LESIONS OF THE URETERIC STUMP AFTER NEPHRECTOMY By THOMAS MOORE, M.D., M.S., F.R.C.S. Consultant Surgeon, United Manchester Hospitals IT is generally accepted that in cases of renal tuberculosis, particularly where there is gross ureteric disease, and in cases of papillary tumours of the renal pelvis, primary nephro-ureterectomy is the treatment of choice. No further reference will therefore be made to these conditions ; attention will be devoted to the treatment of the lesions which may occur in the ureteric stump after nephrectomy for other diseases. The following conditions will be considered : (1) Residual inflammatory lesions and stones in the ureteric stump causing symp- toms; (2) primary neoplasms of the ureteric stump; (3) ureteric stump fistulre. 1. RESIDUAL INFLAMMATORY LESIONS AND STONES IN THE URETERIC STUMP CAUSING SYMPTOMS Although these cases are uncommon, Stepita and Newman (1 950) reported fifteen cases and Schultze (1954) collected ninety-six cases from the literature, including two of his own. When nephrectomy is performed the ureter is still an innervated, vital structure and when stimulated may show peristaltic activity. As there is no urine to be propelled down it, however, it would be expected to atrophy. Latchem (1922) has shown in experimental animals that after nephrectomy atrophy of the muscular coat of the ureter does occur ; no change occurs in its epithelial lining and its lumen remains in ~tatu quo. This is easily demonstrated clinically by retrograde ureterography carried out some years after nephrectomy (Fig. 1). When a grossly diseased pyonephrotic kidney is removed the associated inflammatory changes in the ureter, even in the presence of a residual stone, in the great majority of cases resolve. In such cases the ureter may eventually undergo fibrous years after nephrectomy, showing that the obliteration. Many such cases were demonstrated in the studies of ureteric stumps carried out by Senger et a/. (I 947). Latchem (1922) demonstrated experimentally that any obstruction in an infected ureteric stump resulted in muscular hypertrophy and persistence of the inflammatory changes. The essential factor would appear to be the effect of the obstruction on ureteric drainage. If the hypertrophied muscle can cause adequate drainage of the ureteric stump, inflammatory changes will subside. If not, infection persists resulting in fibrous inflammatory thickening of the ureteric wall and associated periureteritis. The ureter Read at the combined meeting of the Canadian Urological Association and the British Association of Urological Surgeons at Montreal, May 1957. FIG. 1 Retrograde ureterogram of ureteric stump many remains. 268
Transcript
LESIONS OF THE URETERIC STUMP AFTER NEPHRECTOMY
By THOMAS MOORE, M.D., M.S., F.R.C.S. Consultant Surgeon, United Manchester Hospitals
IT is generally accepted that in cases of renal tuberculosis, particularly where there is gross ureteric disease, and in cases of papillary tumours of the renal pelvis, primary nephro-ureterectomy is the treatment of choice. No further reference will therefore be made to these conditions ; attention will be devoted to the treatment of the lesions which may occur in the ureteric stump
after nephrectomy for other diseases. The following conditions will be considered : (1) Residual inflammatory lesions and stones in the ureteric stump causing symp- toms; (2) primary neoplasms of the ureteric stump; (3) ureteric stump fistulre.
1. RESIDUAL INFLAMMATORY LESIONS AND STONES IN THE URETERIC STUMP
CAUSING SYMPTOMS
Although these cases are uncommon, Stepita and Newman (1 950) reported fifteen cases and Schultze (1954) collected ninety-six cases from the literature, including two of his own. When nephrectomy is performed the ureter is still an innervated, vital structure and when stimulated may show peristaltic activity. As there is no urine to be propelled down it, however, it would be expected to atrophy. Latchem (1922) has shown in experimental animals that after nephrectomy atrophy of the muscular coat of the ureter does occur ; no change occurs in its epithelial lining and its lumen remains in ~ t a t u quo. This is easily demonstrated clinically by retrograde ureterography carried out some years after nephrectomy (Fig. 1). When a grossly diseased pyonephrotic kidney is removed the associated inflammatory changes in the ureter, even in the presence of a residual stone, in the great majority of cases resolve. In such cases the ureter may eventually undergo fibrous
years after nephrectomy, showing that the obliteration. Many such cases were demonstrated in the studies of ureteric stumps carried out by Senger et a/. ( I 947). Latchem (1 922) demonstrated experimentally
that any obstruction in an infected ureteric stump resulted in muscular hypertrophy and persistence of the inflammatory changes. The essential factor would appear to be the effect of the obstruction on ureteric drainage. If the hypertrophied muscle can cause adequate drainage of the ureteric stump, inflammatory changes will subside. If not, infection persists resulting in fibrous inflammatory thickening of the ureteric wall and associated periureteritis. The ureter
Read at the combined meeting of the Canadian Urological Association and the British Association of Urological Surgeons at Montreal, May 1957.
