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Ureteral Obstruction in Women
/)O~
TIlE A~lEH\('A.'\ JOUI(.'\AL 01" OB~TETHl(,i:; A.'\I) GYNECOLOGY
'Weichal'(lt: Deutsch, m ed, Wchnschr" 1003, No, 3:1, p , G2·.L r,::;t.holtell, R., ,,1111 Y"it, J'. : 7,(' ut.ratbl. f. UJllii,k., 1!)1.l~, x xvi, I (i!l. 171. cOpie, EugC'lle J,,: .JOU1'. M, ',L R esearch, May 2:'l, 100-+, pp. 1-!7-167, 7Von Kon~talltiJlu\'il.(', II, \\T.: B oHr. z. path. AnaL u. z. nllg. P a th., 1£106-7, xl, ,183G33. iiPottd amI ])" J'-"l'I'ily: I:l'ntrallJL f. Gyniik., HJOi, xxx i, 531-5,10. nFrank, R. '1'.: ZentralbL f. Gyniik., 1007, xxi, ,10-1·,106. JOChiric, J. L.: Bull. Soc. d 'obst. de Par., IDU7, pp. 93-10 3. 11Hollaud, Ean]ll'y: JonI'. Obst anu Gyncc. Brit. ]~mp . , 1110ll, xvi, 35:), :12;), 3.';,1. J2Welch, .f. K: New York L ying ·In Hospital Bul1., 1900, pp. 12, 131. 1 3 ~ewcll, 1<'. S.: Am. J01lJ'. Obs!.., 1!l12, lxvi, 27!l. aWilli:uns, ,f. W.: J o ur. Obst. and Gynel'. Brit. Emp .• 1912, xxii, 2,1;)-26.,. 15Young: Pro". Roy . Me u. Soc.. , IOU, vii , 307. Also J o u r. Obst. and Gynec.. Brit. Emp" xxvi, 1·2S. l GSmyl y, Sir. Ww . : L a ncet , 1910, i , 13313;) . 17Ke llogg, Foster S.: )\)1. JO II R. Om.;"!'. AXD G1 K ]'e., 1032, iii, 366. l sClei sz: AIIlI. tle gyIl(;,·. et .] 'obst. , IfllS-1!!, xiii , 65o . l OKilli:m, ,Tolin A., :w<1 BIi('l'will , Carll'.: AM .•TOl ' R. OIJST. ,\ N D GYN ~;e ., July, 1931, ii, 6. 2I1Calllw('1l, WlII. Eo, a1l(1 Lyl c, A. G.: AM. JUUR. OllS~'. AND O YN EO., 1031, ii, 17. 2lGrulIzit, O. }L: A ~f. JOl ' I1. OBSI'. AND GYNEO., 1£)33, V, ,100. ""Di"cklll:lllll alill l\l('Nali<-y: A~L .IOl 11'. OllST. AND GYl\EO.. 1f1:!iJ, v, 55. 1fEDlCAL A:--:[) TlE N 'l'.\L Bl 1)LDIl\,].
By GEOIWE 1\1.
f..JA W S,
M .D. , P lIILAOE LPllIA, P A.
Mong
than :W per crllt of pat.ients who cOlli e to a gynecologi e service ('omplain o[ llrinary symptollls and. it is evident that. problellls ('ollllPeted with the prlYie ureter ml1st b e dealt with by the pell-ic i'iUrgeOll. To be 1l('v1ll'atp ill diagnoi'iii'i he must recogllize the pathologic COl](litiollS that arc ilsso('iated with lesi011s sueh as 111'et01'itil', strietlll'e, tuber<:nlosis, l,inks allil distortiolls by the pregnant lltel'llS, tlllllors and adhesiolls. 'rhii'i report is based ehiefly upon a st.udy of t lie last fi ft y pati ents pel'i'iOlHllly examined by Ilretera 1 eatheterizatioll ill th e gYllecologie service of the Presbyterian lIoi'ipital , in ,,'holll more 01' Jess lll'etel'al obstructiOJl was fOllnd . 'l'1i<' lll'illl'ipal elillieal ding'llosl'S way be plated ill tJll~ follo\\'illg' g'l'Ollps. N('plll'opt0 8i s allll hydl'ollPplil'usis ( noninfe ctC' d ) __ ____ _ 5 l'yditi~, tlll'Ollie Ill' n'I'UtTl'I1L ___ ~ __ _______ _____ __ ____ ,1
___ _______ ___________ ______ ___ ___ ____ 4
1) yOJl('l'lll'(l s i~ Pyollcplno si s fi nd 1'f.' llnl calculi _____ _ ___ _ ________ __ __ _ :J Pyelitis of pl'cglHw c.y and pucrl'crium ___ __ _____ ______ 5
l Tl'ptcrul rr ctcml Ureteral Ul'ctcml
anonlaly _____ ___________ ___ ______ _______ _ 2 stricture, trauma tic _______ ___ ___ ____ __ ___ ___ 1 st enos is __________________ ______ ___ ________ 8 e-alculus __ _______________ ____ _ ___ _________ 18
Total
________ __ ____________________________ 50
The ohstructi ve lesion was actually a stricturc in six eases, 011C tllliel'cnlolli'i, 1.11'0 trn11lltatic, following ureteral injury during complete *l{c::Lll :It
.'1
1l1cC'tin,~'
(I f th e ObSitctl'ica1 .socipty of l)hil ,ul e lphiD. Ft.-'hruuI'Y 4, 1 fI:!G.
