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Kidney Stone:1 A Review of Thirty-Five Cases
KIDNEY STONE 1 A REVIEW OF THIRTY--FIVE CASES W. CALHOUN STIRLING Washington, D. C.
Urinary lithiasis was one of the earliest surgical diseases recognized by the ancients. Lithotomy had reached such a high degree of perfection that the practice was given special recogni-tion in the Hippocratic oath. The first nephrectomy wi:ts performed in 1869 by Simon, for the removal of a stone. Kidney surgery made rapid strides from that time 01L Other renal explorations were recorded by Czerny, and l'vforris, and others in the year 1880. As a result of the improvement in urography, surgery of the kidney has become one of the most accurate operatfre procedures practiced at the present time. With the aid of blood retention and dye excretion tests, together with the urographic findings one is able to determine accurately the amount of renal damage as a result of calculus. No branch of surgery requires more accuracy and nicety of detail as does renal surgery. One or both organs may be diseased or partially destroyed as a result of stone lodgment, so that many considerations enter into the decision as to the advisability of operative interference. Chute says, "Renal calculi leads to greater destruction of renal tissue than any other surgical renal lesion and if allowed to remain ,yill eventually destroy the kidney that harbors it." This paper comprises a review of 35 cases of renal calculi treated by me. Three outstanding points were noted in this study and it might be well to emphasize them at this time. The first is the amount of renal destruction that occurs in the presence of a stone. The second is the frequency with which renal calculi go unrecognized, 1
Read before the J\1cdica1 Society, District of Columbia, March 16, 1927. 259
FIG. 2
FIG. 1 Fm.
1.
BILATERAL RENAL LITHIASIS
Each minor calyx contains a stone 2.
FIG.
PYELOGRAM OF PREVIOUS CASE SHOWING CALCULI SITUATED Wl~'HIN PEL-
VIC SHADOW WITH RATHER MARKED
PYEI,ECTASIS
AND KINKING
OF
URETER
Lithotomy successfully performed
Fm. 3
Fm.
4
Fm. 3. Two LAMINATED CALcm r SITUATED IN THE KIDNEY AREA The concentric arrangement of many of these renal stones is illustrated in this case. These stones were successfully removed by pyelotomy. Fm.
4.
PYELOGRAM SHOWING A FILLING DEFECT AT POINT OF ARROW CAUSED BY A PooR SHADOW CASTING STONE
This stone was successfully removed
260
KIDNEY STONE
261
and third the number of cases of kidney stone that have been diagnosed as some other condition. In 5 of these cases, both kidneys contained stones, and in 1 case each kidney contained ten and twelve calculi respectively. Braasch reports 12 per cent bilateral stones and per cent. found hydronephrosis in 10 per cent, and pyonephrosis as a complication in more than 25 per cent of a group of kidney stones treated at the Mayo Clinic. Chute found 40 per cent of his cases had severe destruction of the kidney as a result of stone lodgment. The following case emphasizes the amount of renal destruction that may occur in the presence of a stone. Miss G. C, age nineteen, admitted to the hospital July 10, 1926, complaining of a dull aching pain in back together with some frequency of urination. Blood and pus was found on catheterization of the bladder. A plain x-ray showed two stones in the right kidney and two larger ones on the left side. Bilateral pyelograms made at separate times showed the previously seen shadows to be in the kidney pelvis as well as marked pyonephrosis on both sides. The differential thalein was markedly decreased with some elevation of the blood urea. The best kidney was attacked first and on exposure it was found to contain 100 cc. of pus, plus the two stones The cortex was found to be very thin in as a, result of the pyonephrosis. The kidney pelvis was opened and the stones removed. Convalescence normal, The other kidney was explored three months later and found to contain 90 cc. of pus. Two stones situated in the terminal calyces were removed a combined pelvionephrotomy. The kidney healed normally.
