GIANT BILATERAL URETERAL CALCULI A SURGICAL CURIOSITY *

AUGUSTUS HARRIS, M.D., P.A.C.S.

BROOKLYN, N. Y.

M ISS M. M. referred by Dr. R. G. Price, con&ted me in March, 1930, compIaining of marked frequency

and urgency of urination. She aIso experienced considerabIe annoying pain in the Iower abdo- men when walking. The urine contained a Iarge amount of pus and was somewhat ammon- iaca1. Gross hematuria was never seen by the patient. She appeared to be very neurotic and had apparentIy suffered a great dea1.

Ten years ago she was operated upon and a caIcuIus removed from the right kidney. At that time she had severe coIic two days after Ieaving the hospita1, but thereafter she had reIief unti1 three years ago when the severe bIadder symptoms returned. Local bIadder treatment gave a considerabIe measure of relief for a time, and then radiographs were taken which showed a very Iong irreguIar cast stone of the Iower ureter on both sides, aIso a dendritic stone of moderate size in the right renaI pelvis and caIyces.

CarefuI search was made for tubercIe baciIIi in the urine on two occasions and found nega- tive. (Her father had died of pulmonary tubercuIosis.) There was very IittIe Ioss of body weight. She had headache frequentIy. The menstrua1 function was normaI.

PhysicaI examination was essentiaIIy nega- tive excepting for sIight tenderness on deep pressure aIong the Iower ureters and bIadder region. There was no renal tenderness, nor couId either kidney be feIt.

Cystosco~y: Acute and chronic generaIized cystitis was found with numerous hemorrhagic areas. The uretera meati appeared practicaIIy normaI. A No. 6 F opaque catheter passed readiIy on the right side beside the uretera caIcuIus after temporary obstruction. There was no evidence of hydronephrosis on this side. The phenoIsuIphonephthaIein returned in four and one-haIf minutes and 17 per cent was recovered in the first twenty-five minutes. The urine showed a smaI1 amount of pus with BaciIIus coIi and micrococcus ureae. AI1 catheters on the Ieft side, however, faiIed to pass more than 8 cm. after repeated attempts. A smaI1 amount of cIoudy urine was recovered

and found to contain considerabIe pus. It was obviously impossibIe to obtain the function of the Ieft kidney. The puIse was a IittIe rapid but of good quaIity and the bIood pressure normaI. The brood chemistry was normaI excepting for sIight increase in uric acid. There was aIso a sIight anemia.

After a carefu1 consideration of these find- ings, we determined that we had nothing to offer her other than to provide for free uretera drainage by means of a two-step ureterotomy and remova of the uretera caIcuIi. She was young and in fairIy good condition, and we reaIized that she couId not continue for Iong with such obstruction in the upper urinary tract.

Ureterotomy was performed first upon the right side, as we knew its approximate func- tiona1 capacity, and knew IittIe or nothing of the Ieft because of the catheter blockage. AccordingIy a few days Iater a right rectus incision was made, the parieta1 peritoneum dissected away toward the midIine, and the ureter readiIy exposed. It was very Iarge and thick and easiIv isoIated with the Iarge stone within. An in&ion about 2>$ to 3 cm. Iong was made in the anterior waI1 and the stone gentIy grasped with forceps. It was very friabIe and the tip broke off; but, with care, we managed to deIiver the baIance of the stone in toto. After thorough irrigation of the ureter with a Iarge catheter we found there was no obstruction at the Iower end. It was then cIosed with 6 or 7 interrupted No. o catgut sutures passed through outer coats and the wound cIosed in the usua1 manner leaving two Iarge cigarette drains in the bed of the wound. These were removed, in part, between the third and fifth days and the Iast piece on the sixth day.

This procedure onIy required about thirty- five minutes and the patient was returned to bed in good condition. After the third day the wound was entireIy free of urinary Ieakage and heaIing took pIace rapidIy. It was interest- ing to note the symptomatic reIief after operation and how rapidIy she improved.

Nine days Iater a Ieft ureterotomy was * Read before the BrookIyn UroIogicaI Society, April 8, 1930.

