- Email: [email protected]
Heminephrectomy Its Indications and Limitations1
HEMINEPHRECTOMY ITS INDICATIONS AND LIMITATIONS1
ELMER HESS Erie, Pa.
Martinow (1909) reported the first operation for the separation of the two halves of a horseshoe kidney. This he accomplished by a division of the isthmus. Rovsing (1910), and several others practiced this procedure of symphysiotomy, the operative approach being trans-abdominal. Papin (1922), Eisendrath, Phifer, Culver, Gutierrez, Foley, and others, have done this operation from a retroperitoneal approach with apparently excellent results. Heminephrectomy, however, has been done on numerous occasions by various men to remove pathological halves of horseshoe and unilateral fused kidneys with excellent results. It must be conceded that these kidneys are prone to give subjective symptomatology because of their anomalous position and blood supply. These symptoms will be aggravated by any considerable pathological change in one or both sections and will require some form of cystoscopic or surgical treatment as a result thereof. Heminephrectomy is indicated often where the pathological process is limited to one segment. Double kidneys, either unilateral or bilateral, because of their anomalous formation, position and blood supply, are, for the same reasons, prone to pathological changes of a clinical nature and therefore may require treatment or operation. Young (1917) was the first urologist to deliberately plan and perform, after careful preoperative study, a heminephrectomy upon a double kidney. Eisendrath (1925) reports a very interesting case in which he carried out heminephrectomy of the lower pole of bilateral double kidneys for hydronephrosis with excellent results. Wright and others have reported several personal cases where they were obliged to perform heminephrectomy on diseased halves in these anomalous conditions. As a result of the efforts of various men to conserve healthy renal parenchyma by removal of diseased sections of kidneys, the operation of heminephrectomy, or resection, has also been 1 Read before the annual meeting of the American Urological Association, Boston, Mass., May 18-21, 1936. 43
44
ELMER HESS
attempted upon anatomically normal kidneys. Czerny, as early as 1887, resected the lower pole of an anatomically normal kidney for tumor. These efforts, many of them extremely successful, have made it possible to conserve much undamaged renal parenchyma, and while today no one man has seen any very large series of cases requiring this procedure, the sum total of resected kidneys would reach a sufficiently high figure, making a study and analysis of the results much worth while. The author is referred to the report by Kretschmer (1935) in which he cites personal experiences in 22 cases of heminephrectomy. All told, there have been 16 cases of horseshoe and unilateral fused kidneys observed by the writer, 6 of which required definite surgical intervention, 4 being heminephrectomies. In over 100 cases of unilateral or bilateral double kidneys with double ureters, 9 required surgical intervention. Seven of these were heminephrectomized for pathology limited to the upper or lower pole, one to relieve incontinence due to the ureter from the upper half opening into the urethra in a young female, and one, which should have been heminephrectomized, in which nephrectomy was performed. In the other group of cases the operation was performed to remove pathological lesions in either the upper or lower pole of anatomically normal kidneys that could not be considered anomalous, remembering, however, that many anatomically normal kidneys have an abnormal vascular supply. In this series there are 11 heminephrectomies. The purpose of this communication is, therefore, an attempt to evaluate the indications, limitations, and the results of resection of any part of the renal parenchyma, which ordinarily is classified as a heminephrectomy. The urologist is qualified by training and experience to judge much more accurately when renal parenchyma should be conserved. Nephrectomy is a comparatively easy operative procedure, and Hinman has stated that 30 per cent of the kidneys now removed by both urologists and general surgeons could have been saved in whole or in part had the cases been thoroughly studied preoperatively, and an attempt made at operation to conserve as much as possible of the renal parenchyma. It is my opinion that in many cases this can be accomplished by heminephrectomy, the indications for which are: 1. Horseshoe, unilateral fused kidney. A. Pathology limited to one segment or half of such anomalous organs.
HEMINEPHRECTOMY
45
2. Double kidneys (unilateral or bilateral). A. Pathology limited to one segment, except tumor. B. Ectopic ureteral openings from one segment causing incontinence. (May be uterine, vaginal, or urethral.) 3. Anatomically normal kidneys. A. Pathology limited to a localized segment except tuberculosis and tumor. Horseshoe kidney. Tumors or cysts causing symptoms, tuberculous infection, calculous pyonephrosis, and certain types of hydronephrosis limited to one-half of a horseshoe anomaly, are definite indications for the removal of the pathologically diseased portion of such a kidney. In 1924, I reported a calculous pyonephrosis in a horseshoe kidney, the anomaly undiagnosed prior to operation, upon which a heminephrectomy was successfully done. This patient, five years later, was delivered of a normal healthy child, and two years ago, 1934, came back to the Clinic with the remaining right half of the kidney filled with calculus and pus (fig. 1). Through a lumbar retroperitoneal approach a pyelotomy was done with the removal of all of this calculous debris (fig. 2). The patient made a satisfactory recovery and at the present time is symptomless, although she reports to the Clinic regularly for lavage of this infected nephrotic right half. Again, in 1931, I reported a heminephrectomy in a horseshoe kidney with hypernephroma of the right half with excellent immediate results. The patient died a little over a year later from bony metastases (fig. 3). I have performed 2 other successful herninephrectomies, one a case of tuberculosis, and the other a case of pyogenic pyonephrosis. Two other horseshoe kidneys were subjected to surgical attack, however, that were not heminephrectomized and therefore have no bearing. There have been in the series 17 cases of horseshoe and unilateral fused kidneys. Four have required heminephrectomy. This about checks up with the findings of Gutierrez, who did two heminephrectomies in 25 cases reported in 1934. Judd, Braasch and Scholl report 7 heminephrectomies in a series of 60 cases. Eisendrath, Phifer and Culver, in reviewing 132 cases in the literature by many operators, report 63 heminephrectomies. Jeck, in 1931, reports 3 heminephrectomies in 4 horseshoe kidneys. Campbell, in 1931, reports 2 heminephrectomies on infants. Lowsley reports 24 cases of horseshoe kidney with herninephrectomy required twice. (This may be the same report as Gutierrez.) Rathbun THE JOURNAL OF UROLOGY, VOL.
38,
NO.