The frequency with which renal stones remain silent and escape recognition has been observed by many urologists. The larger the stone the fewer the symptoms. The following case illustrates this point. Mr. locomotive engineer, was seen August 10, 1926. Patient to his family physician for life insurance and on ex-· amination, red blood cells were found in the urine. An x-ray was made on the advice of his doctor and revealed a giant calculus in the right No subjective symptoms had been noted the
Fm. 5
Fm. 6
Fm. 5. BILATERAL RENAL LITHIASis Kidneys much enlarged as result of acute blockage of ureter
FIG. 6.
PYELOGRAM SHOWING MODERATE DEGREE PYONEPHROSIS RESULT OF STONE
Minor calyces blunted with some dilatation of pelvis - - - - --
·7
I
Fm. 7
Fm. 7.
Fm. 8
STAG-HORN RENAL CALCULUS WHICH PRODUCED PERINEPHl,ITIC AnscEss
Nephrectomy suggested but refused. which was drained.
Fm. 8.
Three weeks later abscess developed
SrLEN1' GIANT RENAL CALCULUS AccrnENTAI,LY D1scovERED DunINa LIFE INSURANCE EXAMINATION
Primary nephrectomy was done
262
KIDNEY STONE
263
previous to this examination. A cystoscopy was done and a phthalein determination made which showed the right kidney to be functionless. A pyelogram confirmed the position of the stone and also showed the kidney to be a mere pus sac. In view of the active occupation of the patient a nephrectomy was suggested and was agreed to by the patient. At operation the kidney was found to be completely destroyed, the stone measuring 4 by 6 cm.
One cannot too strongly emphasize the necessity of taking a routine radiogram in all cases presenting urinary symptoms or in any case in which the diagnosis is ob;,cure. Some time ago I reported a series of forty ureteral stones and found that over 30 per cent of this group had been operated on elsewhere for some other condition without relief. Hinman, Cabot, Braasch and others report an even higher percentage of errors in the diagnoses of urinary lithiasis. The following case illustrates the frequency with which renal calculi are mistaken for abdominal conditions: Mr. G. M. M., age forty-five, occupation salesman, entered hospital complaining of distress in the epigastrium and inability to assimilate solid foods. Some dysuria, and nocturia was noticed. Past history: Patient had gastro-enterostomy for a supposedly gastric ulcer several years previously without relief. He subsisted entirely on ice cream and other soft foods. A routine x-ray showed a large indefinite shadow in the region of the right kidney, A cystoscopy and pyelogram were done and a thalcin test made. The affected kidney function was almost normal so a pyelotomy was done and the stone removed. The relief following this operation was very marked. Previous to this operation tho patient weighed 102 pounds1 following the operation he was able to resume his regular diet eating solid foods as desired and gained 20 po:mds within a short time. The patient refused to have the accompanying renal infection cleared following operation and had to have two secondary kidney operations later for the removal of stones which reformed within a few months time in each instance.
This case also shows the necessity of having patients return for a regular examination. Any foci found in the oral cavity should be eliminated as well as free the kidney of any infection
264
W. CALHOUN STIRLING
following a renal operation as subsequent stone formation occurs in from 5 to 12 per cent of the cases. ETIOLOGY
The factors involved in the formation of kidney stones are threefold. The first is mechanical, the second bacter,ial and the third physico-chemical. The mechanical factor may result from any upper urinary tract lesion which produces residual urine in the kidney pelvis. A practical illustration of this cause may be pointed out by citing the frequency with which stone occurs with prostatic hypertrophy, i.e., 15 per cent. Runner is of the opinion that ureteral stricture is the principal cause of stone formation in the upper urinary tract. Many writers including C. H. Mayo, Beer and others believe that infection is the principal cause of stone. The experimental work 0£ Rosenow and others tends to bear out the theory of focal infection as one of the causative agents in renal lithiasis. Several years ago I reported a case of bilateral nephrolithiasis with calcification of the renal vein in which I was able to trace the formative factors to an infection of the entire oral denture. The patient apparently possessed a stone producing organism capable of causing precipitation of lime salts throughout both kidneys as well as one renal vein. The diagnosiE' made previous to her entry in the hospital was gall bladder disease. I resected the lower half of the renal vein removing the growth therefrom as well as removing the multiple renal calculi. Her recovery was normal and the function on that side was excellent subsequent to the operation. Sixteen diseased teeth were also withdrawn. No recurrence has been noted since that time. Focal infections should be eradicated in any renal disease more particularly in kidney stones. The physico-chemic relationship between the urinary colloids and crystalloids has received much consideration in the literature as a cause of stone. Braasch, Spitzer, H~llkowitz and Keyser and others believe that an alteration of the normal protective
KIDNEY STONE
colloids of the urine may result in the precipitation and deposit of urinary crystals which had been previously held in a supersaturated solution. Experimentally renal stones have been produced by feeding animals an excess of certain salts such as oxamid and thereby overwhelming the protective colloid.s. The practical application that we may learn from these various hypotheses is that, it is imperative to clear up a mechanical or
Fm. 9
FIG.10
FIG. 9. ARROW SHows JV[oDERA~'E SrzE KIDNEY STo:-.rrn
A stone of this size frequently comes impacted at the uretero-pelvic junction, and may thus result in complete destruction of the kidney. F10. JO. LATHI,il.L Vrnw OF PREVIOUSLY SHOWN S'l'ONI" Lateral pictures are extremely valuable in localizing shadows which lie in the same vertica.l plane as the pyelogram. Renal stones lie within plane as the spinal column.
