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Pelviolithotripsy in Surgical Management of Staghorn Renal Calculi
THE JOURNAL OF UROLOGY
Vol. 72, No. 3, September 1954 Printed in U.S.A.
PELVIOLITHOTRIPSY IN SURGICAL MANAGEMENT OF STAGHORN RENAL CALCULI JOHN W. DORSEY
Pelviolithotripsy as the term implies, refers to the fragmentation of the renal calculus through a pyelotomy incision. It is a definite adjunct in the surgical management of certain selected cases, particularly where there exists a low renal reserve, or in the solitary kidney, where nephrolithotomy would be hazardous. The concensus of opinion of such men as Zuckerkandl, Beer, Walters, and Counceller, Robinson, and Priestley favors pyelolithotomy over nephrolithotomy as the safer of the two procedures. The reports of Priestley and Dunn, and Prince, Scardino and Presti indicate that surgical removal of staghorn calculi is preferable to medical management. In reviewing the literature we have not encountered an article that discusses fragmentation in detail. Simple fracture through the body of a staghorn calculus will often permit the atraumatic removal of the two fragments through a pyelotomy incision. The Bigelow lithotrite was chosen because the blades are long and slender, and more easily introduced into the pelvis, and yet have great crushing power. The even, steady application of force obtained through the screw mechanism permits shearing the calculus into two major fragments without pulverizing it. The screw mechanism in contrast with the pistol grip type eliminates any sudden jerk at the time of fragmentation that would prove injurious to the kidney. No attempt will be made to discuss the etiology; preoperative selection of cases for surgery; or postoperative medical management, as the literature is replete with excellent articles dealing with these subjects. SURGICAL TECHNIQUE
The kidney, renal pelvis, and proximal ureter are completely mobilized by a combination of blunt and sharp dissection performed through an adequate lumbar incision. The posterior aspect of the pelvis is more completely visualized by elevating the renal hilum with vein retractors in the manner described by Walters, Counseller and Priestley. An elliptical incision (fig. 1, A) is then made in the renal pelvis extending from the superior to the inferior border on the posterior aspect with the convex curve directed toward the renal hilum. The posterior flap of renal pelvis is then peeled off the projecting pelvic portion of the staghorn calculus (fig. 1, B) and the pelvis is then gently retracted anteriorly. The calculus is then manipulated carefully and extracted if possible. In some instances because of close approximation of calculus to pelvis it is necessary to pass a curved hemostat around the pelvic portion of the calculus at the hilum in order to permit the introduction of the blades of the lithotrite. The female blade of the Bigelow lithotrite is introduced into the space between the anterior surface of the calculus and the pelvic mucosa; the male blade is then introduced Read at annual meeting, Western Section of American Urological Association, San Francisco, April 27-30, 1953. 324
STAGHORN RENAL CALCULI
325
on the posterior aspect (fig. 1, C). The most desirable plane for cracking the calculus as determined by preoperative x-ray studies is attained by gentle manipulation of the lithotrite. In the cases reported the calculus was sheared into two major fragments which were readily extracted through the pyelotomy incision. Small calculi may then be removed with stone forceps or scoop. In the presence of a dilated calyx with narrowed infundibulum the small calculi may be removed through a, small, stab type nephrotomy incision as in case 2. ·where a bulbous projection of the staghorn calculus is locked in a minor calyx it ·will be necessary to perform a small nephrotomy incision and fracture the calculus at the level of the constricted infundibulum. An x-ray study of the kidney is then made to determine if any radio-opaque calculi have been overlooked. The calyces are lavaged in an attempt to evacuate any nonradio-opaque calculi or debris that would act as a nidus for recurrent calculus formation. An 18F bulb catheter, and two 5F ureteral catheters are introduced simultaneously into the renal pelvis through an inferior calyx (fig. 1, D). The balloon is distended with 3 cc of water, and left as a nephrostomy tube. The two ureteral catheters are advanced into the ureter 15 to 20 cm., and act as a splint. The elliptical pyelotomy incision is closed with interrupted 000 sutures of plain cat-
Fm. 1. Semidiagrammatic illustration of surgical technique. A, pyleotomy incision. B, reflection of pelvic flap. C, introduction of lithotrite. D, closure.
