Intraoperative Radiography in Conservative Surgery for Renal Calculi

Vol. llO, November Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright© 1973 by The Williams & Wilkins Co.

INTRAOPERATNE RADIOGRAPHY IN CONSERVATIVE SURGERY FOR RENAL CALCULI A. DAVID BECK*

From the Department of Urology, Indiana University School of Medicine and Hospitals, Indianapolis, Indiana

The postoperative recurrence rate of renal calculi, particularly staghorn and multiple types, is dependent upon the length of followup and the thoroughness of investigation. In assessing recurrence a clear distinction must be made between true recurrence with a new stone and false recurrence in which fragments were undetected at operation. Although the incidence of false recurrence is difficult to estimate it is probably higher than generally appreciated. Oppenheimer reported a 23 per cent incidence of residual stones in 141 operations. 1 Williams reported 66 residual stones (most of which were left deliberately) in 370 conservative renal operations; a false recurrence rate of 18 per cent. 2 The importance of residual fragments is stressed by some authors and ignored by others. In Williams' series 27 per cent of calculi not removed at operation passed spontaneously but 47 per cent required further operative intervention. Singh and associates considered that small fragments did not necessarily have disasterous consequences. 3 In a third of their patients such fragments remained unchanged in size for 1 to 7 years, although in an equal proportion the stones acted as a nidus for the formation of larger calculi. If residual calculi were only occasionally responsible for further morbidity, and few would challenge this, it is evident that the optimum time to detect and remove all fragments is during the primary operation. A simple technique for intraoperative radiography of the exposed kidney, capable of allowing identification of tiny fragments of calculous debris is reported herein. The case reports demonstrate that radiographic control permits localization and extraction of most renal stones. Accepted for publication June 1, 1973. Read at annual meeting of North Central Section, American Urological Association, Chicago, Illinois, September 27-30, 1972. * Current address: Division of Urology, Southern Illinois University School of Medicine, Springfield, Illinois 62708. 1 Oppenheimer, G. D.: Nephrectomy versus conservative operation in unilateral calculous disease of the upper urinary tract. Surg., Gynec. & Obst., 65: 829, 1937. 2 Williams, R. E.: Long-term survey of 538 patients with upper urinary tract stone. Brit. J. Urol., 35: 416, 1963. 'Singh, M., Tresidder, G. C. and Blandy, J.: The long-term results of removal of staghorn calculi by extended pyelolithotomy without cooling or renal artery occlusion. Brit. J. Urol., 43: 658, 1971. 494

MATERIAL AND METHODS

The only addition to standard equipment for intraoperative radiography is a light-weight metal cylinder. The dimensions are adjusted according to the type of portable x-ray machine available. At this institution Toshiba equipment is used. The cylinder measures 24 inches in length and 5 inches in diameter with a flange at one end which fits over brackets on the machine (fig. 1). The cylinder is autoclaved and when radiographs are required it is attached directly to the machine. Extensive mobilization of the kidney is required to insure adequate radiographs. A sterile x-ray film (measuring 5½ by 4½ inches)t is placed against the posterior surface of the mobilized kidney which

FIG. 1. Metal cylinder used for intraoperative radiography.

is held upward by tapes around both poles. The cylinder is attached to the machine and is manipulated into the wound over the iliac crest so that the sterile end, covering the anterior surface of the kidney, comes in direct contact with the film. The kidney is thus sandwiched between film and cylinder. With this technique the anode-film distance and exposure factors are the same for every kidney and, since skeletal structures are excluded from the field, every x-ray gives maximum information without trial and error. CASE REPORTS

Case I. J.P., a 32-year-old white man, had had paraplegia since 1958. Since a left renal stone had

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FIG. 2. Case 1. A, x-ray of

495

and bladder shows multiple stones in both kidneys. Proximal right

meter is packed with calculi. B, intrc,or,e,·ative film (right kidney) shows residual calculi which were located and extracted.

