Recurrent Urolithiasis following Anatrophic Nephrolithotomy

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RECURRENT UROLITHIASIS FOLLO\iVING ANATROPHIC NEPHROLITHOTOMY JOHN M. RUSSELL, LLOYD H. HARRISON*

AND

WILLIAM H. BOYCE

From the Section of Urology, Bowman Gray School of llJedicine, Wake Forest University and North Carolina Baptist Hospital, Winston-Salem, North Carolina

ABSTRACT

Analysis of 18 patients who suffered recurrent urolithiasis after anatrophic nephrolithotomy is presented. These patients form a subgroup of 80 patients who underwent 100 consecutive extensive anatrophic nephrolithotomies between 1967 and 1972. Careful documentation of the 18 patients who had recurrent calculi was done in an effort to delineate the causative factors. The recurrence interval varied from less than 6 months to more than 8 years during an over-all followup period of 9.94 years. Marked differences in the characteristics between 14 male and 4 female patients were noted. In the male patients a significant relationship among recurrent staghom calculi, anomalous urinary drainage and Pseudomonas urinary tract infections was noted. The female patients had recurrent or persistent urinary tract infections or undiagnosed metabolic problems as the primary reason for the recurrent urolithiasis. Seventeen recurrences in 14 male and 5 recurrences in 4 female patients are reported. The marked sex differences with regard to stone :recurrence rates (41 per cent in male and 8.6 per cent in female patients) and anatomic characteristics of each group demand separate consideration (tables 3 to 5).

Anatrophic nephrolithotomy, as described in 1968 by Smith and Boyce, provided the surgical elements essential for the successful management of staghorn calculi. 1 Later, in 1974 Boyce and Elkins reported a group of 100 patients undergoing the Boyce procedure who were followed for 3 years, with a stone recurrence rate of 17.7 per cent. 2 In 1979 Russell and associates reported 100 consecutive anatrophic nephrolithotomies in patients followed for a mean of 8.9 years, with an overall recurrence rate of 22 per cent. 3 We herein examine in detail the characteristics of patients with recurrent stone formation from the group reported by Russell and associates.a The cause of these recurrent calculi is determined and the current status of each patient is established through January 1980.

GROUP A-MALE PATIENTS

Urinary tract infection. Before the initial anatrophic nephrolithotomy 7 of the male patients had evidence of persistent and chronic urinary sepsis, 6 had Pseudomonas aeruginosa and 1 had Enterobacte:r species. The 6 male patients with Pseudomonas infections all had significant urological problems, 5 of them having undergone a total of 30 prior operative procedures (cases 1 to 4 and 6) while the sixth patient (case 5) had a urethral stricture requiring urethral dilation and vesicoureteral reflux. One patient (case l) had a failed repair of bladder exstrophy with bladder calculi and incontinence, l (case 3) had meningomyelocele and ileal loop urinary diversion, and 2 (cases 2 and 6) had ~6 procedures done on the kidney or renal pelvis with advanced scar formation present. Another patient (case 4) had advanced intrarenal scar formation and a ureteropelvic junction obstruction secondary to a long-standing nephrostomy tube (table 6). Many of the Pseudomonas species encountered were relaresistant to antibiotic testing and effective antibiotic therapy was difficult to establish. One patient (case 6) with bilateral calculi and 10 previous renal surgical procedures had a Pseudomonas urinary tract infection that was resistant to all antibiotics available in 1968. This patient was treated with gentamicin, polymyxin and a Pseudomonas vaccine. The remaining patients were treated on the basis of in vitro sensitivities with kanamycin, ampicillin, colistin, gentamicin and carbenicillin. Of the 6 male patients who had persistent urinary sepsis preoperatively 5 subsequently suffered recurrent or persistent Pseudomonas urinary tract infections postoperatively. Of these 5 patients 4 (cases 1, 2, 5 and 6) have required at least 1 subsequent operative procedure on the ipsilateral kidney and 3 of these have been found to have significant concurrent metabolic problems (2 with moderate hyperuricuria and l with renal tubular acidosis). The sixth patient (case 4) had an Escherichia coli urinary tract infection postoperatively and is hyperuricuric. Two patients currently are free of stones (cases 4 and 5), 3 have inactive disease by all criteria (cases l to 3) and I recently has

METHOD

Hospital and clinical office records of 100 consecutive patients who underwent anatrophic nephrolithotomy with renal reconstruction between 1967 and early 1972 were reviewed carefully. All patients had a preope:rative metabolic evaluation and all were treated with appropriate antibiotics for a minimum of 8 days postoperatively. These individuals were followed on an outpatient basis until January 1980 with plain x-rays, excretory urograms and urine cultures regularly. Those patients residing out of state or overseas received similar followup care their and results were forwarded to our A patient was classified as having recurrent stones in the ipsilate:ral kidney if radiographically visible stones developed or if there was a of ipsilate:ral renal colic followed the passage of a recoverable calculus. PATIENT POPULATION

