Specific gravity
Permeability to X-ray
Density of shadow
Calcium oxalate
Biliary calculi
Calcium oxalate
Uric acid
Uric acid
Phosphates
Phosphates
Phosphates
Uric acid
Biliary calculi
Calcium oxalate
Biliary calculi
One of the first textbooks on X-rays was Henry Snowden Ward’s 1896 work entitled Practical Radiography [25]. An American textbook followed a bit later in the year by an electrical engineer, Edwin Hammer and a New York City physician, Henry Morton (X–Ray; or, Photography of the Invisible and its Value in Surgery). In their work, Morton and Hammer speculated rather presciently about many of the future applications regarding the new ray [26]. Morton would continue in the field and published The Archives of the Roentgen Ray beginning in July of 1897. David Walsh published the first medical textbook in 1897, The Röntgen Rays in Medical Work. He covered a large possible scope for application. Francis Williams from Boston published his 1902 textbook called The Roentgen Rays in Medicine and Surgery. Here he describes the possibility of diagnosing stone disease. In 1908 Mihran Kassabian of Philadelphia published his Radiography, X–ray Therapeutics and Radium Therapy where he also mentions genito-urinary applications [23]. This brings us to E. Hurry Fenwick’s 1908 textbook The Value of Radiography in the Diagnosis and Treatment of Urinary Stone. A Study in Clinical and Operative Surgery [27]. “Two groups of professional workers are mainly concerned in a careful study of shadows cast by the Röntgen rays in the urinary tract– the operator and the radiographer. Both work independently and yet both are interdependent. The former cannot justly cast the responsibility of shadow deduction upon the latter, though he is dependent upon him for skill in shadow detection. The radiographer cannot be content with merely producing shadows: he must aspire to the knowledge of their causation, and to obtain this he must examine critically and learn from the work of the operator. Each must give: each take” [27]. There is no better opening paragraph to a new era of diagnosis than this one. Fenwick delineated the course of the ureters trying to limit the risks of phleboliths (calcified venous valves in the pelvis) which had caused false negative ureteral explorations. His book has 11 chapters and is richly illustrated by 80 x-ray plates. At this early phase of radiography, this textbook is amazing and clearly points out the potential for changing the way stone patients are diagnosed.
A. Béclère followed the pathway set earlier by Swain and calculated the atomic weights of the elements that make up stones and also correlated this with the X-ray ability to visualize the stones [28]. He noted that of the various salts, such as carbonates, urates, and oxalates that the absorption of X-ray increases with the atomic weight of the salt. In order of their increasing capacity of absorption he listed the stones as follows: urate of ammonia, sodium urate, magnesium urate, potassium urate, and calcium urate. These were the greatest atomic weight salts, but he realized that the number of atoms and the molecular structure might also play a role in X-ray absorption. He realized that the majority of calculi that cast no shadows on X-rays were largely of uric acid. Calcium oxalate, phosphate stones, and calcium carbonate all were readily imaged. Cystine stones he noted cast a faint shadow. He even looked at rare xanthine and cholesterol stones and proved that they were akin to uric acid and were not at all imaged. He noted “The X–ray never lies; it simply penetrates bodies in inverse proportion to their atomic weights– it is not the X–ray that is at fault, it is our interpretation that is at fault” [28].
The urology groups at Johns Hopkins and New York Hospital followed as well. O.S. Lowsley noted that the most common causes for X-ray to fail in the diagnosis of stones are the following: [29]
1.
Faulty x-ray technique
2.
Motion or breathing by the patient
3.
Presence of gas in the intestines
4.
Overlapping the calculus over bone shadows
5.
Obesity of the patient
6.
Failure to make a complete cystoscopic examination with retrograde pyelogram
7.
