An Operation for Valvular Stricture 
of the Ureter. 
CHRISTIAN FENCER, M.D., 
OF CHICAGO. 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
FROM 
December, 1896. Extracted from The American Journal of the Medical Sciences, December, 1896. 
AN OPERATION FOR VALVULAR 
By Christian Fenger, M.D., 
OF CHICAGO. / i 
In cases of hydronephrosis or pyelitis with distention (pyonephrosis) 
it is not uncommon to find comparatively narrow or thin-walled, semi- 
lunar valves located transversely in the ureter. These open upward and 
have the same mechanical action as the valves in veins, and stop the 
passage of liquid through the ureter on its way from the kidney to the 
bladder. These valves are sometimes single and sometimes multiple, 
two or three in the same ureter. They have been depicted in Eayer’s 
atlas,1 and are not uncommonly mentioned in the descriptions of speci- 
mens in the literature. They cause a gradually increasing impediment 
to the flow of urine, and effect dilatation of the ureter above and usu- 
ally near to the valve, so that a ureter with multiple valves will present 
as many dilatations and constrictions as there are valves. It is natural 
that if small stones form in the kidney, they should be arrested at the 
valves. 
That such a valve can be successfully operated upon from within the 
ureter through a longitudinal incision in the latter is well illustrated in 
the following case : 
Case. Synopsis: in 1880, at the age of seventeen years, probably trau- 
matic right floating kidney; remittent attacks of pain, reawakened after first 
pregnancy, in 1885, to disappear for eight years, returning in 1893, subse- 
quent to miscarriage, to become intermittent or almost constant; pyonephro- 
sis, with tumor in region of right kidney; pelviotomy August 6, 1895; 
removal of four stones from ureter above a valvular stricture; longitu- 
dinal ureterotomy over stricture; excision of stricture; plastic operation 
on ureter; wound in pelvis left open for bougie passed down into ureter; 
wound healed without fistula in six weeks; patient well in March, 1896, 
seven months later.—Mrs. G., aged thirty-two years, was referred to me 
by the courtesy of Dr. E. E. Simpson, and entered the German Hospital, 
in my service, August 1, 1895. The patient’s family history was good. 
She had had the ordinary diseases of childhood, but was in other respects 
in excellent health until her seventeenth year. At this time, after 
jumping from a wagon to the ground, she at once experienced pain in 
the right side immediately under the ribs, so severe that she fainted. 
She was not confined to her bed, and the pain was not constant, but 
after an intermission of several days intense pain, lasting from a few 
hours to several weeks, would recur. The pain was located in the right 
1 Rayer: Traite des Maladies des Reins, Paris, 1837. 2 
FENGEE: VALVULAR STRICTURE OF URETER. 
hypochondriac region. No blood was noticed in the urine or stools either 
immediately following the injury or subsequently. 
Menstruation commenced at the age of eighteen years, and she was 
fairly regular and had comparatively little pain or discomfort. She 
married at twenty-one years ; has two children. After the birth of the 
first child the pain in the side again became quite severe, but during her 
second pregnancy she complained of little pain. The second child was 
born three years after the birth of the first, after a tedious labor. On 
the third or fourth day she had a chill, followed by fever, and during 
the six weeks following had fever and intense pain in the back, the left 
half of the abdomen, and the joints in various parts of the body. Dur- 
ing the first week after her confinement a large slough, four inches in 
length, extending from the anus upward over the sacrum, occurred. 
Five weeks later the gangrenous tissue was removed, but the wound did 
not heal for three months and a half. During the next four years the 
patient had three miscarriages. At the time of the last miscarriage, in 
1893, the patient had the same pain that she had had fifteen years pre- 
viously in the right hypochondriac region, ranging to the median line. 
The patient was somewhat emaciated ; heart and lungs normal; ab- 
dominal examination revealed an obscurely defined tumor in the right 
side of the abdomen, close to the umbilicus, four inches long by three 
inches wide, dull upon percussion. The tumor was readily movable to 
the median line and backward to the normal position of the kidney, but 
attempts to move the tumor caused considerable pain. Vaginal exami- 
nation showed that the uterus was somewhat enlarged, but in normal 
position, and not freely movable. Pressure over the ovaries caused only 
slight pain. The urine contained neither albumin nor sugar. 
During the attacks of pain she urinates frequently, but passes only 
small quantities of urine. The pain always begins in the right lumbar 
region, and from here radiates to the epigastrium, anterior part of chest, 
right and left inguinal regions, and also sometimes into the leg. She 
has lost forty pounds in weight during the last seven years. 
Diagnosis. Cystonephrosis of right movable kidney, probably due to 
stone in kidney or pelvis. Probably infected. 
I therefore advised exploratory incision for drainage and possible 
removal of stones. 
Operation. On August 6th I operated in the following manner : the 
patient was anaesthetized with ether and placed on the left side on a 
cushion. An incision was made between the twelfth rib and the rim of 
the pelvis forward for about nine inches from the border of the erector 
spinae muscle. (Fig. 1.) 
The kidney was large with but little perirenal fat, and was freely 
movable. Two small cysts presented on the convex surface of the kid- 
ney, about the size of a pea, which contained clear fluid. A part of 
the kidney-tissue which included these cysts was removed for examina- 
tion. After isolation of the pelvis, which I found to be somewhat dilated, 
but in which I could feel no stones, I laid bare the ureter and felt a 
nodular mass two inches below the pelvis. I then incised the pelvis 
longitudinally and about an ounce of urine escaped, from which cultures 
were made. I could now insert my little finger down into the dilated 
ureter for an inch without feeling a stone, but upon manipulation of the 
ureter with the other hand I was able to squeeze four stones up into the 
pelvis and remove them through the wound in the pelvis. (Fig. 2.) A FENGER: VALVULAR STRICTURE OF URETER. 
