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New Method of Intrarenal Irrigation to Dissolve Calculi
TnE JOURNAL OF UROLOGY
Vol. 92, No. 6 December 1964 Copyright © 1964 by The Williams & Wilkins Co. Printed in U.S.A.
NEW :;vIETHOD OF INTRARENAL IRRIGATION TO DISSOLVE CALCULI THOMAS A. DA VIS The successful removal of renal calculi by dissolving them is dependent upon the use of an effective solvent, an efficient and safe method of delivery of the solvent to the calculi, and the removal of the resulting eflluent. The recent advent of renacidin made available a solvent that has proven successful in dissolving calcium phosphate, calcium carbonate, and magnesium ammonia carbonate renal calculi. At present renacidin has not been approved for intrarenal use. Other chemical compounds have also bee11 used as intrarenal solvents of calculi. The removal of renal calculi by dissolution, when possible, and when it can n10re safely be done than by open operation, is an advantage in many cases. This is especially so in recurrence of calculi after operative removal when reoperation would be technically difficult, when fragments remain after operative removal of calculi, when complications of renal lithiasis occur in advanced pregnancy and in poor operative risks, and in treatment of recurrent calculi in paralytics. The method can be useful when the operative removal of large staghorn calculi might result in extensive damage to, or loss of, the kidney; and for removal of small stones in minor calyces which cause recurrent hematuria and infection, when the operative removal of which might result in unjustifiable parenchymal damage The method of irrigation has been to insert two or more ureteral catheters or a double lumen catheter into the renal pelvis. The solvent, by gravity force, flows in continuously through one catheter or lumen and is expected to flow out in equal rate through the other catheter or lumen. Successful and uneventful elimination of nmny renal calculi by the use of renacidin and this particular method of irrigation has been reported.1-s However, the technique has marked Accepted for publication May 21, 1964. Read at annual meeting of Western Section, American Urological Association, Inc., Coronado, California, February 17-20, 1964. 1 Mulvaney, W. P.: The clinical use of renacidin in urinary calcifications. J. Urol., 84: 206-212, 1960.
2 Russell, JVI.: Reported use of renacidin on bilateral calculi. Presented at Round Table Discussion, annual meeting of Western Section,
599
disadvantages and dangers. Sometimes multiple ureteral catheters cannot be inserted. The small caliber catheters required become obstructed easier than large ones. High pressures are required to maintain flow through a circuit of small catheters. In actual use of the multiple catheter method, the outflow catheter frequently becomes obstructed with resultant increased intrarenal pressure, and this continuous intrarenal pressure may be a factor in producing ischemic necrosis. Frequent attention by attendants is required. Hospital personnel, in attempting to get the irrigation restarted by elevating the solution container, may cause excessive intrarenal pressure. The possibility exists of tremendous pressure being built up intrarenally by such elevation of the container, or by forceful use of a syringe in an obstructed catheter or catheters. Hand syringe irrigation for reopening of obstructed catheters may result in the introduction of bacteria into the kidney. Often the technique of hospital personnel leaves much to be desired from the standpoint of safe mechanical principles and sterility. Multiple catheters are difficult to maintain in position. Extravasation of solution, severe damage to the renal tissues, cerebral and pulm.onary edema, hyperphosphatemia, probable bacterem.ic shock, and deaths following; the use of renaciclin solution by the multiple ureteral catheter system have been reported. Absorption of chemical products of the calculus, with resulting hyperphosphaAmerican Urological Association, Yancouver, B.C., June 20-23, 1960. 3 Sayer, E. A.: Dissolution of renal stones with renacidin. Presented at annual meeting of New England Section, American Urological Association, Manchester, Vermont, October 8, 1960. 4 Goldstein, H. H.: The dissolution of staghorn calculi in a solitary kidney. J. Med. Soc. New Jersey, 58: 409, 1961. 5 Ries, S. W. and Malament, M.: Renacidin; a urinary calculi solvent. J. Ural., 87: 657-661, 1962. 6 Russell, M.: Dissolution of bilateral renal staghorn calculi with renacidin. J. -Ural., 88: 141144, 1962. 7 Mulvaney, W. P. and Henning, D. C.: Solvent treatment of urinary calculi; refinement of technique. J. Urol., 88: 145-149, 1962. 8 Globus, A. R.: Renacidin monograph. Brochure distributed by Guardian Chemical Corporation, Long Island, New York.