1
46
ELMER HESS
studied 108 cases from the literature in which 52 heminephrectomies were performed with 8 deaths. Double kidneys. In this series of over 100 cases diagnosed as double kidney, there were 9 that required surgical attack and all should have been heminephrectomized. One case is most interesting and taught me much. It was a double kidney with a normal upper half and a lower hypoplastic segment (fig. 4). This case should have been heminephrec-
FIG.
1
FIG.
2
1. Shows the calculus and the calculous debris in the nephrotic pelvis of the right half of a horseshoe kidney which had been heminephrectomized years before, the left half having been removed for calculous pyonephrosis. FIG. 2. Shows the advanced nephrosis in the remaining left half of this horseshoe kidney 20 minutes after the injection of diodrast. This illustrates one of the possible pathological conditions that may arise in the remaining segment of a kidney years after heminephrectomy. FIG.
tomized. The line of demarcation was perfect; it could have been done almost bloodlessly, and this would have been perfect surgical treatment (fig. 5). The case was diagnosed preoperatively, heminephrectomy planned, but, unfortunately, the ureter was severed below the point of bifurcation and there was nothing left to do but total nephrectomy. This, with a little more care, could easily have been avoided and the hypertrophic normally functioning upper segment would, as it should,
HEMINEPHRECTOMY
47
have been preserved. This leaves 8 cases that were heminephrectomized; 1 for tuberculosis; 1 for incontinence due to an ectopic ureter from the upper half opening into the female urethra, and the balance for hydronephrosis, pyonephrosis, and calculous disease, or some combination of these three, where the condition was diagnosed as limited to one segment. There are six cases in this series (fig. 6). Where it can be definitely shown that a tuberculous lesion is strictly limited to one-half of a double organ (fig. 7) I believe it to be perfectly safe to remove the involved segment. There is a definite line of demarcation between the two halves where there is complete duplication of the ureter and pelvis.
FIG. 3. Hypernephroma of the upper pole of the right half of a horseshoe kidney with metastasis to the ileum. Patient lived one year after heminephrectomy.
In all of my cases there was no connection noted between the upper and lower pelvis. If there is and this may be ascertained by probing, total nephrectomy should be performed. In these double kidneys the blood supply to each segment is usually separate and preliminary ligation permits almost a bloodless separation of the two halves. If tumor involves one segment being entirely limited thereto, it might be possible to perform heminephrectomy with some degree of safety. Personally, under such circumstances, although never having seen such a case, I would do and advise total nephrectomy. Anatomically normal kidneys. Wright, in his splendid article, con-
48
ELMER HESS
siders that the term "heminephrectomy" should be limited to horseshoe, unilateral fused, and double kidneys. While recognizing that this is a strict interpretation of the term, I believe that it should be used to include partial resection of anatomically normally formed kidneys.
FIG. 4. Pyelogram showing double kidney with a hypoplastic lower fellow. This hypoplastic lower pole should have been removed by heminephrectomy. Such an operation was planned.
Therefore, for the purpose of this communication, heminephrectomy is used for that group of cases where partial resection of the renal parenchyma is deemed indicated as a result of localized pathology in a limited segment of the anatomically normal organ. It must also be remembered
HEMINEPHRECTOMY
49
that even in such a kidney there may be, and usually is, some abnormality in the arterial supply. Many studies have been made in recent years concerning the blood supply of the kidney, and we are working on this problem at the present time. It is, as you all know, surprising to find how bizarre this blood supply may be in the adult in an otherwise anatomically normally formed
FIG. 5. Shows the specimen after total nephrectomy represented by the pyelogram in figure 4. It can be seen that there is plenty of normal renal parenchyma in the upper segment and that the lower segment could easily have been removed if it had not been for an operative accident.
organ. It is these cases that have aroused my interest and concern. In many of them the decision as to whether or not heminephrectomy, or partial resection, whichever you choose to call it, is advisable, must often be made at the operating table, but with careful preliminary study, heminephrectomy should always be considered as conservative and as the operation of choice until operative exposure proves otherwise. It
50
ELMER HESS
would be unwise, for example, in such a kidney with a localized tuberculous lesion in either the upper or lower pole, to do anything short of complete nephrectomy as it would to do a heminephrectomy with a localized tumor (fig. 8). The risk of spreading the disease in both cases would be such that anything short of complete nephrectomy would be poor surgical judgment.
FIG. 6 FIG. FIG.
FIG.
7
6. Tuberculous infection in the upper pole of a double kidney 7. Successful heminephrectomy removing tuberculous segment
Unilateral cysts of either the upper or lower pole where clinical symptoms are caused by the cyst should, in a certain number of cases, be treated by heminephrectomy. I have one such case in the series. Unfortunately, I was unable to follow the case through myself. The patient was operated upon later by a general surgeon whose operation consisted of removing the cyst. Some months later he was obliged to
,,1
'' ''
HEMINEPHRECTOMY
51
do a secondary nephrectomy. It is my impression that had the cyst been removed, with a wide margin of renal tissue, (heminephrectomy) that the procedure would have conserved some good renal tissue and prevented the secondary nephrectomy. This is conjecture on my part,
FIG. 9 FIG.8 FIG. 8. Pyelogram showing tuberculosis limited to the upper segment of a single kidney. There is a tendency here to duplication. This is the type of kidney which we believe heminephrectomy, or resection, is contraindicated and that the whole kidney should be removed even though the tuberculous process is limited to the upper calyx. FIG. 9. Stone in upper calyx of the left kidney. It was considered better surgery to resect the upper pole containing this calyx than to attempt nephrotomy to remove the stone.
although should I ever have the privilege again of seeing a case of this kind, I would attempt such a heminephrectomy. Two conditions stand out in my experience where heminephrectomy is indicated in these anatomically normal kidneys. They are hydronephrosis and calculous nephrosis, with or without infection.