infective process in the urmary tract m order to prevent the reformation of stone. SYMPTOMS
The symptomatology of stone in the kidney is legion. It may simulate an abdominal lesion and often results in a needless exploratory operation. Briefly enumerated the outstanding
266
W. CALHOUN STIRLING
symptoms in the order of their frequency are: pain, hematuria, pyuria, nausea and vomiting,, frequency and dysuria and not infrequently sand is seen in the urine. Pain was present in 26 of these cases, hematuria in 16 and colicky pain was present at sometime in 27 cases. Often the stone produces acute blockage at the ureteropelvic junction, and usually 1~esults in severe colicky pain recognized as such by the laity. This obstruction to the urinary outlet often terminates in hydronephrosis or pyonephrosis if the blockage remains for a considerable period of time. Often large stones are characterized; by a complete absence of all symptoms especially the large immovable stones, which do not result in acute blockage. It is this type of stone that produces such marked destruction of kidney tissue. The diagnosis of kidney stones have been greatly simplified by the introduction of the x-ray and pyelography. By a combination of these methods the percentage of errors has been reduced to a minimum. We are not only in a position to determine 'whether or not a stone is present, but also the number, size aha location of such a stone, also the amount of damage to the host. Approximately 90 per cent of all renal calculi can be demonstrated by careful x-ray. In some of the stones possessing little or no calcium, such as the uric acid and cystin stones, a contrast pyelogram using 5 per cent sodium iodide may be made and will intensify or cause a filling defect in the pyelogram. It is necessary to rule out new growths and blood clots in cases with filling defects as these conditions may give the same impression in the pyelogram. One is never justified in exploring a kid;ney for stone without an x-ray followed by a pyelogram. Two cases in this study had been explored elsewhere without success, one for a migratory stone, the second for calcified mesenteric glands. Gall bladder and other extra-renal calcium deposits may apparently lie in the same plane and yet prove to be several inches distance from the kidney following a pyelogram. Lateral radiograms are invaluable where doubt exists as to the antero-posterior position of a suspect ed stone.
KIDNEY STONE
267
TREATMENT
.
