Modification of cryoprecipitate coagulum pyelolithotomy technique

MODIFICATION

OF CRYOPRECIPITATE

PYELOLITHOTOMY

COAGULUM

TECHNIQUE

SUHAYL S. KALASH, M.D. JOHN D. YOUNG, JR., M.D. GARY HARNE, M.D. From the Department of Surgery, Division of Urology, University of Maryland School of Medicine, Baltimore, Maryland

cryoprecipitate,

Cyoprecipitate coagulum pyelolithotomy usually is performed with the use of calcium, and thrombin. We report a simplification of the technique by the use of ergoprecipitate and calcium only. The mechanism of the coagulum formation is discussed. An illustrative case is presented.

ABSTRACT

The technique of coagulum pyelolithotomy has been well established over the past four decades. In 1943 DeesIB introduced coagulum pyelolithotomy by using pooled human plasma and clotting globulin. PateI presented his experience with this tedious technique using fibrinogen and thrombin in 1973. The Food and Drug Administration banned the manufacture of pooled fibrinogen in December, 1977. Cryoprecipitate was established as a source of concentrated fibrinogen by Pool and Shannon4 and Kasper at uZ.~ Though plasma could be used as a source, the concentration of fibrinogen is only 2-3 mg./ml., and the resultant coagulum is weaka However, some authors reported good results with the use of plasma.‘** Over the past four years, several authors have reported success with cryoprecipitate coagulum pyelolithotomy. 6,9-12Broecker and Hackler” and Sherer12 use calcium cloride mixed with the thrombin in one syringe and cryoprecipitate in another. The contents of the two syringes are introduced into the pyelocalyceal system simultaneously through a small Foley catheter to prevent any leak. However, Fischer, Sonda, and Diokno’ mixed the contents Presented at Annual Meeting of Mid-Atlantic Section, American Urological Association, Inc., White Sulphur Springs, West Virginia, November 4, 1981.

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of the two syringes and injected the contents through an angiocatheter into the renal pelvis immediately since the coagulum will form in thirty seconds. Cryoprecipitate may be preserved with ethylenediamine-tetraacetic acid heparin,

FIGURE

35cc. tube.

1. ButterfEy needle (no. 19) attached to syringe, 6-m. syringe, and short connecting

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FIGURE 2. (A) KUB show 3 fw rd _ _ m&es (arrows). (B) Zntravenous p defects in rend pelvic lower calyceul system. (C) Retrograde pyelogram shows filling defects in pye.hmz&ceal system (arrows). (D) Air pyelograa shows position of 4 stones (arrows).

(EDTA) or citrate-phosphate-dextrose (CPD). If it is preserved in EDTA, it could be used without thrombin to form a coagulum.13 Cryoprecipitate is preserved with citrate-phosphatedextrose in our hospital. Muhiple experiments were performed in vitro by m ixing cryoprecipitate and calcium chloride in a syringe without thrombin. Coagulation started within fifteen m inutes. When used clinically, a tenacious 468

coagulum formed within five mmutes because of the presence of tissue thromboplastin, This modification in cryoprecipitate coagulum pyeIolithotomy has not been reported. Our technique is described. Technique The upper ureter and the renal pelvis-are &ssected posteriorly. The upper ureter is left in UROLOGY

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FIGURE 3. Coagulum: (A) anterior swjizce reveals more stones extracted than anticipated from x-ray studies, and (B) posterior surface shows extremely narrow infundubuli and clubbed calyces.

situ, and a right-angle clamp is passed around it just to pass a vascular loop. A small clamp is applied to the vascular loop next to the ureter to obstruct its lumen. A no. 19 butterfly or no. 20 Jelco needle attached to a short intravenous tube is inserted into the renal pelvis, and the urine content is aspirated (Fig. 1). The needle and its connection are left in place. The cryoprecipitate is warmed in the blood bank one-half hour before its use. It is collected into a large syringe. Another syringe contains 10% calcium chloride. One cc. of calcium chloride is mixed with one unit of cryoprecipitate (approximately lo-15 cc.). The mixture is shaken well. The needle is pulled out of the renal pelvis, and the mixture is injected through the connecting tube to dislodge the air. The needle is reinserted into the renal pelvis, and the mixture is injected slowly until the renal pelvis fills with a leak around the needle. After waiting five minutes, this needle is withdrawn, and a wide pyelotomy is made. The resultant coagulum is tenacious enough to be extracted in one piece with gentle manipulation by use of ring forceps, stone forceps, or

