney. Right kidney, good function, urine negative. Uroselectan injection shows no injection of the left kidney. Right pyelo-ureterogram normal. Patient too sick for nephrectomy. Nephrotomy,
282
H. G. BUGBEE AND A. J. MURPHY
one quart of thick foul pus evacuated. Second injection of uroselectan, one month later, shows improved function of right kidney and functionless left kidney (fig. 7). Case 4. Branching calculus filling pelvis of left kidney. Equal kidney function, no infection. Uroselectan injection shows no distortion of either pelvis. Patient still under observation. Case 5. Woman, aged thirty-eight. , Radium treatment for carcinoma of the cervix in 1928-intestinal obstruction, necessitating operation six months later-followed by ureterovaginal fistula. Cystoscopic investigation showed a healthy left kidney, while a catheter on the right side came out through the fistulous opening into the vagina. Uroselectan films show a normal left pyelo-ureterogram, while there is no elimination from the right kidney (fig. 8). The right kidney was removed, showing marked pyonephrosis. Case 6. Male, thirty-two years of age, large irregular mass in right kidney region. Pyelogram shows horse-shoe kidney. No left ureteral orifice found. Uroselectan films show no left kidney shadow. Case 7. Male, aged fifty-six, cystoscopy showed a healthy right kidney with no flow from the left kidney, on several attempts. Uroselectan films show a normal pyelo-ureterogram on the right side, with no elimination on the left. Left kidney removed and found entirely destroyed; secondary to a calculus wedged into the ureter at its junction with the kidney pelvis. Case 8. Male, aged thirty-two cystoscopic examination followed by uremia in 1928, necessitating hospital treatment for six weeks. Since then, several attacks of renal colic. Further cystoscopic investigation not attempted. Uroselectan films show calculi in both kidneys and in the lower right ureter. Kidney function does not warrant operation at this time. Case 9. Male aged sixty, right epididymitis, large congested prostate, advanced periurethritis. Cystoscopic examination inadvisable.
UlWSELECTAN IN UROLOGICAL DIAGNOSIS
283
Uroselectan films show large mass of prostatic calculi, with bladder and upper urinary tract negative. Case 10. Girl, aged four, developed frequency, dysuria and malaise following measles. Cystoscopic examination impossible owing to large vesical calculus. Films show large vesical calculus, also a large calculus in right ureter, with dilatation of upper ureter and kidney pelvis. Both calculi removed separately, owing to poor kidney function. Removal of ureteral calculus simplified by dilatation of ureter, which was demonstrated by uroselectan films. An incision was made at the brim of the pelvis, the calculus grasped with forceps and withdrawn. Case 11. Male, aged thirty-six symptoms of colic in both lumbar regions. Plain x-ray shows multiple shadows on both sides, which, with Uroselectan films, are proved to be cast by calcareous nodes. Case 12. A girl, aged six, had pyuria for three years. Plain x-rays negative. Uroselectan films show a sharp angulation of the ureter on each side, at the ureteropelvic junction (fig. 9). The kink on the right side is more pronounced, and elimination, as shown by subsequent films, is delayed. Case 13. Female, aged sixty-six, diagnosis elsewhere of bilateral ureteral stricture. Uroselectan films show no dilatation of kidney pelves or ureters, and rapid elimination from each. Case 14. Male aged forty-seven, cystoscopic examination, even under parasacral anesthesia, was unsatisfactory, owing to a contracted bladder and great tenesmus. Uroselectan films show a functionless right kidney. Case 15. Female, aged forty-one, right ureter cannot be catheterized. Films show the right kidney destroyed by large masses of calculi (fig. 10). Case 16. Stricture of left ureter following operation for ectopic (fig. 11). Films show a normal right pyelo-ureterogram with no excretion from the left side (fig. 12). Left nephroureterectomy showed complete destruction of kidney with ureteral dilatation to point of constriction.
tv
00 ,la..
~
p l:d
q
53t,:J t,:J
z>t;:j > :-"
S:: q ::d
'"O ~ >-<1
Fm.
9.
CONGENITAL
OBSTRUCTIO:'<
AT
URE-
TERO-PELVIC JUNCTION (BILATERAL) IN CHILD OF
4 YEARS (UROSELECTAN INJECTION)
Fm.
10.
KIDNEY
DEMONSTRATION CONTAINING
OF
FUNCTIONLESS
MULTIPLE
CALCULI,
WITH NORMAL FUNCTION IN OPPOSITE KIDNEY (UROSELECTAN INJECTION)
q :;d 0
1f).
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~ H
z q :;d
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;i..
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z0
1f).
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Fm. 11.
COMPLETE STRICTURE OF URETER
Fm. 12.
UROSELECTAN INJECTION DEMONSTRAT-
ING FUNCTIONLESS KIDNEY ON SIDE OF STRICTURE WITH SIDE
K ORMAL
KIDNEY
ON
OPPOSITE
G:)
00
c.n
286
H. G. BUGBEE AND A. J. MURPHY
In a limited series of 26 cases, valuable data have been obtained through the use of uroselectan. The following might be mentioned as lesions demonstrated: the absence of a kidney; in 2 cases, the presence of a non-functionating kidney; in 4 instances, marked destruction of kidney tissue in pyonephrosis; nephrolithiasis without kidney destruction; extra-urinary shadows; and outline of the upper tract in cases in which a cystoscopic examination could not be made; the presence and absence of ureteral stricture; valuable data in children where cystoscopy might be avoided; guidance in outlining operative procedures; interesting facts regarding the dynamics of kidney and ureters. On the other hand, only in those cases in which a cystoscopic examination was mechanically impossible, and in one child in whom the symptoms do not warrant surgery at this time, has the information obtained by this method been sufficient without c-ystoscopic confirmation; so that I feel very strongly that, while a remarkable addition has been made to the field of urology through the painstaking work of the pioneers in this technique, yet it is primarily a method of corroboration, to be employed as a supplement to our present known methods of urological diagnosis - except in the-very limited number of cases in which cystoscopic manipulation is impossible. Here it gives much valuable data otherwise unavailable, but when such data are unsupported by cystoscopic information, the interpretations must be made with extreme care and conservatism. 40 East 41 st Street, New York , N. Y .