Vol. 116, November
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Printed in U.S .A.
THE SURGICAL FATE OF URETERAL CALCULI: REVIEW OF MAYO CLINIC EXPERIENCE WILLIAM L. FURLOW*
AND
JOHN J. BUCCHIERE
From the Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT
A review of 1,061 patients who underwent ureterolithotomy or transurethral manipulation revealed 2 fa ctors that are important to consider: 1) the roentgenographic size of the calculi measured at the largest diameter and 2) the location of the calculus . These 2 factors in addition to the general med ical condition of the patient, the duration of severity of symptoms and the status of the upper urinary tract provide suitable guide lines for individual management of ureteral calculi. The management of ureteral calculus can be trying for the patient as well as the urologist . Each case differs in regard to specific urologic and medical needs and, therefore, no hard and fast rules should be followed if the patient is to be best served . 1 • 2 The urologist must be prepared to use all available procedures to remove the offending calculus and to preserve renal function . OUR SERIES
To determine suitable guide lines for the surgical management of ureteral calculi we reviewed the case histories of 1,356 patients who had had one or more ureteral calculi that required either transurethral manipulation or primary ureterolithotomy. The patients were seen between January 1950 and December 1966. Of this group 295 patients were excluded from the series, most of whom underwent multiple surgical procedures in an attempt to remove the calculi. The most frequent procedures were ureterolithotomy combined with pelviolithotomy or nephrolithotomy. Other patients who had had previous urinary diversion also were excluded from the series . An additional group of patients who presented with calculus in the ureteral stump is the subject of a separate report . 3 Our study is based on data from 1,061 patients. There were 792 male and 269 female patients, a ratio of 2.5 to 1. Most patients were between 31 and 70 years old, with the 6th decade being the most vulnerable age group. Of the patients less than 30 years old the male to female ratio was reversed, that is there were 44 female and 29 male subjects (figs. 1 and 2). 3 FINDINGS
Clinical signs and symptoms . Classic renal colic was the presenting symptom in 481 patients. Asymptomatic gross hematuria was noted in 36 patients and 8 patients initially presented with anuria . A completely asym tomatic calculus was noted in 115 pa!i_ents. The ca culi were found usually during routine clinical investigations. Calculus was diagnosed most frequently between May and August each year (fig. 3), with peaks in January and October. A positive history of one or more previous calculi was elicited in 23.8~ per cent of the patients. Of these 65.4 per cent had re rrence lil the u;!Silat ur.ei eL~' 4 -- rographic studies . Except for the ureteral calculus , excretory urography revealed no other abnormality in 390 patients. In 134 patients the ureteral calculus was complicated by nonfunction of the involved kidney. In these 134 patients the calculus was located in the lower third of the ureter in 86, middle third in 23 and upper t hird in 25. Seventy-nine per cent
0
Accepted for publication April 30, 1976.
* Requests for reprints: Mayo Clinic, Rochester, Minnesota 55901.
of the calculi located in the lower third of the ureter were treated by manipulation, whereas 100 per cent of the calculi in the upper third and associated with non-function were treated by primary ureterolithotomy . Surgical management . Primary ureterolithotomy was the treatment of choice in 400 patients . Of this group 93 patients (24 per cent) had a calculus that was 0.9 cm . or less in greatest diameter . A calculus less than 1.0 cm. in diameter was present in the lower third of the ureter in 21 of the 93 patients . In 16 of these 21 patients preliminary cystoscopy did not permit passage of a ureteral catheter beyond the stone . In 2 patients benign prostatic hypertrophy prevented any attempt at ureteral instrumentation. One patient presented with a ureteral stricture after transurethral manipulation had been attempted elsewhere. One hundred calculi in the lower third of the ureter were 1.0 cm. or larger in greatest diameter. Of the calculi removed via primary ureterolithotomy 76 per cent were 1.0 cm. or larger and 6§._5_~ ~ a l ~he_u_pper two-thirds o f the u;eter: _ Surgical complications after ureterolithotomy occurred in 70 patients, an incidence of 17 .5 per cent. Most frequently seen was prolonged drainage of urine from the wound (21 patients). Fourteen patients had cardiovascular complications. Two of the 3 deaths that occurred after ureterolithotomy were secondary to cardiovascular disease (acute myocardial infarction and cardiac arrest) . Transurethral manipulation. Transurethral manipulation of the ureteral calculus was the initial procedure in 661 patients. The Johnson stone basket successfully extracted the calculus in 58 per cent of the cases . The use of the Council instrument followed by use of the Johnson basket was successful in 18 per cent of the cases. The Dormia stone basket was used in 39 patients. Successful extraction of the calculus or calculi was achieved in 588 patients. Of these patients 578 (98 per cent) had a calculus in the lower third of the ureter. Of these 578 patients 362 (63 per cent) had a calculus that was 0.9 cm. or less in greatest diameter. In contrast to stones removed by primary ureterolithotomy 63 per cent of calculi successfully manipulated were 0.9 cm . or less in diameter. Only 28 per cent of manipulated stones were larger than 0.9 cm . and all of these calculi were located in the lower third ofthe ureter . Postoperative complications occurred in 60 patients (10 per cent) . The most frequently encountered complication after successful transurethral extraction was colic, usually secondary to delayed passage of blood clot. Cardiovascular disorders were noted in 10 of the 60 patients with complications . Of the 661 pat ient s who underwent manipulation 3 died postoperatively. Two of these deaths were secondary to cardiovascular disease.
559
560
FURLOW AND BUCCHIERE
120
....."'c::: -~ .....
100
80 ~ - - - - - - - - - - - - - - - - - - - - - ,
El Female II Male
70
80
~
i.:::,
60 40
......