FrG. 3. Case

A, initial intraoperativ,2; filrr1 cvnfirrns presence of stoEe. B, final fi.1:rn reveals stone-free kidney

beBn removed in 1960 he had bsen rnaintained. o:n_ urethral catheter vvithout further

1971 with a 2-year infection and fever. Renal creatinine clearance of 96 mL per minute, apto be well pH was 7 ,5 and culture Proteus mirabilis. of the kidneys, ureters and bladder revealed bilateral

calculi with many stones in the upper ureter and bladder 2, A). Fair concentration was seen on the excretory urograrns (IVPs) with considerable dilatation of both collecting on sizes were removed. Serial formed until all calculi had removed (fig. 2, B). The left renal calculi were

496

BECK

FIG. 4. Case 3. A, multiple cystine calculi in right kidney. B, complete clearance of right kidney. Note air delineating caliceal pattern. C, stones removed at operation.

removed in October and an ilea! conduit was performed in January 1972, at which time no residual or recurrent stone was demonstrable. Comment. Complete clearance of this patient's kidneys would have been nearly impossible without radiographic control. While a high recurrence rate might still be anticipated on the basis of stasis and possible infection, the likelihood would seem to be reduced in the absence of debris acting as a nidus for further stone formation. Case 2. B. P., a 42-year-old obese white woman, was seen in September 1972 with right flank pain 18 months in duration. After full multidisciplinary evaluation, the sole positive finding was a small calculus in the right kidney. In January 1973 the pain increased and the right kidney was explored. Initial x-ray of the exposed kidney verified the position of the stone in a lower pole calix (fig. 3, A). A pyelotomy incision was made, extending into the lower major calix. Probing with stone forceps produced some bleeding but no calculus was recovered. Since the pelvis was entirely intrarenal it was elected to localize the stone with needles in the renal parenchyma and to perform a small nephrotomy incision. Further x-ray of the kidney

failed to reveal the stone (fig. 3, B) and a thorough search of the sponges detected a 5 by 8 mm. calculus surrounded by a blood clot. Comment. Although the indication for an operation in this patient may be questioned, there is little doubt that small calculi have at times taxed the ingenuity of every urologist. Unnecessary trauma to the kidney, which may have resulted in nephrectomy, was averted by the information obtained from intraoperative radiographs. Case 3. W. C., a 20-year-old white man, was hospitalized on July 24, 1971, after 3 days of nausea, vomiting and right lower quadrant abdominal pain. A left ureteral calculus of unknown composition had been removed in 1968. The blood urea nitrogen was 61 mg. per cent and creatinine was 5.5 mg. per cent. Multiple stones were seen in the right kidney on x-rays of the kidneys, ureters and bladder (fig. 4, A). Both kidneys were obstructed on the IVP, the left one from what was proved to be a calculus in the distal ureter. A left ureterolithotomy was performed and analysis revealed a stone of pure cystine composition. The collecting system of the right kidney was explored through an extended pyelotomy incision. X-rays

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the rniddle and ·~Che stones v.,rere extracted and the shov;ed a stone-free I'VP 18 months later shovved prornpt bilateral function '.vithout evidence of residual or recunent stone. 4, sho\~,rs the stones r-e1noved at of

serious threat in this who 1s to a life-long.~,.,~~"~., of recurrence. Intraoperative x-rays were re,m,,n:s1 for achieving a stone-free DISCUSSION

is encountered in renal calculi of moderate size. as as 1971 the staten1ent was that, ~."-~,,-,, inadequate treatment for stones of primarily infected origin".• Since these calculi are usually multiple and fragile even quite large fragments may escape detection. In patients with traumatic cord lesions, in whom there is a significant incidence of multiple stones, in the false recurrence rates have been range of 30 per cent. 5 In the management of staghorn and a false recurrence rate of 36 per cent." Dissolution of these retained stones was achieved with 10 per ceP.t renacidin. In our ence with this the calculi frequently disappear and reappear a few weeks later, suggesting that the matrix was simply tern-· porarily decalcified. Vvhile this it cannot undetected calculi in a third of the

Small presence is not sterile urine and stable renal information that residual calculi are present, a tube may be for postoperative irrigation. Recent advances in conservative operations for renal such as local and the renal sinus together with adequate radiographic control, suggest that an acceptable incidence of residual even in complicated cases, should be ·well belovv 10 per cent. 3 • • radiography is generally accepted to surgery aithough inadequate detail on the exposed fiims and the extra time involved have apparently discouraged its use. The technique described herein is not original; it has been used for many years in England but has received little attention in the United States. 7 described the use of a cone with sterile linen which is brought into the operative field." The principle of contact radiography as described herein appears to be a simpler and more reliable technique. The occasional revelation of have meticulous whether any stones should be control.. The additional time spent in filr.ns is 111.ore than operations can be prevented. SUMMARY

A false recurrence rate of 30 per cent can no be after conservative operations for renal calculi. The cases presented herein indicate that most ~~'''"'"'"'""<, calculi can the ''Nickham, J. E. A. and

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H. G.: Accurate surgical localisation ofrenal J. 3!l: 1867. E.: Renal J.

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