52
ELMER HESS
Several operators have done partial resection of the kidney for car, buncle, but the vast majority of the men feel that simple incision and drainage, or total nephrectomy, is the procedure of choice. One of the most important indications for heminephrectomy will arise often in bilateral calculous disease. Here it is absolutely necessary to conserve as much as possible of the parenchyma. These cases give me much concern. The infecting organism is very important. The staphylococcus is the one most dreaded, not because it is the immediate killer, but because certain types of the organism seem to have a special attribute; namely, the slow, progressive destruction of renal tissue. In bilateral calculosis with a staphylococcus infection, the preliminary preoperative treatment consists of large and small doses of neosalvarsan. There are 5 cases in this series of bilateral calculosis where it has been necessary to remove one kidney and to virtually bisect its fellow. In these cases the heminephrectomized kidney had stones in the lower calyx with much destruction and infection of the lower pole. All of these cases are living and have sufficient kidney function to maintain comfortable life. One case was a morphine addict and has gone back to his morphinism. He was operated four years ago. Three cases are absolutely clinically free from symptoms, living and well after three years. One case has a marked nephrosis of his half kidney but is working, although to be free from symptoms he must have the kidney lavaged weekly. Hydronephrosis, calculous nephrosis, calculous pyonephrosis, or uninfected calculous disease limited to a segment of one kidney can very often be successfully treated by heminephrectomy. Babcock reports a case where the disease was limited to a middle calyx with atrophy and infection of the middle segment of the kidney, in which he successfully carried out resection of the diseased portion. In this series there are 11 cases. 1. Five with total nephrectomy on one side and heminephrectomy of the remaining fellow, the indication being bilateral calculous pyo- and hydronephrosis. 2. Four cases of calculous disease, 3 of which were limited to the upper pole (fig. 9) two to the lower pole (fig. 10) with mild infection. Where the lower pole contains a dilated calyx, with pus or calculus, it is wise to do heminephrectomy thus obliterating the infected lower calyx which, because of gravity, will become filled with infected urine, causing the
HEMINEPHRECTOMY
53
reformation of a stone or extension of the infection, as a result of stasis, to the rest of the kidney. 3. One case of pyonephrosis limited to the lower pole of a kidney complicated by a perirenal inflammatory process, the upper two-thirds of the kidney being free from perirenal inflammation and with grossly normal parenchyma (fig. 11).
FIG. 10 FIG. 11 FIG. 10. Pyelogram after resection of the upper pole, emphasizing how little deformity is created by resection. FIG. 11. Shows a calculous pyonephrosis in the lower pole of a normally functioning left kidney. Lower pole successfully resected with salvage of better than two-thirds of the organ.
Treatment. Let us consider the treatment of the large hydronephroses that have been caused by an aberrant renal artery obstructing the ureter at the uretero-pelvic junction. Young has devised a plastic operation which saves this obstructing vessel to the lower pole. However, other operators, including myself, unhesitatingly sever this artery after which, of course, the lower third or half of the kidney atrophies. Some plastic
54
ELMER HESS
operation usually is then performed upon the dilated pelvis to reduce its size. Birdsall has a splendid movie reel of his technique for handling hydronephrosis caused by aberrant vessels and he advocates heminephrectomizing (resection of) the lower pole where division of the artery is necessary. If the lower calyx is badly dilated or infected, with or without co-existing calculous disease, this is good treatment. If, on the other hand, there is little or no infection and no calculus, a heminephrectomy adds unduly to the time of the surgical procedure and increases the possibilities of infection and is unnecessary. I have divided the artery in this type of case on four occasions with splendid results, the lower segment merely atrophying to the extent to which the blood supply was destroyed. Report of cases. No. 1. D. B., a male, aged 35 entered St. Vincent's Hospital September 16, 1935, complaining of attacks of severe lumbar pain with hematuria. The patient stated that he had had severe attacks of pain since 1927; had always needed a hypodermic for relief; hematuria with each attack, ten of which occurred during the past eight years. During the last year there had been occasions when he could not urinate. The past and family history were negative. The patient was a well developed man, who did not appear acutely ill. The temperature was 99.4, pulse 80, respirations 20, blood pressure 132/82. Cystoscopic examination was negative. A pyelogram showed normal kidneys with the exception that on the right side the lower major calyx was bottle-shaped. There was a shadow in the plain film of stones in the region of the lower major calyx. The Laboratory reports were within normal limits. The urine was negative. The diagnosis was renal calculi, right lower calyx. A heminephrectomy was done September 17 with the removal of about onethird of the lower pole. The pathological report showed a normal renal parenchyma in the lower pole with a sacculated major calyx containing four jack-stone calculi firmly lodged in the calyx. The patient was discharged September 27th, with the incision closed. On May 4, 1936, there had been no recurrence of hematuria or pain since the operation. Case 2. J. W., a male, aged 62 was admitted to St. Vincent's Hospital February 2, 1936, complaining of pain in the right side and back. Patient had suffered attacks of renal colic for ten years. There had been two stones in his right kidney, one firmly fixed in the lower major calyx, the
HEMINEPHRECTOMY
55
other, a loose stone which was free and on over twenty occasions had been caught in the upper inch of the ureter. The patient had been relieved of the pain by pushing the stone back with the ureteral catheter. On February 7, 1936, he had another attack of renal colic and was again relieved by manipulating the stone back into the renal pelvis where it dropped into the lower calyx. On February 14, he had another attack. The patient had an aortic and abdominal aneurysm with a definite history and much treatment for lues. Physical examination was negative except for the aneurysms, as noted, and a markedly hypertrophied heart with some decompensation. There was marked tenderness over the costo-vertebral angle on the right side. Cystoscopic and X-ray examination showed the larger of the two calculi in the right renal region at the top of the catheter. It was impossible to push the stone back into the renal pelvis. On February 15, the X-ray report shows the condition to be the same. The diagnosis was renal calculi, right kidney. February 19, heminephrectomy was successfully performed on the lower pole and through the opening in the lower major calyx a large stone was easily removed from the upper inch of the right ureter. The pathological report showed that the non-migrating stone was firmly imbedded around the papillae of the lower major calyx. The patient made an uneventful recovery and was discharged March 14, 1936 in good condition. On May 4, 1936, he was completely cured and free from pain with a normal functioning kidney on the right side. No attempt will be made to describe the operative technique in detail but a few points which have proved successful to the writer will be emphasized. Horseshoe kidney. All of the cases in this series where heminephrectomy has been done have been approached through the usual lumbar retroperitoneal exposure. It is advisable wherever possible to sever the isthmus with the actual cautery or with the radio knife. It is also advisable whenever possible to ligate and divide those vessels which go to the isthmus. This frees the remaining half and allows it to assume a more nearly normal position. As a rule, an aberrant vessel, or vessels, will be discovered feeding the isthmus and lower poles arising from the iliacs or a low position on the aorta. If these are ligated, the divided isthmus can be handled with very little danger of hemorrhage by tying over the cut wound a piece of muscle or fat with flaps deliberately made from the renal capsule. If this is not possible, mattress sutures tied on pads of fat or muscle usually control the hemorrhage satisfactorily. In removing the half of a horseshoe kidney it is essential to attempt to free the ureter sufficiently to insure adequate drainage from the segment saved.
