Operative treatment of hydronephrosis or pyonephrosis. (Hartmann.)
Until the infectious or suppurative element be added the urine is in these cases but little changed. When infection is added the case becomes one of pyohydronephrosis, and perhaps finally one of distinct pyonephrosis. The symptoms produced at first are not very pronounced and will vary with the exciting cause. If the result of acute obstruction, renal colic is perhaps the most significant. When this is accompanied by tumor in the region of the kidney the interpretation of the phenomenon is easy. Sudden decrease in size of such tumor, with unusually great escape of urine, is also pathognomonic of intermittent hydronephrosis. The discovery and the history of a gradually increasing tumor in which, when large, fluctuation can be determined, and in which fluid is easily found with the aspirating needle, will permit a differentiation of these pseudocysts from solid tumors of the kidney. They are to be distinguished from ovarian cysts, from general ascitic accumulations within the abdomen, and from perinephritic and spinal abscesses. Their location, which corresponds so closely with that of the kidney, especially while they are small, their gradual growth, the displacement of the abdominal viscera forward and to their inner side, their enlargement downward and their fluctuating character will usually provide features by which they may be accurately recognized.
Treatment.
—The treatment of intermittent hydronephrosis in its earlier stage may be accomplished by some measure less radical than nephrectomy or nephrotomy, particularly when due simply to abnormal movability or to pressure of some extrinsic growth. Hydronephrosis due to obstruction by renal calculus may be relieved by removal of the obstructing stone, but a hydronephritic cyst, which has attained large size, in which practically all semblance to secreting kidney structure has disappeared, should be extirpated, unless this should entail too formidable an operation, in which case it should be freely opened and drained until such time as it has contracted to a size justifying enucleation ([Fig. 642]).
THE URETERS.
There are a few morbid surgical conditions of the ureters, so distinct from those of the bladder below or the kidneys above as to require separate consideration here. They are frequently involved in the pyogenic and tuberculous infections, which spread along them in either direction, but the chief surgical diseases deserving mention here are stricture and calculus.
STRICTURE OF THE URETER.
Stricture of the ureter may result from intrinsic or extrinsic lesions. Thus it has been injured in operations upon the pelvic viscera, as in parturition, and it is not infrequently pressed upon by neoplasms; but the majority of its contractions are cicatricial, and are consequences of ulceration or injuries done by calculi. Stricture of the ureter is to be recognized rather by its consequences—i. e., hydronephrosis—than by more direct symptoms. Its accurate location is now possible by the use of the cystoscope and the ureteral bougie or catheter. When by the cystoscope no urine is seen escaping from the ureter one naturally infers its complete obstruction—in fact, the degree of the latter is fairly estimable with this instrument. However, with the passage of a bougie the trouble may be found. This is particularly of value when the lesion is an impacted calculus, for it indicates to the surgeon the level at which he should direct his operative relief, a matter which may also be decided by a skiagram.
While in the hands of experts dilatation of the ureters may be accomplished from below, it is usually beyond the ability of the average surgeon. He has to decide, then, as to whether the ureter should be exposed along its course, from the loin, extraperitoneally along the groin, or by abdominal section. A ureter hopelessly entangled in a mass of cancer may be turned into the other ureter or into the bowel. A ureter fixed in a narrow, cicatricial band may be divided and its upper end turned into the tube below the stricture by a process of transplantation or anastomosis, which is one of the feats of modern surgery; but a ureter hopelessly involved for a considerable portion, or hopelessly diseased, will require nephrectomy, as the kidney above it may be compromised and can probably be well spared.
Calculi impacted in the ureter are most commonly arrested at those points where its caliber is normally smallest, just below its origin, at the pelvic brim, and just above its orifice. The symptoms of impaction are those of renal colic, already considered. It should be sufficient that extreme pain and the escape of pus and blood in the urine, accompanied by more or less distention of the kidney above, are noted. If there be a history of previous attacks of this kind, with the passage of small calculi, the diagnosis may be regarded as positive. This may or may not be confirmed by the x-rays, or by the catheterization of the ureter from below.