326
JOHN W. DORSEY
gut, no attempt being made to obtain a water tight closure. The kidney is suspended in favorable position beneath the twelfth rib, by Kelly triangular sutures. Gerota's fascia is approximated to the quadratus lumborum muscle with interrupted 00 chromic sutures in a modified type of Deming nephropexy. The region around the renal plevis is left open to permit favorable drainage. A Penrose drain is introduced into the parapelvic area posterior to the lmver pole of the kidney, and a second drain along the mobilized portion of the ureter. The incision is closed in layers, and the nephrostomy and splinting nreteral catheters fixed to the skin with 0 silk sutures. POSTOPERATIVE MANAGEMENT
The nephrostomy tube is irrigated only if definite impairment of drainage is evident. The balloon is decompressed in 48 hours. Solvent solutions are not used in the immediate postoperative phase, feeling that their irritant action outweighs their usefulness. Beginning at 72 hours the ureteral catheters are withdrawn 1 to 2 cm. daily. The Penrose drains are left undisturbed until there is a marked dimunition in drainage, then they are shortened daily. Ambulation is inaugurated on the fifth to seventh postoperative day, pelvic circulation having been stimulated previously by passive exercise of the lower extremities at frequent intervals. The immediate medical management consists primarily of adequate supportive measures; hyaluronidase 150 TR units (IVydase) daily; and appropriate antibiotic therapy. The accepted methods for the prevention of recurrent calculus
Fm. 2. Case 1. A, preoperative scout film. B, retrograde pyelogram. C, fifteen months' postoperative scout film. D, retrograde urogram.
STAGHORN RENAL CALCULI
327
fonnation are utilized after the patient has completed his postoperative convalescence. CASE REPORTS
Case 1. Mr. F. L., aged 51, was seen because of two bouts of right flank dis<:omfort. A scout film and retrograde urogram (fig. 2, A and B) revealed a small calculus lodged in an inferior minor calyx of the right kidney, and a left staghorn renal calculus. Indigo carmine appeared from the right kidney in 4 minutes, and from the left kidney in 10 minutes. Urine recovered from each kidney was sterile on culture, and blood chemistry studies were within normal limits. The right renal symptoms promptly subsided. The staghorn calculus was then removed in the manner described. The two major fragments (fig. 4, A) were easily extracted through the pyelotomy incision without evident trauma to the renal parenchyma. Convalescence was uneventful. The voided urine has been sterile since the twenty second postoperative day. A scout film and retrograde urogram (fig. 2, C and D) made 15 months following surgery revealed no recurrent calculus formation, and an excellent return to normal of the calyceal system. The right renal calculus has remained stationary in size and asymptomatic. Case 2. Mrs. K. R., aged 62, had a right nephrectomy performed 15 years previously for calculus pyonephrosis, at which time a small calculus was present in the left kdiney. In recent years she had noted mild, recurrent, left flank discomfort. The scout film and excretory urogram (fig. 3, A and B) revealed a large
Fm. 3. Case 2. A, preliminary scout film. B, excretory urogram. C, three months' postoperative scout film. D, retrograde pyelogram.