Inexpert interpretation of the plates
Harvey W. Cushing (1869–1939) who is considered the father of neurosurgery and a gifted writer, won a Pulitzer Prize for his 1926 biography of his mentor and idol Sir William Osler [30]. Cushing was born in 1869, the tenth child from a family with strong lineage of physicians and scholars. He had just completed his internship at the Massachusetts General Hospital in 1895 when Röntgen discovered the X-ray. Cushing helped develop the early X-ray program in Boston. On February 15, 1886, a mere 6 weeks since Röntgen’s report, Cushing wrote to his mother “Every one is very excited over the new photographic discovery. Professor Roentgen may have discovered something with his cathode rays that may revolutionize medical diagnosis.” He and the house staff at MGH purchased their own X-ray machine and when he left Johns Hopkins it was rumored that he took the tube with him [31]. He certainly brought his radiographic interests with him to Baltimore and he helped junior house staff develop the first X-ray equipment at Johns Hopkins. Let us relate the first X-ray examination performed at Johns Hopkins in Cushing’s own words. “It was in the fall of 1896 that I went to Johns Hopkins and made the first roentgenograms that were taken there, with the aid of a decrepit and perverse static machine as big as a hurdy–gurdy and operated in the same way, by turning a crank. My first paper submitted for publication contained an account of a case of a gunshot wound of the spine with plates showing a bullet which a Baltimorean had planted in the body of his wife’s sixth cervical vertebrae” [32]. He apparently became the technician during the early years, despite his grueling schedule as a resident of William S. Halsted’s surgical service [33]. Another Hopkins’ man who also interacted closely with Cushing was Hugh Hampton Young. Young was given the role to develop genitourinary surgery by the Chief, William S. Halsted. Hugh Hampton Young’s textbook of Urological Roentgenology appeared in 1928. Now radiology assumed its modern foundation in the diagnosis and management of stone disease [34].
At the Hôpital Necker in Paris the department of urology was strongly interested in stone disease and Félix Guyon helped promote the first X-rays of stones. By, 1897, the first four radiological laboratories had been created in Paris, and by Guyon’s colleagues Théodore Tuffier and Janet introduced the ureteral catheters and X-rayed the patients. Joaquin Albarran (1860–1912) was a Cuban-born urologist trained in Barcelona but had come to work with Guyon. He developed a whole host of technologies to improve the radiologic diagnosis, including the first radiolucent catheters. Albarran was the first urologist to ever be nominated for a Nobel Prize in 1912 but he died just prior to the election [23]. Howard Kelly worked with finely waxed catheters prior to radiology that would become scratched or etched when encountering a stone [35]. The X-ray was a vast improvement over this non-specific methodology. By 1914, another urologist named Pasteau developed a marked semi-opaque centimeter scaled ureteral catheter. Contrast materials were thought of, the first utilized was air, oxygen, and carbon dioxide. In 1903 Wittek injected air into the bladder to better X-ray and identified a bladder stone. In 1905 Wulff and Albers-Schönberg in Hamburg injected air and bismuth into the bladder of a stone patient [36].
Then in 1906 the German urologists Voelcker, von Lichtenberg, and Czerny began to investigate opacification agents with a variety of compounds including bismuth, lithium, silver, and then thorium. By 1914, Albarran began to use their silver compound (Collargol®) to perform retrograde pyelograms [37]. Marcel Guerbet, a French chemist had suggested using non-toxic iodinated compounds to Albarran. A German compound Iodipin® from Merck Darmstadt was followed by Lipiodol®. Sodium iodine was used at the Mayo Clinic in 1923 by the pharmacist Rowntree to visualize the bladder on a syphilitic patient. Osborne and colleagues followed with a clinical trial with no great success, but Graham and Cole switched to iodinated phenolphthalein in 1924 [38]. Thorotrast® was a sodium-iodine solution for intravascular X-ray exams but it was found to be carcinogenic. Legueu and colleagues utilized it in the 1920s for retrograde urography. In Berlin between 1928 and 1929 the synthesis of a watersoluble iodinated contrast agent was undertaken by a young American urologist, Moses Swick who worked for Alexander von Lichtenberg. He was in Leopold Lichtwitz’s clinic at the time and knew that Binz and Rath had synthesized a new benzoic acid iodinated material. He tried this new compound, Selectan Neutral® on rabbits and obtained intravenous pyelograms. Swick took the new material and tried it on humans [39]. Von Lichtenberg began the official study using Uroselectan® and the IVP became the mainstay for diagnosing ureterolithiasis [40].