: ;
The treatment may be divided into: Operative and nonoperative. Bugbee, Chute and others have shown that preliminary cystoscopic treatment of a diseased kidney is very· essential just as is done in the preparation of a patient for pros~ tatectomy. We are able to save many diseased kidneys by this method that were formerly removed. In a given case with a small calculus situated in a lower calyx with little or no active infection, and no apPJ3,rent increase in size of the stone shown by the x-ray we are justified in pursuing a less radical course. The patient should be watched from time to time to check up with plain x-ray to see that no increase in size has taken place. Four patients of this series are now enjoying good health plus a small calculus situated in the lower qalyx of the kidney. They report at stated intervals and each case has shown no apparent increase in symptoms nor has the stone increased in size. Before surgical interference is deemed wise we should ask ourselves the following questions. First, can the affected kidney be restored to its normal function if the stone is removed? ~econd, will removal of the stone sacrifice too much renal tissue to justify a nephrotomy? Third, if compensatory hyJ?ertrophy has taken place in the normal kidney, function in the diseased one rarely returns, so are we justified in pursuing a non-operative course when these cases of advanced lithiasis merely serve as a source of further trouble. Cummings and others have shown experimentally that the kidney returns to approximately noi-mal following a nephrotomy, so that unless an advanced pyonephrosis is present we should be very reluctant to remove a kidney with fair function. The stone will frequently produce temporary embarrassment of the kidpey function and it is surprising how quickly it will regain its normal function following the removal of a stone. Careful pre-operative treatment has reduced the number of cases requiring nephrectomy chiefly to those harboring the tubercle bacillus together with pyonephrosis. Generally speaking an operation should be considered when the stone is large or multiple, impacted at the ureteropelvic junction, when calculus THE JOURNAL OF UROLOGY, V OL. XVIII, NO.
3
268
W. CALHOUN STIRLING
anuria supervenes or when an acute pyelonephritis accompanies the stone. Also if the patient has pain, bleeding or other signs of an active process such as a movable stone will produce, then removal of the stone should be considered. If the lithiasis is bilateral a proper decision is more difficult to reach. Most operative cases can be prepared by judicious lavage and drainage of the infected kidney and in many instances a partially damaged kidney can be saved. The tendency is now to be conservative in kidney surgery and only remove those kidneys that are hopelessly diseased. It is remarkable how much comeback a kidney possesses if relieved of the added burden of a stone. In conclusion I wish to emphasize the following points: 1. Renal calculi often escapes recognition as such and may simulate any condition in the abdomen. 2. ~very case presenting urinary symptoms or where the diagnosis is obscure should have a radiogram made. 3. Lithiasis causes more destruction of the kidney than any other renal surgical disease. 4. An exploratory kidney operation is never justified without a preliminary pyelogram. 5. The classical symptoms of nephrolithiasis are misleading and may result from any lesion blocking the urinary outlet. 6. Conservatism should be the keynote as the kidney possesses remarkable recuperative powers.
Urinary lithiasis was one of the earliest surgical diseases recognized by the ancients. Lithotomy had reached such a high degree of perfection that the practice was given special recogni-tion in the Hippocratic oath. The first nephrectomy wi:ts performed in 1869 by Simon, for the removal of a stone. Kidney surgery made rapid strides from that time 01L Other renal explorations were recorded by Czerny, and l'vforris, and others in the year 1880. As a result of the improvement in urography, surgery of the kidney has become one of the most accurate operatfre procedures practiced at the present time. With the aid of blood retention and dye excretion tests, together with the urographic findings one is able to determine accurately the amount of renal damage as a result of calculus. No branch of surgery requires more accuracy and nicety of detail as does renal surgery. One or both organs may be diseased or partially destroyed as a result of stone lodgment, so that many considerations enter into the decision as to the advisability of operative interference. Chute says, "Renal calculi leads to greater destruction of renal tissue than any other surgical renal lesion and if allowed to remain ,yill eventually destroy the kidney that harbors it." This paper comprises a review of 35 cases of renal calculi treated by me. Three outstanding points were noted in this study and it might be well to emphasize them at this time. The first is the amount of renal destruction that occurs in the presence of a stone. The second is the frequency with which renal calculi go unrecognized, 1
Read before the J\1cdica1 Society, District of Columbia, March 16, 1927. 259
FIG. 2
FIG. 1 Fm.
1.
BILATERAL RENAL LITHIASIS
Each minor calyx contains a stone 2.
FIG.
PYELOGRAM OF PREVIOUS CASE SHOWING CALCULI SITUATED Wl~'HIN PEL-
VIC SHADOW WITH RATHER MARKED
PYEI,ECTASIS
AND KINKING
OF
URETER
Lithotomy successfully performed
Fm. 3
Fm.
4
Fm. 3. Two LAMINATED CALcm r SITUATED IN THE KIDNEY AREA The concentric arrangement of many of these renal stones is illustrated in this case. These stones were successfully removed by pyelotomy. Fm.
