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The Treatment of Carbuncle of the Kidney
THE TREATMENT OF CARBUNCLE OF THE KIDNEY KEN MOONEY From the Urological Department of Parkland lfospital and Baylor University College of Medicine, Dallas, Texas INTRODUCTION
Carbuncle of the kidney is now being recognized with increasing frequency as a significant clinical entity due to the excellent writings of Brady, O'Conor, JVIoore, Graves and Parkins and others. Spence and Johnston collected 102 proved cases, including 1 of their own, up to 1938 and since then numerous additional cases have been reported. The purpose of this communication is to record another case which illustrates some of the diagnostic difficulties and vagaries of carbuncle of the kidney, and demonstrates in a strikingly graphic manner the value of cornervative surgery in this malady in c:elected instances. Detailed descriptions of the disease have been given by the writers mentioned and need not be repeated here. In brief, a renal carbuncle may be defined as a circumscribed, indurated, multilocular suppurative process in the renal parenchyma, usually caused by the Staphylococcus aureus borne through the blood stream from a distant septic focus. There is always an associated perinephritis, but a frank perinephric abscess occurs in only about a third of the cases. The clinical picture consists of the insidious onset over a period of weeks of pain and tenderness in the affected renal area plus the constitutional signs of sepsis; i.e., chills, fever, malaise, weight loss and leukocytosis. Urinary symptmm, are usually absent, and the urinalysis is characteristically normal, due to the fact that the lesion is cortical and does not communicate with the urinary pa8sages. Excretory or retrograde urography showing a deformity or filling defect of pelvis or calyces from pressure by the carbuncular mass is the most helpful diagnostic aid. All writers agree that the treatment is primarily surgical; we shall discuss later the factors indicating primary nephrectomy or some more conservative drainage operation. CASE REPORT
C. F., a 15 year old white female, was admitted to Parkland Hospital on :Vlarch 15, 1940, complaining of pain in the right side of the abdomen of 6 weeks' duration. The pain was of a constant dull aching character localized in the right renal area and hypochondrium. There were absolutely no urinary or gastrointestinal symptoms. Fever had not been noted and no history of recent boils or other septic focus could be elicited. She had been up and about until the past week when a physician had noted a tender mass in the abdomen and advised hospitalization. The past history was non-contributory. The patient wa8 an alert, well developed and nourished girl of 15, not acutely ill. Temperature 98.6°F., pulse 90. Abnormal findings were confined to the abdomen, where a smooth mass was readily felt in the right upper quadrant and 24!)
250
KEN MOONEY
right loin posteriorly. Its lower margin extended 2 fingers' breadth below the umbilicus, while upwardly the mass disappeared under the costal margin. The mass was firm, non-tender, and moved slightly on respiration. Urinalysis: Clear, trace of albumin; 7 to 8 leukocytes per low power field; urine culture sterile. Blood examination: Hemoglobin 78 per cent; red blood cells, 3,700,000; white blood cells 16,800, of which 74 per cent were polymorphonuclear leukocytes (71 segmented and 3 band forms). Kline test negative. Blood urea 26.3 mg. per 100 cc. blood. A roentgenogram of the chest was normal. Cystoscopy and pyelography were done the day of admission. The bladder was normal. Urine from the right kidney contained a few leukocytes but
FIG. 1 FIG. 2 Frn. 1. Right retrograde pyelogram on admission showing no significant abnormality FIG. 2. Similar pyelogram 14 weeks later suggesting a mass developing between upper and middle calyces.
showed no organisms on stain of the sediment and culture. Both excretory and retrograde pyelograms (fig. I) were interpreted as normal. On March 18, however, an upright retrograde pyelogram showed slight if any mobility of the right kidney. Following the urological investigation a pneumoperitoneum was done and demonstrated a mass below the liver, occupying the right kidney area. A peritoneoscopy was performed and the operator reported a normal peritoneal cavity and contents. The patient was observed in the ward for 18 days persistently running a low grade fever. During this time the right kidney was suspected, but only towards the end of the time did exploration seem justified. The preoperative diagnosis was perinephric abscess.
