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TiiE 1938 CANADIAN MEDIcALAssoCIATION JOURNAL 320 Tm. CANADIAN MEDICAL ASSOCIATION [April URINARY OBSTRUCTION IN CHILDREN* BY DAVID W. MACKENZIE AND MAX RATNER Montreal DISEASES of the genito-urinary tract in in- The first one was removed at operatioin (Fig. 1). It shows a destroyed kidney with a large dilated fants and children are sufficiently common ureter. There are three definite obstructive lesions to rate them among the important lesions of present. One is at the uretero-pelvic junction, another at the junction of the middle and lower thirds of the early life. Repeated studies have revealed that ureter, and a third (not shown on the photograph) children are subje-t to practically the same near the ureteral orifice. We feel justified in saying that if the obstructions had been recognized at an urological diseases as adults. However, the most early date proper procedures could have been carried common lesions found in the urinary tract of out, thus preventing the complete destruction of both kidney and ureter. the young are obstructive in type, and the great The second specimen was found at autopsy (Fig. majority of them result from anomalous de- 2). The child, male, aged 9 years, was admitted to the hospital in uraemia. A diagnosis of bilateral velopment. When one realizes that the incidence pyonephrosis and pyo-ureter was made. He died of congenital anomalies in the genito-urinary shortly after. The post-mortem examination revealed completely destroyed kidneys, large dilated ureters, tract is higher than in any other system of the trabeculations and diverticula of the bladder, and body it can be appreciated why the greatest finally a cyst in the posterior urethra. Apparently this cyst caused an obstruction which ultimately de- field of urology today lies in the early diagnosis stroyed the urinary tract. This case too stresses the and treatment of these abnormalities. need for early recognition of urinary obstruction. It is reasonable to assume that the urinary tract might The study of urological disease in children is have been saved from complete damage if the child not new, yet the importance of a complete uro- had undergone an urological examination early in life. logical investigation in the young has not been Campbell, in a recent article on urinary ob- fully appreciated by the medical profession in struction in children, emphasized this very point general until quite recently. We have failed by stating that the greatest field for preventive consistently to realize the gravity of persistent medicine today lies in the early recognition and urinary complaints and findings. In the past treatment of these obstructive lesions in the few years there has been a beneficial change. young. It is of interest to emphasize at this time Internists and paediatricians have been very the prevalence of multiple obstructive lesions in willing to cooperate with the urologists, with the the same organ. It is not uncommon to discover result that today many more children are being at operation or on the autopsy table two or three examined urologically than ever before. More- varieties of congenital lesions along the course over, all children's hospitals of repute have come of the one ureter. This possibility must always to realize the importance of genito-urinary dis- be borne in mind by the surgeon (Fig. 3). in eases children, and have established urological Urinary obstruction in children may be di- services. vided into two groups: (1) upper urinary tract Any obstructive lesion in the genito-urinary obstructions; (2) lower urinary tract obstruc- tract is of prime importance because of the back tions. In the upper urinary tract group the pressure and destructive changes that it eventu- obstruction may be encountered anywhere along ally produces on the renal parenchyma. It is the ureter, including the ureteral orifice. The also an important factor in causing urinary lower urinary tract lesions, on the other hand, stasis and infection. If the obstructive lesion include all obstructions occurring anywhere is not removed the destructive process goes on from the external urethral meatus to the neck until the kidney or kidneys are destroyed. The of the bladder. importance of recognizing such obstructing lesions early is apparent. OBSTRUCTIONS OF THE UPPER URINARY TRACT For the sake of emphasis we wish to discuss 1. Obstruction due to aberrant vessels.-Al- briefly two specimens that were found in young though vascular obstruction of the ureter in children. children is not an uncommon occurrence, yet the' condition is frequently unrecognized and * From the Departments of Urology, Royal Victoria Hospital and Children's Memorial Hospital, Montreal. rarely diagnosed. The aberrant vessels which MAcKENZIE AND IEZATNER: URINARY OBSTRUCTION 321 April 1938] MACKENZIE AND RATNER: URINARY OBSTRUCTION 321 may be arteries, veins, or both, usually cross point that not all anomalous vessels that cross anteriorly to the ureter. The most common site the ureter cause urinary obstruction. Several of these is in the upper portion of the ureter, cases of aberrant vessels have been observed at although cases have been observed where the autopsy and on the operating table without any vessels cross the lower portion of the ureter evidence of hydronephrosis or hydroureter. near the bladder. It will be appreciated at this There has been considerable controversy re- ~ 2 Fig. 1.