NEPHROPEXY FOR URETERAL

A REVIEW AND RESULTS OF NINETY

AUGUSTUS RILEY, M.D.

BOSTON

KINKS*

CASES

TN a paper entitIed “Nephropexy for not the kink of the ureter was obIiterated,

1 UreteraI Kinks,” read b-y me1 before the New EngIand Branch of the

and what degree of improvement, if an?, there was in the amount of diIatation of the kidney peIvis in any case that showed some degree of kidney peIvis dilatation before nephropexy was done.

A study of these go cases showed the foIIowing :

American UroIogicaI Association, May, 1929, a review of the Iiterature was made up to the time the paper was written. Quotations were made from different authors who were doing nephropexy for ureteral kinks, and the comments of note made by each were mentioned. At this time I tried to meet the criticisms of those who were opposed to nephropexy.

The technique for taking pyeIograms in a11 cases was described. This technique has been carried out in a11 cases since this time, in a11 of my pyeIographic studies; and I firmIy believe that it is the proper technique in each and every case that may come to pyeIographic study.

The technique of the operation described at that time has been foIIowed and carried out in a11 cases with only minor aIterations in an occasional case. I tried to point out the danger of damaging the kidney par- enchyma by placing deep sutures in this most important portion of the kidney.

A group of 35 cases was reported at that time and comments were made on the resuIts. Since then the group has enlarged to more than IOO cases. Ninety cases of this group form the subject for discussion in this paper. All the patients of this group have been seen, questioned, and examined since their operation. Ninety per cent have had foIIow-up pyeIograms, taken four to six months after operation, to determine the position of the kidney and whether or

1 Riley, A. Nephropexy for ureteral kinks. New England J. Med., 201: No. 19, 929-938 (Nov. 7) ~929.

MaIes; 29 cases. Females; 61 cases. Kinks; Right ureter, 65 cases. Left

ureter, 35 cases. Kinks of both ureters: In the same case,

IO, MaIes, 4 cases. FemaIes, 6 cases. Operations on both sides at different

times; 4 cases. MaIes, I case. FemaIe, 3 cases.

Ages in which uretera kinks producing symptoms were found in ten year periods are as foIIows:

.

Age (Years) Cases 10-20.. 3 (youngest fifteen years) 20~30................. 26 30-40...... 27 40-$0.. 25

sodo.... 7 60-70.. 2 (oIdest sixty-four years)

An anaIysis of these cases show that about two females to one maIe have kinked ureters. The right ureter is affected aImost two to one as compared with the Ieft ureter. The ages at which most patients compIain, and kinks are found, are rbetween the twenty and fifty year periods.

OPERATIVE FINDINGS

AI1 patients with kinked ureters with symptoms enough to warrant one to do pyeIographic studies wiII show some definite cause why the ureter kinks at some

* From the Harvard SurgicaI Teaching Service, Boston City Hospital. Read before the CIinicaI Staff Meeting, Boston City HospitaI.

534

NEW SERIES VOL. XXVII, No. 3 RiIey-Nephropexy American Journal of Surgery 535

definite point. That point is fixed and tion, or in getting out of bed quickIy. One shows, in the pyeIograms taken, to be patient in particuIar had renaI coIic when about I to 19; inches below the uretero- she turned on her back at night during peIvic junction. Eight of the cases in this sleep. The kink in this case was found to reported group shovired definite pulsating be due to a smaI1 artery crossing t.he ureter arteries, causing the kinks by krossing the posteriorIy. Between attacks of coIic some ureter or rotating the kidney in such a way were free of pain, others had a more or as to cause a kink of the ureter. Two cases Iess dragging pain in the region of the showed retroperitonea1 maIignant disease. kidney.

One was that of a man, whose malignant disease was a metastasis from a malignant disease of the testicIe. The testicle had given no symptoms, and was not discovered as malignant at the time the patient came into the hospital, because of his renaI coIic. The patient was operated on some months after- wards for the maIignant testicle, and the specimen from the retroperitoneal glands and testicle compared, and were found to be of the same maIignant disease.

The other was a woman; the site of the origina growth was not determined. One case, with a very low right kidney and marked kinking of the ureter, had a Iarge stone in the kidney peIvis, r.nd a smaIIer stone in the Iower calys.

The renaI colics have been reheved in a11 cases. The duI1 dragging pain may Iast for some time, due to the readjustment of the kidney in its new bed where it had been pIaced at the time of the operation, or to an existing pyeIitis. A few of the patients have had to have uretera diIata- tion, because of the constriction of t’he ureter at the point where there was a Iong- standing anguIation or kink, before com- pIete reIief of pain was obtained.

