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Percutaneous extraction of renal calculi in patients with solitary kidneys
PERCUTANEOUS EXTRACTION OF RENAL CAI C' [; t IN PATIENTS WITH SOLITARY KIDNEYS STEVAN B . STREEM, M .D . MARGARET G . ZELCH, M .D . BARBARA RISIUS, M .D . MICHAEL A . GEISINGER, M .D . From the Departments of Urology and Radiology, Cleveland Clinic, Cleveland, Ohio
ABSTRACT-Percutaneous techniques have become widely accepted for the management cf' nonq patients with renal calculi . Little is known, however, about the efficacy of utilizing the. E xmooedures for patients with solitary kidneys . We studied five such patients to determine whether p erc utaneous techniques could be utilized safely, effectively, and efficiently in this setting . Tl.e r( .%J'ls achieved .suggest that the percutaneous removal of renal calculi should be considered a viable t"e-tment option for selected patients with stones in solitary kidneys.
Several centers have reported their experience with large numbers of patients with calculi treated percutaneously, and the satisfactory results of such treatment are well documented for the majority of these cases . I I Little is known, however, about the efficacy of performing percutaneous stone extraction in patients with solitary kidneys . This study was therefore done to determine whether or not these techniques could be safely and efficiently applied to patients with solitary kidneys . Our experience in the management of 5 such patients is reported here . The satisfactory outcome in each case suggests that percutaneous techniques should be considered viable treatment options in the management of patients requiring removal of calculi from solitary kidneys .
tients has been the percutaneous aprroacl, with a primary open surgical procedure reserved for some patients with extensively branched staghorn calculi, '-inaccessible' upper, lateral calyceal calculi, or patients with irreversible coagulopathies .' Using such criteria, 94 patients have c .ndegone percutaneous stone extraction . Five of these patients had solitary kidneys and are tle subjects of this study. In each case, the patient was apprised of the potential risks and benefit of a percutaneous versus open surgica . . approach, including the potential need fol emergent open surgery with the former .
Patient Selection The indications for removing renal calculi at our institution include pain, obstruction, significant hematuria or infection resulting from the stone, or active stone growth despite appropriate medical management . Since October, 1983, when we first performed percutaneous pyelolithotomy our preferred treatment of such pa-
Our technique is described in detail else where.' Briefly, the pelviocalyceal sstem a, , as visualized fluoroscopically following' injcel :ton of contrast medium either intravenously or via a retrograde catheter placed cystoscopically. IRtrasonography was utilized for patients with complete obstruction resulting from the calculus . The percutaneous tract was established with a 20-cm, 21-gauge needle that is passed
UROLOGY
; MARCH 1986 /
VOLUME xxVU . NUMBER 3
Material and Methods
:A",
TABLE I .
Case No . 1
Results of percutaneous extraction of calculi in 5 cases
Serum Creatinine (mg/dl) Transfusion Preop . Peak Postop . Required 0.9 1 .8 No
Complications None
Hospitalization Days Postop . 7
2
5 .2
1 .6
No
None
8
3
1.0
1 .1
No
None
5
4
1 .2
1 .2
No
5
2 .1
2 .0
No
Ureteral fragments None
from the dorsal lateral aspect of the flank, inferior to the margin of the twelfth rib, to the posterolateral aspect of the kidney. Generally, a lower pole calyx or infundibulum was chosen for entry into the pelviocalyceal system . A 0.018-inch stainless steel flexible tip guide wire was then passed through the needle, leaving a redundant portion within the renal pelvis . The puncture needle was substituted with a 6 .3-F introducing catheter over the guide wire . The guide wire was then withdrawn and replaced with a 0 .038-inch J-tipped guide wire which was passed to the distal ureter. The 6 .3-F introducing catheter was finally substituted with a 6-F, 65-cm Teflon angiographic "pyeloureteral" catheter with multiple side holes which also was placed to the distal ureter . If significant obstructive uropathy had been present, percutaneous drainage was continued to allow recovery of renal function . Once that was established, the patient was taken to a fluoroscopically equipped surgical suite. General endotracheal anesthesia was administered, and the patient placed in the prone position . The pyeloureteral catheter was replaced with a 0 .038-inch Lunderquist guide wire, over which the tract was dilated to 24-F with sequential fascial dilators . A second "safety wire" was placed during the dilatation . Following dilatation to 24 F, the last dilator was replaced with the 24 .5-F universal nephroscope . Light, suction, and normal saline irrigation attachments were made, and the stones were visualized . In each of these cases, ultrasonic lithotripsy was utilized . When visual and x-ray control revealed complete stone removal, the nephroscope was removed, and a second guide wire again was 248