4.
PYELOGRAM SHOWING A FILLING DEFECT AT POINT OF ARROW CAUSED BY A PooR SHADOW CASTING STONE
This stone was successfully removed
260
KIDNEY STONE
261
and third the number of cases of kidney stone that have been diagnosed as some other condition. In 5 of these cases, both kidneys contained stones, and in 1 case each kidney contained ten and twelve calculi respectively. Braasch reports 12 per cent bilateral stones and per cent. found hydronephrosis in 10 per cent, and pyonephrosis as a complication in more than 25 per cent of a group of kidney stones treated at the Mayo Clinic. Chute found 40 per cent of his cases had severe destruction of the kidney as a result of stone lodgment. The following case emphasizes the amount of renal destruction that may occur in the presence of a stone. Miss G. C, age nineteen, admitted to the hospital July 10, 1926, complaining of a dull aching pain in back together with some frequency of urination. Blood and pus was found on catheterization of the bladder. A plain x-ray showed two stones in the right kidney and two larger ones on the left side. Bilateral pyelograms made at separate times showed the previously seen shadows to be in the kidney pelvis as well as marked pyonephrosis on both sides. The differential thalein was markedly decreased with some elevation of the blood urea. The best kidney was attacked first and on exposure it was found to contain 100 cc. of pus, plus the two stones The cortex was found to be very thin in as a, result of the pyonephrosis. The kidney pelvis was opened and the stones removed. Convalescence normal, The other kidney was explored three months later and found to contain 90 cc. of pus. Two stones situated in the terminal calyces were removed a combined pelvionephrotomy. The kidney healed normally.
The frequency with which renal stones remain silent and escape recognition has been observed by many urologists. The larger the stone the fewer the symptoms. The following case illustrates this point. Mr. locomotive engineer, was seen August 10, 1926. Patient to his family physician for life insurance and on ex-· amination, red blood cells were found in the urine. An x-ray was made on the advice of his doctor and revealed a giant calculus in the right No subjective symptoms had been noted the
Fm. 5
Fm. 6
Fm. 5. BILATERAL RENAL LITHIASis Kidneys much enlarged as result of acute blockage of ureter
FIG. 6.
PYELOGRAM SHOWING MODERATE DEGREE PYONEPHROSIS RESULT OF STONE
Minor calyces blunted with some dilatation of pelvis - - - - --
·7
I
Fm. 7
Fm. 7.
Fm. 8
STAG-HORN RENAL CALCULUS WHICH PRODUCED PERINEPHl,ITIC AnscEss
Nephrectomy suggested but refused. which was drained.
Fm. 8.
Three weeks later abscess developed
SrLEN1' GIANT RENAL CALCULUS AccrnENTAI,LY D1scovERED DunINa LIFE INSURANCE EXAMINATION
Primary nephrectomy was done
262
KIDNEY STONE
263
previous to this examination. A cystoscopy was done and a phthalein determination made which showed the right kidney to be functionless. A pyelogram confirmed the position of the stone and also showed the kidney to be a mere pus sac. In view of the active occupation of the patient a nephrectomy was suggested and was agreed to by the patient. At operation the kidney was found to be completely destroyed, the stone measuring 4 by 6 cm.
One cannot too strongly emphasize the necessity of taking a routine radiogram in all cases presenting urinary symptoms or in any case in which the diagnosis is ob;,cure. Some time ago I reported a series of forty ureteral stones and found that over 30 per cent of this group had been operated on elsewhere for some other condition without relief. Hinman, Cabot, Braasch and others report an even higher percentage of errors in the diagnoses of urinary lithiasis. The following case illustrates the frequency with which renal calculi are mistaken for abdominal conditions: Mr. G. M. M., age forty-five, occupation salesman, entered hospital complaining of distress in the epigastrium and inability to assimilate solid foods. Some dysuria, and nocturia was noticed. Past history: Patient had gastro-enterostomy for a supposedly gastric ulcer several years previously without relief. He subsisted entirely on ice cream and other soft foods. A routine x-ray showed a large indefinite shadow in the region of the right kidney, A cystoscopy and pyelogram were done and a thalcin test made. The affected kidney function was almost normal so a pyelotomy was done and the stone removed. The relief following this operation was very marked. Previous to this operation tho patient weighed 102 pounds1 following the operation he was able to resume his regular diet eating solid foods as desired and gained 20 po:mds within a short time. The patient refused to have the accompanying renal infection cleared following operation and had to have two secondary kidney operations later for the removal of stones which reformed within a few months time in each instance.