AI1 the other cases showed a definite point

of fixation, due either to tough fibrous bands crossing the ureter at the point of

kinking, or tying the ureter down at the point of kinking to the posterior abdomina1

waI1. Whether these fibrous bands are due to some oId inflammatory process, as peri- ureteritis, it is hard to say.

NearIy a11 patients have pain in the site of the operative scar or aIong the course of some of the Iarge nerves in the region of the operative fieId. These pains wiI1 disappear in time if such nerves have not been caught in the operative scar. One patient had to have the nerve dissected out before she obtained reIief. One patient compIained of pain some months after relief of the pain for which she first came into the cIinic. From Iater x-ray findings it is evident that her pain is no doubt due to an oId arthritic spine.

There was one death in this series. The death can hardIy be attributed to the operation, because the chart showed that the patient began a genera1 systemic infec- tion the evening before the operation; it was either not discovered, or overIooked by the attending house-oficer and nurse in charge.

Three of these women have gone through pregnancies successfuIIy without any kid- ney disturbance on the operated kidney.

POSTOPERATIVE PYELOGRAPHIC STUDIES

RESULTS

Pain was the chief symptom in a11 the cases, and the symptom from which the patient sought reIief. AI1 of the patients at some time had had a typica renaI coIic, especialIy when in the upright position, a sudden jar of the body whiIe in this posi-

PyeIograms taken in some cases four months, in most cases six months, in a few one year after operation, have been most gratifying. AI1 cases show the ureters straight, and the kidney Iying high up, where it was pIaced at the time of the operation. The kidney peIvis shows good drainage, and where there was any degree of hydronephrosis and bIunting of the carices, the whore picture approaches that of a more norma kidney.

536 American Journal of Surgery RiIey-Nephropexy MARCH, ,935

I have chosen from this group of go Operation: Nepbropexy: A large pulsating

cases, pyelograms of 4 cases to iIlustrate artery, extending from the Iower poIe of the what nephropexy wiI1 do to relieve these kidney to the low abdomina1 aorta, was found.

FIG. I. Case I.

individuaIs of their distressing symptoms,

and change an approaching pathoIogica1 condition to a more normaI appearing and

functioning organ.

CASE I. A man aged forty-seven years, was operated on in March, 1927. He had compIained of attacks of coIicky pain in the right abdomen and back for some time. The pain radiated down into the scrotum. There was a history of frequency and nocturia.

Examination: LocaI: A paIpabIe movabie tender mass feIt in the right Iower abdomen and Ioin.

A pyeIogram (Fig. I) shows a low right kidney; its Iower poIe beIow the iliac crest. The kidney is rotated more than 45’. The ureter is near the midIine at the fourth Iumbar level. This displacement of the ureter is due to the rotation of the kidney. There is some diIatation of the kidney peIvis. This diIatation is more evident when compared with the other kidney, which is not shown in this particuIar pyeIogram. At the uretero-peIvic junction there is a break in the ureterogram, which suggests some interference or constric- tion at this point.

FIG. 2. Case I.

It was impossible to bring the kidney into a norma position, because of the artery, which was the cause of the kidney rotation. Cramping the artery between the finger and thumb showed it suppIied onIy a smaI1 area of the Iower poIe of the kidney. The artery was Iigated in two different pIaces and cut. The ureter had to be freed from its midline position.

A second pyeIogram (Fig. z) was made eight months after nephropexy showed the kidney practicaIIy in a norma position. The ureter is straight. There is stiI1 a constricted point in the ureter at the uretero-pelvic junction. The constricted point is most Iikely due to the Iong-standing kinking of the ureter at this point.

There was some postoperative pain which was reIieved by diIatating this constricted point in the ureter.

CASE II. A man, aged twenty-two years at the time of operation, November, 1928. His chief compIaint was severe pain in the right Iower abdomen. The first attack of pain was about five weeks previous to the time he was first seen. He has had severa attacks. He had an appendectomy, November, 1927. Since then he had feIt perfectIy we11 unti1 five weeks

NEW SERIES VOL. XXVII, No. 3 Riley-Nephropexy American Journal of Surgery 537

ago. He had frequency of urination, which was much below the iliac crest. There is a marked getting worse. kinking and tortuosity of the ureter at the

Examination: Local: There was a right lower ureteropeIvic junction.