328
JOHN W. DORSEY
Frn. 4. Surgical specimens. A, case 1. B, case 2
staghorn calculus, and several smaller calculi in the solitary left kidney. The superior group of calyces appeared to be involved in a localized hydronephrotic change. The general condition of this patient was excellent; blood pressure 160 systolic and 90 diastolic; blood chemistry studies were within normal limits, and Gram's stain of the urinary sediment, negative for organisms. At surgery the calculus was found to be in such close approximation with the pelvic mucosa that it was necessary to free it in the manner previously described, before the blades of the Bigelow lithotrite could be introduced. Figure 4, B shows the calculus sheared into two major fragments. Within 30 minutes following surgery the kidney was secreting relatively clear urine, and at no time was urinary suppression noted. The maximum elevation of nonprotein nitrogen was 42 mg. per cent. Three months later the nonprotein nitrogen was 21.5 mg. per cent. The scout film and retrograde urogram (fig. 3, C and D) reveal no recurrent calculus formation, and a definite regression in the previously noted hydronephrotic changes. Repeated cultures of the urine have been sterile. The patient has been leading a fully active, comfortable existence. DISCUSSION
Meticulous care in handling the kidney with low renal reserve during mobilization coupled with the atrumatic removal of the staghorn calculus tends to reduce to a minimum the likelihood of immediate postoperative urinary suppression. The use of the elliptical pyelotomy incision is very important. It permits the reflection of the pelvis and ureteropelvic junction out of the field of manipulation, and in contrast with the longitudinal pyelotomy incision there is no tendency for
STAGHORN RENAL CALCULI
329
extension of the incision to involve the ureteropelvic junction with subsequent stricture formation. This incision permits greater accessibility in manipulating the calculus, and thus facilitates the introduction of the blades of the lithotrite. Due to the adequacy of the pyelotomy incision, digital palpation and instrumental removal of small calculi is simplified. Closure is simple, and being located at the widest portion of the pelvis there is less likelihood of distortion by scar tissue. The shearing affect of the Bigelow lithotrite is evidenced by the surgical specimens (fig. 4, A and B). It is mandatory to correct any ureteropelvic junction obstruction at the time of surgical removal of the calculus. The two splinting ureteral catheters maintain the ureter and ureteropelvic junction in good alignment, and permit constant ureteral drainage of the renal pelvis. The nephrostomy tube allows immediate drainage, and may be left in situ as a permanent method of drainage if the situation so demands. Nephropexy, further enhances a favorable alignment of ureter and pelvis, and facilitates the change of nephrostomy tubes if this be necessary. The parapelvic drains are left relatively undisturbed to prevent pooling of urine seeping from the pelvic incision, which would predispose for scar tissue formation and subsequent obstructive uropathy. X-ray control at the time of surgery is of the utmost importance. The two cases reported fulfill the tenets laid down by Hess for obligatory, conservative renal surgery. vVe believe that the favorable response to surgery in these two cases was due primarily to the relatively a traumatic method of removing the calculi. SUMMARY
The technique of pelviolithotripsy utilizing the Bigelow lithotrite is described and the use of this method of surgical management in selected cases of staghom renal calculi advocated. The posterior elliptical pyelotomy incision is described and the many advantages of this incision discussed. Two cases of staghorn renal calculi requiring obligatory, conservative surgery are reported wherein this technique was utilized with favorable results.
125 E. 8th St., Long Beach, Calif. REFERENCES BEER, E.: Points in the technique of operative removal of kidney stones. Ann. Surg., 87: 428-4-34, 1928. HESS, E., ROTH, R. B., KAMINSKY, A. F. AND SwrcK, H. V.: Surgery for the conservation of renal parenchyma. J. Urol., 64: 175-187, 1950. HEss, E., ROTH, R. B. AND KAMINSKY, A. F.: Staghorn calculi. J. Urol., 69: 347-353, 1953. MARION, G.: La pyelotomie elargie. J. d'urol., 13: 1-8, 1922. PRATHER, G. C.: A method of hemostasis during nephrotomy for large kidney calculi. J. Urol., 32: 578-599, 1934.
330
JOHN W. DORSEY
PRIESTLEY, J. T.: Treatment for unilateral and bilateral, staghorn renal calculi. J. Urol., 42: 933-942, 1939. PRIESTLEY, J. T. AND DUNN, J. H.: Branched renal calculi. J. Urol., 61: 194-203, 1949. PRINCE, C. L., SCARDINO, P. L. AND PRESTI, J.C.: The management of staghorn renal calculi. Am. Surg., 17: 1057-1063, 1951. ROBINSON, R.H. 0. B.: Some problems of renal lithiasis. Proc. Royal Soc. Med., 40: 201216, 1946-47. WALTERS, W., CouNSELLER, V. S. AND PRIESTLEY, J. T.: Treatment of unilateral and bilateral "staghorn" renal calculi. Proc. Staff. Meet., Mayo Clinic, 9: 144-147, 1934. ZucKERKANDL, 0.: Ueber Niersteine. Arch. f. klin. Chir., 87: 481-489, 1908.