FIG. 1
Retrograde ureterogram of ureteric stump many
remains.
268
L E S I O N S O F THE U R E T E R I C S T U M P AFTER N E P H R E C T O M Y 269
may become a bag of pus and occasionally this may leak through the wall into surrounding tissues. Histologically the ureteric stump shows fibrous thickening, inflammatory cellular infiltration of the wall, and squamous metaplasia of the epithelial lining.
Although atones or fibrous narrowing of the ureter are the usual obstructive factors, rarer lesions have been reported as congenital anomalies of the ureteric insertion (Smith, 1934) and ureterocele (Senger et al., 1947). Jeck (1 93 1) postulated that in some cases the inefficient ureteric drainage may be adynamic in consequence of damage to its nerve supply at operation or by subsequent periureteritis. It is possible also that, apart from obstructions in the ureteric stump itself, reflux from the bladder may be a factor in some cases.
A curious feature of all these cases is the length of time which may elapse between the original nephrectomy and the subsequent ureteric symptoms ; it may be as long as twenty-seven years (Bennetts et af., 1955), twenty-six years (Case I) , and twenty-three years (Senger et al., 1947).
Clinically, obstruction of the ureteric stump is manifested by recurrent attacks of ureteric pain, unexplained pyrexia (Davison, 1942), recurrent episodes of urinary infection (sometimes associated with hrematuria), persistent pyuria, or ureteric fistula. Nor are these symptoms the only danger of the stump ; Ljunggren (1944) has reported a case in which chronic infection of the ureteric stump persisting for many years led to infection of the remaining kidney and death from urremia.
Like Ljunggren (1948) and Rieser (1950), I believe that careful pre-operative investigation of the ureter should always be carried out before nephrectomy. If these studies show either inefficient drainage of the ureter or ureteric reflux, then if the renal lesion necessitates nephrectomy a total nephro-ureterectomy should be performed. Only by this means can these cases of late complications from the ureteric stump, rare though they are, be avoided.
When a ureteric stump causes symptoms the most satisfactory treatment is its extraperitoneal removal. Mason (1957) has described a transvesical route; in cases where there is severe periureteritis, however, I am sure this would not prove satisfactory. Occasionally more conservative methods, such as transurethral dilatation of the ureteric stump orifice (with or without intermittent irrigation), may help drainage and allow inflammatory changes to subside (see Case 3). Recently at the Mayo Clinic I saw Dr E. N. Cook remove a ureteric stump stone, using a Johnson stone basket. It is not certain that removal of the stone in such cases will always relieve the symptoms, some of which can undoubtedly be caused by the inflammatory changes in the wall itself.
Many of the points already mentioned are illustrated by the following cases :-
First seen by me in May 1956. In 1930 she had had a right nephrectomy at the Manchester Royal Infirmary for what was thought to be a stone in the kidney. At operation an atrophic, non-tuberculous kidney with a small area of calcification in it was found. Afterwards she remained quite well until five years previously when she developed a sudden acute pain in the right iliac fossa ; this was referred towards the groin and associated with some frequency of micturition. It settled down in a few days. She had two further attacks of this pain and an urgent appendicectomy was carried out but the appendix was not abnormal. In some of these attacks she thought she passed blood in the urine. Since this time she had had frequent attacks of pain in the right side with terminal dysuria occurring about every five weeks and lasting for a few days. The most severe attack occurred about three weeks before I saw her and she had to have morphia for the pain. She had otherwise been quite well.
On clinical examination no abnormality was found and the patient was regarded as suffering from right ureteric colic from the residual part of the right ureter.
