- Email: [email protected]
Reconstructive Renal Surgery Following Anatrophic Nephrolithotomy: Followup of 100 Consecutive Cases
Vol. 111. March
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1974 by The Williams & Wilkins Co.
RECONSTRUCTIVE RENAL SURGERY FOLLOWING ANATROPHIC NEPHROLITHOTOMY: FOLLOWUP OF 100 CONSECUTIVE CASES WILLIAM H. BOYCE* AND IRVING B. ELKINS From the Department of Urology, Bowman Gray School of Medicine, Winston-Salem, North Carolina
Surgical removal of renal calculi is an essential element in the successful management of the majority of patients with calculous disease. In some series extirpation alone has been associated with recurrence of calculi in 70 to 80 per cent of patients. 1 It has been our experience that the recurrences of calculi and the progressive attrition of renal function are inversely related to the restoration of anatomical and physiological normalcy to the affected kidney and the system in which it functions. Many technological developments have permitted the urologic surgeon to approach or achieve the ideal of renal reconstruction. These developments have included many diverse fields of science. Roentgenological techniques of tomography, angiography, magnification techniques and organ radiography permit accurate preoperative and operative localization of small calculi. An increasing number of effective antimicrobial agents and techniques have greatly enhanced the successful therapy of urinary infection. Local renal hypothermia, microsurgical instruments and sutures have permitted surgical techniques not previously possible. Metabolic surveys that screen patients for the endocrinologic, malignant, degenerative and other diseases associated with renal calculi have become technologically more sophisticated and increasingly effective. Supportive measures for the patient in extreme renal failure include not only dialysis but special programs of intravenous hyperalimentation designed to re-establish homeostasis of protein, carbohydrate and electrolyte metabolism. These and related technical procedures have been used with as much uniformity as possible in a consecutive series of patients with gross anatomical deformity of one or both kidneys. The primary objective in our series was a reconstructive renal operation and to this end no nephrectomy or partial nephrectomy was performed as a primary procedure.
operation. The 100 cases include those done resident house staff, postgraduate fellows private staff physicians. Followup has been tained on these patients through January 197:'l. All patients had either a large multiple large calculi of such nature as to an operation equivalent to that for a calculus (table 2). Forty-six per cent of patients had a previous ipsilateral open for stones. Fifteen patients had previously had ipsilateral nephrolithotomy. Twenty per cent the patients were asymptomatic at the time hospitalization, the remaining presenting with history of urinary tract infection, pain or hematuria. Parathyroid adenomas had been removed from patients and 3 patients had classical cystinuria unresponsive to medical therapy. Seven had a solitary kidney, a nephrectomy done for calculous disease at other institutions. At the time of hospitalization 60 (6'7 '7 per cent) had urinary infection documented culture (fig. 1). Proteus species and/or Pseudomo· nas were the predominant organisms in ~-m pa tients, with Escherichia coli and/or Klebsiella present in another 19 patients. Antimicrobial therapy initiated before hospitalization is considered account for failure to isolate organisms from a.n indeterminate number of the :30 patients with sterile urine. The persistence of bacteria calculi after the urine has become sterile is documented. 2 Sixty-four patients (71 per received intensive parenteral antibiotic fm at least 36 hours prior to an operation. Our pres(--mt philosophy is to continue this high dose antibiotic treatment throughout the intraoperative and postoperative period. Antibiotic therapy in remaining 26 patients was initiated at the time of the operation and continued throughout the operative period. SURGICAL TECHNIQUE
The surgical technique remains as 3 described by Smith and Figure demonstrates the planned site of incision between the anterior and posterior vascular segments. Thi:o site is demonstrated at the time of the operation the peripheral intravenous administration of meth ylene blue while the anterior segmental circulation is occluded with a rubber-shod clamp. Surgical
CHARACTERISTICS OF THE PATIENT POPULATION
Between January 1967 and January 1972, 90 patients underwent 100 anatrophic nephrolithotomies with reconstruction of the intrarenal collecting system (table 1). During this time no patient with obstructing calculous disease was refused an Accepted for publication ,July 6 1973. * Requests for reprints: Department of Urology, Bowman Gray School of Medicine, Winston-Salem, ;\/orth Carolina 27103. 1 Williams, R. E.: The results of conservative surgery for stone. Brit. J. Urol., 44: 292, 1972.