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right-angle clamps. As a part of the coagulum is delivered, the remainder is manipulated gently and extracted. The renal pelvis should not be overdistended as recommended previously. Overdistention of the pyelocalyceal system may cause rupture of a fornix and pulmonary embolization as reported by Novicki et al. l4 By deletion of thrombin, there is no need to fill the pyelocalyceal system within thirty seconds. The coagulation never started in less than fifteen minutes when the calcium chloride cryoprecipitate was mixed in a syringe and placed in a water bath at 37” C. However, it forms within five minutes in vivo because of tissue thromboplastin. Deletion of thrombin may prevent thromboembolism. Novicki showed, in dogs, high concentration of thrombin without overdistention of the pelvis causes thromboembolism, low concentration of thrombin with overdistention causes thromboembolism, and low concentration of thrombin without overdistention is safe. This modified technique thus eliminates the two predisposing risk factors for thromboembolism. However, in this modification, thrombin is generated from the cryoprecipitate in the pyelocalyceal system as discussed below. This modified technique is simple and has been performed successfully on 9 patients with extraction of all the stones in the pyelocalyceal system. Case Report A seventy-five-year-old white woman underwent right nephrectomy for right contracted nonfunctioning kidney with pyonephrosis secondary to a 1.3 by 1 cm. midureteral stone obstruction in November, 1980. Creatinine was 1.1 mg./ 100 ml., and urine culture grew Proteus mirabilis greater than 100,000/m1. Intravenous pyelogram at that time revealed multiple faintly radiopaque densities over the left kidney on KUB (Fig. 2A) and filling defects in the pyelocalyceal system (Fig. 2B). These were delineated well by a right retrograde pyelogram (Fig. 2C). The patient declined surgery. She was discharged and given ampicillin suppression therapy and readmitted six weeks later with anuria of forty-eight hours’ duration and a serum creatinine of 7.1 mg./lOO ml. Emergency catheterization of the left ureter revealed ureteropelvic obstruction, and a no. 5 ureteral .catheter was left in place fixed to a Foley catheter. The patient had mild postobstructive diuresis, and

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Tissue thromboplastin

No.

IX VI

\ (Intrinsic pathway)

VIII (Extrimic

pathway)

/

\

Thrombin+

IX

I Fibrin

(loose)

I

X XI

XIII

Fibrin

(tight)

FIGURE 4. Diagram of clotting mechanism. (Reproduced and modified from Deykin D: Thrombogenesis, N. Engl. J. Med., 276: 622 (1967), with permission. )

stabilized at 1.2 mg./lOO m l. the creatinine seventy-two hours later. Air pyelogram identified m u ltiple faintly radiopaque stones in the left renal pelvis, m iddle and lower calyces (Fig. 2D). She underwent cryoprecipitate coagulum pyelolithotomy with extraction of a tenacious

coagulum

containing

had been anticipated (Fig. 3).

more stones than

from the x-ray studies

Factor

.~ .-~ ~~.- .Fibrinogen Prothrombin Tissue thromboplastin Calcium Proaccelerin, or labile factor, or accelerator globulin Proconvertin Antihemophilic factor (AFH) or antihemophilic factor A, or antihemophilic globulin (AHG) Plasma thromboplastin component (PTC) or Christmas factor, or antihemophilic factor B Stuart-Prower factor Plasma thromboplastin antecedent (PTA), or antihemopbilic factor C Hageman factor, or glass contact factor Fibrin stabilizing factor, or LakiLorand factor

I II III IV V VII VIII

Fibrinogen

Prothrombin

__l_l.

XII XIII

*Factor VI omitted, no longer thought to be a separate entity. (From Ganong’* with permission of’Lange Medica.! Pub1icatinns.j

pure cryoprecipitate; however, this is m ixed with 7- 10 cc. of titrated plasma and supplied as a bag of lo-15 cc. ” The supplied cryoprecipitate unit contains all the coagulation factors to initiate the extrinsic and intrinsic pathways of the coagulation mechanism. These two pathways are presented in F igure 4. The extrinsic pathway

needs tissue

thromboplastin

which

is

Comment W h o le blood usually is preserved in citratephosphate-dextrose. l5 The citrate is an anticoagulant to prevent banked blood and plasma from coagulation, the phosphate m a intains a higher level of 2,3-diphosphoglyeerate (DPG) for better oxygenation of tissues from transfused blood, and the dextrose is for the metabolism of the red blood cells. Plasma contains all coagula-

present in all tissues of the body including the kidnevs. l* As seen from F igure 4, all the coagulation. factors needed to initiate thrombin are present in the commercially available cryoprecipitate except for tissue thromboplastin and calcium for the extrinsic pathway, and calcium for the intrinsic pathway. Calcium is needed for three reasons: (1) to act as a co-factor to convert prothrombin to thrombin, (2) to chelate the citrate which is the anticoagulant present in the cryopreeipitate, and (3) to increase the tensile

tion factors I to XIII (Table I), citrate, fibrinogen (2-3 mg./cc.). l6 Cryoprecipitate