362

NEW SERIES VOL. X, No. z Harris-UreteraI CaIcuIi American Journal of Surgery 363

performed for the second caMus. The pro- cedure on this side was simiIar to the previous one excepting that it was somewhat more diffIcuIt (requiring fifty minutes). After the ureter was incised the stone was crooked at the lower end Iike a hockey-stick and couId not be removed excepting with the aid of the pressure of the index finger at the lower end of the stone with traction on the upper end of the stone. The ureter was thick-waIIed and as Iarge as the smaI1 intestine. It was then irrigated and no obstruction found at the Iower end. ArgyroI soIution was instiIIed into the Ieft renaI pelvis. The ureter was then cIosed tightIy and two periuretera1 drains inserted as in the first procedure, and wound closed in the usual manner.

The earIy convaIescence was satisfactory after the second operation. Intravenous gIucose and hypodermocIyses were given. There was moderate Ieakage of urine for about five days from the Ieft ureter which graduaIIy cIosed. Her temperature became norma and she took nourishment fairIy weI1. Urinary output after both procedures was very satisfactory.

On the morning of the eIeventh day after her second operation whiIe sitting up in bed on piIIows, she very suddenIy deveIoped an attack of weakness, shaIIow breathing and thready pulse. She ceased to breathe within a few minutes even though hypodermic stimu- Iation was given.

This came out of a “clear sky” when we were about ready to aIIow the patient out of bed. Her quaIity of puIse for days before gave no warning whatever of such a catastrophe. We concluded she must have died of emboIus.

The caIcuIi were of brownish coIor and very friabIe, Iike chaIk. AnaIysis showed calcium carbonate.

COMMENTS

In reviewing the Iiterature, we have been abIe to find the report of but one other case of giant biIatera1 uretera caMi. This is recorded by Dr. Wm. E. Stevens. Despite this fact, about IO per cent of the cases of uretera caIcuIi are said to be biIatera1.

A very Iimited number of cases of very Iarge uniIatera1 ureteral caIcuIi are re- corded. The avaiIabIe references to these are given Iater. It is worthy of note that the majority of these have occurred on

the Ieft side. Some have been removed through simpIe extraperitonea1 ureterot- omy; others have required transperitonea1

FIG. I. Giant uretera caIcuIi removed from Iower ureters (actual size). GoodIy portion of right-sided stone taken for chemica1 analysis.

ureterotomy; stiI1 others have required nephrectomy. Some have needed nephrec- tomy at a Iater date when a smaI1 stone had been Ieft in the ureter.

An interesting case report by Carson (two Iarge stones in one ureter) required four operative procedures : I. Nephros- tomy for drainage of acute pyonephrosis. 2. Ureterotomy for stone remova one week Iater. 3. Nephrectomy two weeks Iater. 4. Ureterectomy for discharging uretera stump four months Iater, with recovery. This last case iIIustrates the vaIue of present-day “stepping up” opera- tions in renaI surgery, and aIso indicates the wisdom of the operator in not trying to do too much at one time. In many cases of caIcuIi the acute septic condition must first be reIieved.

363 American Journal of Surgery Harris-Ureteral CalcuIi NOVEMBER. 1930

A striking exampIe of cIever and con- There is no question but that there is a servative surgery is shown in the case of growing fieId for this sort of management, W. Waiters. He performed ureterotomy and that Iives have been sacrificed in

FIG. 2. Giant uretera caIcuIi (taken June 1928). FIG. 3. Giant ureteral caIcuIi (taken March 1930). Note increase in size of caIcuIi.

for the remova of seven stones of .j to many instances in the past because of too 2 cm. in diameter accompanied by pyo- much surgery at one sitting.

FIG. 4. Dendritic caIcuIus in right kidney (taken June FIG. 2. Dendritic caIcuIus in right kidney (taken March 1928). 1930). Note marked increase in size.

nephrosis. He dissected the ureter free and WhiIe simpIe nephrectomy for pyoneph- brought it out in the flank and later rosis resulting from caIcuIus in the performed nephrectomy with recovery. Iower ureter may cure a certain number of

cases, others undoubtedIy are IikeIy to prospective dificuIty in ureterotomy or have troubIe with the remaining infected ureterectomy in a chronic case. Many uretera stump containing the caIcuIus. experienced surgeons have encountered A prehminary ureterohthotomy in certain similar pathoIogy about the peIvis in instances seems IogicaI and necessary very oId stone cases. Berry has recorded before a permanent cure may be expected an instance of spontaneous perforation from nephrectomy. In a given case of of a ureter by a stone with resuItant uretera caIcuIi, a11 factors must be care- extravasation of urine, sepsis, uremia fuIIy reviewed and weighed by the operator and death. before any procedure is decided upon, One of the Iargest of uretera caIcuIi especiaIIy in the presence of advanced is that recorded by Jefferson, weighing renaI pathoIogy. 1639 grains. CoIIinson’s case was aImost a