LA WS:
URETERAL OBS'fRUC1'ION I N WO::VJEN
803
hysterectomy and three inflammatory, verified by operation. It is believed that some of th e cases in which the term stenosis is used were also strictures but they were not absolutely proved. About two years ago the location of the point of obstruction in approximately half of the cases was charted. l<'i g. 1 shows the cases of impacted ureteral calculus and "B'ig. 2 the clinical diagnosis and th e obstructive site in the lloncaleulus cases. A review of this material sllOwed that calculi Illay he arrest.ed at various points not cOITesponelillg accnrately to the so-called norm al points of anatomic n arrowing. It is ,yell lmown that 1hc size of 11 calculus bears but little r ela tion to its symptoms anel that fairly large
Location of Calculi arre~ted in urrrer: con firmed b!J Xray and b~ Catheter in each case.
o II 13-
" ..
F ig . 1.-./\.. series of in1pacteLl ure t e ral caleuli showing th e (listance a buve the un::- t l:l'a l orific e a t ""hich each "\V,lS arl'est.cd.
ea lculi may be passed by some patients and slllall ones may heeolll c impacted in others. The caliher of the uret er is variable in different individuals and one can hardly define the normal caliber at different levels. 'l'he narrowest points seem to be at the broad ligament, about 3.5 cm. aboye the ureteral orifice, and at the u reteroyesical junct ion. The symptoms of ureteral obstruction of yarions types are practically the same as those of an impact.eel ureteral calculus and vary with the location and degree of obstruction 3nd with the presence or absence of infection anel with its seyerity. The chart of nonc alculus obstructions represents patients that were examined by ordinary N o.5 or NO.6 catheters ns a rule, since larger
804
TIlE A\IEI~W ,\N ,JOUnNAL OF OB~TETIW'S AXD GYXECOLOOY
SIZCS werc rarcl,v cmployed clllrillg the period ill whi('h they ,,'ere cxallli11ed, [t ocel1sionally }liIppens that. diffie11lt)' arises in passing' 11 eatheiel' ])('),0]](1 a eeriilill ]loint, bllt this ('1111 li1l11wd in"ariabl," ]n' OYl'n'·Olll(' h~' the use of ;Illothe]' l'llthetcl' or hy an attl'lllpt at allol itP]' sittillg 1111I('ss SOIllC patllOlog'ie process exists, Thc x-ray was lIsl'(l routinp},,' all(1 p,"l'log'l'a1ns anll 1lI'eteJ'op:l'aIliS '\'l'I'C lIlade ol'l'w;iol1;i1ly, l"unetiollal t('sts. wnwll," "'itll illclig'O-l'
~ire
.c,f'tJOnephrosls: . prOSIS
I(~
0 ...
25
I
nancy: :su~p"nd"cl I\idn"y
en inrl'C:red Kidney
Puerperal.~wol
""R~onephrosls, . __
20
tuberculous K
Q'
Hdemaruna in preq"
Larye prosed Kidney
PaSeuere pyelirisOY-
2.0
. 15
H'Jdro ureter inCh pregnanc.y
Pregnane'] Gr, Rl'currenr pljl!litis
10
operations WCl'e performed by YiIl'lOnS mellll)(']'s of the hospital staff
Ob"trnd.ioll ill lhe Ill'etel' e
pathologic
changes
in
the
kiun(~y
p:.u'ench:nn::t.
of
SOlll('
of
the
patients
l'1,ft'lT('Ll to in the cha,rt are 8110\vn in Figs. 3-~L The descriptions "vert:~ \vritten by Dr. John Einlan, Pathologi::;;t at tht~ Presbyterian HospitnI. "Tho studied thCl11 illllstr:-lti()n~"
LAW:-;:
805
Pig. 3.-1\TlIyablv kitlne~:. Dir)p~:,-~ sectinn :;::p{'ul'C'll at op('rn.tion for Dietl's CrISIS. DilRtation of tubllh's (Iue to back pn::'S~UI'(' ·whkh t.listt.'ntls then1. Cells in good condition but somc\\That flattened out. Space of Bo,vn1an enlarged an(1 glOIlWl'uli show degenerative changes.
Fig. 4.-Biopsy spction secl11'l',l at exploratory operation for hel110l'l'ha.ge in pregnancy frolll a pn:vionsly 8ltspehllc(1 left lllovubic ki<1npy. Changes due to back pressure'. Cells show deg'enel'utiye changes. Space of Bo·wll1an increa.sed ·with atrophy
of tufts.