A total of 80 patients underwent 100 consecutive anatrophic nephrolithotomies between 1967 and early 1972. Of the patients 18 had recurrent stones in a total of 22 kidneys. Fourteen of 34 male and 4 of 46 female patients had recurrence. Two patients had repeat bilateral nephrolithotomy in the study period, 1 of whom suffered a second set of bilateral calculi. The other patient is free of stones after repeat bilateral nephrolithotomy. Four patients who originally underwent bilateral sequential nephrolithotomy have since suffered stones in a total of 6 kidneys (tables 1 and 2). Accepted for publication June 20, 1980. * Requests for reprints: Department of Urology, Bowman Gray School of Medicine, Winston-Salem, North Carolina 27103. 471

--472

RUSSELL, HARRISON AND BOYCE

undergone an operation for active stone disease (case 6). The male patient with a preoperative Enterobacter species urinary tract infection suffered E. coli and Enterobacter infections postoperatively. This patient returned with a recurrent calculus on the left side 2 years later and has since undergone 2 ipsilateral stone operative procedures. The patient has been free of stones and infection for the last 4 years. Sterile urine. Of the male patients 7 had no evidence of urinary tract infection for an interval of 6 months preoperatively and were found to have metabolic causes for the renal calculous

disease. Preoperative evaluation revealed homozygous cystinuria in 1 patient (case 8), renal tubular acidosis with nephrocalcinosis and hypercalciuria in 1 (case 9), 3 with dietary related hypercalciuria (1 of these also had hyperuricuria) and 2 with persistent hypercalciuria (cases 12 and 13). These patients all were given antibiotics perioperatively, consisting of high dose penicillin, cephalosporin, ampicillin, colistin or chloramphenicol, respectively (table 7). Several new metabolic problems became apparent in these 7 patients. Case 12 was proved to have a 75 gm. parathyroid TABLE 3.

TABLE

1. Patient population Nephrolithotomy 1967-1971

Total No. pts. Sex: F(%) M(%)

Mean age at operation (range) N ephrolithotomy: Single (No. pts.) Bilat. (No. pts.)

80

18

46 34 43 (17-69)

4 (8.6) 14 (41.0) 36 (19-56)

64 16

12

Pt.-Age No. (yrs.)

1-27

Bilat. nephrolithotomy (1968)

2-28

Bilat. nephrolithotomy (1967)

3-19

Lt. nephrolithotomy (1971)

4-47

Lt. nephrolithotomy (1970)

5-47

Bilat. nephrolithotomy (1970)

6-40

Bilat. nephrolithotomy (1968)

7-56

Lt. nephrolithotomy (1967)

No Growth 105 organisms: Proteus species Pseudomonas species Enterobacter

History-total group Non-Recurrent

Recurrent

62 4.6 (0-38)

18 13.8 (0-40)

0

1 1

3 2 3

0

3

No. Male Pts.

No. Female Pts.

7

0

0 6 1

4 0 0

No. Pos. Urine Cultures Magnesium ammonium phosphate Calcium phosphate Calcium oxalate Calcium oxalate/ calcium phosphate Cystine

6

10 2.6

0.9

No. Female Pts.

6 6

5. Initial stone analysis

30

16 14 24

Anatomy

TABLE

No. Male Pts.

Preoperative urine cultures

6

TABLE

Operative Procedure at Presentation (date)

N ephrolithotomy Pyelolithotomy Ureterolithotomy Other genitourinary procedures No genitourinary operation

TABLE 4.

TABLE 2.

Total No. pts. Duration years of stone history (mean) No. previous operative procedures: lpsilat. st1me operation Contralat. stone operation Other genitourinary operation Mean genitourinary procedures per pt.

Recurrent Calculi 1967-1980

History of patients who had recurrent stones

No. Sterile Urine

6

1 0 4 0

1 1 4

1

6. Male patients with urinary tract infections

Previous Operation

Periop. Antibiotics

RecurPostop. Urine rence In- Metabolic Culture and terval Findings Sensitivity (yrs.)