portional to the calcium concentration added. rg

and is

strength

of the coagulum

Moreover, Marshal12’ strength of the coagulum

which

is directly

pro-

had shown that the is directly proportional

prepared from fresh frozen plasma by thawing at 2-4” C. The cryoprecipitate is about one-third fibrinogen (38-58 mg./cc.) and contains smaller amounts of all plasma proteins including factors II (prothrombin), V (proaccelerin), VII (proconvertin), IX (PTC), X (Stuart-Prower), XI (PTA), XII (Hageman), and XIII (fibrin stabiliz-

to the concentration of calcium and inversely proportional to the added thrombin concentration. So the addition of calcium and deletion of

ing). 4 Each

strong coagulum

470

unit

of plasma

yields

3-5

cc. of

thrombin

to the

cryoprecipitate

results

stronger coagulum as was evidenced

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Conclusion Cryoprecipitate coagulum pyelolithotomy is a well-established modality for extracting kidney stones in selected patients. The technique of coagulum pyelolithotomy is modified by deleting the thrombin. The ratio of cryoprecipitate to 10 per cent calcium chloride solution is 1 unit (lo-15 cc.) to 1 cc. The role of calcium and the mechanism of generation of thrombin from within the system have been discussed. There are several advantages to our modification. The technique is simplified by the use of only one syringe to inject the mixture of calcium chloride and cryoprecipitate. It is not necessary to inject the mixture within thirty seconds. It can be done slowly and gently without fear of premature coagulation. Deletion of thrombin may reduce any risk of embolization and result in stronger coagulum. 22 S. Green Street Baltimore, Maryland 21201 (DR. YOUNG) References 1. Dees JE: The use of an intrapelvic coagulum in pyelolithotomy, South. Med. J. 36: 167 (1943). 2. Dees JE, and Fox H: The properties of human fibrinogen coagulum, J. Ural. 49: 503 (1943). 3. Pate1 VJ: The coagulum pyelolithotomy, Br. J. Surg. 60: 230 (1973). 4. Pool JG, and Shannon AE: Production of high potency concentrates of antihemophilic globulin in a closed-bag system, N. Engl. J. Med. 273: 1443 (1965).

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5. Kasper CK, et al: Determinants of factor VIII recovery in cryoprecipitate, Transfusion 15: 312 (1975). 6. Fischer CP, Sonda LP III, and Diokno AC: Use of cryoprecipitate coagulum in extracting renal calculi, Urology 15: 6 (19SO). 7. Seddon JM, and Bonin RE: Coagulum pyelolithotomy, ibid. 9: 564 (1977). 8. Rathore A, and Hartwell HJ: Coagulum pyelolithotomy using autogenous plasma and bovine thrombin, J. Ural. 116: 8 (1976). 9. Marshall S, Lyon R, and Scott MP Jr: Further simplification for coagulum pyelolithotomy, ibid. 119: 588 (1978). IO. Fischer CP, and Sonda LP III: Cryoprecipitate: its use and effects in canine coagulum pyelolithotomy, Invest. Urol. 16: 266 (1979). 11. Broecker BH, and Hackler RH: Simplified coagulum pyelolithotomy using cryoprecipitate, Urology 14: 143 (1979). 12. Sherer JF Jr: Cryoprecipitate coagulum pyelolithotomy, J. Ural. 123: 621 (1980). 13. Smith Mfl: Personal communication, October, 1979. 14. Novicki DE, et al: Pulmonary emboli associated with coagulum pyelolithotomy, presented at Annual Meeting of American Urological Association, Boston, May 13, 1981. IS. Silver D: Blood transfusions and disorders of surgical bleeding, in Sabiston DC (Ed): Textbook of Surgery, Philadelphia, W. B. Saunders Co., ed. 10, chap. 6, 1972, p. 131. 16. Johnson AJ, Aronson DL, and Williams WI: Preparation and cl&al use of plasma and plasma fractions, in Brehm-JJ (Ed): Textbook of Hematolozv.-, New York. McGraw-Hill Book Comparry, ed. 2, chap. 169, 1977, p. 1561: 17. Eastlund DT: Medical Director, American Red Cross Blood program, Northwestern New York Region, personal communication, April, 1981. 18. Ganong WF: Circulation, in Review of Medical Physi010~. Los Altos. California. Lange Medical Publication, ed. 7, chap. 27, 1975, p. 378. 19. Ratnoff DD, and Potts AM: The accelerating effect of calcium and other cations on the conversion of fibrinogen to fibrin, J. Clin. Invest. 33: 206 (1954). 20. Marshall S: Commercial fibrinogen, autogenous plasma, whole blood, and cryoprecipitate for coagulum pyelolithotomy: a comparative study, J. Urol. 119: 310 (1978). .,c

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