600
DAVIS
A
B
F
E •oosoo-
FIG. 1. Diagram of apparatus. A, reservoir flaskB air inlet vacuum-break tube. C, fluid refill tube. n' air vent to measure flask. E, measuring flask. F, m~asuring pipette. G, flow rate regulating clamp. H shut-off clamp. I, renal fill control clamp. J, re~al emptying control clamp. K, ureteral catheter. L, tube to drainage receptacle. temia, may occur as a result of increasedintrarenal pressure and increased concentration of chemical products resulting from restrained fl.ow through the renal pelvis. These mechanical factors may, in effect, convert the kidney from an excretory organ to an absorptive organ. 9- 11 Complications that have occurred in the use of renacidin intrarenally may have been due to mechanical rather than chemical factors. 9
Kohler, F. P. : Renacidin and tissue reactions.
J. Urol., 87: 102-105, 1962.
10 Auerbach, S., Mainwaring, R. arnc1 Sch~~rz, F.: Renal and ureteral damage followmg chmcal . use of renacidin. J.A.M.A., 183: 61--63, 1963. 11 Fostvedt, G. A. and Barnes, R. W.: Oompl~cations during lavage therapy for renal calculi.
J. Urol., 89: 329-331, 1963.
FIG. 2. Bedside picture of apparatus in use. Drainage bag is connected to Foley catheter to which ureteral catheter is fastened.
It seemed to the author that an improvement would be a method of irrigating renal calculi which required only one ureteral catheter through which the renal collecting system was alternately filled and emptied with measured amounts of solution at a constant low pressure, from a closed sterile apparatus, and required a simple operative technique which could be regulated by the patient. This would result in increased effectiveness and safety and, therefore, greater utilization of the solution method of removing renal calculi. The apparatus which I devised for this purpose is shown in figure 1. The irrigating solution is placed in container A. This keeps container E filled to a near constant level by vacuum action. The irrigant fills the pipette F when valve I is
NEW METHOD OF INTRARENAL IRRIGATION TO DISSOLVE CALCULI
601
Fm. 3. Flat x-rays of patient, D. C. A, before intrarenal irrigation. Note multiple calculi in left kidney. B, after irrigation of left kidney.Note reduction in size of calculi to tiny fragments. C, 5 months after renal irrigation. closed. Valve G is set to slow the fl.ow rate from the container to a degree where very little solution flows from container E in the time required for the pipette F to deliver a measured amount of solution to the ureteral catheter K when valve I is opened. The catheter K is No. 7 to llF, the size being determined by the ureteral caliber. It is maintained in place by being fastened to a small urethral retention catheter. An amount of irrigant determined to be equal to the intrarenal capacity is fl.owed into the kidney by closing valve J and opening valve I. These are the Davol shut-off spring type easily opened or closed with one hand. When the pre-determined volume of irrigant has fl.owed in, valve I is closed. Ten minutes later valve J is opened to empty the kidney. The cycle is repeated 2 minutes after opening valve J, the pipette F having refilled in the meantime. The patient opens and closes the valves by the clock. When not in action, or when the patient is sleeping, valve H and valve I are closed, and J is left open. The fl.ow pressure of the irrigating solution is determined by the height of solution in container E. The distance tube C extends below Bin container E is 1¼ inch. The open ends of the
pipette and tube D are loosely plugged with cotton. Figure 2 is a bedside picture of the apparatus in use in the following case. D. C., a 61-year-old man, had a left nephrolithotomy on January 8, 1959. Multiple calculi reformed in his left kidney and therapy-resistant pyelonephritis developed (fig. 3, A). Removal of the calculi by the aforedescribed apparatus, using sterilized 10 per cent renacidin solution with neomycin added, 1 gm. per 3000 cc through a No. 8F ureteral catheter was started October 26, 1961 using 10 cc increments. The catheter was changed to a No. 11F on October 31. This was the first case on which the apparatus was used and there were several interruptions of the procedure in perfecting it. The hospitalization days, therefore, were greater than the irrigation time. The calculi decreased in size and density until they were only faintly visible in an x-ray taken November 20, after 6½ days of irrigation (fig. 3, B). Irrigation occurred only during the daytime while the patient was awake. It was considered probable that the tiny fragments remaining would be spontaneously eliminated and the patient was discharged from the hospital November 21. On re-examination May 4,