Vol. 72, No. 3, September 1954 Printed in U.S.A.
PELVIOLITHOTRIPSY IN SURGICAL MANAGEMENT OF STAGHORN RENAL CALCULI JOHN W. DORSEY
Pelviolithotripsy as the term implies, refers to the fragmentation of the renal calculus through a pyelotomy incision. It is a definite adjunct in the surgical management of certain selected cases, particularly where there exists a low renal reserve, or in the solitary kidney, where nephrolithotomy would be hazardous. The concensus of opinion of such men as Zuckerkandl, Beer, Walters, and Counceller, Robinson, and Priestley favors pyelolithotomy over nephrolithotomy as the safer of the two procedures. The reports of Priestley and Dunn, and Prince, Scardino and Presti indicate that surgical removal of staghorn calculi is preferable to medical management. In reviewing the literature we have not encountered an article that discusses fragmentation in detail. Simple fracture through the body of a staghorn calculus will often permit the atraumatic removal of the two fragments through a pyelotomy incision. The Bigelow lithotrite was chosen because the blades are long and slender, and more easily introduced into the pelvis, and yet have great crushing power. The even, steady application of force obtained through the screw mechanism permits shearing the calculus into two major fragments without pulverizing it. The screw mechanism in contrast with the pistol grip type eliminates any sudden jerk at the time of fragmentation that would prove injurious to the kidney. No attempt will be made to discuss the etiology; preoperative selection of cases for surgery; or postoperative medical management, as the literature is replete with excellent articles dealing with these subjects. SURGICAL TECHNIQUE
The kidney, renal pelvis, and proximal ureter are completely mobilized by a combination of blunt and sharp dissection performed through an adequate lumbar incision. The posterior aspect of the pelvis is more completely visualized by elevating the renal hilum with vein retractors in the manner described by Walters, Counseller and Priestley. An elliptical incision (fig. 1, A) is then made in the renal pelvis extending from the superior to the inferior border on the posterior aspect with the convex curve directed toward the renal hilum. The posterior flap of renal pelvis is then peeled off the projecting pelvic portion of the staghorn calculus (fig. 1, B) and the pelvis is then gently retracted anteriorly. The calculus is then manipulated carefully and extracted if possible. In some instances because of close approximation of calculus to pelvis it is necessary to pass a curved hemostat around the pelvic portion of the calculus at the hilum in order to permit the introduction of the blades of the lithotrite. The female blade of the Bigelow lithotrite is introduced into the space between the anterior surface of the calculus and the pelvic mucosa; the male blade is then introduced Read at annual meeting, Western Section of American Urological Association, San Francisco, April 27-30, 1953. 324
STAGHORN RENAL CALCULI
325
on the posterior aspect (fig. 1, C). The most desirable plane for cracking the calculus as determined by preoperative x-ray studies is attained by gentle manipulation of the lithotrite. In the cases reported the calculus was sheared into two major fragments which were readily extracted through the pyelotomy incision. Small calculi may then be removed with stone forceps or scoop. In the presence of a dilated calyx with narrowed infundibulum the small calculi may be removed through a, small, stab type nephrotomy incision as in case 2. ·where a bulbous projection of the staghorn calculus is locked in a minor calyx it ·will be necessary to perform a small nephrotomy incision and fracture the calculus at the level of the constricted infundibulum. An x-ray study of the kidney is then made to determine if any radio-opaque calculi have been overlooked. The calyces are lavaged in an attempt to evacuate any nonradio-opaque calculi or debris that would act as a nidus for recurrent calculus formation. An 18F bulb catheter, and two 5F ureteral catheters are introduced simultaneously into the renal pelvis through an inferior calyx (fig. 1, D). The balloon is distended with 3 cc of water, and left as a nephrostomy tube. The two ureteral catheters are advanced into the ureter 15 to 20 cm., and act as a splint. The elliptical pyelotomy incision is closed with interrupted 000 sutures of plain cat-
Fm. 1. Semidiagrammatic illustration of surgical technique. A, pyleotomy incision. B, reflection of pelvic flap. C, introduction of lithotrite. D, closure.