7 5
1-Month Follow-Up Normal urogram S . creat . 1 .0 mg/dl Normal urogram S. treat . 1 .2 mg/dl Normal urogram S. Great . 1 .0 mg/dl Normal urogram S . creat . 0 .9 mg/dl Normal urograrn S. treat . 2 .0 mg/dl
placed . One guide wire was replaced with a 22F Foley catheter as a nephrostomy tube, and the second guide wire was replaced with a 6-F pyeloureteral catheter which allowed rapid antegrade access across the ureteropelvic junction should that be necessary in the early postoperative period . Tests for hemoglobin, hematocrit, serum electrolytes, and creatinine were performed on all patients in the recovery room and at periodic intervals thereafter as necessary . A nephrostogram was performed approximately forty-eight hours postoperatively . In the absence of residual stones, extravasation or obstruction, the pyeloureteral catheter was removed and the nephrostomy tube clamped . The nephrostomy tube was removed twentyfour hours later if there had been no flank pain, oliguria, or rise in serum creatinine, and the patient was discharged after an additional twenty-four to forty-eight hours of observation . These patients were allowed to return to full prehospitalization activity and employment one to two weeks after hospital discharge . Results The results obtained in these patients are summarized in Table I . Case 1
A sixty-year-old paraplegic male with multiple sclerosis and a long-standing ileal conduit diversion for a neurogenic bladder was admitted to Cleveland Clinic with recurrent urinary tract infections . Several years prior to this time he had undergone a right nephrectomy for complications of stone disease . An excretory urogram revealed a 1,2-em, left renal pelvic calculus without obstruction (Fig . 1) . The following UROLOGY i
MARCH 1986
/
VOLUME XXVII, NUMBER 3
Case 1 . Exprogram reveals
FIGURE 1 .
cretory
1 .2-cm, opaque renal pelvic calculus (arrow) in solitary left kidney: (A) scout film, and (B) thirty-minute film .
day, percutaneous nephrostomy, tract dilatation, and percutaneous ultrasonic pyelolithotomy were performed uneventfully . He was discharged seven days later . An excretory urogram one month later revealed no further calculi, prompt function, and no obstruction . Case 2
A twenty-eight-year-old male with end-stage renal disease was the recipient of an HLA identical renal allograft from his brother. A rise in serum creatinine during the first post-transplant week prompted a percutaneous biopsy which resulted in brisk bleeding, complicated by complete anuria secondary to clot obstruction in the renal pelvis and ureter. He underwent percutaneous nephrostomy, and subsequent antegrade pyelography revealed complete resolution of the obstruction . The nephrostomy tube was removed, and the serum creatinine was stabilized at 1 .3 mg/dl .
He did well for the next five month, until he experienced intermittent passage of "gravel ." analysis of which revealed calcium oxalate . Six months post-transplantation he was readmitted with complete anuria and elevation of the serum creatinine to 5 .2 mg/dl . Ultrasonographr confirmed obstruction, and a percutaneous nephrostomy was placed with a prompt diuresis . Serum creatinine stabilized at 1 .5 mg!dl . A plain film revealed no calcifications in the area of the allograft . However, antegrade pyelography revealed several large, smooth, oval-filling defects (Fig . 2A) . Computed tomography (CT) without contrast confirmed these to be of high density (Fig . 2B) . Tract dilatation and percutaneous ultrasonic pyelolithotoiny were then performed . Chemical analysis revealed layers of calcium oxalate over dried blood . A followup antegrade nephrostogram and CT scan without contrast revealed no residual calculi . The nephrostomy tube was removed, and the
FIGURE 2 . Case 2 . (A) Antegrade pyelography reveals several large filling defects . (B) CT without contrast reveals filling defects in renal pelvis to be of high density (arrow), consistent with calculi .
