CASE REPORTS
MIGRATION OF A URETERIC CALCULUS TO THE BLADDER VIA A URETEROCOLIC AND A VESICOCOLIC FISTULA MALCOLM S. S. EARLAM Royal Prince Alfred Hospital, Sydney Following a difficult nephrectomy for pyonephrosis, two large calculi i n the left pelvic ureter were not removed. T h e upper of these two calculi Rnally found its way into the bladder after ulcerating into the sigmoid colon and thence into the bladder. T h e calculi and the residual ureter were removed and the fistulze closed, with a successful outcome.
THE following record is published because the sequence of events described must not only be excessively rare, but may well be unique.
CLINICALRECORD The patient, then a medical student, came under the care of the late R. K. Lee-Brown in the early 1930s. At this time he had some vague left-sided lower abdominal pain, the only potential explanation for this being a dilated left lower ureter, with a pin-point ureteric orifice. Radiologically the urinary tract was otherwise normal, and the urine was uninfected. H e was treated by periodic dilatation of the small ureteric orifice. I t must be remembered that in this era, although the theories and practice of Guy L. Hunner were becoming somewhat discredited, dilatation of the ureter was practised by most urologists, who indeed, on occasions, had little else to offer. The case records are no longer in existence, but a few years after the death of R. K. Lee-Brown in 1934, the patient, now a medical graduate whose major interest was paediatrics, consulted the author. He now had three calculi, each about a centimetre in diameter, in his dilated lower left ureter. Other findings were as before. H e w a s experiencing some periodic pain, but not of major severity. H e was advised that on the evidence there was no- long. term future in a plain ureterolithotomy, thzt reluctance would be felt in severing a dilated ureter and reimplanting it into the bladder, and that without nephrectomy there was every probability that if removed, his stones would recur. At this time, of course, little if any consideration had been given to operations for the possible cure of ureteric AUST. N.Z. J. SURG.,VOL.47-"o.
4, AUGUST,1977
reflux. Not unreasonably, he decided to carry on, which he felt well able to do. After consideration, he decided, again not unreasonably, to seek the advice of another (and more senior) urologist. H e wrote later to the effect that advice that he undergo operation for removal of the calculi had been given and accepted. Unfortunately, however, one stone only had been recovered, the other two having presumably migrated upwards during positioning of the patient for operation. Convalescence had been uneventful, and he was carrying on again with his practice. H e was lpst sight of for several years, but then presented in somewhat dire straits. H e was experiencing severe left flank pain and was quite unable to carry on with his work. H e was acutely tender in the left flank, and his urine was grossly purulent. Radiological examination showed normal findings on the right side, while the left kidney was non-functioning, and the two calculi in his left pelvic ureter had greatly increased in size. An excessively difficult and prolonged nephrectomy was carried out, after which, in view of blood loss which could not be replaced as it occurred, and the fact that the a n s t h e t i s t was not happy at the thought of any prolongation of operation not immediately essential, it was decided to do nothing further at the time. He was transfused after return to the ward, following which he convalesced well. As he was comfortable and afebrile, he decided to return to his practice, but presented again in January 1949, with severe frequency of micturition, pyuria, and pneumaturia. X-ray examination (Figure I ) showed that the upper of his two calculi had found its way into the bladder. This it could only have done through a ureterocolic fistula (note the
519
EARLAIS
MIGRATION O F URETERIC CALCULUS
FIGURE 2 : Photograph of the two calculi after removal.
FIGURE I : (upper) plain skiagram showing the two calculi at the time of the patient’s final presentation, with air in the left ureter; (lower) cystogram, showing appearance at fundus of bladder consistent with bullous cedema around the vesicocolic fistula. The conformation of the ureteric calculus is somewhat better delineated than in the film above.
air in the ureter in Figure I ) , followed by vesico colic fistula. Why this latter should have occurred, and the calculus not have been passed per rectum, can only be a matter for speculation. At this stage it was decided that the patient’s interests would be better served by an experienced abdominal surgeon than by a urologist, and the aid of the late Mr (later Sir) Benjamin Edye was sought. With his concurrence, the vesical calculus was removed suprapubically, a small suprapubic tube being left in for drainage. M r Edye then carried out a transverse colostomy, later closing the two f i s t u k and removing the residual ureter and calculus in the process. Recovery was uneventful, the colostomy was closed, the cystostomy allowed to heal, and the patient left hospital cured. Figure 2 shows the two calculi. It is a n interesting commentary that the patient stated that given the choice of living with a colostomy or a cystostomy, he would settle for a colostomy every time. H e sustained a fatal coronary occlusion several years later. They had been active and comfortable years, and after all his vicissitudes he deserved a better fate.
ACKNOWLEDGEMENT It would be ungracious not to pay tribute to Sir Benjamin Edye’s surgical skill, which was directly responsible for this patient’s return to normal living. AUST. N.Z. J. SURG.,VOL.@-No.
