Ureteral Physiology and Exstrophy of the Bladder

Vol. 93, May Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright © 1965 by The Williams & Wilkins Co.

URETERAL PHYSIOLOGY AND EXSTROPHY OF THE BLADDER PAULK. MALONEY, JR., DONALD M. GLEASON

AND

JOHN K. LATTIMER

From the Squier Urological Clinic, Columbia-Presbyterian Medical Center, New York, New York

A significant number of patients with exstrophy of the bladder when first seen at the Squier Urological Clinic were found to have unilateral or bilateral hydroureteronephrosis.1 Seventeen of 50 patients already had dilatation of their upper tracts (table 1), even though half of the patients were less than 1 year old (table 2). Several patients showed progressive deterioration of their upper tracts even while awaiting surgery (figs. 1 and 2). Therefore, it was thought worthwhile to investigate whether there existed an intrinsic defect in the ureters of exstrophic patients which was responsible for these early changes. Our study was further prompted by the high incidence of reflux found to occur in patients after the open bladder had been closed surgically. MATERIALS AND METHODS

ureter in the same patient and the rate in the same ureter occasionally changed during the time observed. Resting and contraction pressures often differed between the 2 ureters in the same patient (fig. 3). With one exception, resting pressures varied from O to 10 nnn. per Hg., the higher pressures being recorded in the lower segment. The contraction pressures ranged from 8 to 25 mm per Hg., but with the higher pressures recorded in the upper third segment (fig. 4). The pressures recorded within the distal centimeter (4 cases) were uniformly lower than pressures in the more proximal portion of the ureter, averaging 1 to 2 mm. per Hg. resting pressure and 3 to 5 mm. per Hg. contraction pressure. No major differences could be noted between 1. Severity of upper urinary tract dilatation in 17 patients with exstrophy of the bladder

TABLE

Eight consecutive patients with exstrophy of the bladder were examined on their first admission to the urological service of Babies Hospital or Presbyterian Hospital. Four patients were 3 months old; the others were 16 months, 36 months, 4 years, and 17 years. The status of the upper tracts was first determined by excretory urography. Ureteral tone and contractility were studied by strain gauge measurements of ureteral pressures, and excretory and retrograde cinefluoroscopy. Ureteral pressures were taken through a 4F ureteral catheter or a 5F polyvinyl catheter.

Pathology

Slight

Moderate

Severe

Hydronephrosis Hydroureter Ureteral tortuosity

8 9 3

5 5

1 1 1

TABLE

1

2. Age at which abnormal urogram was

detected 0 to 6 mos. 6 to 12 mos.

9

1 to 5 yrs. 5 yrs. and above

5 2

1

RESULTS

All 8 patients had normal upper tracts on excretory urography. Cinefluorography was performed on 4 patients and all showed normal active peristalsis. All ureters showed clearly marked peaks of contraction pressures. The frequency of contraction differed between the right and left Accepted for publication September 23, 1964. Read at annual meeting of New York Section, American Urological Association, Inc., New York, New York, April 17, 1963. This work was supported in part by the generosity of Governor and Mrs. Charles Edison. 1 Landau, S. J. and Lattimer, J. K.: Functional closure of bladder exstrophy. Pediat., 31: 433, 1963.

the tracings of the 3-month-old patients and that of the 17-year-old patient (fig. 3). The values obtained in one 3-month-old infant were unusual. Resting pressure varied from 10 to 20 mm. per Hg. and contraction pressures were found to measure 80 mm. per Hg. in the upper third and gradually tapered to 15 mm. per Hg. in the distal third (fig. 5). DISCUSSION

The introduction of direct ureteral pressure measurements by Kiil2 has provided a new mode 2 Kiil, F.: The Function of the Ureter and Renal Pelvis. Philadelphia: W. B. Saunders, Co., 1957. 588

.Fm. 1. Progressive cleteriorntion of upper urinary trnc\,s while r,waiting surg;ery. J, at ag;e :i_i1 mos B, at age G mos.

FrG. 2. Preoperative urogrnrn. A, at age G yrs. !J, 8 mos. later. 580

590

MALONEY, GLEASON AND LATTIMER

A URETERAL PRESSURE TRACING transducer technique pt. RIGHT

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0

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MIDDLE

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Fw. 3. A, ureteral pressure tracing of lG-month-old patient demonstrates good contractile ability throughout each ureter. Pressures recorded are in same range as those of adult patients. B, ureteral pressure tracing of 17-year-old patient with exstrophy of bladder and normal upper tracts on excretory urography.

of study of ureteral physiology and normal values are still in the process of being established. Pressures in the ureters of patients with exstrophy of the bladder have not been reported as far as we are aware nor have they been reported in infants. For the adult patient, our studies and those reported in the literature would Reem to indicate that nonnal ureteral resting pressure varies from

0 to 10 mm.. per Hg. 2 - 5 Contraction pressures range from 10 to 30 mm. per Hg. but have often 3 Davis, D. M. and Zimskind, P. D.: Pathologic types of ureteral pressure graphs with remarks on their relation to lower tract obstruction. J. Urol., 90: 677, 1963. 4 Stephens, F. D. and Lenaghan, D.: The anatomic basis in dynamics of vesicoureteral reflux. J. Urol., 87: 669, 1962. 5 Boyarsky, S. and Martinez, J.: Ureteral peristaltic pressures in dogs with changing urine flows. J. Urol., 87: 25, 1962.