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On March 2, under general anesthesia, Dr. J. C. Alexander drained a large right perinephric abscess through an oblique loin incision. Staphylococcus aureus was cultured from the pus. The patient made a satisfactory convalescence but ran a persistent fever of 99° to 101 °F. She was discharged the sixteenth day and remained at home for 2½ months. During this interval the wound healed nicely, but a tender painful mass gradually recurred at the original site and there was a daily elevation of temperature. She re-entered the hospital 3 months after the original operation. On her second admission the temperature was 100°F.; pulse 120. The patient showed obvious loss of weight and strength. The only other abnormal findings were in the abdomen. Motion of the spine was unrestricted. The loin incision was well healed. In the right upper quadrant was a firm, smooth, rounded, moderately tender mass extending medially to the midline and downward almost to the iliac fossa. It could be palpated with the hand in the right costovertebral angle and did not move on reRpiration. Under the fluoroscope there was normal excursion of both leaves of the diaphragm. Urinalysis of a catheterized specimen showed clear urine which was negative for albumin and sugar; it contained 7 to 10 leukocytes per low power field, ] to 3 erythrocytes and a few epithelial cells. A urine culture was negative and a direct smear showed no organisms. Blood chemistry was normal. Blood count: red blood cells 3,420,000; white blood cells 15,700; Differential count: small lymphocytes 25 per cent, monocytes 3 per cent, total polymorphonuclears per cent (segmented forms 67, band forms 1, eosinophiles I per cent and basophiles 3 per cent). The sedimentation rate suggested a markedly active process: Sedimentation time 60 minutes; sedimentation index 32 mm. Cystoscopy and pyelography were repeated. The bladder again appeared normal. Indigo carmine appeared in normal time and strong concentration from both ureteral orifices. Retrograde pyelograms (fig. 2) revealed a normal left kidney. On the right side, however, on comparison of the original pyelograms, there was considerable dilatation of the right kidney pelvis with the middle major calyx elongated with its concavity directed upward as though surrounding a maRs. From these findings and from the clinical course a diagnosis of renal carbuncle involving the upper portion of the right kidney was made. On July 6, 1940, under general anesthesia, through a right loin incision, the right kidney was exposed by Dr. A. I. Folsom. The perirenal tissues were indurated and edematous. A typical appearing carbuncle occupied the upper third of the cortical portion of the kidney. This mass (fig. 3) measured 2¾" by l¼" by l¼'' and was easily shelled out of its inflammatory capsule; the bleeding was readily controlled by iodoform pack. The wound was loosely closed. The patient stood the procedure very well. There was a moderate febrile reaction for several days. The pack ,vas removed on the fourth day. Sulfathiazole effected a rapid clearing of the purulent drainage and the patient was discharged on the twenty-eighth postoperative day with the wound well healed. The patient has gained 16 pounds in weight, has a firm wound with no mass
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KEN MOOKEY
FIG. 3. Photographs of enuclcated carbuncle
FIG. 4 FIG. 5 FIG. 4. Right retrograde pyelogram 3 months after enucleation of the carbuncle. ney is remarkably normal in appearance. Fm. 5. Respiratory pyelogram on same date as figure 4
Kid-
palpable, and a normal urine. Retrograde pyelograms (fig. 4) made 5 months after enucleation of the carbuncle show a remarkably normal appearance of the
TREATMENT OF CARBUNCLE OF KIDNEY
253
right kidney and respiratory pyelogram (fig. 5) shows an excursion of the right kidney equal to that of its normal left mate. DISCUSSION
No categorical rules can be laid down as to the proper surgical treatment of renal carbuncle. However, the old idea that nephrectomy is routinely indicated in this condition should be revised in the light of the numerous cases now recorded which have been treated successfully by less radical measures. Thus Nesbit and Dick in a series of 9 renal carbuncles seen at the University Hospital, Ann Arbor, reported nephrectomy in only 1 case, while drainage of the carbuncle was carried out in the remainder with eventual complete healing in every instance, thus justifying conservative surgical management. In addition to illustrating the above fact our case also demonstrates that simple drainage of the perinephric abscess is inadequate when a true carbuncle of the kidney is the underlying pathological process. However, when a carbuncle is not suspected and a large perinephric accumulation of pus is encountered, it is preferable to institute simple drainage as was done here at the initial operation. On the other hand, if the surgeon feels reasonably confident that a