Invesrigations.-Urine : showed a few W.B.C. and on culture grew coliform bacilli. Blood : hamoglobin, 90 per cent. ; W.B.C., 6,200 per cmm. Plain X-ray and I.V.U. : good function on the left side with normal outlines. On the right side a small shadow was present at the level of the fourth lumbar transverse process which could have been a small stone in the right ureteric stump (Fig. 2).
Case I.-Mrs N . L., aged 47.
Admitted to the Manchester Royal Infirmary on 2nd July 1956 for further treatment. Cystoscopy.-3rd July 1956, under G.A. Bladder, vesical neck, and left ureteric orifice normal. Right
ureteric orifice red and swollen ; no catheter could be passed up for more than 1 cm. It was decided to explore the right ureteric stump. This was carried out on 10th July 1956 under general
anasthesia. Through an oblique muscle-cutting incision in the right iliac fossa the ureter was exposed
270 B R I T I S H J O U R N A L O F U R O L O G Y
extraperitoneally; it was obviously very thick-walled and dilated and was traced up to the level of the second lumbar vertebra, where it disappeared into fibrous tissue. The entire structure was carefully separated and removed with a small piece of bladder. The opening in the bladder was closed with fine plain catgut.
The patient had an uninterrupted convalescence and has had no further trouble since. About 8 in. of ureter were removed, showing thickening and dilatation, particularly just above the bladder.
When it was removed no fluid leaked out from the lower end showing a competent sphincter here. After fixation
FIG. 2 FIG. 3 Fig. Z.--Case I. Intravenous urogram, showing normal left kidney and ureter; shadow in right lumbar
Fig. .i.-Case 1. Drawing of specimen, showing thickening of ureteric wall, dilatation of lower end, and region of debris in right ureteric stump.
debris in upper end.
it was opened and shown to be very thick-walled and the lumen at the upper end contained some calcareous debris (Fig. 3). Microscopy showed that the ureter was lined by squamous epithelium, with cedema and congestion and lymphoid infiltration of the wall ; in some parts the mucosa was lost. The case was regarded as one of acute on chronic ureteritis.
Case 2.-W. J . C., aged 59. First seen on 26th November 1951 suffering from right pyonephrosis due to blockage of the upper ureter by a stone. There were also two stones lower in the ureter (Figs. 4 and 5). A very difficult nephrectomy was carried out with removal of the upper 2 in. of the ureter, the lower stones being left in situ. Three months later the patient developed right epididymo-orchitis which settled on chemotherapy.
Re-investigation in December 1953, when he was symptom-free. Plain X-ray and I.V.U. : good function of the left kidney. There were some shadows in the position of the
right ureter which were thought to be the residual stones. Urine : normal. Blood : normal. C.vstoscopy.-l8th December 1953, under G.A. Left ureteric orifice normal. Right orifice atrophic and
difficult to find. As the patient had become symptom-free no further treatment was carried out. He was seen again on 20th February 1957 having noticed blood in the urine one week previously and
complaining of occasional pain in the right iliac fossa.
L E S I O N S O F T H E U R E T E R I C S T U M P A F T E R N E P H R E C T O M Y
FIG. 4 FIG. 5 Fig. 4.-Case 2 (November 1951). Plain radiograph with right ureteric catheter i i i siru. showing stone blocking upper part of right ureter and
further stones in lumbar and pelvic parts. Fig. 5.-Case 2 (November 1951). Right retrograde ureterogram, showing
Plain radiograph. showing residual stones in right ureteric stump. Right urelerogram. showing stones in ureteric stump.
3 E
27 1
272 B R I T I S H J O U R N A L O F U R O L O G Y
On Examinntiun.-General condition : good ; very fat man. Abdomen : well healed right nephrectomy scar. P.R. : some simple prostatic enlargement. No residual urine.
/~ii~c,.sti~ations.-Plain X-ray and I .V.U. : good function and normal outlines of the left kidney. Two stones in the right ureter, one at about the level of the fourth lumbar transverse process, the other just below the sacro-iliac joint (Fig. 6). Urine : microscopically, many W.B.C. and a few R.B.C. Culture : heavy growth of Bmillus coli. Blood : hanoglobin, 102 per cent. Blood urea, 37 mg. per 100 ml.