I
_..l..
56
ELMER HESS
Double kidney. Usually, there is a distinct blood supply to both portions of the double kidney. Careful pedicle dissection will enable the operator, before attempting heminephrectomy, to ligate that portion supplying the segment to be removed. This simplifies the surgical technique inasmuch as the amputation may be made in a distinctly nonvascular line of cleavage and hemostasis can be accomplished again by simply tying capsular flaps (natural ribbon sutures) over a pad of fat or muscle covering the raw surface. Anatomically normally formed kidney. In removing segments of anatomically normally formed kidneys if an aberrant vessel is found it may be clamped off, accomplishing much the same purpose and the situation is handled in much the same manner as in double kidney; however, it is often necessary to amputate the segment to be removed without ligating the supply to the segment. The operator can control hemostasis beautifully by grasping the kidney just above the line of amputation with his thumb and forefinger, cutting out the wedge-shaped piece to be removed and placing his mattress ligatures through the kidney substance, tying both sides over fat or muscle. I prefer muscle. The bleeding is inconsequential, is under perfect control, and it has never been necessary to ligate any vessels in the cut in the parenchyma. I have never found it necessary to clamp off the renal pedicle to do a heminephrectomy. It seems to me that this not only prolongs the time of operation but endangers the renal pedicle and the vitality of the kidney substance to be conserved, and may be the direct cause, because of injury, of a subsequent nephrectomy or atrophy of the remaining portion of the kidney. The operative procedures are extremely simple and must be modified to meet the conditions found in the operating room. The simpler the procedure, and the gentleness with which the kidney and its pedicle are handled, is very often the difference between a successful conservation of renal substance and the subsequent necessity for further surgical procedure. Mortality and morbidity. The results in this series of cases are as follows: There has been no immediate mortality. One of the heminephrectomies in the horseshoe kidney series died a little over a year after operation from metastases. Another case developed calculous nephrosis of the remaining half of the kidney but is living twelve years after the primary heminephrectomy. There has been no mortality in any of the operations upon the double kidneys or upon the anatomically normally formed kidneys. All of these cases on our list have been checked, are living and well and comparatively free from the symptoms which brought them to the Clinic.
HEMINEPHRECTOMY
57
CONCLUSIONS
Since this paper is based almost solely on personal experiences, it is in itself one of the writer's conclusions, and therefore: Heminephrectomy is indicated in all cases where pathology necessitating surgical treatment is limited to a section of any kidney, whether it be a horseshoe, double, or an anatomically normal organ. It is particularly indicated in single kidneys where surgery is necessary for the same reasons, and finally, it should be always considered in all planned surgical attacks upon the kidney in an endeavor to preserve all the functional parenchyma possible. REFERENCES BABCOCK, W.W.: Textbook of Surgery. W. B. Saunders Co., 1935. BIRDSALL, J. C.: The etiology, diagnosis, and treatment of hydronephrosis. Penn. Med. Jour., 39: 497-501, 1936. CAMPBELL, M. F.: Uretero-heminephrectomy in infancy. Jour. Urol., 26: 433-445, 1931. EISENDRATH, D. N., AND PmFER, F. M.: Bilateral heminephrectomy in bilateral double kidney. Jour. Urol., 13: 525-535, 1925. EISENDRATH, D. N., PmFER, F. M., AND CULVER, H.B.: Horseshoe kidney. Ann. Surg., 82: 735-764, 1925. FOLEY, F. E. B.: Discussion. Jour. Urol., 32: 657, 1934. GUTIERREZ, R.: The clinical management of horseshoe kidney. Amer. Jour. Surg., 14: 657, 1931; 15: 132; 15: 345, 1932. GUTIERREZ, R.: The Clinical Management of Horseshoe Kidneys. Paul B. Hoeber, Inc., 1935, p. 119. HESS, E.: Surgical horseshoe kidney. Report of one unusual case. Jour. Urol., 12: 627633, 1924. HEss, E.: Adenocarcinoma horseshoe kidney. Jour. Urol., 27: 47-58, 1932. HESS, E.: Nephrotomy. Its indications, limitations and terminal results. Calif. and West. Med., 41: 74-79, 1934. HINMAN, F.: PrinciplesandPracticeofUrology. W. B. Saunders Co., 1935, p. 661. JECK, H. S.: Horseshoe kidney with especial reference to surgical technique. Jour. Amer. Med. Assoc., 98: 603-609, 1932. JUDD, E. S., BRAASCH, W. F., AND SCHOLL, A. J., JR.: Horseshoe kidney. Jour. Amer. Med. Assoc., 79: 1189-1195, 1922. MARK, E.G.: Carbuncle of the kidney. Urol. and Cutan. Rev., 36: 93-94, 1932. MARTINOW, A. V.: Intervention sur le rein en fer a cheval. Zentralbl. f. chir., 37: 314-316, 1910. PAPIN, E.: Rein en fer a cheval. Section de l'isthme. Ass. franc d'urol. xxii Congres, Paris, Oct. 1922, p. 557. RATHBUN, N. P.: Notes on the clinical aspects of horseshoe kidney. Jour. Urol., 12: 611625, 1924. RovsrnG, T.: Beitrag zur Symptomatologie, Diagnose und Behandlung der Hufeisenniere Ztschr. £. Urol., 5: 586-601, 1911. STONE, E.: Heminephrectomy. Jour. Urol., 28: 301-321, 1932. WRIGHT, B. W.: Heminephrectomy. ,Report of three cases. Urol. and Cutan. Rev., 36: 592-597, 1932. YOUNG, H. H., AND DAVIS, E.G.: Double ureter and kidney with calculous pyonephrosis of one-half; cure by resection; the embryology and surgery of double ureter and kidney. Jour. Urol., 1: 17-32, 1917. YOUNG, H. H.: Young's Practice of Urology. W. B. Saunders Co., 1926, Vol. II, p. 296.