SOG
THE AMEIW'AN JOL'IC\Af, Ole OllS'fETIUCS AND GYNECOLOGY
Fig. G.-Xf'j)hrcctoH1Y for suppul'nti\'c pyelunephritis and inlpassablc ureteral stl'ictun.'. SOD1C chl'onic interstitial change \vith overgrowth of connectivE' tifiSUC. Pressure ~trophy of tuft~ of glomeruli.
Pig G.-N(·vhr(-:'ctomy for acute suppurative pyonephrosis and tuberculoUA killney. Markc(l interstitial changes, Some hyalinized glomeruli; pressure effects on cells of glomeruli. Collection of round-celled infiltrations,
therlllore it showed that the obstructions that had been recognized wm'e associated with advanced pathologic' conditions. 'fhis led to the belief that earlier stages and lesser degrees of obstruction should be
LAWS:
URETERAL OBSTRUCTION IN WOMEN
F ig . 7.- Nephrect o n w f or "nJcul ou s p y onephrosis. Diffuse· infiltra ti on s with rounel c.ells a,nll polys. Rt'fcc ts o f back Pl' E.'~~l1 l'(~ as 8('i.~n in g l om(,l'uli.
807
s m a ll
Fig . S.-Nephrect omy for acute pyonephrosis a nd old nephroptos i s. Ureteral kink C h ro n ic interstitia l n ephritis. D is t e nd ed capsules of Bowman fr om back press ure. Atrophy of tufts.
diagnosed. To this end bulb ca theters wer e employ ed, with the t eaching~ of IlUlmer as a background, for inyesti gation of what may b e call ed strictures of large caliber and oth er form of uret eral stenosis
of Jesset' degree, Ureteral stridure eall IVII'(lly be lIlelltiolled without raising mallY poiuts that hilye been the snbjeet of eOllt]'oYen;y hetw('ell Hllllller alld his sehoo1, Oil OlW side, anel ce!'taill elllinent ul'ologists on the otller. 'rhese sllhj(,(,ts are of lhe greatest acadelllic illterest amI 110 (lonht we shall en'utllally leaI'll th(' t1'1I1h. In tllP Jll('antillle one may 11'," to forlll an illdependellt opillion IJ
Fi,u:. ~1.--Nl'phl'('etulllY for calculf1u8 v:n)nerdll'nsis of long st:ln(ling' following Vypli-
tis of vregnnncy. on glollleruli.
SOlne interstitbl chang('s but
v('r~r
distinct back
pl'(!~surc
effects
n'a(lil~' passed all(1 withdrawn \vithont the" hang'," exeept in olle illstanec when it could be seen to clrag upon the bladder wall. These patients had had either repeated attaeks of pyelitis or :.;e\'('r(' paill referred to the ki(llley regioJl. 'rhey were regarded as negative.
In one patiellt who hall chronic p:' elitis with fl'ec[nent renal eolic aud dilatation of \,hose ureter ,vas shm\1l hy x-ray (Fig. 10) the ~(). 10 bulb was reaflil.,' passed aIHl 110 "hallg''' detect ell. l\Ial'ked illlprovement followed a sing'le dilalation to .\To. 11 and lavag'e with lIH'l'CllrOchrollle. ]<'urthcl' experieJlce is required to Lletermine wlwther oj' lint this represents a "stl'ietul'e" of a ealilH'], larger than iI :\0, 10, aJld raises the qnestion wl!ptlH'J' olle shonlcl lIP
LA Wei :
UHETE1·: AL
013~'rInT(
"nON IN
WO~lE'"
SO!]
co/d ent to di smiss t h e patiellts as havin g' no stenos is, ",hen the No. 10 bulb is withdrawn without a " hang. " .Anothel· patif'llt had parOXYSlllS of p a in alollg' the eourse of the pelvic ureter of about. tell :\'{~at·s duration, dating' f rolll an attack of cy~l.itis. A distill ct "lUlllg''' was felt, on witltllrawillg the No. 10 hulh, at a point ~ em . H1>O\'P the urcteral orifice and the bladclPl' wall was dragg:('(l UpOll aJl(1 (li:;t illd blpcding: illllll cl[ iatc'ly followed. Th e examinatioll r es ult ed ill l'l'lll'O(lut'i llg: Olle or lIl'l' typieal attacks.
Fig. lO.--Pydogra lll of pati e nt ,vith chronic p:o.:f!litis :lJ1(1 l'r'c lIl're nt renal colic f oll owi ng pyelitis of pregnan cy.