326
JOHN W. DORSEY
gut, no attempt being made to obtain a water tight closure. The kidney is suspended in favorable position beneath the twelfth rib, by Kelly triangular sutures. Gerota's fascia is approximated to the quadratus lumborum muscle with interrupted 00 chromic sutures in a modified type of Deming nephropexy. The region around the renal plevis is left open to permit favorable drainage. A Penrose drain is introduced into the parapelvic area posterior to the lmver pole of the kidney, and a second drain along the mobilized portion of the ureter. The incision is closed in layers, and the nephrostomy and splinting nreteral catheters fixed to the skin with 0 silk sutures. POSTOPERATIVE MANAGEMENT
The nephrostomy tube is irrigated only if definite impairment of drainage is evident. The balloon is decompressed in 48 hours. Solvent solutions are not used in the immediate postoperative phase, feeling that their irritant action outweighs their usefulness. Beginning at 72 hours the ureteral catheters are withdrawn 1 to 2 cm. daily. The Penrose drains are left undisturbed until there is a marked dimunition in drainage, then they are shortened daily. Ambulation is inaugurated on the fifth to seventh postoperative day, pelvic circulation having been stimulated previously by passive exercise of the lower extremities at frequent intervals. The immediate medical management consists primarily of adequate supportive measures; hyaluronidase 150 TR units (IVydase) daily; and appropriate antibiotic therapy. The accepted methods for the prevention of recurrent calculus
Fm. 2. Case 1. A, preoperative scout film. B, retrograde pyelogram. C, fifteen months' postoperative scout film. D, retrograde urogram.
STAGHORN RENAL CALCULI
327
fonnation are utilized after the patient has completed his postoperative convalescence. CASE REPORTS
Case 1. Mr. F. L., aged 51, was seen because of two bouts of right flank dis<:omfort. A scout film and retrograde urogram (fig. 2, A and B) revealed a small calculus lodged in an inferior minor calyx of the right kidney, and a left staghorn renal calculus. Indigo carmine appeared from the right kidney in 4 minutes, and from the left kidney in 10 minutes. Urine recovered from each kidney was sterile on culture, and blood chemistry studies were within normal limits. The right renal symptoms promptly subsided. The staghorn calculus was then removed in the manner described. The two major fragments (fig. 4, A) were easily extracted through the pyelotomy incision without evident trauma to the renal parenchyma. Convalescence was uneventful. The voided urine has been sterile since the twenty second postoperative day. A scout film and retrograde urogram (fig. 2, C and D) made 15 months following surgery revealed no recurrent calculus formation, and an excellent return to normal of the calyceal system. The right renal calculus has remained stationary in size and asymptomatic. Case 2. Mrs. K. R., aged 62, had a right nephrectomy performed 15 years previously for calculus pyonephrosis, at which time a small calculus was present in the left kdiney. In recent years she had noted mild, recurrent, left flank discomfort. The scout film and excretory urogram (fig. 3, A and B) revealed a large
Fm. 3. Case 2. A, preliminary scout film. B, excretory urogram. C, three months' postoperative scout film. D, retrograde pyelogram.