602
DAVIS
1962, no calculi could be seen in the area of the left kidney (fig. 3, G). ,, , There have been no complaints of renal pain or discomfort by the patients during the irrigation period. No hematuria has been apparent. There have been no reactions or complications. The method is not one that can be ordered set up after return of the patient to the ward following placement of the ureteral catheter. The urologist must connect, start, and adjust the apparatus, and teach the patient the operation of it. Only the urologist should decide the necessity of hand syringe irrigation and then he should do it himself after sterilizing as thoroughly as possible the ends of the disconnected tubing. If the injected solution or irrigating fluid injected by hand syringe does not return in full amount, and freely, the ureteral catheter should be removed
and replaced later, as it may have descended from the renal pelvis. This is primarily a report of the design and technique of the apparatus described. I believe that this method of irrigation is an improvement over the previously used multiple catheter continuous flow method. SUMMARY
There has been described a new method of intrarenal irrigation with a closed sterile system by alternating flow direction through a single ureteral catheter using measured increments of irrigant at constant controlled pressure. Renal calculi have been safely removed by use of this method using renacidin solution as the irrigant. 405 Medical Dental Building, Portland, Oregon 97205
Vol. 92, No. 6 December 1964 Copyright © 1964 by The Williams & Wilkins Co. Printed in U.S.A.
NEW :;vIETHOD OF INTRARENAL IRRIGATION TO DISSOLVE CALCULI THOMAS A. DA VIS The successful removal of renal calculi by dissolving them is dependent upon the use of an effective solvent, an efficient and safe method of delivery of the solvent to the calculi, and the removal of the resulting eflluent. The recent advent of renacidin made available a solvent that has proven successful in dissolving calcium phosphate, calcium carbonate, and magnesium ammonia carbonate renal calculi. At present renacidin has not been approved for intrarenal use. Other chemical compounds have also bee11 used as intrarenal solvents of calculi. The removal of renal calculi by dissolution, when possible, and when it can n10re safely be done than by open operation, is an advantage in many cases. This is especially so in recurrence of calculi after operative removal when reoperation would be technically difficult, when fragments remain after operative removal of calculi, when complications of renal lithiasis occur in advanced pregnancy and in poor operative risks, and in treatment of recurrent calculi in paralytics. The method can be useful when the operative removal of large staghorn calculi might result in extensive damage to, or loss of, the kidney; and for removal of small stones in minor calyces which cause recurrent hematuria and infection, when the operative removal of which might result in unjustifiable parenchymal damage The method of irrigation has been to insert two or more ureteral catheters or a double lumen catheter into the renal pelvis. The solvent, by gravity force, flows in continuously through one catheter or lumen and is expected to flow out in equal rate through the other catheter or lumen. Successful and uneventful elimination of nmny renal calculi by the use of renacidin and this particular method of irrigation has been reported.1-s However, the technique has marked Accepted for publication May 21, 1964. Read at annual meeting of Western Section, American Urological Association, Inc., Coronado, California, February 17-20, 1964. 1 Mulvaney, W. P.: The clinical use of renacidin in urinary calcifications. J. Urol., 84: 206-212, 1960.