The (lUestion b efore us at this time is: do es tllis of it self Illean "stricture ," or does it mean" st.ricture " only j f pyelogram or ureterogram show dilatation 1 Certainl y one finds uret eral orifices too sm all to adm it e"PH a :-,r o. 10 bulb that hav e n o associated symptoms and are presumably con genitally smaller than the aYel'ag:e. 1 H
810
THE A:\lERIC\N JOFRNAL OF OBSTETIU('S A~D GYNEC'OLOGY
has showlI that olle ('an 11eal'l~' always pass a bulb 12 11Ull. ill (,lrclllllfCl'cIIl'c up to tll(' c'alcnlus \\·ithout too mnch foree. In fonr C1'S('S. ill which the entire clillieal stuely alld repcah'c1 exmllilIations \\'('re fairly eOllelllSiYe of ure1eral stridlll'(" the Xo. 8 hnlb eOrt'ohonltl'cl this opinion 1)y delllolistrating a "hmlg" at 11le p()int of p1lrtial ohstrl1dioll s('Yenil c'elltilll<'iers ahoye th(' blacld('r \\'all. Two operative ease;.; were fOllllll to han' clellse eieatl'ic'ial stridure:> that had ]1rrwed impassible even to ]\0. :j eatheten; as was a s1ridllre preyio1181,\' reported \\'lIil'll followt'cl ligation of tll(' 111'('tt'r.
Fig'.
ll.-S:'lille
p:lth'nt.
C:-ttl1t:,t01'
partly \vithllnnvn
dilatation of ureter.
an41
llrl'tcr
inj('("b'cl
tel
;:.;how
In another ease of stridUl'e following traumatie ureteral fistula amI treated by gradual dilatation the 1\0. 8 bulb revealed a "hang." Before the time of llsing the bulbs fo]' cliagnosis the No.9 Garceau dilating catheter was often notel1 as being gripped by the lower ureter at various levels Oll the eathe1e1' in such 11 11'11)" as to lw fairly conclusive of deeided stenosis. The treatment of uretenil stridure Olle would expeet to be analOgOllS to treatment of stricture of other mucous canals and if possible by the plan of gradual, gentle dilatatioll. Thi;.; has been effected ill a fe\\' eases gaining' O1]e or two millimetel'f; r'irelllllfel'pn('e 11t P!l<'li tJ'pat-
LAWc\:
LTIU}TBIUL OnC\'l'RUt'TION IN
WO~IE.'\
Sll
ment. The dilatation should be at intervals not more frequent than ten to twelve days. Under thi" plan the gain is held and, when carried to what is believed to be full "ize, the gain is held for at least a number of months. Experience has not been long enongh to determine ·whether or not it is permanent, but there has heen no tell(lency ,,110W11 to narrowing beyond the calilier of the last
In Olle case of neplm:ctomy and one ease of ureteral ealculus, strictures that had been impassable from below ,,"ere forcibly dilated by the operator from aboye. Both strictures pl·Olllptly reCU1"1"e(1.
Fig. l~.--lTl'("'teral f'trictun'
(If 3111all calibc!' ,,,ith without diln.tation of
1110(1f'l'atc
tlilatation of lUE'tcr but
V('lyi~.
One patient (i,'ig. ]~) re([uired twelve trl'atlllellts to carry the dilatation from Ko. G to :0:0. 14 and local pain was noi relieved nntil this point was reachrc1. '1'he ureterogram taken at the second exalllinat.ion shO\ys a JllO!leratl' dilatation of the ureter. After dilatation to ~o. ]2 failed to give relief the patient was examined by Dr. Hunner in consultation and the c1iaglioflis confirl1le
812
'rIlE A}U~RIC,\X .JOTTI{NAL UF OBi'TETHI('S AXil GYXECOLOC:Y CONCLUSIONS
], TlIt'l'e
]I]
,,'Olllell 1hat
2. They <1l'e foulld a:;;:;;oelatpd \\·ith dilatation of the ureter, hyt1rolIephrosis or (' haek pl'eSS11re" erreets 011 the rellal parelH.'hyma. ,Vhell thesl' sYlllPtom:;; exist am1 ealenlns is ]Jot delllollstrahle, examination is nsna11y ill(lieated to determine the no]'mal patpney of the llr('fc'l'. :l. 'l'heir s.nllptoms m'e ('ssentia11y silllilal' to those prod\lep(1 by stOll P. .,t.. Thp Imlbed (,
fi. Gentlp, gTac1nal c1ilata1 iOIl is the tn';itlllPllt of ehoie!' for 111'('t(,I'
]i\TnA!~TEHIKE
DE;\TlI OF TIlE
j\W\()IU[ALl'l'm~
By K h
l~T:\(),
01<' TJlB .l\I.D.,
FETU~
l~.i\mlrJICATJ
IWE Tn
e()l{D
~EW OltLEAN:-:, hI.