This case also shows the necessity of having patients return for a regular examination. Any foci found in the oral cavity should be eliminated as well as free the kidney of any infection
264
W. CALHOUN STIRLING
following a renal operation as subsequent stone formation occurs in from 5 to 12 per cent of the cases. ETIOLOGY
The factors involved in the formation of kidney stones are threefold. The first is mechanical, the second bacter,ial and the third physico-chemical. The mechanical factor may result from any upper urinary tract lesion which produces residual urine in the kidney pelvis. A practical illustration of this cause may be pointed out by citing the frequency with which stone occurs with prostatic hypertrophy, i.e., 15 per cent. Runner is of the opinion that ureteral stricture is the principal cause of stone formation in the upper urinary tract. Many writers including C. H. Mayo, Beer and others believe that infection is the principal cause of stone. The experimental work 0£ Rosenow and others tends to bear out the theory of focal infection as one of the causative agents in renal lithiasis. Several years ago I reported a case of bilateral nephrolithiasis with calcification of the renal vein in which I was able to trace the formative factors to an infection of the entire oral denture. The patient apparently possessed a stone producing organism capable of causing precipitation of lime salts throughout both kidneys as well as one renal vein. The diagnosiE' made previous to her entry in the hospital was gall bladder disease. I resected the lower half of the renal vein removing the growth therefrom as well as removing the multiple renal calculi. Her recovery was normal and the function on that side was excellent subsequent to the operation. Sixteen diseased teeth were also withdrawn. No recurrence has been noted since that time. Focal infections should be eradicated in any renal disease more particularly in kidney stones. The physico-chemic relationship between the urinary colloids and crystalloids has received much consideration in the literature as a cause of stone. Braasch, Spitzer, H~llkowitz and Keyser and others believe that an alteration of the normal protective
KIDNEY STONE
colloids of the urine may result in the precipitation and deposit of urinary crystals which had been previously held in a supersaturated solution. Experimentally renal stones have been produced by feeding animals an excess of certain salts such as oxamid and thereby overwhelming the protective colloid.s. The practical application that we may learn from these various hypotheses is that, it is imperative to clear up a mechanical or
Fm. 9
FIG.10
FIG. 9. ARROW SHows JV[oDERA~'E SrzE KIDNEY STo:-.rrn
A stone of this size frequently comes impacted at the uretero-pelvic junction, and may thus result in complete destruction of the kidney. F10. JO. LATHI,il.L Vrnw OF PREVIOUSLY SHOWN S'l'ONI" Lateral pictures are extremely valuable in localizing shadows which lie in the same vertica.l plane as the pyelogram. Renal stones lie within plane as the spinal column.