2 Russell, JVI.: Reported use of renacidin on bilateral calculi. Presented at Round Table Discussion, annual meeting of Western Section,
599
disadvantages and dangers. Sometimes multiple ureteral catheters cannot be inserted. The small caliber catheters required become obstructed easier than large ones. High pressures are required to maintain flow through a circuit of small catheters. In actual use of the multiple catheter method, the outflow catheter frequently becomes obstructed with resultant increased intrarenal pressure, and this continuous intrarenal pressure may be a factor in producing ischemic necrosis. Frequent attention by attendants is required. Hospital personnel, in attempting to get the irrigation restarted by elevating the solution container, may cause excessive intrarenal pressure. The possibility exists of tremendous pressure being built up intrarenally by such elevation of the container, or by forceful use of a syringe in an obstructed catheter or catheters. Hand syringe irrigation for reopening of obstructed catheters may result in the introduction of bacteria into the kidney. Often the technique of hospital personnel leaves much to be desired from the standpoint of safe mechanical principles and sterility. Multiple catheters are difficult to maintain in position. Extravasation of solution, severe damage to the renal tissues, cerebral and pulm.onary edema, hyperphosphatemia, probable bacterem.ic shock, and deaths following; the use of renaciclin solution by the multiple ureteral catheter system have been reported. Absorption of chemical products of the calculus, with resulting hyperphosphaAmerican Urological Association, Yancouver, B.C., June 20-23, 1960. 3 Sayer, E. A.: Dissolution of renal stones with renacidin. Presented at annual meeting of New England Section, American Urological Association, Manchester, Vermont, October 8, 1960. 4 Goldstein, H. H.: The dissolution of staghorn calculi in a solitary kidney. J. Med. Soc. New Jersey, 58: 409, 1961. 5 Ries, S. W. and Malament, M.: Renacidin; a urinary calculi solvent. J. Ural., 87: 657-661, 1962. 6 Russell, M.: Dissolution of bilateral renal staghorn calculi with renacidin. J. -Ural., 88: 141144, 1962. 7 Mulvaney, W. P. and Henning, D. C.: Solvent treatment of urinary calculi; refinement of technique. J. Urol., 88: 145-149, 1962. 8 Globus, A. R.: Renacidin monograph. Brochure distributed by Guardian Chemical Corporation, Long Island, New York.
600
DAVIS
A
B
F
E •oosoo-
FIG. 1. Diagram of apparatus. A, reservoir flaskB air inlet vacuum-break tube. C, fluid refill tube. n' air vent to measure flask. E, measuring flask. F, m~asuring pipette. G, flow rate regulating clamp. H shut-off clamp. I, renal fill control clamp. J, re~al emptying control clamp. K, ureteral catheter. L, tube to drainage receptacle. temia, may occur as a result of increasedintrarenal pressure and increased concentration of chemical products resulting from restrained fl.ow through the renal pelvis. These mechanical factors may, in effect, convert the kidney from an excretory organ to an absorptive organ. 9- 11 Complications that have occurred in the use of renacidin intrarenally may have been due to mechanical rather than chemical factors. 9
Kohler, F. P. : Renacidin and tissue reactions.
J. Urol., 87: 102-105, 1962.
10 Auerbach, S., Mainwaring, R. arnc1 Sch~~rz, F.: Renal and ureteral damage followmg chmcal . use of renacidin. J.A.M.A., 183: 61--63, 1963. 11 Fostvedt, G. A. and Barnes, R. W.: Oompl~cations during lavage therapy for renal calculi.
J. Urol., 89: 329-331, 1963.
FIG. 2. Bedside picture of apparatus in use. Drainage bag is connected to Foley catheter to which ureteral catheter is fastened.