Subsequent Operation

Current Status 1980

Male pts. with Pseudomonas urinary tract infection Exstrophy, incon- 6 lower tract pro- Kanamycin Pseudomonas ½, bilat. Hyperuri- Cutaneous ureter- Small stones, tinence cedures curia ostomy 1969, biinactive dislat. nephroliease; medithotomy 1974 cation-allopurinol, antibiotics Retained It. ure- 4 pyelolithotomies, Colistin, ampicillin Pseudomonas ½,It. Renal tu- Pyelolithotomies Bilat. small teral stent partial nephrecbular 1968, 1969 on stones, staacidosis side of stent, tomy, 2 nephroble; medication-diet, subphrenic lithotomies Pseudomonas antibiotics abscess 1978 Meningomyelo4 lower tract pro- Gentamicin, ampi- Pseudomonas, 6 Neg. None Inactive discele, ileal loop cedures Proteus cillin ease 1963 Old nephrostomy 3 It. pyelolithoto- Colistin 8 E. coli 1971, Hyperuri- Lt. nephrolithot- Free of stones; tube, ureteropel- mies, l lt. pyelono growth curia omy 1979 medication since -allopurivie junction obplasty, 1 It. nephrolithotomy struction stricnol, sodium ture bicarbonate Bilat. vesicoure2, rt. Hyperuri- Rt. nephrolitho"t- Free of stones; Dilate stricture Gentamicin, car- Pseudomonas curia benicillin teral reflux, monthly medication omy 1972 urethral stric-allopuriture nol Advanced intra8 nephrolithotoLt. nephrolithot- Active stone Neg. Gentamicin, poly- Persistent ½ renal scarring mies, 2 partial omy 1980 disease; mixin, PseudoPseudomonephrectomies monas vaccine nas medication (in vitro resist-antibiotics ant to all antibiotics) Male pt. with Enterobacter urinary tract infection Intrarenal abscess Rt. pyelolithotomy Kanamycin Enterococcus, containing stone 1966 E. coli

2

None

Lt. ureterolithotomy 1969, It. pyelolithotomy 1976

Free of stones

RECtJRREI"I'l' UR.OLITI-fI.A8}3 FOLLOVVIf
adenoma and absor;itive hypercalciuria and hyperuricuria. Case 13 (persistent hypercalciuria) has been proved subsequen.tly to have renal leak type hypercalciuria and was treated accordingly with thiazides. Four patients (cases 8, 10, 12 and 14) have been found to have hyperuricuria in addition to the previously known metabolic abnormalities. Only 1 patient has had no real change in the metabolic diagnosis. Of these 7 patients 5 have required an additional operation. Three patients (cases 8, 10 and 13) currently are free of stones, 3 (cases 11, 12 and 14) have inactive stone disease and l (case 9) still has calculi intermittently. GROUP B-FEMALE PATIENTS

Urinary tract infection. Recurrent calculi developed in 4 female patients, all with preoperative Proteus u:rinary tract infections since the initial stone operation. Case 17 (bilateral recurrences with non-absorbable sutures and E.coli) had repeat bilateral nephrolithotomy 6 months after the initial operation. Since that time the patient has remained free of stones and infection. Non-absorbable suture was used in another patient (case 18) for caliceal closure and this patient has been free of infection. However, followup metabolic studies revealed homozygous cystinuria. All subsequent stones have passed and the patient currently is being maintained on a high fluid intake regimen. Metabolic assessments of the other 3 patients were negative. One female patient (case 16) had a ureteral stricture after a subsequent ureterolithotomy and has required a nephrectomy for pyonephrosis. All 4 female patients currently are free of infection and stones (table 8). RESULTS

Recurrent stone formation occurred at intervals ranging from 4 months to 8 years, with a mean of 2.8 years, and without significant difference between male and female patients, or between infected and uninfected patients. Six patients suffered recurrences within 6 months: 3 male patients with urinary TABLE

Operative Pt.-Age Procedure at No. (yrs.) Presentation (date) 8-41

9-34

10-48

11-33

History

Preop. Metabolic Assessment

1

Stones 11 yrs., 4 operative procedures

Hypercalciuria

DISCUSSION

Analysis of 18 patients with recurrent calculi after anatrophic nephrolithotomy delineates clearly certain groups at risk for recurrent stone formation. The preponderance of male patients with calculi is highly significant. The male patients who suffered recurrent stones were either those with Pseudomonas urinary tract infection, abnormal u:rinary drainage or with definite and difficult to treat metabolic anomalies. In several patients the recurring calculi possibly could have been prevented. Non-absorbable suture material was used for caliceal closure in a small group of patients, and those patients with urinary tract infection and this suture material suffered recurrent stones promptly. It is a well understood dictum that non-absorbable suture material should never be used in contact with the collecting system but these particular sutures had been used previously in some encouraging preliminary studies and were believed to be acceptable. The retained ureteral stent also provided a foreign body nidus for recurrent stone formation. Today, we would not allow a patient to leave the hospital with an indwelling stent; those that have not passed spontaneously are removed. The timing of an operation is important particularly in the presence of lower urinary tract abnormalities. If the patient with exstrophy and bladder calculi did not have significant