The intravenous pyelogram (IVP) was the “gold standard” evaluation despite recent detractors favoring other methods. After the development of Uroselectan® Schering AG developed Uroselectan B® and then Diodone®. Bayer came out with Abrody® and the French developed a diiodinated molecule called Tenebryl®. By 1930, Coliez noted that improved imaging was possible with ureteral dilation and Zeigler developed an abdominal compression device to aid upper tract visualization [41]. Von Lichtenberg summarized all of these developments in 1931 [42]. IVP provided accurate size, shape, location, and functional data regarding the calculus and the kidney. In one recent evaluation, the IVP revealed unexpected findings in 42 % of patients and altered the management strategy in 60 % [43]. The modern era was ushered into existence by the introduction of CT scanning which has proved to be superior for ureteral calculus imaging to all other modalities.
From Ureterolithotomy to Stone Basketing
Surgery was now possible and stone disease was ready to undergo an epiphany. No longer was colic to be suffered, endured, when surgery offered a now painless, and less risky method of delivering those suffering with stones. Aseptic surgery rapidly reduced the postoperative mortality and morbidity from wound infections. Upper tract disease could be diagnosed with first with finely waxed catheters as demonstrated by Kelly, then increasingly with X-rays, and finally with intravenous pyelograms that could now accurately determine the size and location of the stone. But these massively successful methods did not all come at once. Many were the patients following the availability of both general anesthesia and aseptic surgical technique that would undergo surgery for an upper tract stone, with none being found. Aggressive surgeons were perhaps following the dictum of George Bernard Shaw.
In 1923, Herman Kretschmer summarized the knowledge of ureteral calculous disease into three distinct eras. First was the early time following X-ray introduction when patients were explored for presumed ureteral stones, and significant numbers of patients had none. Next, the era when ureteral catheters and retrograde pyelograms were done in suspected ureteral stone cases, but open exploration was again necessary with significant morbidity. He now describes the current trends of cystoscopic retrograde techniques [1]. Howard A. Kelly catheterized the ureters in most cases that he suspected a ureteral stone, even with good quality X-rays. “It is our habit in catheterizing ureters in practically all cases to wax the catheter tip before its introduction. The wax on the end of the catheter serves the purpose of a tell–tale, revealing the presence of any stone encountered by it in its passage up the urinary tract.” He discusses the nuances of ureteral catheterization for stones.” The catheter must be introduced into the ureter without touching the side of the speculum. Striking the metal makes a flat, smooth facet which cannot be mistaken for the gouge of the calculus.” Once withdrawn, the waxed catheter is taken and examined in bright light with a magnifying lens from three to five diameters, looking for the tell tale scratches of a stone. Kirkendall described a method of adapting Kelly’s technique of waxed catheter passage for catheterizing cystoscopes. He lined the outer sheath of the outer sheath of the cystoscope with a loose-fitting rubber tube which protects the catheter during passage [44].