ELMER HESS Erie, Pa.
Martinow (1909) reported the first operation for the separation of the two halves of a horseshoe kidney. This he accomplished by a division of the isthmus. Rovsing (1910), and several others practiced this procedure of symphysiotomy, the operative approach being trans-abdominal. Papin (1922), Eisendrath, Phifer, Culver, Gutierrez, Foley, and others, have done this operation from a retroperitoneal approach with apparently excellent results. Heminephrectomy, however, has been done on numerous occasions by various men to remove pathological halves of horseshoe and unilateral fused kidneys with excellent results. It must be conceded that these kidneys are prone to give subjective symptomatology because of their anomalous position and blood supply. These symptoms will be aggravated by any considerable pathological change in one or both sections and will require some form of cystoscopic or surgical treatment as a result thereof. Heminephrectomy is indicated often where the pathological process is limited to one segment. Double kidneys, either unilateral or bilateral, because of their anomalous formation, position and blood supply, are, for the same reasons, prone to pathological changes of a clinical nature and therefore may require treatment or operation. Young (1917) was the first urologist to deliberately plan and perform, after careful preoperative study, a heminephrectomy upon a double kidney. Eisendrath (1925) reports a very interesting case in which he carried out heminephrectomy of the lower pole of bilateral double kidneys for hydronephrosis with excellent results. Wright and others have reported several personal cases where they were obliged to perform heminephrectomy on diseased halves in these anomalous conditions. As a result of the efforts of various men to conserve healthy renal parenchyma by removal of diseased sections of kidneys, the operation of heminephrectomy, or resection, has also been 1 Read before the annual meeting of the American Urological Association, Boston, Mass., May 18-21, 1936. 43
44
ELMER HESS
attempted upon anatomically normal kidneys. Czerny, as early as 1887, resected the lower pole of an anatomically normal kidney for tumor. These efforts, many of them extremely successful, have made it possible to conserve much undamaged renal parenchyma, and while today no one man has seen any very large series of cases requiring this procedure, the sum total of resected kidneys would reach a sufficiently high figure, making a study and analysis of the results much worth while. The author is referred to the report by Kretschmer (1935) in which he cites personal experiences in 22 cases of heminephrectomy. All told, there have been 16 cases of horseshoe and unilateral fused kidneys observed by the writer, 6 of which required definite surgical intervention, 4 being heminephrectomies. In over 100 cases of unilateral or bilateral double kidneys with double ureters, 9 required surgical intervention. Seven of these were heminephrectomized for pathology limited to the upper or lower pole, one to relieve incontinence due to the ureter from the upper half opening into the urethra in a young female, and one, which should have been heminephrectomized, in which nephrectomy was performed. In the other group of cases the operation was performed to remove pathological lesions in either the upper or lower pole of anatomically normal kidneys that could not be considered anomalous, remembering, however, that many anatomically normal kidneys have an abnormal vascular supply. In this series there are 11 heminephrectomies. The purpose of this communication is, therefore, an attempt to evaluate the indications, limitations, and the results of resection of any part of the renal parenchyma, which ordinarily is classified as a heminephrectomy. The urologist is qualified by training and experience to judge much more accurately when renal parenchyma should be conserved. Nephrectomy is a comparatively easy operative procedure, and Hinman has stated that 30 per cent of the kidneys now removed by both urologists and general surgeons could have been saved in whole or in part had the cases been thoroughly studied preoperatively, and an attempt made at operation to conserve as much as possible of the renal parenchyma. It is my opinion that in many cases this can be accomplished by heminephrectomy, the indications for which are: 1. Horseshoe, unilateral fused kidney. A. Pathology limited to one segment or half of such anomalous organs.
HEMINEPHRECTOMY
45
2. Double kidneys (unilateral or bilateral). A. Pathology limited to one segment, except tumor. B. Ectopic ureteral openings from one segment causing incontinence. (May be uterine, vaginal, or urethral.) 3. Anatomically normal kidneys. A. Pathology limited to a localized segment except tuberculosis and tumor. Horseshoe kidney. Tumors or cysts causing symptoms, tuberculous infection, calculous pyonephrosis, and certain types of hydronephrosis limited to one-half of a horseshoe anomaly, are definite indications for the removal of the pathologically diseased portion of such a kidney. In 1924, I reported a calculous pyonephrosis in a horseshoe kidney, the anomaly undiagnosed prior to operation, upon which a heminephrectomy was successfully done. This patient, five years later, was delivered of a normal healthy child, and two years ago, 1934, came back to the Clinic with the remaining right half of the kidney filled with calculus and pus (fig. 1). Through a lumbar retroperitoneal approach a pyelotomy was done with the removal of all of this calculous debris (fig. 2). The patient made a satisfactory recovery and at the present time is symptomless, although she reports to the Clinic regularly for lavage of this infected nephrotic right half. Again, in 1931, I reported a heminephrectomy in a horseshoe kidney with hypernephroma of the right half with excellent immediate results. The patient died a little over a year later from bony metastases (fig. 3). I have performed 2 other successful herninephrectomies, one a case of tuberculosis, and the other a case of pyogenic pyonephrosis. Two other horseshoe kidneys were subjected to surgical attack, however, that were not heminephrectomized and therefore have no bearing. There have been in the series 17 cases of horseshoe and unilateral fused kidneys. Four have required heminephrectomy. This about checks up with the findings of Gutierrez, who did two heminephrectomies in 25 cases reported in 1934. Judd, Braasch and Scholl report 7 heminephrectomies in a series of 60 cases. Eisendrath, Phifer and Culver, in reviewing 132 cases in the literature by many operators, report 63 heminephrectomies. Jeck, in 1931, reports 3 heminephrectomies in 4 horseshoe kidneys. Campbell, in 1931, reports 2 heminephrectomies on infants. Lowsley reports 24 cases of horseshoe kidney with herninephrectomy required twice. (This may be the same report as Gutierrez.) Rathbun THE JOURNAL OF UROLOGY, VOL.
38,
NO.