carbuncle is present it is unquestionably preferable to mobilize the kidney and make an adequate exploration at the time. When the exposed kidney is found to be the seat of a carbuncular lesion, the extent of the destructive. parenchymal involvement and the general condition of the patient resulting from the associated sepsis determine the procedure to be followed. Undoubtedly, if the major portion of the kidney is hopelessly destroyed by single or multiple lesions, or if the patient is so debilitated as to demand immediate and complete relief of the septic burden, a rapid primary nephrectomy should be done. However, unless the patient is well-nigh exhausted from infection, or if only approximately a third or less of the organ is involved, we believe enucleation, incision and drainage or partial resection is the procedure of choice. We have been surprised at the comparative ease with which the carbuncle may be shelled out from its false capsule of inflammatory tissue. The bleeding at first profuse, is readily controlled with gauze packing which is brought out as a drain through the loosely closed wound. The shock of such an operation has seemed much less than might be anticipated from a difficult nephrectomy in similar circumstances. Prolonged and copious purulent drainage is to be expected as the inflammatory process resolves and wound suppuration is likely. In our case sulfathiazole by :mouth was of distinct aid postoperatively and in similar cases in the future its local application in the wound would seem indicated. We feel this powerful chemotherapeutic agent is an additional factor making for conservative surgery in carbuncle of the kidney. SUMMARY
Another case of carbuncle of the kidney successfully treated by conservative surgical procedure is reported.
254
KEN MOONEY
REFERENCES BRADY, L.: Renal lesions caused by staphylococcus with special reference to kidney carbuncle. Internat. Clin., 2: 210-228, 1935. GRAVES, R. C., AND PARKINS, L . E .: Carbuncle of the kidney. J . Urol., 35: 1-15, 1936. MOORE, T. D.: Renal carbuncle. J. A. M.A., 96: 754-759, 1931. NESBIT, REED M., AND DICK, VERNON S.: Acute staphylococcus infections of the kidney. J. Urol., 43: 623-636, 1940. O'CoNoR, V. J.: Carbuncle of kidney. J. Urol., 30: 1-13, 1933. SPENCE, H . M., AND JOHNSTON, L. W. : Renal carbuncle. Ann. Surg., 109: 99, 1939.
Carbuncle of the kidney is now being recognized with increasing frequency as a significant clinical entity due to the excellent writings of Brady, O'Conor, JVIoore, Graves and Parkins and others. Spence and Johnston collected 102 proved cases, including 1 of their own, up to 1938 and since then numerous additional cases have been reported. The purpose of this communication is to record another case which illustrates some of the diagnostic difficulties and vagaries of carbuncle of the kidney, and demonstrates in a strikingly graphic manner the value of cornervative surgery in this malady in c:elected instances. Detailed descriptions of the disease have been given by the writers mentioned and need not be repeated here. In brief, a renal carbuncle may be defined as a circumscribed, indurated, multilocular suppurative process in the renal parenchyma, usually caused by the Staphylococcus aureus borne through the blood stream from a distant septic focus. There is always an associated perinephritis, but a frank perinephric abscess occurs in only about a third of the cases. The clinical picture consists of the insidious onset over a period of weeks of pain and tenderness in the affected renal area plus the constitutional signs of sepsis; i.e., chills, fever, malaise, weight loss and leukocytosis. Urinary symptmm, are usually absent, and the urinalysis is characteristically normal, due to the fact that the lesion is cortical and does not communicate with the urinary pa8sages. Excretory or retrograde urography showing a deformity or filling defect of pelvis or calyces from pressure by the carbuncular mass is the most helpful diagnostic aid. All writers agree that the treatment is primarily surgical; we shall discuss later the factors indicating primary nephrectomy or some more conservative drainage operation. CASE REPORT
C. F., a 15 year old white female, was admitted to Parkland Hospital on :Vlarch 15, 1940, complaining of pain in the right side of the abdomen of 6 weeks' duration. The pain was of a constant dull aching character localized in the right renal area and hypochondrium. There were absolutely no urinary or gastrointestinal symptoms. Fever had not been noted and no history of recent boils or other septic focus could be elicited. She had been up and about until the past week when a physician had noted a tender mass in the abdomen and advised hospitalization. The past history was non-contributory. The patient wa8 an alert, well developed and nourished girl of 15, not acutely ill. Temperature 98.6°F., pulse 90. Abnormal findings were confined to the abdomen, where a smooth mass was readily felt in the right upper quadrant and 24!)