UROLOGY
1
MARCH 1986
i VOLUME XXVII, NUMBER 3
249
Case 3 . Excretory urogramm reveals 1 .1-em, opaque renal pelvic calculus (arrow) in solitary right kidney : (A) scout film, and (B) five-minute film . FIGURE 3 .
patient was discharged eight days post-stone extraction after an uneventful course . An excretory urogram one month later revealed no residual calculi, prompt function, and no obstruction .
omy were performed the day after admission . A postoperative nephrostogram revealed two small distal ureteral fragments which were then managed with antegrade basket extraction . Her hospital course was otherwise uneventful, and the patient was discharged seven
Case 3 A forty-year-old female patient with right flank pain was admitted to Cleveland Clinic . She previously had undergone both a left nephrostomy for complications of stone disease and a right pyelolithotomy. An excretory urogram revealed a 1 .1-cm, opaque right renal pelvic calculus with mild fullness of the collecting system behind the stone (Fig . 3) . Percutaneous nephrostomy, tract dilatation, and percutaneous ultrasonic pyelolithotomy were performed the following day. Her postoperative course was uneventful, and she was discharged five days later . An excretory urogram one month later revealed no residual calculi, prompt function, and no obstruction . Case 4 A sixty-eight-year-old female patient with left flank pain was admitted to the Clinic . A right nephrestomy for complications of infected stone disease had been performed several years prior to this admission . An excretory urogram revealed a 2-cm renal pelvic calculus and a 1-cm lower infundibular calculus in the left kidney (Fig . 4) . Percutaneous nephrostomy, tract dilatation, and ultrasonic pyelolithotCase 4 . Scout film reveals 2-cm calculus in left renal pelvis and 1-cm calculus in lower calyx (arrows) . FIGURE 4 .
250
UROLOGY
/
MARCH
1986 / VOLUME XXVII, NUMBER 3
Fleuffv 5 . Retrograde study rereuls cm, opaque calculus (arrow) in renal pc of solitary right kidney : (A) scout film . (B) bilateral retrograde study . (C) So, t wire, nephroscope, and sonotrode it) ph . , (D) Scout film, and (E) twenty-rnimrte i n of follow-up urogram reveals prompt fi : u tion, no residual calculi . art(] uo obsti +r lion .
UBOLOQY
/ MARCH 1986
:
VOLUME XXVIL NUMBER 3
251
days after the initial procedure . Excretory urography one month later revealed no residual stone fragments, prompt function, and no obstruction . Case 5
A sixty-six-year-old male with right flank pain and hematuria was admitted to the Clinic . He previously had undergone a left nephrectomy for complications of stone disease as well as a right pyelolithotomy. Cystoscopy and bilateral retrograde studies revealed a 1 .2-cm right renal pelvic calculus (Fig . 5A, B) . Right percutaneous nephrostomv was performed the day after admission while tract dilatation and right percutaneous ultrasonic pyelolithotomy were accomplished twenty-four hours later (Fig . 5C) . His postoperative course was uneventful, and he was discharged five days later. An excretory urogram one month later revealed no residual calculi, prompt function, and no obstruction (Fig . 5D, E) . Comment Results from several treatment centers suggest that percutaneous removal of renal calculi can be performed safely and efficiently in large numbers of patients . I 6 However, the efficacy of these techniques specifically for the management of patients with solitary kidneys cannot be determined from those studies . Obviously, the primary concern in utilizing a percutaneous technique for these patients is the risk of a complication requiring nephrectomy. The overall complication rate for percutaneous procedures appears to be lower than that for open surgery, and the complications that do occur may be less serious . 4 The complication most likely to lead to a nephrectomy is hemorrhage . However, in experienced hands, the transfusion rate may be as low as 1 per cent,' and in our own patients has been only 3 per cent .' In fact, the risk of nephrectomy is extremely low . In a combined series of over 600 patients, only 1 (0 .15%) required a nephrectomy for complications of the percutaneous procedure . 1-6 A second consideration in choosing a percutaneous technique for patients with solitary kidneys is the overall effect on renal function . While total renal function remains stable or improved in nearly all patients undergoing a percutaneous procedure, the contribution of the operated kidney is difficult to accurately determine . In the patients presented here, renal function, as determined by the serum 252