Retrograde ureterogram showed some dilatation of the ureter, particularly the lower part, with two stones in it (Fig. 7).
~ ~ ~ , s f o . s c o ~ p ~ ~ . ~ l 9 t h March 1957, under G.A. Right ureter catheterised to I5 cm.
FIG. 8 FIG. 9 Fig. 8.-Case 2. Drawing of specimen, showing thickened wall of ureteric stump, dilatation of
Fig. 9.-Case 3 (May 1951). Left retrograde ureteropyelogram, showing gross hydro-ureter lower end, and stones in situ.
and hydronephrosis.
Opc~ution.-26th March 1957, under G.A. Oblique incision in right iliac fossa. Ureter exposed extraperitoneally and traced up to the upper lumbar region where it was freed. Also freed down to the bladder and divided through this lower end which was tied.
The patient made good progress after operation and has had no further trouble. Pnthologicul Report.-Naked eye: 17 cm. of ureter. It is considerably dilated over a distance of 6 cm. at
one end and the wall is thickened; there is an irregular brownish-black calculus 5 mm. diameter in the lumen at this point. At the other end the lumen contains numerous small granular brown calculi and is slightly dilated. The mucosa shows areas of roughening and irregularity at several points (Fig. 8). Microscopically : The wall of the ureter shows a diffuse non-specific chronic inflammatory infiltration. The mucosa is flattened in most parts and tends towards the squamous pattern.
Case 3.-P. B., aged 24. Under the care of a colleague at the Manchester Royal Infirmary, on 24th May 195 1, In-patient from 3rd suffering from left hydronephrosis and hydro-ureter (Fig. 9) ; was treated conservatively.
L E S I O N S O F T H E U R E T E R I C S T U M P A F T E R N E P H R E C T O M Y 273
September 1951 to 22nd October 1951 suffering from left pyonephrosis and pyo-ureter. The patient was very i l l and a left nephrostomy was performed.
Readmitted on 9th December 1952 and a very difficult left nephrectomy was carried out with removal of the upper part of the ureter. Histology showed that the kidney was the site of marked hydronephrosis with much fibrosis and dense lymphocytic infiltration. Patient made good progress and was discharged on 24th January 1953.
Readmitted on 7th May 1956. Since nephrectomy he had had four attacks of pain in the left loin ; these were of an aching character. With the first attack he had vomiting but had none since then.
On Examination.-General condition : good. Abdomen : some deep tenderness in the left iliac fossa. Invrsrigutions.-Plain X-ray and I.V.U. : good function of the right kidney with normal outlines. No sign
of stone in the left ureter. Urine: microscopically, moderate number of W.B.C. Culture sterile. Blood: hanoglobin, 100 per cent. ; W.B.C., 10,800 per c m m . Blood urea: 34 mg. per 100 ml.
C.vstuscup.~~.-I7th May 1956, under L.A. Bladder normal. Right ureteric orifice normal. Left ureteric orifice could not be catheterised except for about 1 cm.
The condition was regarded as an infection of the ureteric stump. He has had no recurrence of his symptoms to date.
In my opinion it would have been much better if a total nephro-ureterectomy had been done at the primary operation. The case illustrates, however, that even a grossly dilated and infected ureter can resolve. A similar case was reported by Scholl (1950).
2. PRIMARY NEOPLASMS OF THE URETERIC STUMP
In my view chronic inflammation of any epithelial surface is very likely to be followed This sequence is often demonstrated in eventually by the development of malignant disease.
the urinary tract, in the bladder and bladder diverticula, and in the kidney. I am surprised how uncommon primary lesions of the ureteric stump appear to be, only three cases previously having been reported by Loeff and Casella (1952), Taylor and Berry (1954), and Bennetts et al. (1955). In any case of unexplained haematuria the ureteric stump must, of course, come under diag- nostic survey in the same way as the rest of the urinary tract.
Case 4.-Mrs A. C . , aged 52. Admitted to the Manchester Royal Infirmary on 28th October 1948. Patient underwent a left nephrectomy on 2nd November 1948 for a large left. hydronephrosis secondary to a stag- horn calculus in the pelvis of the kidney. Pathological examination of the specimen showed no macroscopic or microscopic evidence of tumour in the kidney and renal pelvis or in the excised part of the ureter. The patient had no further urinary trouble until December 1955, when she passed blood on several occasions.