(Froln till' j)'lJartlilcilf of (lu8tdlics, Co//c,!le of 11/1 dici!l(', l'lI/alil Unil'lrsit!J of 1.0/1;8;(11117)
T
HE llIajOl'ity of the textbooks Oil obstdri('s "'II it'll 1 haye COJlsl1lteal'ticldal'l~' tltp ljlH'stiollS of llia~,!'llosis allli treatlilellt. Tllt' possiblp eallS('S oj' fdal (knt h llPi'Ol'P tIlt' onSt't of labor are not 1Il1'1ItiOlH'11 ill sOlile ,,'ol'k:; lind ill'(' g'i\'t'll Illil :-want ('llllsidt'l'
TIlE A~lEH\('A.'\ JOUI(.'\AL 01" OB~TETHl(,i:; A.'\I) GYNECOLOGY
'Weichal'(lt: Deutsch, m ed, Wchnschr" 1003, No, 3:1, p , G2·.L r,::;t.holtell, R., ,,1111 Y"it, J'. : 7,(' ut.ratbl. f. UJllii,k., 1!)1.l~, x xvi, I (i!l. 171. cOpie, EugC'lle J,,: .JOU1'. M, ',L R esearch, May 2:'l, 100-+, pp. 1-!7-167, 7Von Kon~talltiJlu\'il.(', II, \\T.: B oHr. z. path. AnaL u. z. nllg. P a th., 1£106-7, xl, ,183G33. iiPottd amI ])" J'-"l'I'ily: I:l'ntrallJL f. Gyniik., HJOi, xxx i, 531-5,10. nFrank, R. '1'.: ZentralbL f. Gyniik., 1007, xxi, ,10-1·,106. JOChiric, J. L.: Bull. Soc. d 'obst. de Par., IDU7, pp. 93-10 3. 11Hollaud, Ean]ll'y: JonI'. Obst anu Gyncc. Brit. ]~mp . , 1110ll, xvi, 35:), :12;), 3.';,1. J2Welch, .f. K: New York L ying ·In Hospital Bul1., 1900, pp. 12, 131. 1 3 ~ewcll, 1<'. S.: Am. J01lJ'. Obs!.., 1!l12, lxvi, 27!l. aWilli:uns, ,f. W.: J o ur. Obst. and Gynel'. Brit. Emp .• 1912, xxii, 2,1;)-26.,. 15Young: Pro". Roy . Me u. Soc.. , IOU, vii , 307. Also J o u r. Obst. and Gynec.. Brit. Emp" xxvi, 1·2S. l GSmyl y, Sir. Ww . : L a ncet , 1910, i , 13313;) . 17Ke llogg, Foster S.: )\)1. JO II R. Om.;"!'. AXD G1 K ]'e., 1032, iii, 366. l sClei sz: AIIlI. tle gyIl(;,·. et .] 'obst. , IfllS-1!!, xiii , 65o . l OKilli:m, ,Tolin A., :w<1 BIi('l'will , Carll'.: AM .•TOl ' R. OIJST. ,\ N D GYN ~;e ., July, 1931, ii, 6. 2I1Calllw('1l, WlII. Eo, a1l(1 Lyl c, A. G.: AM. JUUR. OllS~'. AND O YN EO., 1031, ii, 17. 2lGrulIzit, O. }L: A ~f. JOl ' I1. OBSI'. AND GYNEO., 1£)33, V, ,100. ""Di"cklll:lllll alill l\l('Nali<-y: A~L .IOl 11'. OllST. AND GYl\EO.. 1f1:!iJ, v, 55. 1fEDlCAL A:--:[) TlE N 'l'.\L Bl 1)LDIl\,].
By GEOIWE 1\1.
f..JA W S,
M .D. , P lIILAOE LPllIA, P A.
Mong
than :W per crllt of pat.ients who cOlli e to a gynecologi e service ('omplain o[ llrinary symptollls and. it is evident that. problellls ('ollllPeted with the prlYie ureter ml1st b e dealt with by the pell-ic i'iUrgeOll. To be 1l('v1ll'atp ill diagnoi'iii'i he must recogllize the pathologic COl](litiollS that arc ilsso('iated with lesi011s sueh as 111'et01'itil', strietlll'e, tuber<:nlosis, l,inks allil distortiolls by the pregnant lltel'llS, tlllllors and adhesiolls. 'rhii'i report is based ehiefly upon a st.udy of t lie last fi ft y pati ents pel'i'iOlHllly examined by Ilretera 1 eatheterizatioll ill th e gYllecologie service of the Presbyterian lIoi'ipital , in ,,'holll more 01' Jess lll'etel'al obstructiOJl was fOllnd . 'l'1i<' lll'illl'ipal elillieal ding'llosl'S way be plated ill tJll~ follo\\'illg' g'l'Ollps. N('plll'opt0 8i s allll hydl'ollPplil'usis ( noninfe ctC' d ) __ ____ _ 5 l'yditi~, tlll'Ollie Ill' n'I'UtTl'I1L ___ ~ __ _______ _____ __ ____ ,1
___ _______ ___________ ______ ___ ___ ____ 4
1) yOJl('l'lll'(l s i~ Pyollcplno si s fi nd 1'f.' llnl calculi _____ _ ___ _ ________ __ __ _ :J Pyelitis of pl'cglHw c.y and pucrl'crium ___ __ _____ ______ 5
l Tl'ptcrul rr ctcml Ureteral Ul'ctcml
anonlaly _____ ___________ ___ ______ _______ _ 2 stricture, trauma tic _______ ___ ___ ____ __ ___ ___ 1 st enos is __________________ ______ ___ ________ 8 e-alculus __ _______________ ____ _ ___ _________ 18
Total
________ __ ____________________________ 50
The ohstructi ve lesion was actually a stricturc in six eases, 011C tllliel'cnlolli'i, 1.11'0 trn11lltatic, following ureteral injury during complete *l{c::Lll :It
.'1
1l1cC'tin,~'
(I f th e ObSitctl'ica1 .socipty of l)hil ,ul e lphiD. Ft.-'hruuI'Y 4, 1 fI:!G.