Winsbury White in his 1,929 textbook Stone in the Urinary Tract devotes Chaps. 7, 8, and 9 to the diagnosis and treatment of calculus in the ureter [45]. He notes the percentage of stones presenting at different levels of the ureter as follows: lumbar 22 %, iliac 7 %, pelvic 51 %, and intra-mural 17 %. He too, did not depend solely upon the radiograph, he used Kelly’s method of waxed catheter method. He begins “There are three alternatives in dealing with a ureteric calculus: the stone may be left to pass by natural means, its passage may be aided by transcystoscopic measures, or it may be removed by operation” [1]. In Young’s magnum opus Young’s Practice of Urology, Based on a Study of 12, 500 cases, his table 48 in Volume II, displays the outcomes from their 116 cases of stone disease [46]. Ureterolithotomy was performed in only six patients (“3 well, 1 improved, 1 dead, 2 no reply). Kretschemer noted in 140 cases of ureteral stones, patients passed them spontaneously in 26 % of the time [1]. He also reported that stones 5 mm or less were the most likely to pass. Crowell presented a series of cystoscopic management of stones and reports on various methods of management. He used local anesthesia of 2–5 % procaine and injected the anesthetic up the ureter on impacted stones, occasionally injecting oil to get a catheter to slide by the stone. The catheters were tied in place and slowly exchanged for larger sizes daily until two No. 11’s and one No. 6 are all in together [47]. Rapid dilation of the ureter was described by Bransford Lewis using metal dilators and bougies but noted a danger in pushing the stone back into the kidney. Bugbee recorded the success of cystoscopic treatment as 326 successes out of 347 cases and Crowell noted 88 successes in 98 cases [48]. Contraindications to cystoscopic manipulation of ureteral stones were described as stone sizes above 2 cm., impacted or encysted stones, acute infection and in cases where there is known disease in the bladder or prostate. Ravich reported on a personal series of 758 cases or ureteral stones in a private series. Only 48 patients passed their stones spontaneously, 456 passed the stone after simpler cystoscopic manipulations, 17 were advised to have surgery but refused, and 68 were required open surgery. His open surgical incidence was 11.2 % [49].
John Swift Joly also waxed eloquently on the management of ureteral stones in his Chap. 6 of Stone and Calculous Disease of the Urinary Organs [50]. Joly presented the incidence of bilaterality of ureteral stones to be 3 % but thought it could actually be higher in silent cases that present only as post mortem cases. He worried about small stones as well as large ones, “A large ureteric calculus simply means that the stone has not given rise to obstruction, and that the function of the kidney above it has been more or less preserved. This is only relative, as rapid growth of the stone indicates the presence of infection, and the kidney sooner or later succumbs to the infection” [51]. Joly also discussed methods that have been used historically to try to induce ureteral stone passage. He noted that Albarran recommended significant hydration. “Diuretics have been suggested including citrate of potash, diuretin, theocin sodium acetate, weak tea, barley water, Vittel and Contrexéville water (mineral waters)” [50]. Belladonna was recommended by some, but questioned by Macht, and he describes the use of papaverin injected subcutaneously recommended by Bachrach. Oral glycerin “does not appear to have any definite action” [51].
Bumpus and Scholl reported on 640 cases of ureterolithotomy from the Mayo Clinic and had an operative mortality rate of 0.62 % [52]. They discussed the imperative of knowing at the time of exploration the exact location of the concretion for planning the surgical incision site. They recommended an X-ray within 1 day of the surgery. They recommend an extra-peritoneal approach in all cases, and once the stone was palpated to secure it prior to incising the ureter to prevent it slipping retrograde back up the dilated ureter. Once removed they further recommended exploring the ureter with a bougie to insure that there are no further stones. They did not routinely suture the ureterotomy closed stating that it difficult to suture the ureter many times because of the inflammation. They recommended leaving a small drainage tube which is placed next to the ureter in the vicinity of the incision and generally removed after 48 h. Closing this discussion on ureterolithotomy with some comments by Frederic E.B. Foley, the inventor of the indwelling catheter seems appropriate [53]. He began with the following comments, “In recent years, ingenious devices and methods have been perfected for the passage or removal of ureteral stones without resort to operation.” You can almost anticipate at this point that he is going to decry the newer, less invasive therapies for a careful open alternative, like the naysayers to Civiale. “There is much evidence that this attitude has carried too far and that the just purpose of such management is becoming subordinate to mere zeal for its use.” We can follow his path throughout the article, but he believes that the open surgery itself can be modified; making what was a major open operation, far less incapacitating. “Lumbar ureterotomy, as described in textbooks and as usually seen, is also a definitely major operation; it can and should be a relatively minor one. A method and technic for lumbar have been perfected and are described here that so minimize the operation that in this form it scarcely belongs to major surgery” [53].
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