creatinine, was in fact the same or better in all cases after percutaneous stone extraction . The final consideration in choosing a percutaneous procedure for patients with solitary kidneys is whether or not these techniques offer a significant advantage over open surgery in regard to patient comfort, length of hospitalization, and time away from work . Those factors have been addressed by several investigators .'-6 It appears clear that percutaneous stone procedures offer significant advantages, and the results obtained in the patients reported here appear to be no different . The indications to perform stone removal percutaneously in these patients with solitary kidneys were no different than those for our patients with two functioning renal units . However, this was a relatively high-risk group of patients . Not only did they have solitary kidneys, but two of these patients previously had undergone open surgery on the affected side . One other previously had undergone urinary diversion and had a chronic infection, while another patient was a renal transplant recipient . In all cases, however, the intraoperative and postoperative courses were uneventful, renal function was stable-to-improved, the length of hospitalization was relatively short, and return to full prehospitalization activity was rapid . We believe the results obtained in this series justify the consideration of percutaneous techniques as viable alternatives to open surgery in selected renal stone patients with solitary kidneys . 9500 Euclid Avenue Cleveland, Ohio 44106 (DR. STREEM) References 1 . Alken P, Hutsehenreiter G, Gunter R, and Marherger M : Percutaneous stone manipulation, J Urol 125 : 463 (1981) . 2 . Wickham JEA, Kellett MJ, and Miller RA : Elective percutaneous nephrolithotomy in 50 patients : an analysis of the technique, results and complications, ibid 129 : 904 (1983) . 3 . Segura JW, et al : Percutaneous lithotripsy, ibid 130 : 1051 (1983) . 4 . Clayman RV, et at : Percutaneoms nephrolithotomy : extraction of renal and ureteral calculi from 100 patients, ibid 131 : 868 (1984) . 5 . White DC, and Smith AD : Percutaneous stone extraction from 200 patients, ibid 132 : 437 (1984) . 6 . Streem SB, Zelch MG, and Risius B : Single-stage percutaneous extraction of renal calculi, Cleve Clin Q 52 : 15 (1985) . 7 . Streem SB . Zelch MG, Resins B, and Geisinger M : Percutaneous extraction of renal calculi, Urol Clin North Am 13 : 381 (1985) .
UROLOGY / MARCH 1986 / VOLUME XXVII, NUMBER 3
ABSTRACT-Percutaneous techniques have become widely accepted for the management cf' nonq patients with renal calculi . Little is known, however, about the efficacy of utilizing the. E xmooedures for patients with solitary kidneys . We studied five such patients to determine whether p erc utaneous techniques could be utilized safely, effectively, and efficiently in this setting . Tl.e r( .%J'ls achieved .suggest that the percutaneous removal of renal calculi should be considered a viable t"e-tment option for selected patients with stones in solitary kidneys.
Several centers have reported their experience with large numbers of patients with calculi treated percutaneously, and the satisfactory results of such treatment are well documented for the majority of these cases . I I Little is known, however, about the efficacy of performing percutaneous stone extraction in patients with solitary kidneys . This study was therefore done to determine whether or not these techniques could be safely and efficiently applied to patients with solitary kidneys . Our experience in the management of 5 such patients is reported here . The satisfactory outcome in each case suggests that percutaneous techniques should be considered viable treatment options in the management of patients requiring removal of calculi from solitary kidneys .
tients has been the percutaneous aprroacl, with a primary open surgical procedure reserved for some patients with extensively branched staghorn calculi, '-inaccessible' upper, lateral calyceal calculi, or patients with irreversible coagulopathies .' Using such criteria, 94 patients have c .ndegone percutaneous stone extraction . Five of these patients had solitary kidneys and are tle subjects of this study. In each case, the patient was apprised of the potential risks and benefit of a percutaneous versus open surgica . . approach, including the potential need fol emergent open surgery with the former .