LA WS:
URETERAL OBS'fRUC1'ION I N WO::VJEN
803
hysterectomy and three inflammatory, verified by operation. It is believed that some of th e cases in which the term stenosis is used were also strictures but they were not absolutely proved. About two years ago the location of the point of obstruction in approximately half of the cases was charted. l<'i g. 1 shows the cases of impacted ureteral calculus and "B'ig. 2 the clinical diagnosis and th e obstructive site in the lloncaleulus cases. A review of this material sllOwed that calculi Illay he arrest.ed at various points not cOITesponelillg accnrately to the so-called norm al points of anatomic n arrowing. It is ,yell lmown that 1hc size of 11 calculus bears but little r ela tion to its symptoms anel that fairly large
Location of Calculi arre~ted in urrrer: con firmed b!J Xray and b~ Catheter in each case.
o II 13-
" ..
F ig . 1.-./\.. series of in1pacteLl ure t e ral caleuli showing th e (listance a buve the un::- t l:l'a l orific e a t ""hich each "\V,lS arl'est.cd.
ea lculi may be passed by some patients and slllall ones may heeolll c impacted in others. The caliher of the uret er is variable in different individuals and one can hardly define the normal caliber at different levels. 'l'he narrowest points seem to be at the broad ligament, about 3.5 cm. aboye the ureteral orifice, and at the u reteroyesical junct ion. The symptoms of ureteral obstruction of yarions types are practically the same as those of an impact.eel ureteral calculus and vary with the location and degree of obstruction 3nd with the presence or absence of infection anel with its seyerity. The chart of nonc alculus obstructions represents patients that were examined by ordinary N o.5 or NO.6 catheters ns a rule, since larger
804
TIlE A\IEI~W ,\N ,JOUnNAL OF OB~TETIW'S AXD GYXECOLOOY
SIZCS werc rarcl,v cmployed clllrillg the period ill whi('h they ,,'ere cxallli11ed, [t ocel1sionally }liIppens that. diffie11lt)' arises in passing' 11 eatheiel' ])('),0]](1 a eeriilill ]loint, bllt this ('1111 li1l11wd in"ariabl," ]n' OYl'n'·Olll(' h~' the use of ;Illothe]' l'llthetcl' or hy an attl'lllpt at allol itP]' sittillg 1111I('ss SOIllC patllOlog'ie process exists, Thc x-ray was lIsl'(l routinp},,' all(1 p,"l'log'l'a1ns anll 1lI'eteJ'op:l'aIliS '\'l'I'C lIlade ol'l'w;iol1;i1ly, l"unetiollal t('sts. wnwll," "'itll illclig'O-l'
~ire
.c,f'tJOnephrosls: . prOSIS
I(~
0 ...
25
I
nancy: :su~p"nd"cl I\idn"y
en inrl'C:red Kidney
Puerperal.~wol
""R~onephrosls, . __
20
tuberculous K
Q'
Hdemaruna in preq"
Larye prosed Kidney
PaSeuere pyelirisOY-
2.0
. 15
H'Jdro ureter inCh pregnanc.y
Pregnane'] Gr, Rl'currenr pljl!litis
10
operations WCl'e performed by YiIl'lOnS mellll)(']'s of the hospital staff
Ob"trnd.ioll ill lhe Ill'etel' e
pathologic
changes
in
the
kiun(~y
p:.u'ench:nn::t.
of
SOlll('
of
the
patients
l'1,ft'lT('Ll to in the cha,rt are 8110\vn in Figs. 3-~L The descriptions "vert:~ \vritten by Dr. John Einlan, Pathologi::;;t at tht~ Presbyterian HospitnI. "Tho studied thCl11 illllstr:-lti()n~"
LAW:-;:
805
Pig. 3.-1\TlIyablv kitlne~:. Dir)p~:,-~ sectinn :;::p{'ul'C'll at op('rn.tion for Dietl's CrISIS. DilRtation of tubllh's (Iue to back pn::'S~UI'(' ·whkh t.listt.'ntls then1. Cells in good condition but somc\\That flattened out. Space of Bo,vn1an enlarged an(1 glOIlWl'uli show degenerative changes.