On Examination.~General condition : good ; patient very fat. Patient suffered from a considerable degree of chronic bronchitis and myocardial insufficiency. Abdomen: N.A.D. P.V. : N.A.D.
Invrstigutions.~Urine : microscopically, numerous R.B.C. Culture sterile. Blood urea: 32 mg. per 100 ml. Plain X-ray and I.V.U.: good function of the right kidney with normal outlines.
C.vstoscopy.-26th January 1956, under L A . The urethra had to be dilated before a cystoscope could be passed. The bladder appeared normal. Right ureteric orifice normal. At the position of the left ureteric orifice there was a papillary neoplasm about 1 cm. in diameter which could be seen coming through the left ureteric orifice. A biopsy specimen was taken of this and retrograde ureterography carried out. The ureterogram showed marked dilatation of the ureter with several filling defects in it very suggestive FIG. 10 of tumour (Fig. 10). The biopsy report was stated to show chronic non- Case4(Januaryl956). Leftretrograde specific inflammation. ureterogram, showing dilatation and
filling defects in the ureteric stump. Operation.-21st February 1956 under G.A. The left ureter was exposed extraperitoneally through an oblique incision in the left iliac fossa. It was very dilated and adherent to surrounding tissues. In one part there appeared to be a growth extending through the ureteric wall. The ureter was carefully separated to the upper end and down to the bladder and removed.
The patient had an uninterrupted convalescence and was discharged from hospital on 15th March 1956 very
214 B R I T I S H J O U R N A L O F U R O L O G Y
well. The excised ureter was 17 cm. in length. The lower 10 cm. were very dilated, to 6.5 cm. in diameter. On section the dilated part of the ureter was found to be filled with papillary masses of grey and greyish-red friable tumour (Fig. 1 I). Histological examination showed moderately differentiated squamous-cell carcinoma. In one part there was invasion of the muscle coat and the growth appeared almost to infiltrate through the wall. On section the ureter below the growth showed non-specific inflammation of the mucosa with partial squamous metaplasia of the epithelium but no sign of tumour.
The patient was seen again on 14th June 1956 and appeared very well with no sign of recurrence. She was, however, greatly troubled by chronic bronchitis and chronic cardiac changes, from which she had had trouble for
many years. She died suddenly from a coronary thrombosis on 23rd December 1956. At this time there was undoubted recurrence of the growth, as a mass could be felt in the left iliac fossa and she was complaining of pain down the left leg for the last few weeks before death.
3. URETERIC STUMP FISTULA3
(a) With a Competent Uretero-vesical Valve.-When a ureteric stump communicates with the renal operation wound, either because it was not ligated at operation or through slipping or sloughing of the ligature later, provided the valve at the lower end of the ureter is competent, no contamination of the wound with urine will occur. Inflammatory collections in the ureter or stones may, however, escape into the wound and keep up long-continued infection and discharge. A persistent wound sinus may originate from a ureteric stump in both non-specific and tuberculous cases. Similarly, inflammatory lesions in the wound may discharge through the ureter and cause a continuing bladder infection. Bladder infection may also be caused by inflammatory lesions contiguous to the ureter, e.g., of bone or bowel, eventually ulcerating into and discharging through the ureteric stump. These must be very rare but must be remembered in cases of obscure urinary infections.
(b) When the Uretero-vesical Valve is Incompetent.-With in- competence of the uretero-vesical valve, inflammatory lesions in the bladder may contaminate the kidney operation wound and cause prolonged inflammatory changes there. ‘A urinary fistula may form and necessitate further surgical treatment of the ureter. Dillingham (1930) reported a cure of a ureteric stump fistula by transurethral destruction of its mucosa, using quinine and urethane. Before any treatment of a urinary ureteric fistula is carried out it is important that the discharge from the wound, no matter how profuse, should actually be proved to be urine by chemical analysis. Unless the discharge is urine, excision of the ureteric stump or its ligation in continuity will not cure the “ fistula.” FIG. 11
Case 4. Drawing, showingdilated ureter with papillary growth in Case 5.-Miss J. W., aged 21. Admitted to the Manchester Royal Infirmary
the lumen of the lower part. on November 1953 (under the care of a colleague) suffering from a right hydronephrosis, for which a plastic repair was carried out. This was not a
great success. Because of continuing urinary leakage from the wound and infection, secondary nephrectomy was carried out some weeks later. Afterwards the wound kept on discharging quite profusely. In March 1954 a sinogram showed that the dye injected into the wound discharged through the ureteric stump into the bladder (Fig. 12). In July 1954 the ureter was exposed through an oblique incision in the right iliac fossa and as much as possible of this part was removed ; in spite of this the wound continued to discharge. A further sinogram in September 1954 showed that the medium ran into the upper part of the right ureter but none, of course, could go down into the bladder because part of the ureter had been removed (Fig. 13). The part was explored on three further occasions and eventually healed in April 1955, after a length of unabsorbed suture had been found and removed.