1
46
ELMER HESS
studied 108 cases from the literature in which 52 heminephrectomies were performed with 8 deaths. Double kidneys. In this series of over 100 cases diagnosed as double kidney, there were 9 that required surgical attack and all should have been heminephrectomized. One case is most interesting and taught me much. It was a double kidney with a normal upper half and a lower hypoplastic segment (fig. 4). This case should have been heminephrec-
FIG.
1
FIG.
2
1. Shows the calculus and the calculous debris in the nephrotic pelvis of the right half of a horseshoe kidney which had been heminephrectomized years before, the left half having been removed for calculous pyonephrosis. FIG. 2. Shows the advanced nephrosis in the remaining left half of this horseshoe kidney 20 minutes after the injection of diodrast. This illustrates one of the possible pathological conditions that may arise in the remaining segment of a kidney years after heminephrectomy. FIG.
tomized. The line of demarcation was perfect; it could have been done almost bloodlessly, and this would have been perfect surgical treatment (fig. 5). The case was diagnosed preoperatively, heminephrectomy planned, but, unfortunately, the ureter was severed below the point of bifurcation and there was nothing left to do but total nephrectomy. This, with a little more care, could easily have been avoided and the hypertrophic normally functioning upper segment would, as it should,
HEMINEPHRECTOMY
47
have been preserved. This leaves 8 cases that were heminephrectomized; 1 for tuberculosis; 1 for incontinence due to an ectopic ureter from the upper half opening into the female urethra, and the balance for hydronephrosis, pyonephrosis, and calculous disease, or some combination of these three, where the condition was diagnosed as limited to one segment. There are six cases in this series (fig. 6). Where it can be definitely shown that a tuberculous lesion is strictly limited to one-half of a double organ (fig. 7) I believe it to be perfectly safe to remove the involved segment. There is a definite line of demarcation between the two halves where there is complete duplication of the ureter and pelvis.
FIG. 3. Hypernephroma of the upper pole of the right half of a horseshoe kidney with metastasis to the ileum. Patient lived one year after heminephrectomy.
In all of my cases there was no connection noted between the upper and lower pelvis. If there is and this may be ascertained by probing, total nephrectomy should be performed. In these double kidneys the blood supply to each segment is usually separate and preliminary ligation permits almost a bloodless separation of the two halves. If tumor involves one segment being entirely limited thereto, it might be possible to perform heminephrectomy with some degree of safety. Personally, under such circumstances, although never having seen such a case, I would do and advise total nephrectomy. Anatomically normal kidneys. Wright, in his splendid article, con-
48
ELMER HESS
siders that the term "heminephrectomy" should be limited to horseshoe, unilateral fused, and double kidneys. While recognizing that this is a strict interpretation of the term, I believe that it should be used to include partial resection of anatomically normally formed kidneys.
FIG. 4. Pyelogram showing double kidney with a hypoplastic lower fellow. This hypoplastic lower pole should have been removed by heminephrectomy. Such an operation was planned.
Therefore, for the purpose of this communication, heminephrectomy is used for that group of cases where partial resection of the renal parenchyma is deemed indicated as a result of localized pathology in a limited segment of the anatomically normal organ. It must also be remembered
HEMINEPHRECTOMY
49
that even in such a kidney there may be, and usually is, some abnormality in the arterial supply. Many studies have been made in recent years concerning the blood supply of the kidney, and we are working on this problem at the present time. It is, as you all know, surprising to find how bizarre this blood supply may be in the adult in an otherwise anatomically normally formed
FIG. 5. Shows the specimen after total nephrectomy represented by the pyelogram in figure 4. It can be seen that there is plenty of normal renal parenchyma in the upper segment and that the lower segment could easily have been removed if it had not been for an operative accident.
organ. It is these cases that have aroused my interest and concern. In many of them the decision as to whether or not heminephrectomy, or partial resection, whichever you choose to call it, is advisable, must often be made at the operating table, but with careful preliminary study, heminephrectomy should always be considered as conservative and as the operation of choice until operative exposure proves otherwise. It
50
ELMER HESS
would be unwise, for example, in such a kidney with a localized tuberculous lesion in either the upper or lower pole, to do anything short of complete nephrectomy as it would to do a heminephrectomy with a localized tumor (fig. 8). The risk of spreading the disease in both cases would be such that anything short of complete nephrectomy would be poor surgical judgment.
FIG. 6 FIG. FIG.
FIG.
7
6. Tuberculous infection in the upper pole of a double kidney 7. Successful heminephrectomy removing tuberculous segment
Unilateral cysts of either the upper or lower pole where clinical symptoms are caused by the cyst should, in a certain number of cases, be treated by heminephrectomy. I have one such case in the series. Unfortunately, I was unable to follow the case through myself. The patient was operated upon later by a general surgeon whose operation consisted of removing the cyst. Some months later he was obliged to
,,1
'' ''
HEMINEPHRECTOMY
51
do a secondary nephrectomy. It is my impression that had the cyst been removed, with a wide margin of renal tissue, (heminephrectomy) that the procedure would have conserved some good renal tissue and prevented the secondary nephrectomy. This is conjecture on my part,
FIG. 9 FIG.8 FIG. 8. Pyelogram showing tuberculosis limited to the upper segment of a single kidney. There is a tendency here to duplication. This is the type of kidney which we believe heminephrectomy, or resection, is contraindicated and that the whole kidney should be removed even though the tuberculous process is limited to the upper calyx. FIG. 9. Stone in upper calyx of the left kidney. It was considered better surgery to resect the upper pole containing this calyx than to attempt nephrotomy to remove the stone.
although should I ever have the privilege again of seeing a case of this kind, I would attempt such a heminephrectomy. Two conditions stand out in my experience where heminephrectomy is indicated in these anatomically normal kidneys. They are hydronephrosis and calculous nephrosis, with or without infection.