Patient Selection The indications for removing renal calculi at our institution include pain, obstruction, significant hematuria or infection resulting from the stone, or active stone growth despite appropriate medical management . Since October, 1983, when we first performed percutaneous pyelolithotomy our preferred treatment of such pa-
Our technique is described in detail else where.' Briefly, the pelviocalyceal sstem a, , as visualized fluoroscopically following' injcel :ton of contrast medium either intravenously or via a retrograde catheter placed cystoscopically. IRtrasonography was utilized for patients with complete obstruction resulting from the calculus . The percutaneous tract was established with a 20-cm, 21-gauge needle that is passed
UROLOGY
; MARCH 1986 /
VOLUME xxVU . NUMBER 3
Material and Methods
:A",
TABLE I .
Case No . 1
Results of percutaneous extraction of calculi in 5 cases
Serum Creatinine (mg/dl) Transfusion Preop . Peak Postop . Required 0.9 1 .8 No
Complications None
Hospitalization Days Postop . 7
2
5 .2
1 .6
No
None
8
3
1.0
1 .1
No
None
5
4
1 .2
1 .2
No
5
2 .1
2 .0
No
Ureteral fragments None
from the dorsal lateral aspect of the flank, inferior to the margin of the twelfth rib, to the posterolateral aspect of the kidney. Generally, a lower pole calyx or infundibulum was chosen for entry into the pelviocalyceal system . A 0.018-inch stainless steel flexible tip guide wire was then passed through the needle, leaving a redundant portion within the renal pelvis . The puncture needle was substituted with a 6 .3-F introducing catheter over the guide wire . The guide wire was then withdrawn and replaced with a 0 .038-inch J-tipped guide wire which was passed to the distal ureter. The 6 .3-F introducing catheter was finally substituted with a 6-F, 65-cm Teflon angiographic "pyeloureteral" catheter with multiple side holes which also was placed to the distal ureter . If significant obstructive uropathy had been present, percutaneous drainage was continued to allow recovery of renal function . Once that was established, the patient was taken to a fluoroscopically equipped surgical suite. General endotracheal anesthesia was administered, and the patient placed in the prone position . The pyeloureteral catheter was replaced with a 0 .038-inch Lunderquist guide wire, over which the tract was dilated to 24-F with sequential fascial dilators . A second "safety wire" was placed during the dilatation . Following dilatation to 24 F, the last dilator was replaced with the 24 .5-F universal nephroscope . Light, suction, and normal saline irrigation attachments were made, and the stones were visualized . In each of these cases, ultrasonic lithotripsy was utilized . When visual and x-ray control revealed complete stone removal, the nephroscope was removed, and a second guide wire again was 248
7 5
1-Month Follow-Up Normal urogram S . creat . 1 .0 mg/dl Normal urogram S. treat . 1 .2 mg/dl Normal urogram S. Great . 1 .0 mg/dl Normal urogram S . creat . 0 .9 mg/dl Normal urograrn S. treat . 2 .0 mg/dl
placed . One guide wire was replaced with a 22F Foley catheter as a nephrostomy tube, and the second guide wire was replaced with a 6-F pyeloureteral catheter which allowed rapid antegrade access across the ureteropelvic junction should that be necessary in the early postoperative period . Tests for hemoglobin, hematocrit, serum electrolytes, and creatinine were performed on all patients in the recovery room and at periodic intervals thereafter as necessary . A nephrostogram was performed approximately forty-eight hours postoperatively . In the absence of residual stones, extravasation or obstruction, the pyeloureteral catheter was removed and the nephrostomy tube clamped . The nephrostomy tube was removed twentyfour hours later if there had been no flank pain, oliguria, or rise in serum creatinine, and the patient was discharged after an additional twenty-four to forty-eight hours of observation . These patients were allowed to return to full prehospitalization activity and employment one to two weeks after hospital discharge . Results The results obtained in these patients are summarized in Table I . Case 1
A sixty-year-old paraplegic male with multiple sclerosis and a long-standing ileal conduit diversion for a neurogenic bladder was admitted to Cleveland Clinic with recurrent urinary tract infections . Several years prior to this time he had undergone a right nephrectomy for complications of stone disease . An excretory urogram revealed a 1,2-em, left renal pelvic calculus without obstruction (Fig . 1) . The following UROLOGY i
MARCH 1986
/
VOLUME XXVII, NUMBER 3
Case 1 . Exprogram reveals
FIGURE 1 .
cretory
1 .2-cm, opaque renal pelvic calculus (arrow) in solitary left kidney: (A) scout film, and (B) thirty-minute film .