7. Male patients with uninfected urine Antibiotic During Operation

Lt. nephroli- Stones since age Homozygous cys- Penicillin 1 yr., 2 lt. pyetinuria thotomy (1969) lolithotomies, prostatitis Rt. nephroli- Neg. neck explo- Renal leak, hyPenicillin ration, multiple percalciuria, thotomy (1971) nephrocalcistones (passed), prosnosis, renal tubular acidosis tatitis Lt. nephroli- Multiple stones Absorptive hy(15-yr. history), percalciuria thotomy (1971) recur.rent prostatitis, multiple renal cysts Absorptive hyRt. nephroli- Strong family percalciuria thotomy history hyperuricuria (1970)

preoperatively, 1 male patient with sterile urine and 2 female patients. Of these 3 male f'a.c,,,w,b with Pseudomonas species urinary tract infection 1 had a retained ureteral stent that migrated proximally, 1 had persistent bladder calculi and urinary incontinence, and l had a resistant Pseudomonas infection. In the male patient with sterile urine non-absorbable suture material was used in caliceal repair and he also had undiagnosed hyperparathyroidism. Two female patients suffered rapid stone recurrence: l had bilateral recurrences owing to non-absorbable sutures and 1 appeared to have an incomplete stone removal initially. The mean recurrence interval of the remaining 9 patients was 5.9 years (table 9).

Stone Analysis

Postop. Therapy

Cystine, stru- Fluids, penicilvite lamine

Recurrence Interval (yrs.)

Subsequent Metabolic Evaluation

8, passed Hyperuricuria stone

Subsequent Treatment

Current Status

Force fluids, Free of penicillastones mine, alkalize urine Fluid Passes occasion.al stone

Calcium oxa- Fluids, contralat. late, calnephrolithotcium phosomies, transuphate rethral prostatic resection 1974 Diet, lt. pyeloCalciu1n plasty 1978 phosphate

3

No change

5

Hyperuricu:ria

Calcium oxa- Diet, diphoslate, calphonates, rt. cium phosanatrophic phate nephrolithotomy 1976 Repeat nephroliCo!istin, Calcium ampicillin phosphate, thotomy 1969, calcium oxremoval unabsorbable sualate tures bilat.

3

Type IV hyperlipidemia

½

HyperparathyParathyroid- Inactive ectomy stone disroidism 1971, absorptive hy1971 ease percalciuria, hyperuricuria

Penicillin

Penicillin

12-33

Bilat. nephrolithotomy (1968)

13-22

Lt. nephroli- Nephrolithotomy Hypercalciuria thotomy 1969 (1971)

Penicillin

14-57

Rt. nephroli- Lt. nephrectomy Absorptive hypercalciuria thotomy for stones, rt. nephrolithotsolitary omy 1965 kidney (1968)

Chloromycetin

Diet, allopurinol

Free of stones

Potassiun1 Non-acute phosphate, disease thiazides, on rt. allopurinol side

1972

Calcium Diphosphonates, It. nephroliphosphate, thotomy 1973 calcium oxalate Calcium oxa- Orthophosphate late

Renal leak hyper- Thiazide, po- Free of calciuria 1977 tassium stones phosphate 2

Hypercalciuria, hyperuricuria

Thiazide

Inactive stone disease

474

RUSSELL, HARRISON AND BOYCE TABLE

Pt.-Age No. (yrs.)

15-27

16-30

17-40

18-50

Operative Procedure at Presentation (date)

Preop. Urine Culture and Sensitivity

History

Antibiotic

8. Female patients

Postop. Urine Metabolic Recurrence Culture and AssessInterval Sensitivity ment (yrs.)

Lt. nephrolithot- Recurrent uri- Proteus Ampicillin, E.coli, Kleb- Neg. omy (1969) nary tract ingentamicin siella, enterococcus fection, staghorn calculus post-pregnancy Rt. nephrolithot- Recurrent uri- Proteus Kanamycin, Proteus, En- Neg. omy (1968) nary tract inampicillin terobacter fection

Recurrent uri- Proteus Cephalothin E. coli nary tract infection, laminectomy Lt. nephrolithot- Stones 17 yrs., Proteus Kanamycin, No growth omy (1968) 6 lt. stone ampicillin procedures Bilat. nephrolithotomy (1968)

TABLE

9. Cause of recurrent stone formation No. Male Pts.

Recurrent infection alone: Pseudomonas species Proteus species Enterobacter Many species Recurrent infection plus: Anatomic factors (Pseudomonas) Foreign body Metabolic anomaly diagnosed previously: Absorptive hypercalciuria/hyperuricuria Cystinuria Renal leak hypercalcinosis/renal tubular acidosis Undiagnosed metabolic anomaly: Hyperparathyroidism Cystinuria Renal leak hypercalciuria Totals

0 0

No. Female Pts.