Fig. 4.-Biopsy spction secl11'l',l at exploratory operation for hel110l'l'ha.ge in pregnancy frolll a pn:vionsly 8ltspehllc(1 left lllovubic ki<1npy. Changes due to back pressure'. Cells show deg'enel'utiye changes. Space of Bo·wll1an increa.sed ·with atrophy
of tufts.
SOG
THE AMEIW'AN JOL'IC\Af, Ole OllS'fETIUCS AND GYNECOLOGY
Fig. G.-Xf'j)hrcctoH1Y for suppul'nti\'c pyelunephritis and inlpassablc ureteral stl'ictun.'. SOD1C chl'onic interstitial change \vith overgrowth of connectivE' tifiSUC. Pressure ~trophy of tuft~ of glomeruli.
Pig G.-N(·vhr(-:'ctomy for acute suppurative pyonephrosis and tuberculoUA killney. Markc(l interstitial changes, Some hyalinized glomeruli; pressure effects on cells of glomeruli. Collection of round-celled infiltrations,
therlllore it showed that the obstructions that had been recognized wm'e associated with advanced pathologic' conditions. 'fhis led to the belief that earlier stages and lesser degrees of obstruction should be
LAWS:
URETERAL OBSTRUCTION IN WOMEN
F ig . 7.- Nephrect o n w f or "nJcul ou s p y onephrosis. Diffuse· infiltra ti on s with rounel c.ells a,nll polys. Rt'fcc ts o f back Pl' E.'~~l1 l'(~ as 8('i.~n in g l om(,l'uli.
807
s m a ll
Fig . S.-Nephrect omy for acute pyonephrosis a nd old nephroptos i s. Ureteral kink C h ro n ic interstitia l n ephritis. D is t e nd ed capsules of Bowman fr om back press ure. Atrophy of tufts.
diagnosed. To this end bulb ca theters wer e employ ed, with the t eaching~ of IlUlmer as a background, for inyesti gation of what may b e call ed strictures of large caliber and oth er form of uret eral stenosis
of Jesset' degree, Ureteral stridure eall IVII'(lly be lIlelltiolled without raising mallY poiuts that hilye been the snbjeet of eOllt]'oYen;y hetw('ell Hllllller alld his sehoo1, Oil OlW side, anel ce!'taill elllinent ul'ologists on the otller. 'rhese sllhj(,(,ts are of lhe greatest acadelllic illterest amI 110 (lonht we shall en'utllally leaI'll th(' t1'1I1h. In tllP Jll('antillle one may 11'," to forlll an illdependellt opillion IJ
Fi,u:. ~1.--Nl'phl'('etulllY for calculf1u8 v:n)nerdll'nsis of long st:ln(ling' following Vypli-
tis of vregnnncy. on glollleruli.
SOlne interstitbl chang('s but
v('r~r
distinct back
pl'(!~surc
effects
n'a(lil~' passed all(1 withdrawn \vithont the" hang'," exeept in olle illstanec when it could be seen to clrag upon the bladder wall. These patients had had either repeated attaeks of pyelitis or :.;e\'('r(' paill referred to the ki(llley regioJl. 'rhey were regarded as negative.
In one patiellt who hall chronic p:' elitis with fl'ec[nent renal eolic aud dilatation of \,hose ureter ,vas shm\1l hy x-ray (Fig. 10) the ~(). 10 bulb was reaflil.,' passed aIHl 110 "hallg''' detect ell. l\Ial'ked illlprovement followed a sing'le dilalation to .\To. 11 and lavag'e with lIH'l'CllrOchrollle. ]<'urthcl' experieJlce is required to Lletermine wlwther oj' lint this represents a "stl'ietul'e" of a ealilH'], larger than iI :\0, 10, aJld raises the qnestion wl!ptlH'J' olle shonlcl lIP
LA Wei :
UHETE1·: AL
013~'rInT(
"nON IN
WO~lE'"
SO!]
co/d ent to di smiss t h e patiellts as havin g' no stenos is, ",hen the No. 10 bulb is withdrawn without a " hang. " .Anothel· patif'llt had parOXYSlllS of p a in alollg' the eourse of the pelvic ureter of about. tell :\'{~at·s duration, dating' f rolll an attack of cy~l.itis. A distill ct "lUlllg''' was felt, on witltllrawillg the No. 10 hulh, at a point ~ em . H1>O\'P the urcteral orifice and the bladclPl' wall was dragg:('(l UpOll aJl(1 (li:;t illd blpcding: illllll cl[ iatc'ly followed. Th e examinatioll r es ult ed ill l'l'lll'O(lut'i llg: Olle or lIl'l' typieal attacks.
Fig. lO.--Pydogra lll of pati e nt ,vith chronic p:o.:f!litis :lJ1(1 l'r'c lIl're nt renal colic f oll owi ng pyelitis of pregnan cy.