day, percutaneous nephrostomy, tract dilatation, and percutaneous ultrasonic pyelolithotomy were performed uneventfully . He was discharged seven days later . An excretory urogram one month later revealed no further calculi, prompt function, and no obstruction . Case 2
A twenty-eight-year-old male with end-stage renal disease was the recipient of an HLA identical renal allograft from his brother. A rise in serum creatinine during the first post-transplant week prompted a percutaneous biopsy which resulted in brisk bleeding, complicated by complete anuria secondary to clot obstruction in the renal pelvis and ureter. He underwent percutaneous nephrostomy, and subsequent antegrade pyelography revealed complete resolution of the obstruction . The nephrostomy tube was removed, and the serum creatinine was stabilized at 1 .3 mg/dl .
He did well for the next five month, until he experienced intermittent passage of "gravel ." analysis of which revealed calcium oxalate . Six months post-transplantation he was readmitted with complete anuria and elevation of the serum creatinine to 5 .2 mg/dl . Ultrasonographr confirmed obstruction, and a percutaneous nephrostomy was placed with a prompt diuresis . Serum creatinine stabilized at 1 .5 mg!dl . A plain film revealed no calcifications in the area of the allograft . However, antegrade pyelography revealed several large, smooth, oval-filling defects (Fig . 2A) . Computed tomography (CT) without contrast confirmed these to be of high density (Fig . 2B) . Tract dilatation and percutaneous ultrasonic pyelolithotoiny were then performed . Chemical analysis revealed layers of calcium oxalate over dried blood . A followup antegrade nephrostogram and CT scan without contrast revealed no residual calculi . The nephrostomy tube was removed, and the
FIGURE 2 . Case 2 . (A) Antegrade pyelography reveals several large filling defects . (B) CT without contrast reveals filling defects in renal pelvis to be of high density (arrow), consistent with calculi .
UROLOGY
1
MARCH 1986
i VOLUME XXVII, NUMBER 3
249
Case 3 . Excretory urogramm reveals 1 .1-em, opaque renal pelvic calculus (arrow) in solitary right kidney : (A) scout film, and (B) five-minute film . FIGURE 3 .
patient was discharged eight days post-stone extraction after an uneventful course . An excretory urogram one month later revealed no residual calculi, prompt function, and no obstruction .
omy were performed the day after admission . A postoperative nephrostogram revealed two small distal ureteral fragments which were then managed with antegrade basket extraction . Her hospital course was otherwise uneventful, and the patient was discharged seven
Case 3 A forty-year-old female patient with right flank pain was admitted to Cleveland Clinic . She previously had undergone both a left nephrostomy for complications of stone disease and a right pyelolithotomy. An excretory urogram revealed a 1 .1-cm, opaque right renal pelvic calculus with mild fullness of the collecting system behind the stone (Fig . 3) . Percutaneous nephrostomy, tract dilatation, and percutaneous ultrasonic pyelolithotomy were performed the following day. Her postoperative course was uneventful, and she was discharged five days later . An excretory urogram one month later revealed no residual calculi, prompt function, and no obstruction . Case 4 A sixty-eight-year-old female patient with left flank pain was admitted to the Clinic . A right nephrestomy for complications of infected stone disease had been performed several years prior to this admission . An excretory urogram revealed a 2-cm renal pelvic calculus and a 1-cm lower infundibular calculus in the left kidney (Fig . 4) . Percutaneous nephrostomy, tract dilatation, and ultrasonic pyelolithotCase 4 . Scout film reveals 2-cm calculus in left renal pelvis and 1-cm calculus in lower calyx (arrows) . FIGURE 4 .
250
UROLOGY
/
MARCH
1986 / VOLUME XXVII, NUMBER 3
Fleuffv 5 . Retrograde study rereuls cm, opaque calculus (arrow) in renal pc of solitary right kidney : (A) scout film . (B) bilateral retrograde study . (C) So, t wire, nephroscope, and sonotrode it) ph . , (D) Scout film, and (E) twenty-rnimrte i n of follow-up urogram reveals prompt fi : u tion, no residual calculi . art(] uo obsti +r lion .