1

0 1 0

0

1

5 1 (Pseudomonas)

0 1 (Proteus)

3

0 0 0

0

1 14

0 1 0 4

obstruction from the renal calculi then urinary diversion would have been more appropriate initially rather than anatrophic nephrolithotomy. We recommend currently that all efforts be made to correct the lower tract obstructive problems before an upper tract operation is considered. The high incidence of recurrent calculus formation in male patients with Pseudomonas infections appears to be related more closely to the coexistence of anomalous urinary drainage or scar formation than to the Pseudomonas infection itself. It also is true that antibiotic coverage of Pseudomonas species with aminoglycocide in combination with semisynthetic penicillins appears to be more effective in vitro. It also is significant that 4 of the 6 male patients with Pseudomonas urinary sepsis also had significant metabolic anomalies often detected only after stone removal. The male patients with sterile urine had definite metabolic problems. In the late 1960s the understanding of various types of hypercalciurias was less clear than now and the treatment options were limited. Several patients subsequently have been found to have had renal leak hypercalciuria or hyperuricuria and have done well recently with thiazides and allopurinol, respectively. It is evident that all male patients with sterile urine who have suffered recurrent calculi had a definite metabolic lesion. It is hoped that the incidence of recurrence in this particular group of patients could be reduced with more effective treatment protocols presently available for metabolic stone disease.

Neg.

Cystinuria 1977

Subsequent Treatment

Cause of Recurrence

Current Status and Treatment

½

Lt. nephrolithot- Infection, incom- Free of stones on omy 1970 plete stone reno medication moval

3

Free of stones Rt. nephrolithot- Infection, ureomy 1971, rt. teral stricture ureterolithotomy 1973, rt. nephrectomy 1977 Free of stones Bilat. nephroli- Unabsorbable thotomy 1969 sutures bilat.

½, bilat.

4

None, 3 yrs. of penicillamine

Undiagnosed Free of stones, cystinuria, unforce fluids absorbable sutures

Recurrent calculus formation in the female patients was rare, with an over-all recurrence rate of 8.6 per cent. One patient clearly had a preventable cause with non-absorbable suture material being used in the caliceal repair and another patient had undiagnosed cystinuria. The other 2 clearly had recurrent infection as the etiologic factor in stone recurrence. The current status of each of the patients who had recurrent stones demonstrates clearly that with persistent endeavor almost all patients except those with the most severe anomalies can at least have the stone disease rendered inactive. None of the female patients currently has calculi and stones form actively in only 2 of the male patients. Six are free of stones. Six patients who initially underwent bilateral nephrolithotomy before 1970 suffered recurrent calculi in a total of 10 kidneys. All 6 patients in our study group have since required a repeat operation, which is in contradistinction to a more recent short-term followup of patients with bilateral staghorn calculi. 4 In that study the cause for recurrent calculi included persistent infection with anomalous drainage of foreign body and definite metabolic problems. CONCLUSIONS

Long-term results reported previously 3 demonstrate clearly that when the Boyce anatrophic nephrolithotomy is combined with adequate metabolic assessment and careful long-term followup an over-all recurrence rate of 22 per cent may be achieved. Those patients with recurrent calculi after anatrophic nephrolithotomy form a small, troublesome group. We have presented a detailed analysis of a series of postoperative patients in whom stones form in an attempt to identify those patients at greatest risk of recurrent calculus formation and who require special treatment. REFERENCES

1. Smith, M. J. V. and Boyce, W. H.: Anatrophic nephrotomy and

plastic calyrhaphy. J. Urol., 99: 521, 1968. 2. Boyce, W. H. and Elkins, I. B.: Reconstructive renal surgery following anatrophic nephrolithotomy: followup of 100 consecutive cases. J. Urol., 111: 307, 1974. 3. Russell, J. M., Webb, R. T., Harrison, L. H. and Boyce, W. H.: Long-term follow-up of 100 anatrophic nephrolithotomy (with calyceal reconstruction). Read at the International Stone Conference, Perth, W. Australia, 1979. 4. Resnick, M. I. and Boyce, W. H.: Bilateral staghorn calculi-patient evaluation and management. J. Urol., 123: 338, 1980.