3 
sound passed down fxom the pelvis into the ureter was arrested two 
and a half inches below the pelvis, at a point where a somewhat soft 
thickening was felt on palpation. A longitudinal incision was now made 
three-eighths of an inch long into the ureter upon the end of the sound 
Fig. i. 
Line of incision when wound was nearly healed. 
above, through and below a transverse valvular stricture. “A probe in- 
serted through the opening in the ureter below the stricture passed easily 
down into the bladder. By holding the longitudinal wound open and 
stretching this part of the ureter over the index-finger I clipped offjhe 
Fig. 2. 
Stones from ureter above stricture; natural size. 
valvular stricture (Fig. 3) from within the ureter with scissors, leaving the 
muscular and internal coats of the ureter intact. I now made my plastic 
operation on the ureter1 and inserted a flexible bougie, No. 12, from the 
wound in the pelvis into the ureter. The wound in the pelvis was left 
open. Upon digital exploration of the calices through the wound in 
1 Fenger : Journal of the American Medical Association, March 10,1894. 4 
FENGrER : VALVULAR STRICTURE OF URETER. 
the pelvis I found the calices moderately dilated, and in one of them 
a small stone, which I removed. No other stones were found after care- 
ful examination. On this account I did not consider it necessary to 
incise the kidney on its convex surface. Rubber drainage-tubes were 
then inserted, one down to the wound in the ureter, and another to the 
pelvis of the kidney. These tubes were surrounded with gauze. The 
external wound was closed with heavy silk sutures. 
Fig. 3. 
Circular valve in the ureter ; natural size. 
The operation occupied 'two hours. At the close of the operation the 
patient was in good condition, pulse strong, respiration good. She vom- 
ited twice after the operation. In the evening she was catheterized and 
two ounces of dark-brown urine withdrawn. She complained of severe 
pain in the wound. During the night she passed four ounces of urine 
and toward morning the pain decreased. 
Fig. 4. 
Microscopic section of valve. 
Microscopical examination of the valve (Fig. 4) showed that this con- 
sisted of firm fibrillary connective, tissue, with normal distribution of 
vessels (a), no muscular fibres of the wall extending into it. The free 
border of the valve looking into the lumen of the ureter (d) was clad 
with stratified cylindrical and cuboid epithelium (6). The border of FENGEE: VALVULAR STRICTURE OF URETER. 
5 
the valve was folded, and thus a cross-section through the bottom of a 
fold showed an island of cuboid epithelial cells (e). 
Ith. The patient vomited several times, complained of severe pain in 
the afternoon, and passed bloody urine. During the twenty-four hours 
she passed sixteen and a half ounces of urine. She complained of severe 
pain in the wound, but was otherwise bright and cheerful. Considerable 
discharge found in the dressings. , 
Bth. The patient passed bloody urine throughout the day and com- 
plained of very severe pain. 
9th. The patient had but little pain during the day, and the nausea 
and vomiting ceased. 
10th. The gauze was almost dry, indicating that the urine had passed 
along the bougie through the ureter. 
11th. The patient was perspiring profusely for about half an hour in 
the evening, and a little later complained of severe pain. 
12th. Thirty ounces of urine were passed in the twenty-four hours. 
18th. The patient complains of severe pain. The bougie was removed, 
but the drainage-tube allowed to remain in place. In the afternoon she 
complained of severe pain. 
15th. The patient complains of sharp pain in the bladder at the close 
of urination and also of pain in the wound. 
20th. Condition of wound and patient excellent. 
26th. No urine in the dressings. Drainage-tube to the pelvis of the 
kidney removed and tube to the wound in ureter shortened. 
September Ist. Drainage-tube removed. 
Bth. The patient sitting up. Feels strong, and is bright and cheerful. 
20th. The patient left the hospital for her home. The wound was 
healed with the exception of a narrow superficial granulating line. 
On March 19, 1896, Dr. Simpson wrote me as follows : “ Mrs. G. is 
doing remarkably well.” 
It will be seen that the operation for infected cystonephrosis in this 
case was not nephrotomy, as the convex surface of the kidney was not 
divided at all. Pelviotomy (opening of the pelvis) was made, partly for 
the removal of the stones squeezed up out of the ureter and partly for 
the exploration of the ureter and calices. 
Exploration of the ureter with the sound led to the detection of the 
stricture, a valve, which was excised through a longitudinal opening 
in the ureter at its seat. I consider this operation preferable to excision 
of the entire wall of the ureter and invagination after Van Hook’s 
method, as it is followed by the least possible shortening of the canal. 
This point may be of importance if more than valvular stricture should 
have to be operated upon. 
Exploration of the calices can be made just as well through an in- 
cision in a somewhat dilated pelvis when the latter is wide enough to 
permit exploration with the finger and sound. For additional security 
against leaving stones in hidden calices with narrow entrances it would 
be Avell to explore through the convex surface of the kidney with steel 
needles. When this is done in addition to digital exploration through 6 
FEJSTGEE: VALVULAR STRICTURE OE URETER. 
the pelviotomy-wound I think there is as little risk of overlooking 
stones as exists when the convex surface of the kidney is divided. To 
avoid dividing the posterior surface of the kidney avoids hemorrhage, 
the operation on the pelvis of the kidney being entirely bloodless. 
For the local treatment of pyelitis—that is, inflammation of the pelvis 
and calices—drainage through the wound in the pelvis will be sufficient, 
at least in ordinary cases of stones and valves in which, by removal of 
the cause, we may reasonably expect the pyelitis to come to an end. 
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