infective process in the urmary tract m order to prevent the reformation of stone. SYMPTOMS
The symptomatology of stone in the kidney is legion. It may simulate an abdominal lesion and often results in a needless exploratory operation. Briefly enumerated the outstanding
266
W. CALHOUN STIRLING
symptoms in the order of their frequency are: pain, hematuria, pyuria, nausea and vomiting,, frequency and dysuria and not infrequently sand is seen in the urine. Pain was present in 26 of these cases, hematuria in 16 and colicky pain was present at sometime in 27 cases. Often the stone produces acute blockage at the ureteropelvic junction, and usually 1~esults in severe colicky pain recognized as such by the laity. This obstruction to the urinary outlet often terminates in hydronephrosis or pyonephrosis if the blockage remains for a considerable period of time. Often large stones are characterized; by a complete absence of all symptoms especially the large immovable stones, which do not result in acute blockage. It is this type of stone that produces such marked destruction of kidney tissue. The diagnosis of kidney stones have been greatly simplified by the introduction of the x-ray and pyelography. By a combination of these methods the percentage of errors has been reduced to a minimum. We are not only in a position to determine 'whether or not a stone is present, but also the number, size aha location of such a stone, also the amount of damage to the host. Approximately 90 per cent of all renal calculi can be demonstrated by careful x-ray. In some of the stones possessing little or no calcium, such as the uric acid and cystin stones, a contrast pyelogram using 5 per cent sodium iodide may be made and will intensify or cause a filling defect in the pyelogram. It is necessary to rule out new growths and blood clots in cases with filling defects as these conditions may give the same impression in the pyelogram. One is never justified in exploring a kid;ney for stone without an x-ray followed by a pyelogram. Two cases in this study had been explored elsewhere without success, one for a migratory stone, the second for calcified mesenteric glands. Gall bladder and other extra-renal calcium deposits may apparently lie in the same plane and yet prove to be several inches distance from the kidney following a pyelogram. Lateral radiograms are invaluable where doubt exists as to the antero-posterior position of a suspect ed stone.
KIDNEY STONE
267
TREATMENT
.
: ;
The treatment may be divided into: Operative and nonoperative. Bugbee, Chute and others have shown that preliminary cystoscopic treatment of a diseased kidney is very· essential just as is done in the preparation of a patient for pros~ tatectomy. We are able to save many diseased kidneys by this method that were formerly removed. In a given case with a small calculus situated in a lower calyx with little or no active infection, and no apPJ3,rent increase in size of the stone shown by the x-ray we are justified in pursuing a less radical course. The patient should be watched from time to time to check up with plain x-ray to see that no increase in size has taken place. Four patients of this series are now enjoying good health plus a small calculus situated in the lower qalyx of the kidney. They report at stated intervals and each case has shown no apparent increase in symptoms nor has the stone increased in size. Before surgical interference is deemed wise we should ask ourselves the following questions. First, can the affected kidney be restored to its normal function if the stone is removed? ~econd, will removal of the stone sacrifice too much renal tissue to justify a nephrotomy? Third, if compensatory hyJ?ertrophy has taken place in the normal kidney, function in the diseased one rarely returns, so are we justified in pursuing a non-operative course when these cases of advanced lithiasis merely serve as a source of further trouble. Cummings and others have shown experimentally that the kidney returns to approximately noi-mal following a nephrotomy, so that unless an advanced pyonephrosis is present we should be very reluctant to remove a kidney with fair function. The stone will frequently produce temporary embarrassment of the kidpey function and it is surprising how quickly it will regain its normal function following the removal of a stone. Careful pre-operative treatment has reduced the number of cases requiring nephrectomy chiefly to those harboring the tubercle bacillus together with pyonephrosis. Generally speaking an operation should be considered when the stone is large or multiple, impacted at the ureteropelvic junction, when calculus THE JOURNAL OF UROLOGY, V OL. XVIII, NO.
3
268
W. CALHOUN STIRLING
anuria supervenes or when an acute pyelonephritis accompanies the stone. Also if the patient has pain, bleeding or other signs of an active process such as a movable stone will produce, then removal of the stone should be considered. If the lithiasis is bilateral a proper decision is more difficult to reach. Most operative cases can be prepared by judicious lavage and drainage of the infected kidney and in many instances a partially damaged kidney can be saved. The tendency is now to be conservative in kidney surgery and only remove those kidneys that are hopelessly diseased. It is remarkable how much comeback a kidney possesses if relieved of the added burden of a stone. In conclusion I wish to emphasize the following points: 1. Renal calculi often escapes recognition as such and may simulate any condition in the abdomen. 2. ~very case presenting urinary symptoms or where the diagnosis is obscure should have a radiogram made. 3. Lithiasis causes more destruction of the kidney than any other renal surgical disease. 4. An exploratory kidney operation is never justified without a preliminary pyelogram. 5. The classical symptoms of nephrolithiasis are misleading and may result from any lesion blocking the urinary outlet. 6. Conservatism should be the keynote as the kidney possesses remarkable recuperative powers.