52
ELMER HESS
Several operators have done partial resection of the kidney for car, buncle, but the vast majority of the men feel that simple incision and drainage, or total nephrectomy, is the procedure of choice. One of the most important indications for heminephrectomy will arise often in bilateral calculous disease. Here it is absolutely necessary to conserve as much as possible of the parenchyma. These cases give me much concern. The infecting organism is very important. The staphylococcus is the one most dreaded, not because it is the immediate killer, but because certain types of the organism seem to have a special attribute; namely, the slow, progressive destruction of renal tissue. In bilateral calculosis with a staphylococcus infection, the preliminary preoperative treatment consists of large and small doses of neosalvarsan. There are 5 cases in this series of bilateral calculosis where it has been necessary to remove one kidney and to virtually bisect its fellow. In these cases the heminephrectomized kidney had stones in the lower calyx with much destruction and infection of the lower pole. All of these cases are living and have sufficient kidney function to maintain comfortable life. One case was a morphine addict and has gone back to his morphinism. He was operated four years ago. Three cases are absolutely clinically free from symptoms, living and well after three years. One case has a marked nephrosis of his half kidney but is working, although to be free from symptoms he must have the kidney lavaged weekly. Hydronephrosis, calculous nephrosis, calculous pyonephrosis, or uninfected calculous disease limited to a segment of one kidney can very often be successfully treated by heminephrectomy. Babcock reports a case where the disease was limited to a middle calyx with atrophy and infection of the middle segment of the kidney, in which he successfully carried out resection of the diseased portion. In this series there are 11 cases. 1. Five with total nephrectomy on one side and heminephrectomy of the remaining fellow, the indication being bilateral calculous pyo- and hydronephrosis. 2. Four cases of calculous disease, 3 of which were limited to the upper pole (fig. 9) two to the lower pole (fig. 10) with mild infection. Where the lower pole contains a dilated calyx, with pus or calculus, it is wise to do heminephrectomy thus obliterating the infected lower calyx which, because of gravity, will become filled with infected urine, causing the
HEMINEPHRECTOMY
53
reformation of a stone or extension of the infection, as a result of stasis, to the rest of the kidney. 3. One case of pyonephrosis limited to the lower pole of a kidney complicated by a perirenal inflammatory process, the upper two-thirds of the kidney being free from perirenal inflammation and with grossly normal parenchyma (fig. 11).
FIG. 10 FIG. 11 FIG. 10. Pyelogram after resection of the upper pole, emphasizing how little deformity is created by resection. FIG. 11. Shows a calculous pyonephrosis in the lower pole of a normally functioning left kidney. Lower pole successfully resected with salvage of better than two-thirds of the organ.
Treatment. Let us consider the treatment of the large hydronephroses that have been caused by an aberrant renal artery obstructing the ureter at the uretero-pelvic junction. Young has devised a plastic operation which saves this obstructing vessel to the lower pole. However, other operators, including myself, unhesitatingly sever this artery after which, of course, the lower third or half of the kidney atrophies. Some plastic
54
ELMER HESS
operation usually is then performed upon the dilated pelvis to reduce its size. Birdsall has a splendid movie reel of his technique for handling hydronephrosis caused by aberrant vessels and he advocates heminephrectomizing (resection of) the lower pole where division of the artery is necessary. If the lower calyx is badly dilated or infected, with or without co-existing calculous disease, this is good treatment. If, on the other hand, there is little or no infection and no calculus, a heminephrectomy adds unduly to the time of the surgical procedure and increases the possibilities of infection and is unnecessary. I have divided the artery in this type of case on four occasions with splendid results, the lower segment merely atrophying to the extent to which the blood supply was destroyed. Report of cases. No. 1. D. B., a male, aged 35 entered St. Vincent's Hospital September 16, 1935, complaining of attacks of severe lumbar pain with hematuria. The patient stated that he had had severe attacks of pain since 1927; had always needed a hypodermic for relief; hematuria with each attack, ten of which occurred during the past eight years. During the last year there had been occasions when he could not urinate. The past and family history were negative. The patient was a well developed man, who did not appear acutely ill. The temperature was 99.4, pulse 80, respirations 20, blood pressure 132/82. Cystoscopic examination was negative. A pyelogram showed normal kidneys with the exception that on the right side the lower major calyx was bottle-shaped. There was a shadow in the plain film of stones in the region of the lower major calyx. The Laboratory reports were within normal limits. The urine was negative. The diagnosis was renal calculi, right lower calyx. A heminephrectomy was done September 17 with the removal of about onethird of the lower pole. The pathological report showed a normal renal parenchyma in the lower pole with a sacculated major calyx containing four jack-stone calculi firmly lodged in the calyx. The patient was discharged September 27th, with the incision closed. On May 4, 1936, there had been no recurrence of hematuria or pain since the operation. Case 2. J. W., a male, aged 62 was admitted to St. Vincent's Hospital February 2, 1936, complaining of pain in the right side and back. Patient had suffered attacks of renal colic for ten years. There had been two stones in his right kidney, one firmly fixed in the lower major calyx, the
HEMINEPHRECTOMY
55
other, a loose stone which was free and on over twenty occasions had been caught in the upper inch of the ureter. The patient had been relieved of the pain by pushing the stone back with the ureteral catheter. On February 7, 1936, he had another attack of renal colic and was again relieved by manipulating the stone back into the renal pelvis where it dropped into the lower calyx. On February 14, he had another attack. The patient had an aortic and abdominal aneurysm with a definite history and much treatment for lues. Physical examination was negative except for the aneurysms, as noted, and a markedly hypertrophied heart with some decompensation. There was marked tenderness over the costo-vertebral angle on the right side. Cystoscopic and X-ray examination showed the larger of the two calculi in the right renal region at the top of the catheter. It was impossible to push the stone back into the renal pelvis. On February 15, the X-ray report shows the condition to be the same. The diagnosis was renal calculi, right kidney. February 19, heminephrectomy was successfully performed on the lower pole and through the opening in the lower major calyx a large stone was easily removed from the upper inch of the right ureter. The pathological report showed that the non-migrating stone was firmly imbedded around the papillae of the lower major calyx. The patient made an uneventful recovery and was discharged March 14, 1936 in good condition. On May 4, 1936, he was completely cured and free from pain with a normal functioning kidney on the right side. No attempt will be made to describe the operative technique in detail but a few points which have proved successful to the writer will be emphasized. Horseshoe kidney. All of the cases in this series where heminephrectomy has been done have been approached through the usual lumbar retroperitoneal exposure. It is advisable wherever possible to sever the isthmus with the actual cautery or with the radio knife. It is also advisable whenever possible to ligate and divide those vessels which go to the isthmus. This frees the remaining half and allows it to assume a more nearly normal position. As a rule, an aberrant vessel, or vessels, will be discovered feeding the isthmus and lower poles arising from the iliacs or a low position on the aorta. If these are ligated, the divided isthmus can be handled with very little danger of hemorrhage by tying over the cut wound a piece of muscle or fat with flaps deliberately made from the renal capsule. If this is not possible, mattress sutures tied on pads of fat or muscle usually control the hemorrhage satisfactorily. In removing the half of a horseshoe kidney it is essential to attempt to free the ureter sufficiently to insure adequate drainage from the segment saved.