L E S I O N S OF T H E U R E T E R I C S T U M P A F T E R N E P H R E C T O M Y 275
All that has been said about the ureteric stump, of course, applies to the stump of any ureter which is left behind whether it be the single normal ureter or an accessory ureter with an opening into the bladder or an ectopic opening elsewhere. In my experience (Moore, 1952) cases of ectopic ureters in which partial nephrectomy and ureterectomy have been performed
FIG. 12 FIG. 13
Fig. 12.-Case 5 . Sinogram, showing that dye has entered right ureter and bladder. Fig. I3.-Case 5 . Sinogram after part of right ureteric stump has been removed, showing
that dye still enters the upper part of the ureter.
have had no further trouble with the residual piece of ureter. In spite of this, however, 1 am sure that total removal of the offending ureter is preferable. Although in these cases incontinence has been the usual symptom and there has been no inflammatory lesion present in the ureter at the time, ascending infection in the stump later is certainly possible.
SUMMARY
1. Careful pre-operative assessment of the state of the ureter from the point of view of drainage and reflux from the bladder should be carried out in every case where nephrectomy is proposed.
2. Where any obstruction or reflux is present, total nephro-ureterectomy is the best treatment. 3. If this is not done, residual symptoms can occur from the ureteric stump. Three cases
4. Primary neoplasm may develop in the ureteric stump. 5. Fistulx, either internal or external, may involve the ureteric stump.
are reported. One case is reported.
276 B R I T I S H J O U R N A L O F U R O L O G Y
I must record my indebtedness to my colleagues at the Manchester Royal Infirmary for allowing me access to their case records, particularly Mr R. L. Newall. I am also indebted to Professor A. C. P. Campbell for his pathological reports and to Miss D. Davison, the Medical Artist at the Manchester Royal Infirmary, and Dr G . R. W. Ollerenshaw, of the Department of Medical Illustration, Manchester Royal Infirmary, for their help with the illustrations.
REFERENCES
BENNETTS, F. A., CRANE, J. F., CRANE, J. J., GUMMESS, G. H., and MILES, H. B. (1955). J . Urol., 73, 238.
DAVISON, S. (1942). J. Amer. med. Ass., 118, 137. DILLINGHAM, F. S . (1930). J. Urol., 23, 58. JECK, H. S. (1931). Surg. Gynec. Obstet., 52, 1158. LATCHEM, R. L. (1922). J. Urol., 8, 257. LJUNGGREN, E. (1944). Acta chir. scand., 91, 172. ~ (1948). J . Urol., 59, 179. LOEFF, J. A., and CASELLA, P. A. (1952). J. Urol., 67, 159. MASON, T. (1957). Surg. Gynec. Obstet., 104, 238. MOORE, T. (1952). Brit. J. Urol., 24, 3. RIESER, C. (1950). J. Urol., 64, 275. SCHOLL, A. J. (1950). J . Urof., 63, 524. SCHULTZE, B. B. (1954). Acta chir. scand., 107, 41. SENGER, F. L., BELL, A. L. L., WARRES, H. L., and TIRMAN, W. S. (1947).
Surg., 73, 69. SMITH, G. G. (1934). Trans. Amer. Ass. Gen. Urin. Surg., 27, 279. STEPITA, C. T., and NEWMAN, H. R. (1950). J. Urol., 63, 500. TAYLOR, A.. and BERRY, J. V. (1954). J . Urol., 72, 817.