250
KEN MOONEY
right loin posteriorly. Its lower margin extended 2 fingers' breadth below the umbilicus, while upwardly the mass disappeared under the costal margin. The mass was firm, non-tender, and moved slightly on respiration. Urinalysis: Clear, trace of albumin; 7 to 8 leukocytes per low power field; urine culture sterile. Blood examination: Hemoglobin 78 per cent; red blood cells, 3,700,000; white blood cells 16,800, of which 74 per cent were polymorphonuclear leukocytes (71 segmented and 3 band forms). Kline test negative. Blood urea 26.3 mg. per 100 cc. blood. A roentgenogram of the chest was normal. Cystoscopy and pyelography were done the day of admission. The bladder was normal. Urine from the right kidney contained a few leukocytes but
FIG. 1 FIG. 2 Frn. 1. Right retrograde pyelogram on admission showing no significant abnormality FIG. 2. Similar pyelogram 14 weeks later suggesting a mass developing between upper and middle calyces.
showed no organisms on stain of the sediment and culture. Both excretory and retrograde pyelograms (fig. I) were interpreted as normal. On March 18, however, an upright retrograde pyelogram showed slight if any mobility of the right kidney. Following the urological investigation a pneumoperitoneum was done and demonstrated a mass below the liver, occupying the right kidney area. A peritoneoscopy was performed and the operator reported a normal peritoneal cavity and contents. The patient was observed in the ward for 18 days persistently running a low grade fever. During this time the right kidney was suspected, but only towards the end of the time did exploration seem justified. The preoperative diagnosis was perinephric abscess.
TREATMENT OF CARBUNCLE OF KIDNEY
251
On March 2, under general anesthesia, Dr. J. C. Alexander drained a large right perinephric abscess through an oblique loin incision. Staphylococcus aureus was cultured from the pus. The patient made a satisfactory convalescence but ran a persistent fever of 99° to 101 °F. She was discharged the sixteenth day and remained at home for 2½ months. During this interval the wound healed nicely, but a tender painful mass gradually recurred at the original site and there was a daily elevation of temperature. She re-entered the hospital 3 months after the original operation. On her second admission the temperature was 100°F.; pulse 120. The patient showed obvious loss of weight and strength. The only other abnormal findings were in the abdomen. Motion of the spine was unrestricted. The loin incision was well healed. In the right upper quadrant was a firm, smooth, rounded, moderately tender mass extending medially to the midline and downward almost to the iliac fossa. It could be palpated with the hand in the right costovertebral angle and did not move on reRpiration. Under the fluoroscope there was normal excursion of both leaves of the diaphragm. Urinalysis of a catheterized specimen showed clear urine which was negative for albumin and sugar; it contained 7 to 10 leukocytes per low power field, ] to 3 erythrocytes and a few epithelial cells. A urine culture was negative and a direct smear showed no organisms. Blood chemistry was normal. Blood count: red blood cells 3,420,000; white blood cells 15,700; Differential count: small lymphocytes 25 per cent, monocytes 3 per cent, total polymorphonuclears per cent (segmented forms 67, band forms 1, eosinophiles I per cent and basophiles 3 per cent). The sedimentation rate suggested a markedly active process: Sedimentation time 60 minutes; sedimentation index 32 mm. Cystoscopy and pyelography were repeated. The bladder again appeared normal. Indigo carmine appeared in normal time and strong concentration from both ureteral orifices. Retrograde pyelograms (fig. 2) revealed a normal left kidney. On the right side, however, on comparison of the original pyelograms, there was considerable dilatation of the right kidney pelvis with the middle major calyx elongated with its concavity directed upward as though surrounding a maRs. From these findings and from the clinical course a diagnosis of renal carbuncle involving the upper portion of the right kidney was made. On July 6, 1940, under general anesthesia, through a right loin incision, the right kidney was exposed by Dr. A. I. Folsom. The perirenal tissues were indurated and edematous. A typical appearing carbuncle occupied the upper third of the cortical portion of the kidney. This mass (fig. 3) measured 2¾" by l¼" by l¼'' and was easily shelled out of its inflammatory capsule; the bleeding was readily controlled by iodoform pack. The wound was loosely closed. The patient stood the procedure very well. There was a moderate febrile reaction for several days. The pack ,vas removed on the fourth day. Sulfathiazole effected a rapid clearing of the purulent drainage and the patient was discharged on the twenty-eighth postoperative day with the wound well healed. The patient has gained 16 pounds in weight, has a firm wound with no mass