I
_..l..
56
ELMER HESS
Double kidney. Usually, there is a distinct blood supply to both portions of the double kidney. Careful pedicle dissection will enable the operator, before attempting heminephrectomy, to ligate that portion supplying the segment to be removed. This simplifies the surgical technique inasmuch as the amputation may be made in a distinctly nonvascular line of cleavage and hemostasis can be accomplished again by simply tying capsular flaps (natural ribbon sutures) over a pad of fat or muscle covering the raw surface. Anatomically normally formed kidney. In removing segments of anatomically normally formed kidneys if an aberrant vessel is found it may be clamped off, accomplishing much the same purpose and the situation is handled in much the same manner as in double kidney; however, it is often necessary to amputate the segment to be removed without ligating the supply to the segment. The operator can control hemostasis beautifully by grasping the kidney just above the line of amputation with his thumb and forefinger, cutting out the wedge-shaped piece to be removed and placing his mattress ligatures through the kidney substance, tying both sides over fat or muscle. I prefer muscle. The bleeding is inconsequential, is under perfect control, and it has never been necessary to ligate any vessels in the cut in the parenchyma. I have never found it necessary to clamp off the renal pedicle to do a heminephrectomy. It seems to me that this not only prolongs the time of operation but endangers the renal pedicle and the vitality of the kidney substance to be conserved, and may be the direct cause, because of injury, of a subsequent nephrectomy or atrophy of the remaining portion of the kidney. The operative procedures are extremely simple and must be modified to meet the conditions found in the operating room. The simpler the procedure, and the gentleness with which the kidney and its pedicle are handled, is very often the difference between a successful conservation of renal substance and the subsequent necessity for further surgical procedure. Mortality and morbidity. The results in this series of cases are as follows: There has been no immediate mortality. One of the heminephrectomies in the horseshoe kidney series died a little over a year after operation from metastases. Another case developed calculous nephrosis of the remaining half of the kidney but is living twelve years after the primary heminephrectomy. There has been no mortality in any of the operations upon the double kidneys or upon the anatomically normally formed kidneys. All of these cases on our list have been checked, are living and well and comparatively free from the symptoms which brought them to the Clinic.
HEMINEPHRECTOMY
57
CONCLUSIONS
Since this paper is based almost solely on personal experiences, it is in itself one of the writer's conclusions, and therefore: Heminephrectomy is indicated in all cases where pathology necessitating surgical treatment is limited to a section of any kidney, whether it be a horseshoe, double, or an anatomically normal organ. It is particularly indicated in single kidneys where surgery is necessary for the same reasons, and finally, it should be always considered in all planned surgical attacks upon the kidney in an endeavor to preserve all the functional parenchyma possible. REFERENCES BABCOCK, W.W.: Textbook of Surgery. W. B. Saunders Co., 1935. BIRDSALL, J. C.: The etiology, diagnosis, and treatment of hydronephrosis. Penn. Med. Jour., 39: 497-501, 1936. CAMPBELL, M. F.: Uretero-heminephrectomy in infancy. Jour. Urol., 26: 433-445, 1931. EISENDRATH, D. N., AND PmFER, F. M.: Bilateral heminephrectomy in bilateral double kidney. Jour. Urol., 13: 525-535, 1925. EISENDRATH, D. N., PmFER, F. M., AND CULVER, H.B.: Horseshoe kidney. Ann. Surg., 82: 735-764, 1925. FOLEY, F. E. B.: Discussion. Jour. Urol., 32: 657, 1934. GUTIERREZ, R.: The clinical management of horseshoe kidney. Amer. Jour. Surg., 14: 657, 1931; 15: 132; 15: 345, 1932. GUTIERREZ, R.: The Clinical Management of Horseshoe Kidneys. Paul B. Hoeber, Inc., 1935, p. 119. HESS, E.: Surgical horseshoe kidney. Report of one unusual case. Jour. Urol., 12: 627633, 1924. HEss, E.: Adenocarcinoma horseshoe kidney. Jour. Urol., 27: 47-58, 1932. HESS, E.: Nephrotomy. Its indications, limitations and terminal results. Calif. and West. Med., 41: 74-79, 1934. HINMAN, F.: PrinciplesandPracticeofUrology. W. B. Saunders Co., 1935, p. 661. JECK, H. S.: Horseshoe kidney with especial reference to surgical technique. Jour. Amer. Med. Assoc., 98: 603-609, 1932. JUDD, E. S., BRAASCH, W. F., AND SCHOLL, A. J., JR.: Horseshoe kidney. Jour. Amer. Med. Assoc., 79: 1189-1195, 1922. MARK, E.G.: Carbuncle of the kidney. Urol. and Cutan. Rev., 36: 93-94, 1932. MARTINOW, A. V.: Intervention sur le rein en fer a cheval. Zentralbl. f. chir., 37: 314-316, 1910. PAPIN, E.: Rein en fer a cheval. Section de l'isthme. Ass. franc d'urol. xxii Congres, Paris, Oct. 1922, p. 557. RATHBUN, N. P.: Notes on the clinical aspects of horseshoe kidney. Jour. Urol., 12: 611625, 1924. RovsrnG, T.: Beitrag zur Symptomatologie, Diagnose und Behandlung der Hufeisenniere Ztschr. £. Urol., 5: 586-601, 1911. STONE, E.: Heminephrectomy. Jour. Urol., 28: 301-321, 1932. WRIGHT, B. W.: Heminephrectomy. ,Report of three cases. Urol. and Cutan. Rev., 36: 592-597, 1932. YOUNG, H. H., AND DAVIS, E.G.: Double ureter and kidney with calculous pyonephrosis of one-half; cure by resection; the embryology and surgery of double ureter and kidney. Jour. Urol., 1: 17-32, 1917. YOUNG, H. H.: Young's Practice of Urology. W. B. Saunders Co., 1926, Vol. II, p. 296.