328
JOHN W. DORSEY
Frn. 4. Surgical specimens. A, case 1. B, case 2
staghorn calculus, and several smaller calculi in the solitary left kidney. The superior group of calyces appeared to be involved in a localized hydronephrotic change. The general condition of this patient was excellent; blood pressure 160 systolic and 90 diastolic; blood chemistry studies were within normal limits, and Gram's stain of the urinary sediment, negative for organisms. At surgery the calculus was found to be in such close approximation with the pelvic mucosa that it was necessary to free it in the manner previously described, before the blades of the Bigelow lithotrite could be introduced. Figure 4, B shows the calculus sheared into two major fragments. Within 30 minutes following surgery the kidney was secreting relatively clear urine, and at no time was urinary suppression noted. The maximum elevation of nonprotein nitrogen was 42 mg. per cent. Three months later the nonprotein nitrogen was 21.5 mg. per cent. The scout film and retrograde urogram (fig. 3, C and D) reveal no recurrent calculus formation, and a definite regression in the previously noted hydronephrotic changes. Repeated cultures of the urine have been sterile. The patient has been leading a fully active, comfortable existence. DISCUSSION
Meticulous care in handling the kidney with low renal reserve during mobilization coupled with the atrumatic removal of the staghorn calculus tends to reduce to a minimum the likelihood of immediate postoperative urinary suppression. The use of the elliptical pyelotomy incision is very important. It permits the reflection of the pelvis and ureteropelvic junction out of the field of manipulation, and in contrast with the longitudinal pyelotomy incision there is no tendency for
STAGHORN RENAL CALCULI
329
extension of the incision to involve the ureteropelvic junction with subsequent stricture formation. This incision permits greater accessibility in manipulating the calculus, and thus facilitates the introduction of the blades of the lithotrite. Due to the adequacy of the pyelotomy incision, digital palpation and instrumental removal of small calculi is simplified. Closure is simple, and being located at the widest portion of the pelvis there is less likelihood of distortion by scar tissue. The shearing affect of the Bigelow lithotrite is evidenced by the surgical specimens (fig. 4, A and B). It is mandatory to correct any ureteropelvic junction obstruction at the time of surgical removal of the calculus. The two splinting ureteral catheters maintain the ureter and ureteropelvic junction in good alignment, and permit constant ureteral drainage of the renal pelvis. The nephrostomy tube allows immediate drainage, and may be left in situ as a permanent method of drainage if the situation so demands. Nephropexy, further enhances a favorable alignment of ureter and pelvis, and facilitates the change of nephrostomy tubes if this be necessary. The parapelvic drains are left relatively undisturbed to prevent pooling of urine seeping from the pelvic incision, which would predispose for scar tissue formation and subsequent obstructive uropathy. X-ray control at the time of surgery is of the utmost importance. The two cases reported fulfill the tenets laid down by Hess for obligatory, conservative renal surgery. vVe believe that the favorable response to surgery in these two cases was due primarily to the relatively a traumatic method of removing the calculi. SUMMARY
The technique of pelviolithotripsy utilizing the Bigelow lithotrite is described and the use of this method of surgical management in selected cases of staghom renal calculi advocated. The posterior elliptical pyelotomy incision is described and the many advantages of this incision discussed. Two cases of staghorn renal calculi requiring obligatory, conservative surgery are reported wherein this technique was utilized with favorable results.
125 E. 8th St., Long Beach, Calif. REFERENCES BEER, E.: Points in the technique of operative removal of kidney stones. Ann. Surg., 87: 428-4-34, 1928. HESS, E., ROTH, R. B., KAMINSKY, A. F. AND SwrcK, H. V.: Surgery for the conservation of renal parenchyma. J. Urol., 64: 175-187, 1950. HEss, E., ROTH, R. B. AND KAMINSKY, A. F.: Staghorn calculi. J. Urol., 69: 347-353, 1953. MARION, G.: La pyelotomie elargie. J. d'urol., 13: 1-8, 1922. PRATHER, G. C.: A method of hemostasis during nephrotomy for large kidney calculi. J. Urol., 32: 578-599, 1934.
330
JOHN W. DORSEY
PRIESTLEY, J. T.: Treatment for unilateral and bilateral, staghorn renal calculi. J. Urol., 42: 933-942, 1939. PRIESTLEY, J. T. AND DUNN, J. H.: Branched renal calculi. J. Urol., 61: 194-203, 1949. PRINCE, C. L., SCARDINO, P. L. AND PRESTI, J.C.: The management of staghorn renal calculi. Am. Surg., 17: 1057-1063, 1951. ROBINSON, R.H. 0. B.: Some problems of renal lithiasis. Proc. Royal Soc. Med., 40: 201216, 1946-47. WALTERS, W., CouNSELLER, V. S. AND PRIESTLEY, J. T.: Treatment of unilateral and bilateral "staghorn" renal calculi. Proc. Staff. Meet., Mayo Clinic, 9: 144-147, 1934. ZucKERKANDL, 0.: Ueber Niersteine. Arch. f. klin. Chir., 87: 481-489, 1908.