UBOLOQY
/ MARCH 1986
:
VOLUME XXVIL NUMBER 3
251
days after the initial procedure . Excretory urography one month later revealed no residual stone fragments, prompt function, and no obstruction . Case 5
A sixty-six-year-old male with right flank pain and hematuria was admitted to the Clinic . He previously had undergone a left nephrectomy for complications of stone disease as well as a right pyelolithotomy. Cystoscopy and bilateral retrograde studies revealed a 1 .2-cm right renal pelvic calculus (Fig . 5A, B) . Right percutaneous nephrostomv was performed the day after admission while tract dilatation and right percutaneous ultrasonic pyelolithotomy were accomplished twenty-four hours later (Fig . 5C) . His postoperative course was uneventful, and he was discharged five days later. An excretory urogram one month later revealed no residual calculi, prompt function, and no obstruction (Fig . 5D, E) . Comment Results from several treatment centers suggest that percutaneous removal of renal calculi can be performed safely and efficiently in large numbers of patients . I 6 However, the efficacy of these techniques specifically for the management of patients with solitary kidneys cannot be determined from those studies . Obviously, the primary concern in utilizing a percutaneous technique for these patients is the risk of a complication requiring nephrectomy. The overall complication rate for percutaneous procedures appears to be lower than that for open surgery, and the complications that do occur may be less serious . 4 The complication most likely to lead to a nephrectomy is hemorrhage . However, in experienced hands, the transfusion rate may be as low as 1 per cent,' and in our own patients has been only 3 per cent .' In fact, the risk of nephrectomy is extremely low . In a combined series of over 600 patients, only 1 (0 .15%) required a nephrectomy for complications of the percutaneous procedure . 1-6 A second consideration in choosing a percutaneous technique for patients with solitary kidneys is the overall effect on renal function . While total renal function remains stable or improved in nearly all patients undergoing a percutaneous procedure, the contribution of the operated kidney is difficult to accurately determine . In the patients presented here, renal function, as determined by the serum 252
creatinine, was in fact the same or better in all cases after percutaneous stone extraction . The final consideration in choosing a percutaneous procedure for patients with solitary kidneys is whether or not these techniques offer a significant advantage over open surgery in regard to patient comfort, length of hospitalization, and time away from work . Those factors have been addressed by several investigators .'-6 It appears clear that percutaneous stone procedures offer significant advantages, and the results obtained in the patients reported here appear to be no different . The indications to perform stone removal percutaneously in these patients with solitary kidneys were no different than those for our patients with two functioning renal units . However, this was a relatively high-risk group of patients . Not only did they have solitary kidneys, but two of these patients previously had undergone open surgery on the affected side . One other previously had undergone urinary diversion and had a chronic infection, while another patient was a renal transplant recipient . In all cases, however, the intraoperative and postoperative courses were uneventful, renal function was stable-to-improved, the length of hospitalization was relatively short, and return to full prehospitalization activity was rapid . We believe the results obtained in this series justify the consideration of percutaneous techniques as viable alternatives to open surgery in selected renal stone patients with solitary kidneys . 9500 Euclid Avenue Cleveland, Ohio 44106 (DR. STREEM) References 1 . Alken P, Hutsehenreiter G, Gunter R, and Marherger M : Percutaneous stone manipulation, J Urol 125 : 463 (1981) . 2 . Wickham JEA, Kellett MJ, and Miller RA : Elective percutaneous nephrolithotomy in 50 patients : an analysis of the technique, results and complications, ibid 129 : 904 (1983) . 3 . Segura JW, et al : Percutaneous lithotripsy, ibid 130 : 1051 (1983) . 4 . Clayman RV, et at : Percutaneoms nephrolithotomy : extraction of renal and ureteral calculi from 100 patients, ibid 131 : 868 (1984) . 5 . White DC, and Smith AD : Percutaneous stone extraction from 200 patients, ibid 132 : 437 (1984) . 6 . Streem SB, Zelch MG, and Risius B : Single-stage percutaneous extraction of renal calculi, Cleve Clin Q 52 : 15 (1985) . 7 . Streem SB . Zelch MG, Resins B, and Geisinger M : Percutaneous extraction of renal calculi, Urol Clin North Am 13 : 381 (1985) .
UROLOGY / MARCH 1986 / VOLUME XXVII, NUMBER 3