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Printed in U.S .A.
THE SURGICAL FATE OF URETERAL CALCULI: REVIEW OF MAYO CLINIC EXPERIENCE WILLIAM L. FURLOW*
AND
JOHN J. BUCCHIERE
From the Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT
A review of 1,061 patients who underwent ureterolithotomy or transurethral manipulation revealed 2 fa ctors that are important to consider: 1) the roentgenographic size of the calculi measured at the largest diameter and 2) the location of the calculus . These 2 factors in addition to the general med ical condition of the patient, the duration of severity of symptoms and the status of the upper urinary tract provide suitable guide lines for individual management of ureteral calculi. The management of ureteral calculus can be trying for the patient as well as the urologist . Each case differs in regard to specific urologic and medical needs and, therefore, no hard and fast rules should be followed if the patient is to be best served . 1 • 2 The urologist must be prepared to use all available procedures to remove the offending calculus and to preserve renal function . OUR SERIES
To determine suitable guide lines for the surgical management of ureteral calculi we reviewed the case histories of 1,356 patients who had had one or more ureteral calculi that required either transurethral manipulation or primary ureterolithotomy. The patients were seen between January 1950 and December 1966. Of this group 295 patients were excluded from the series, most of whom underwent multiple surgical procedures in an attempt to remove the calculi. The most frequent procedures were ureterolithotomy combined with pelviolithotomy or nephrolithotomy. Other patients who had had previous urinary diversion also were excluded from the series . An additional group of patients who presented with calculus in the ureteral stump is the subject of a separate report . 3 Our study is based on data from 1,061 patients. There were 792 male and 269 female patients, a ratio of 2.5 to 1. Most patients were between 31 and 70 years old, with the 6th decade being the most vulnerable age group. Of the patients less than 30 years old the male to female ratio was reversed, that is there were 44 female and 29 male subjects (figs. 1 and 2). 3 FINDINGS
Clinical signs and symptoms . Classic renal colic was the presenting symptom in 481 patients. Asymptomatic gross hematuria was noted in 36 patients and 8 patients initially presented with anuria . A completely asym tomatic calculus was noted in 115 pa!i_ents. The ca culi were found usually during routine clinical investigations. Calculus was diagnosed most frequently between May and August each year (fig. 3), with peaks in January and October. A positive history of one or more previous calculi was elicited in 23.8~ per cent of the patients. Of these 65.4 per cent had re rrence lil the u;!Silat ur.ei eL~' 4 -- rographic studies . Except for the ureteral calculus , excretory urography revealed no other abnormality in 390 patients. In 134 patients the ureteral calculus was complicated by nonfunction of the involved kidney. In these 134 patients the calculus was located in the lower third of the ureter in 86, middle third in 23 and upper t hird in 25. Seventy-nine per cent
0
Accepted for publication April 30, 1976.
* Requests for reprints: Mayo Clinic, Rochester, Minnesota 55901.
of the calculi located in the lower third of the ureter were treated by manipulation, whereas 100 per cent of the calculi in the upper third and associated with non-function were treated by primary ureterolithotomy . Surgical management . Primary ureterolithotomy was the treatment of choice in 400 patients . Of this group 93 patients (24 per cent) had a calculus that was 0.9 cm . or less in greatest diameter . A calculus less than 1.0 cm. in diameter was present in the lower third of the ureter in 21 of the 93 patients . In 16 of these 21 patients preliminary cystoscopy did not permit passage of a ureteral catheter beyond the stone . In 2 patients benign prostatic hypertrophy prevented any attempt at ureteral instrumentation. One patient presented with a ureteral stricture after transurethral manipulation had been attempted elsewhere. One hundred calculi in the lower third of the ureter were 1.0 cm. or larger in greatest diameter. Of the calculi removed via primary ureterolithotomy 76 per cent were 1.0 cm. or larger and 6§._5_~ ~ a l ~he_u_pper two-thirds o f the u;eter: _ Surgical complications after ureterolithotomy occurred in 70 patients, an incidence of 17 .5 per cent. Most frequently seen was prolonged drainage of urine from the wound (21 patients). Fourteen patients had cardiovascular complications. Two of the 3 deaths that occurred after ureterolithotomy were secondary to cardiovascular disease (acute myocardial infarction and cardiac arrest) . Transurethral manipulation. Transurethral manipulation of the ureteral calculus was the initial procedure in 661 patients. The Johnson stone basket successfully extracted the calculus in 58 per cent of the cases . The use of the Council instrument followed by use of the Johnson basket was successful in 18 per cent of the cases. The Dormia stone basket was used in 39 patients. Successful extraction of the calculus or calculi was achieved in 588 patients. Of these patients 578 (98 per cent) had a calculus in the lower third of the ureter. Of these 578 patients 362 (63 per cent) had a calculus that was 0.9 cm. or less in greatest diameter. In contrast to stones removed by primary ureterolithotomy 63 per cent of calculi successfully manipulated were 0.9 cm . or less in diameter. Only 28 per cent of manipulated stones were larger than 0.9 cm . and all of these calculi were located in the lower third ofthe ureter . Postoperative complications occurred in 60 patients (10 per cent) . The most frequently encountered complication after successful transurethral extraction was colic, usually secondary to delayed passage of blood clot. Cardiovascular disorders were noted in 10 of the 60 patients with complications . Of the 661 pat ient s who underwent manipulation 3 died postoperatively. Two of these deaths were secondary to cardiovascular disease.
559
560
FURLOW AND BUCCHIERE
120
....."'c::: -~ .....
100
80 ~ - - - - - - - - - - - - - - - - - - - - - ,
El Female II Male
70
80
~
i.:::,
60 40
......