FIG. 3. Case II. FIG. 4. Case II.

abdominal scar in the region of the appendix. A pyelogram m-as made two years after A tender movable mass was feIt Iow down nephropexy (Fig. 4), and it shows the ureter through the anterior abdomina1 wal1, and in straight, and the kidney high up, where it

Frc. 5. Case III. FIG. 6. Case III.

back just above the crest of the iIium. was pIaced at the time of the operation. A pyeIogram of the right kidney (Fig. 3) This young man has been engaged in athletic

shows the lower poIe of the kidney to be contests, since he was operated on, and before

538 American Journal of Surgery RiIey-Nephropexy MARCH, 1932

his postoperative pyeIogram was made, without after vomiting. On the day of her admission any III effects. the pain centered more to the right Iower

CASE III. A married woman, aged thirty- quadrant of the abdomen. There were no

FIG. 7. Case IV.

nine years, who was operated on in February, 1930. She was referred to the cIinic because of attacks of severe pain in the region of her right. kidney. She had had several attacks of severe pain. Between the attacks of severe pain, there was a more or Iess dragging pain in her right back, especiaIIy while on her feet doing her housework.

Examination: A tender paIpabIe and freeIy movabIe mass was feIt between the examining fingers front and back.

A pyeIogram (Fig. 3) shows the kidney much Iower than normaI, and rotated so as to appear with its peIvis higher than the calices. The ureter is markedIy kinked at and below the ureteropelvic junction.

A pyeIogram was taken eight months after nephropexy (Fig. 6) shows norma cupping of the caIices and the peIvis norma in shape. but it &II shows some dilatation.

CASE IV. A married woman, aged thirty- nine years, was operated in May, 1929. The patient was admitted to the hospital because of abdomina1 pain, nausea and vomiting; the pain began four days before admission. The pain was first in the epigastric region, and at times was quite severe. There was some reIief

FIG. 8. Case IV.

urinary symptoms. E.xamination: There was some tenderness in

the right abdomen to just beIow the IeveI of the umbiIicus. A palpable, movabIe, tender mass, extending from the right. epigastric region to the IeveI of the umbiIicus, was found. Temperature IOO’F. White count 12,000.

UrinaIysis was reported negative. A pyeIogram (Fig. 7) shows the kidney to

be Iow, the Iower poIe about the IeveI of the right iIiac crest. There is some diIatation of the kidney peIvis. The ureter shows a marked kink just beIow the UreteropeIvic junction. BeIow this kink the ureter is diIated and tortuous; and is dispIaced more towards the midIine than normaI.

A pyeIogram was made tweIve months after nephropexy. Figure 8 shows anatomica changes from that of the pyeIogram before nephropexy which are remarkabIe. This patient feeIs most grateful for the reIief she has obtained.

The symptoms of epigastric pain and digestive disturbances, nausea and vomit- ing, are sometimes most prominent in patients with renaI pathoIogy. They were the chief symptoms in 2 cases of this series.

NEW SERIES VOL. XXVII, No. 3 Riley --Nephropexy Amcric;~n J<,,lrn:ll III S,lr&<ry $39

Cases with renaI pathoIogy and gastro- intestinal symptoms predominating, with or without urinary symptoms, have been reported by Colby,2 Swan” and Smith.4

CONCLUSIONS

Nephropexy &II has a definite pIace in kidney surgery. The operation is not in- dicated where the kidneys are simpIy Iow and easiIy feIt, but for kidneys that giving patients symptoms marked enough to cause them to seek an examination, expecting reIief of the symptoms. Patients whose symptoms warrant pyelographic studies, and whose pyeIographic studies show a kinked ureter, with or without rotation of the kidney and with or without a noticeabIe diIatation of the kidney peIvis, shouId have nephropexy.

AI1 patients shouId have postoperative pyeIographic studies, made at Ieast four months after operation, to determine the

’ Colby, F. H. Kidney lesions as a cause of gastro- intestinal symptoms. Truns. Am. Assoc. Cenito-Urin. Snr&, pp. 29-34, ‘932.

3 Swan, C. S. Castro-intestinal symptoms from Ieft renal tumor. New England J. Med., 210: No. 7, 345-

346 (Feb. 15) 1934. 4 Smith, E. Gastrointestinal symptoms in hydro-

nephrosis and renaI colic. Canadian M. A. J., p. 281 (March) 1933.

condition of the kidney pelvis and ureter. The cause for any pain or which a patient may compIain after nephropexy shouId be determined before the operation is said to be of no benefit to the patient.

SUMMARY

A series of 90 patients, who had enough symptoms referabIe to the kidney region to seek reIief, was thoroughly examined, and those found to have kinked ureters, with or without rotation of the kidney and with or without marked diIatation of the kidney peIvis, had a nephropexy.

A comparative study of this series show that about two females to one maIe have kinked ureters. The right ureter is affected aImost twice as often as the left.

Seventy-eight, about 85 per cent, of the 90 patients were between the ages of twenty and fifty years.

AI1 cases have had postoperative pyeIo- graphic studies, covering a period of four months to more than a year,

Al1 patients have been reIieved of their symptoms of kidney pain. Where there was marked diIatation of the kidney peIvis; the picture has been changed to practicaIIy norma after nephropexy.

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*Continued

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from p. 517.