After extraction of stones from the compIete cast of the ureter. Federoff’s ureter we beIieve that the Iatter shouId case measured Ig cm. in Iength. Very be sutured carefuIIy with fine plain catgut. IittIe is given regarding the chemica1 Repeated experience in pyeIotomy and anaIysis of these giant caIcuIi. It is worthy ureterotomy procedures in our own prac- of note aIso that in some of the cases, the tice bears out this point. The contention stone was somewhat s shaped or hooked by some that the use of sutures invites shaped. This couId easiIy add materiaIIy to deIayed heaIing and tendency to fistuIa the dificuIties of surgica1 removal. formation, is not we11 founded, AI1 uroIogists appreciate the formidabIe

It is interesting to note that a number probIems presented by muItipIe urinary of these giant uretera caIcuIi faiIed to tract caIcuIi and their tendency to recur- give coIic. In some of them uretera rence. WhiIe obstruction and stasis are catheters passed to the peIvis without proved factors in the etioIogy, we beIieve diffIcuIty. A goodIy number of the re- that these factors are aImost the exception corded cases had had a previous “insufh- to the ruIe, particuIarIy with stones in the cient ” appendectomy, an experience so upper urinary tract. The chief cause may commonly found in a11 types of renaI be summed up in two vague words “fauIty and uretera caIcuIi. Buerger described 2 metaboIism.” Our hope Iies in an ever- cases of very Iarge uniIatera1 ureteric widening knowIedge of body chemistry, caIcuIi, accompanied by a Iarge amount of to make possibIe the prevention of stones periuretera1 fibroIipomatous formation. and eIimination of mutiIating surgica1 This is important especiaIIy in regard to procedures.

NEW SERIES VOL. X. No. z Harris-UreteraI CaIcuIi American Journal of Surgery 365

REFERENCES

1. ABELL, I. Giant uretera caIcuIus. Surg. Gynec. Obst., 23: 33: 1916.

2. ALLEN, C. D. Report of a case of ureteral caIcuIus. U. S. Vet. Bur. M. Bull., 5: 127, 1929.

3. BALDWIN, A. Large caIcuIus impacted in ureter in a youth. West. London M. J., 20: 113, 1915.

4. BAKER. J. N. The removal of an unusuaIIv Iarge ureteral stone. J. A. M. A., 58: 1473, 1912. -

5. BERRY, J. Perforation of ureter by caIcuIus, etc. Brit. J. Surg., 8: 372, 1921.

6. BOVEB, J. W. Case of unusuaIIy large uretera calculus; transperit. uretero-Iithotomy. Wash. M. Ann., 4: 233-239, 1905.

7. BRIGGS, W. T. Large uretera caIcuIi. Ural. @’ Cutan. Rev., 30: 708-710, 1926.

8. BUERGER, L. UnusuaIIy Iarge uretera caIcuIus. New York M. J., 100: 1103, 1914.

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CARSON, W. J. Giant ureteral caIcuIi. Ann. Surg.. 91: 141-144, 1930.

COLLINSON. H. Notes on four cases of uretera calculi, in one of which a compIete cast of the ureter was present. Lancet, 2: 1456, 1913.

FEDEROFF. S. P. Zur Kasuistik der Uretersteine. Ztscbr. j. Ural., 3: 65, 1909.

FISHER, M. K. Report of a case of giant uretera caIcuIus. Ural. e+ Cutan. Rev., 23: 401, 1919.

GIBBON, J. H. UreteraI caIcuIi. Surg. Gvnec. Obst., _ I 6: 483-501, 1908.

GO~LIEB, J. G. 244 Cas de Iith r&ale et UretkraI. J. d’urol., 28: 433, 1921.

HEATH. P. M. Giant uretera caIcuIus. Brit. J. Surg., 10: 153, 1922.

HOLDEN, W. B. UreteraI caIcuIus. S. Clin. North America, 8: 1407, 1928.

366 American JournaI of Surgery Krida-Tibia1 Pseudoarthrosis NOVEMBER, 1930

17. ISRAEL, J. Demonstration UngewohnIich Grosser uretera caIculi. Ann. de roentgenol. et. radial.,

Uretersteine. Berl. k&n. Wchnscbr., 44: 1054, 2: 123-126, 1926.