4, AUGUST,1977
MIGRATION OF A URETERIC CALCULUS TO THE BLADDER VIA A URETEROCOLIC AND A VESICOCOLIC FISTULA MALCOLM S. S. EARLAM Royal Prince Alfred Hospital, Sydney Following a difficult nephrectomy for pyonephrosis, two large calculi i n the left pelvic ureter were not removed. T h e upper of these two calculi Rnally found its way into the bladder after ulcerating into the sigmoid colon and thence into the bladder. T h e calculi and the residual ureter were removed and the fistulze closed, with a successful outcome.
THE following record is published because the sequence of events described must not only be excessively rare, but may well be unique.
CLINICALRECORD The patient, then a medical student, came under the care of the late R. K. Lee-Brown in the early 1930s. At this time he had some vague left-sided lower abdominal pain, the only potential explanation for this being a dilated left lower ureter, with a pin-point ureteric orifice. Radiologically the urinary tract was otherwise normal, and the urine was uninfected. H e was treated by periodic dilatation of the small ureteric orifice. I t must be remembered that in this era, although the theories and practice of Guy L. Hunner were becoming somewhat discredited, dilatation of the ureter was practised by most urologists, who indeed, on occasions, had little else to offer. The case records are no longer in existence, but a few years after the death of R. K. Lee-Brown in 1934, the patient, now a medical graduate whose major interest was paediatrics, consulted the author. He now had three calculi, each about a centimetre in diameter, in his dilated lower left ureter. Other findings were as before. H e w a s experiencing some periodic pain, but not of major severity. H e was advised that on the evidence there was no- long. term future in a plain ureterolithotomy, thzt reluctance would be felt in severing a dilated ureter and reimplanting it into the bladder, and that without nephrectomy there was every probability that if removed, his stones would recur. At this time, of course, little if any consideration had been given to operations for the possible cure of ureteric AUST. N.Z. J. SURG.,VOL.47-"o.
4, AUGUST,1977
reflux. Not unreasonably, he decided to carry on, which he felt well able to do. After consideration, he decided, again not unreasonably, to seek the advice of another (and more senior) urologist. H e wrote later to the effect that advice that he undergo operation for removal of the calculi had been given and accepted. Unfortunately, however, one stone only had been recovered, the other two having presumably migrated upwards during positioning of the patient for operation. Convalescence had been uneventful, and he was carrying on again with his practice. H e was lpst sight of for several years, but then presented in somewhat dire straits. H e was experiencing severe left flank pain and was quite unable to carry on with his work. H e was acutely tender in the left flank, and his urine was grossly purulent. Radiological examination showed normal findings on the right side, while the left kidney was non-functioning, and the two calculi in his left pelvic ureter had greatly increased in size. An excessively difficult and prolonged nephrectomy was carried out, after which, in view of blood loss which could not be replaced as it occurred, and the fact that the a n s t h e t i s t was not happy at the thought of any prolongation of operation not immediately essential, it was decided to do nothing further at the time. He was transfused after return to the ward, following which he convalesced well. As he was comfortable and afebrile, he decided to return to his practice, but presented again in January 1949, with severe frequency of micturition, pyuria, and pneumaturia. X-ray examination (Figure I ) showed that the upper of his two calculi had found its way into the bladder. This it could only have done through a ureterocolic fistula (note the
519
EARLAIS
MIGRATION O F URETERIC CALCULUS
FIGURE 2 : Photograph of the two calculi after removal.
FIGURE I : (upper) plain skiagram showing the two calculi at the time of the patient’s final presentation, with air in the left ureter; (lower) cystogram, showing appearance at fundus of bladder consistent with bullous cedema around the vesicocolic fistula. The conformation of the ureteric calculus is somewhat better delineated than in the film above.
air in the ureter in Figure I ) , followed by vesico colic fistula. Why this latter should have occurred, and the calculus not have been passed per rectum, can only be a matter for speculation. At this stage it was decided that the patient’s interests would be better served by an experienced abdominal surgeon than by a urologist, and the aid of the late Mr (later Sir) Benjamin Edye was sought. With his concurrence, the vesical calculus was removed suprapubically, a small suprapubic tube being left in for drainage. M r Edye then carried out a transverse colostomy, later closing the two f i s t u k and removing the residual ureter and calculus in the process. Recovery was uneventful, the colostomy was closed, the cystostomy allowed to heal, and the patient left hospital cured. Figure 2 shows the two calculi. It is a n interesting commentary that the patient stated that given the choice of living with a colostomy or a cystostomy, he would settle for a colostomy every time. H e sustained a fatal coronary occlusion several years later. They had been active and comfortable years, and after all his vicissitudes he deserved a better fate.
ACKNOWLEDGEMENT It would be ungracious not to pay tribute to Sir Benjamin Edye’s surgical skill, which was directly responsible for this patient’s return to normal living. AUST. N.Z. J. SURG.,VOL.@-No.
4, AUGUST,1977