-A destroyed kidney and a large dilated ureter removed from a young child. There are two definite obstructive lesions shown. One is at the uretero-pelvic junction, and the other at the junction of the middle and lower thirds of the ureter. There was a third obstruction near the ureteral orifice (not shown on this photograph). rig. 2.-Specimen removed at autopsy from a male child aged 9 years. Note the large dilated renal pelves and ureters; also the trabeculated bladder, and the presence of a cyst in the posterior urethra. Fig. 3.-A; specimen removed from a young child illustrating the presence of several obstruction lesions in the same organ. Note (1) the narrow- ing at the uretero-pelvic junction; (2) the presence of multiple valve-like projections about the middle of the ureter; (3) a narrowing of the ureter as it enters the bladder. rig. 4.-A large hydronephrosis and hydroureter. These were caused by several tight fibrous bands at the uretero-pelvic junction, and by three small aberrant vessels crossing the upper and middle portions of the ureter. Fig. 5.-A large hydronephrosis on the left side. This was due to an aberrant artery and vein, which were firmly adherent to the lower portion of the pelvis. rig. 6.-A moderate hydronephrosis and a very large dilated ureter. This was due to a definite stricture just near the ureteral orifice. THE 1938 MEDICAL CANADIAN AssoCIATION 322 THE JOURNAL [April garding the etiological relationship of aberrant graphy, are all important in the diagnosis. The vessels and hydronephrosis. It is believed by pyelogram undoubtedly is the most important some that hydronephrosis results from direct single aid. There is usually a hydronephrosis, compression of the ureter by the vessel; others with at times an abrupt transverse ureteral ob- are of the opinion that there is primarily some struction below it (Fig. 5). Occasionally the renal ptosis which in turn causes the aberrant obstructing vessel causes a complete filling defect vessel to compress the ureter. Quinby assumes in the outline of the pyelogram. In extreme that the pulsation of the aberrant artery against cases the pyelographic substance does not pass the ureter inhibits peristalsis and so causes beyond the obstruction. stasis. The pathological picture depends upon The treatment of this lesion is always surgi- the degree of obstruction and the length of time cal. Whether the procedure will be radical or it has been present. In early cases a mild conservative will depend of course on the con- hydronephrosis is found; as the compression be- dition of the kidney. If the obstruction has comes more aggravated greater stasis results, been present for a long time and has caused until, finally, infection sets in and now there is severe renal damage, then a nephrectomy may a large infected hydronephrosis. Ultimately the be necessary. On the other hand if the kidney entire kidney is destroyed. has not been irreparably hurt a plastic operation The symptoms of obstruction from aberrant will be the procedure of choice. The type of vessels are those of hydronephrosis, with or with- operation will depend on the size and position out infection. A common symptom is pain. This of the vessels. Small arteries may be sacrificed. is usually present in one or other loin, and may If the aberrant vessel is too large some form of be dull or colicky in character. At times it is plastic operation is to be performed. There are confined entirely to the abdomen. Often it is several such procedures. Transplantation of the associated with chills, fever, nausea and vomit- ureter into another portion of the pelvis has ing. More frequently the picture is suggestive been recommended by some. Recently Young'5 of a gastro-enteritis. Recently we observed a described a plastic operation whereby the ureter case that resembled an acute intussuseeption. is not severed. He simply removes a portion The symptomatology is characteristically inter- of the renal pelvis in front, and another portion mittent. There may be long intervals of months behind. In so doing the renal pelvis and ureter or even years during which the patient may be are drawn away from the obstructing vessel, absolutely free of symptoms. On the other hand thus eliminating the necessity of severing any attacks may occur very freqeuntly. of these structures. When infection sets in symptoms of cystitis 2. Obstruction due to fibrous bands.-This appear.

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