URETERAL PHYSIOLOGY AND EXSTROPHY OF BLADDER mmHg

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Fm. 4. Average ureteral pressures in 7 patients with exstrophy of bladder. Contraction pressure gradually declines as orifice is reached, but resting pressure is slightly higher in lower third of ureter.

patient. Kiil1 and Weinberg and .'\Ia1etta8 found slightly higher contraction pressures in tlw lower· third of the ureters as opposed to the upper third. We did not find this in our cases of have (fig. 4). Our studies in the adult often shown a gradual decrease in contraction pressure as the lower third is if t,he bladder is empty. In view of this, a similar in patients with exstrophy of the bladder would seem reasonable and not indicative of any eon-· tractile defect. It is generally accepted that the twie, i.e. th<-J resting pressure, of the lower ureter is somewhat

URETERAL PRESSURE TRACING transducer technique

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Fm. 5. Ureteral pressure tracing in 3-month-old patient. Excretory urogram showed normal uppet tracts. Unusually high contraction pressures recorded, with slightly elevated resting pressure in upper third of ureter. Values of this graph not included in composite figure 4. been reported as high as 60 mm. per Hg. without apparent pathological changes. Kiil has reported a contraction pressure of 80 mm. per Hg. in an adult patient. Normal contraction pressures for children have also been reported to lie within these ranges. 6 • 7 Our pressure measurements of Oto 10 mm. per Hg. resting pressure and 8 to 25 mm. per Hg. contract.ion pressure are within these ranges and in this respect appear to indicate normal contractile ability of the ureter of the exstrophic 6 Melick, W. F. and Naryka, J. J.: Pressure studies of the normal and abnormal ureter in children by means of the strain gauge, J. Urol., 83: 267, 1960. 7 Lenaghan, D.: Bifid ureters in children: An anatomic, physiological and clinical study. J. Urol., 87: 808, 1962.

higher than that of the upper and middle thirds ancl our patients abo demonstrated this The presence of an intad bladder i" therefore apparently not necessary for nonnal ureteral tone. The tracing of case 4 (fig. 5) shows that the ureter of a 3-month-old child can ~enerat.c u, pressure of 80 mm. per Hg. Thi, ,rn-i an unexpected finding. The graph does not demonstrate any of the usual signs of ohstruetion the n,cording catheter, such as rising pressure and rising contraction pressures until a plaiea.u is reached in ,vhich resting pressure remains high and contraction pressure gradually ,!(,neasr:s However, the elevated resting 1m ,."nrP ol 20 0

8 Weinberg, S. R. and Malet.ta, T. J. :\Jpasme ment of peristalsis of the ureter and its rl'lation to drugs. J.A.JVI.A., 175: 15, 19Cil.

592

MALONEY, GLEASON AND LATTIMER

mm. per Hg. in the upper third with a gradual decrease to IO mm. per Hg. in the lower third cannot be accepted as typical of a normal tracing and is probably related to partial obstruction by the catheter. While this pressure tracing might not represent the usual working pressure in this patient, the capabilities of the ureters in this infant are of interest. Measurements in the intramural portion of the ureter were taken with special interest in view of the atypical ureterovesical junction. The distal centin1eter of the exstrophic ureter is often distal to its entrance into the bladder wall because of prolapse of the ureters. Hutch has estimated that the intravesical segment in normal cases ranged from 3 mm. in the newborn to 13 mm. in the adult. 9 The surgical specimen of our 17-year-old boy showed intravesical segments of 15 mm. and 12 mm. Since this was measured on a surgical specimen, some degree of contraction had probably already occurred. The infants probably had a correspondingly shorter segment but the bladders were not removed and measurements are not available. Contraction pressures in the distal centimeter of the ureter have been reported to be lower than the rest of the ureter. 2 • 4 Our patients showed contraction pressures less than 5 mm. per Hg. but since exact ureteral pressures in the submucosal tunnel of the normal ureter are not available, it is difficult to be sure whether this is due to the disturbed ureterovesical junction of these patients. In addition, some force of the 9 Hutch, J. A.: Theory of maturation of the intravesical ureter. J. Urol., 86: 534, 1961.

contraction pressure undoubtedly leaked around the recording catheter and out the nearby orifice, preventing an absolute reading. The prolapse of the ureters with their low peristaltic pressures must certainly play a dominant role in postoperative reflux. SUMMARY

Eight patients (16 ureters) with exstrophy of the bladder were carefully studied for defects in the contractile mechanism of the ureter before the onset of ureteral dilatation. This group included infants, children and 1 adult, all previously untreated. All patients showed active peristalsis throughout the length of the ureters and the values obtained are considered to be within normal range. The contraction pressures usually gradually decreased in magnitude as the ureteral orifice was approached. Although this may be indicative of some loss of contractile power peculiar to exstrophy of the bladder, it is suggested that this is probably a normal finding and further research is needed to determine its full significance. Resting pressures of 1 to 2 mm. per Hg. and contraction pressures of 5 mm. per Hg. or less were found in, t:he distal centimeter, corresponding to that portion of the ureter which is intramural and prolapsed through the vesical wall. These extremely low pressures are probably the result of the lax ureterovesical junction. The authors acknowledge the assistance of Mrs. Sara S. Fleming, R.N. in the performance of these studies.