252
KEN MOOKEY
FIG. 3. Photographs of enuclcated carbuncle
FIG. 4 FIG. 5 FIG. 4. Right retrograde pyelogram 3 months after enucleation of the carbuncle. ney is remarkably normal in appearance. Fm. 5. Respiratory pyelogram on same date as figure 4
Kid-
palpable, and a normal urine. Retrograde pyelograms (fig. 4) made 5 months after enucleation of the carbuncle show a remarkably normal appearance of the
TREATMENT OF CARBUNCLE OF KIDNEY
253
right kidney and respiratory pyelogram (fig. 5) shows an excursion of the right kidney equal to that of its normal left mate. DISCUSSION
No categorical rules can be laid down as to the proper surgical treatment of renal carbuncle. However, the old idea that nephrectomy is routinely indicated in this condition should be revised in the light of the numerous cases now recorded which have been treated successfully by less radical measures. Thus Nesbit and Dick in a series of 9 renal carbuncles seen at the University Hospital, Ann Arbor, reported nephrectomy in only 1 case, while drainage of the carbuncle was carried out in the remainder with eventual complete healing in every instance, thus justifying conservative surgical management. In addition to illustrating the above fact our case also demonstrates that simple drainage of the perinephric abscess is inadequate when a true carbuncle of the kidney is the underlying pathological process. However, when a carbuncle is not suspected and a large perinephric accumulation of pus is encountered, it is preferable to institute simple drainage as was done here at the initial operation. On the other hand, if the surgeon feels reasonably confident that a carbuncle is present it is unquestionably preferable to mobilize the kidney and make an adequate exploration at the time. When the exposed kidney is found to be the seat of a carbuncular lesion, the extent of the destructive. parenchymal involvement and the general condition of the patient resulting from the associated sepsis determine the procedure to be followed. Undoubtedly, if the major portion of the kidney is hopelessly destroyed by single or multiple lesions, or if the patient is so debilitated as to demand immediate and complete relief of the septic burden, a rapid primary nephrectomy should be done. However, unless the patient is well-nigh exhausted from infection, or if only approximately a third or less of the organ is involved, we believe enucleation, incision and drainage or partial resection is the procedure of choice. We have been surprised at the comparative ease with which the carbuncle may be shelled out from its false capsule of inflammatory tissue. The bleeding at first profuse, is readily controlled with gauze packing which is brought out as a drain through the loosely closed wound. The shock of such an operation has seemed much less than might be anticipated from a difficult nephrectomy in similar circumstances. Prolonged and copious purulent drainage is to be expected as the inflammatory process resolves and wound suppuration is likely. In our case sulfathiazole by :mouth was of distinct aid postoperatively and in similar cases in the future its local application in the wound would seem indicated. We feel this powerful chemotherapeutic agent is an additional factor making for conservative surgery in carbuncle of the kidney. SUMMARY
Another case of carbuncle of the kidney successfully treated by conservative surgical procedure is reported.
254
KEN MOONEY
REFERENCES BRADY, L.: Renal lesions caused by staphylococcus with special reference to kidney carbuncle. Internat. Clin., 2: 210-228, 1935. GRAVES, R. C., AND PARKINS, L . E .: Carbuncle of the kidney. J . Urol., 35: 1-15, 1936. MOORE, T. D.: Renal carbuncle. J. A. M.A., 96: 754-759, 1931. NESBIT, REED M., AND DICK, VERNON S.: Acute staphylococcus infections of the kidney. J. Urol., 43: 623-636, 1940. O'CoNoR, V. J.: Carbuncle of kidney. J. Urol., 30: 1-13, 1933. SPENCE, H . M., AND JOHNSTON, L. W. : Renal carbuncle. Ann. Surg., 109: 99, 1939.