It seemed to the author that an improvement would be a method of irrigating renal calculi which required only one ureteral catheter through which the renal collecting system was alternately filled and emptied with measured amounts of solution at a constant low pressure, from a closed sterile apparatus, and required a simple operative technique which could be regulated by the patient. This would result in increased effectiveness and safety and, therefore, greater utilization of the solution method of removing renal calculi. The apparatus which I devised for this purpose is shown in figure 1. The irrigating solution is placed in container A. This keeps container E filled to a near constant level by vacuum action. The irrigant fills the pipette F when valve I is
NEW METHOD OF INTRARENAL IRRIGATION TO DISSOLVE CALCULI
601
Fm. 3. Flat x-rays of patient, D. C. A, before intrarenal irrigation. Note multiple calculi in left kidney. B, after irrigation of left kidney.Note reduction in size of calculi to tiny fragments. C, 5 months after renal irrigation. closed. Valve G is set to slow the fl.ow rate from the container to a degree where very little solution flows from container E in the time required for the pipette F to deliver a measured amount of solution to the ureteral catheter K when valve I is opened. The catheter K is No. 7 to llF, the size being determined by the ureteral caliber. It is maintained in place by being fastened to a small urethral retention catheter. An amount of irrigant determined to be equal to the intrarenal capacity is fl.owed into the kidney by closing valve J and opening valve I. These are the Davol shut-off spring type easily opened or closed with one hand. When the pre-determined volume of irrigant has fl.owed in, valve I is closed. Ten minutes later valve J is opened to empty the kidney. The cycle is repeated 2 minutes after opening valve J, the pipette F having refilled in the meantime. The patient opens and closes the valves by the clock. When not in action, or when the patient is sleeping, valve H and valve I are closed, and J is left open. The fl.ow pressure of the irrigating solution is determined by the height of solution in container E. The distance tube C extends below Bin container E is 1¼ inch. The open ends of the
pipette and tube D are loosely plugged with cotton. Figure 2 is a bedside picture of the apparatus in use in the following case. D. C., a 61-year-old man, had a left nephrolithotomy on January 8, 1959. Multiple calculi reformed in his left kidney and therapy-resistant pyelonephritis developed (fig. 3, A). Removal of the calculi by the aforedescribed apparatus, using sterilized 10 per cent renacidin solution with neomycin added, 1 gm. per 3000 cc through a No. 8F ureteral catheter was started October 26, 1961 using 10 cc increments. The catheter was changed to a No. 11F on October 31. This was the first case on which the apparatus was used and there were several interruptions of the procedure in perfecting it. The hospitalization days, therefore, were greater than the irrigation time. The calculi decreased in size and density until they were only faintly visible in an x-ray taken November 20, after 6½ days of irrigation (fig. 3, B). Irrigation occurred only during the daytime while the patient was awake. It was considered probable that the tiny fragments remaining would be spontaneously eliminated and the patient was discharged from the hospital November 21. On re-examination May 4,
602
DAVIS
1962, no calculi could be seen in the area of the left kidney (fig. 3, G). ,, , There have been no complaints of renal pain or discomfort by the patients during the irrigation period. No hematuria has been apparent. There have been no reactions or complications. The method is not one that can be ordered set up after return of the patient to the ward following placement of the ureteral catheter. The urologist must connect, start, and adjust the apparatus, and teach the patient the operation of it. Only the urologist should decide the necessity of hand syringe irrigation and then he should do it himself after sterilizing as thoroughly as possible the ends of the disconnected tubing. If the injected solution or irrigating fluid injected by hand syringe does not return in full amount, and freely, the ureteral catheter should be removed
and replaced later, as it may have descended from the renal pelvis. This is primarily a report of the design and technique of the apparatus described. I believe that this method of irrigation is an improvement over the previously used multiple catheter continuous flow method. SUMMARY
There has been described a new method of intrarenal irrigation with a closed sterile system by alternating flow direction through a single ureteral catheter using measured increments of irrigant at constant controlled pressure. Renal calculi have been safely removed by use of this method using renacidin solution as the irrigant. 405 Medical Dental Building, Portland, Oregon 97205