1907. 26. SFECKLIN, P. A. A giant caIcuIus of the ureter. 18. JEFFERSON, J. C. A Iarge uretera caIcuIus. &it. Am. J. urol., II: 270, 191s.

- M. J., I: 1928. 14, 19. KLEIN, W. 0. ExtravesicaI GeIegener Grosser

Ureterstein. Ztscbr. f. urol. Cbir., 24: 538, 1928. 20. LEWIS, B., and CARROLL G. UreteraI stones of

Iarge Size. J. UrOl., 23: 13-17, 1930.

21. PORTER, M. F. Kidney and uretera stones.

J. A. M. A., 55: 1691, 1910. 22. Pozzr, S. Contribution d I’itude des caIcuIs de 1’

uretkre DeIvien chez Ia femme: etc. Revue de gyntc. et-de cbir. abd., 13: 873-94&, rgog.

23. RESHOWER, I. C. An unusua1 uretera stone. AILI. J. SURG., 2: 386, 1927.

24. ROVSING, T. Erfahrungen fiber Uretersteine Mon- ats. 6: 385-426, Igor.

25. SIMONSON, S. Contribution to study of giant

27. STEVENS, W. E. Case of b&era1 uretera caIcuIi. CaliJornia H West. Med., 28: 206, 1928.

28. STROPENI, L. CaIcoIo gigante dell’ uretere peIvico

‘estratto per via paravesicale con tagIio mediano

sopra pubico. Gior. d. T. Accad. di. med. di. TO&O, 33: 135-142, 1927.

29. TENNANT, E. E. UreteraI stone of unusual size. J. A. M. A., 82: 1122, 1924.

10. WALTERS. W. UnusuaI number of Iarge stones in the lower portion of the ureter. S. Clin. North America, g: 913, 1929.

31. HAWKES, F. Ann. Surg., 35: 519, 1902. 32. JACOBS, C. Ann. de gynfc. et d’obst., 59: 136, 1903. 33. SCHMIDT, A. Cases of unusuaIIy Iarge caIcuIus in

ureter. Gy6gyiiszat, 68: 264-266, 1929.

MOMMSEN’S METHOD OF SUBMAXIMAL STIMULATION FOR

TIBIAL PSEUDOARTHROSIS*

ARTHUR KRIDA, M.D., P.A.C.S.

NEW

I N Ig2g1 Mommsen pubIished a method of submaxima .stimuIation of ununited fractures of the tibia and reported

4 successfu1 cases. In this paper he shows that the reIativeIy maxima1 stimuIation invoIved in weight bearing, even with the protections of a brace, may convert a deIayed union into a pseudo-arthrosis. He devised a variation of the weII-known hammer and dam method of Thomas which is simpIe of appIication and seemingIy more effective.

The method consists in the intermittent appIication of a submaxima stimuIation of the fracture by Iight bIows on the bottom of the hee1. A hammer is sIung on a pin; a string is attached to the handIe of the hammer, and with this the patient stimu- Iates his fracture by repeated bIows of the hammer. The Iimb is encased in pIaster of Paris, the hammer device is incorporated in it, and a fenestrum is made, exposing the heel. The patient does the hammering systematicaIIy for five to ten minutes every waking hour, for one to two months.

YORK

Since the train of events and the outcome paraIIe1 the reported cases, I am showing this case here.

P. A., aged thirty-seven, Seaman, U. S. Marine HospitaI No. 43.

History: August 1926. Simple fracture Iower third tibia and fibuIa. In pIaster three months. Non-union.

December, 1926. SIiding bone graft, eIse- where. In pIaster three months PIUS.

JuIy, 1927. Discharged, union reported. Returned to work. Ten days Iater, pain and sweIIing.

Operation: (eIsewhere), August, 1927. Lane pIate. PIaster three months foIIowed by caIiper brace. Lane pIate removed.

November, 1927 to December 1928, in hospita1, wearing caIiper brace.

December, 1928, examined by myseIf; non- union with considerabIe outward bowing. Extensive scar with chronic dermatitis. Opera- tion for correction of deformity, as it was felt that no bone graft couId be done through the extensive scar.

May, 1928, discharged to return to work, partial union. Worked three weeks, then

* Presented before the Section of Orthopedic Surgery, New York Academy of Medicine, February, 1930.