The (lUestion b efore us at this time is: do es tllis of it self Illean "stricture ," or does it mean" st.ricture " only j f pyelogram or ureterogram show dilatation 1 Certainl y one finds uret eral orifices too sm all to adm it e"PH a :-,r o. 10 bulb that hav e n o associated symptoms and are presumably con genitally smaller than the aYel'ag:e. 1 H
810
THE A:\lERIC\N JOFRNAL OF OBSTETIU('S A~D GYNEC'OLOGY
has showlI that olle ('an 11eal'l~' always pass a bulb 12 11Ull. ill (,lrclllllfCl'cIIl'c up to tll(' c'alcnlus \\·ithout too mnch foree. In fonr C1'S('S. ill which the entire clillieal stuely alld repcah'c1 exmllilIations \\'('re fairly eOllelllSiYe of ure1eral stridlll'(" the Xo. 8 hnlb eOrt'ohonltl'cl this opinion 1)y delllolistrating a "hmlg" at 11le p()int of p1lrtial ohstrl1dioll s('Yenil c'elltilll<'iers ahoye th(' blacld('r \\'all. Two operative ease;.; were fOllllll to han' clellse eieatl'ic'ial stridure:> that had ]1rrwed impassible even to ]\0. :j eatheten; as was a s1ridllre preyio1181,\' reported \\'lIil'll followt'cl ligation of tll(' 111'('tt'r.
Fig'.
ll.-S:'lille
p:lth'nt.
C:-ttl1t:,t01'
partly \vithllnnvn
dilatation of ureter.
an41
llrl'tcr
inj('("b'cl
tel
;:.;how
In another ease of stridUl'e following traumatie ureteral fistula amI treated by gradual dilatation the 1\0. 8 bulb revealed a "hang." Before the time of llsing the bulbs fo]' cliagnosis the No.9 Garceau dilating catheter was often notel1 as being gripped by the lower ureter at various levels Oll the eathe1e1' in such 11 11'11)" as to lw fairly conclusive of deeided stenosis. The treatment of uretenil stridure Olle would expeet to be analOgOllS to treatment of stricture of other mucous canals and if possible by the plan of gradual, gentle dilatatioll. Thi;.; has been effected ill a fe\\' eases gaining' O1]e or two millimetel'f; r'irelllllfel'pn('e 11t P!l<'li tJ'pat-
LAWc\:
LTIU}TBIUL OnC\'l'RUt'TION IN
WO~IE.'\
Sll
ment. The dilatation should be at intervals not more frequent than ten to twelve days. Under thi" plan the gain is held and, when carried to what is believed to be full "ize, the gain is held for at least a number of months. Experience has not been long enongh to determine ·whether or not it is permanent, but there has heen no tell(lency ,,110W11 to narrowing beyond the calilier of the last
In Olle case of neplm:ctomy and one ease of ureteral ealculus, strictures that had been impassable from below ,,"ere forcibly dilated by the operator from aboye. Both strictures pl·Olllptly reCU1"1"e(1.
Fig. l~.--lTl'("'teral f'trictun'
(If 3111all calibc!' ,,,ith without diln.tation of
1110(1f'l'atc
tlilatation of lUE'tcr but
V('lyi~.
One patient (i,'ig. ]~) re([uired twelve trl'atlllellts to carry the dilatation from Ko. G to :0:0. 14 and local pain was noi relieved nntil this point was reachrc1. '1'he ureterogram taken at the second exalllinat.ion shO\ys a JllO!leratl' dilatation of the ureter. After dilatation to ~o. ]2 failed to give relief the patient was examined by Dr. Hunner in consultation and the c1iaglioflis confirl1le
812
'rIlE A}U~RIC,\X .JOTTI{NAL UF OBi'TETHI('S AXil GYXECOLOC:Y CONCLUSIONS
], TlIt'l'e
]I]
,,'Olllell 1hat
2. They <1l'e foulld a:;;:;;oelatpd \\·ith dilatation of the ureter, hyt1rolIephrosis or (' haek pl'eSS11re" erreets 011 the rellal parelH.'hyma. ,Vhell thesl' sYlllPtom:;; exist am1 ealenlns is ]Jot delllollstrahle, examination is nsna11y ill(lieated to determine the no]'mal patpney of the llr('fc'l'. :l. 'l'heir s.nllptoms m'e ('ssentia11y silllilal' to those prod\lep(1 by stOll P. .,t.. Thp Imlbed (,
fi. Gentlp, gTac1nal c1ilata1 iOIl is the tn';itlllPllt of ehoie!' for 111'('t(,I'
]i\TnA!~TEHIKE
DE;\TlI OF TIlE
j\W\()IU[ALl'l'm~
By K h
l~T:\(),
01<' TJlB .l\I.D.,
FETU~
l~.i\mlrJICATJ
IWE Tn
e()l{D
~EW OltLEAN:-:, hI.
(Froln till' j)'lJartlilcilf of (lu8tdlics, Co//c,!le of 11/1 dici!l(', l'lI/alil Unil'lrsit!J of 1.0/1;8;(11117)
T
HE llIajOl'ity of the textbooks Oil obstdri('s "'II it'll 1 haye COJlsl1lte