2 Stamey, T. A.: Urinary Infections, 1st ed. Baltimore: The Williams & Wilkins Co., p. 218, 1972. 3 Smith, M. J. V. and Boyce. W. H.: nephrotomy and plastic calyrhaphy. J. Urol., 99: 1968.
307
308
BOYCE AND ELKINS
entrance into the pelvis is just anterior to the posterior row of calices (fig. 2, B). The primary objective in the reconstructive phase of the procedure is to convert the infunTABLE
Affected Kidney Rt.
1. Patient characteristics for 100 consecutive anatrophic nephrolithotomies* Sex
32
M 18
48
Bilat.
10
Totals
90t
Total Procedures for White Followup
Race
No. Pts.
Lt.
dibulum of each calix into a widely patent channel. After removal of the pelvic calculi and the more accessible caliceal stones, an infundibulotomy is performed on each calix in which the papilla is not visualized (fig. 3). This procedure opens the anterior surface of the posterior row of calices and the posterior surface of the anterior row of calices. All
Black 1 2 0 4 0
F 14 M25 F 23 M 3 F 7 M46 F 44
17 12 25 19 3 6 45 37
7
TABLE
No.(%)
:l2
Previous ipsilateral nephrolithotomy Previous ipsilateral open stone procedure Asymptomatic Urinary tract infection Pain (ipsilateral)
48 20 100
Hematuria (gross)
* January 1967 to January 1972; followup through ,January 1973. t Average age 42.4 years, range 19 to 65 years.
50
37.5
2. Presenting history
15 (16.6) 42 (46.6) 18 (20.0) 55 (61.0) 58(64.4) 12 (1:l.O)
Primary hyperparathyroidism (adenoma removed) Cystinuria
:l (3.3)
Previous contralateral nephrectomy
7 (7.7)
4 (4.4)
~
>-
%
33.3%
32.2%
NO GROWTH
PROTEUS SP
PATIENTS
25
,..
125
-
12.2% E.COLI
10% PSEUDOMONAS
8.8% KLEBSIELLA
I 33%
IENTERO- ,
coccus
FIG. 1. Initial urine bacteriology in 90 patients
A
ct: 0
ct:
w
1-
z
of incision
B
ct: 0
ct:
w IC/)
0 0...
Renal artery
FIG. 2. A, demonstration ofnephrotomy incision between anterior and posterior vascular segments. B, cross-section of kidney demonstrates surgical entrance into pelvis. Note large anterior caliceal calculus and opened posterior calix with its papilla.
RECONSTRUCTIVE RENAL SURGERY FOLLOWING ANATROPHIC NEPHROLITHOTOMY
FIG. :3. lnfundibulotomy is which papilla is not visible. opened anterior calix.
stones and concretions can be removed, the papillae inspected and the calices thoroughly irrigated. Repair of the calices may be achieved a number of surgical other than primary resuture. The infundibular of adjacent calices may be approximated over the columns of Bertin with a running 6-zero atraumatic chromic catgut suture 4, A). The upper and lower pole calices may be for a lesser distance and sutured to the adjacent anterior and In some cases only a calix is stenotic and a calyrhaphy need only be done on this calix. After infundibulotomy the caliceal neck is shortened markedly partial closure of the infundibulotomy incision. The nnnn°,, flap is then tented during the closure and sutured to the remaining free edge of the infundibular (fig. 4, B). The presence of stones in a bifid collecting system may require another variation of the techniques presented. The 2 systems are opened in the same plane and converted into one larger collecting unit 5). ca!iceal repairs may also be accompl.ished. closure of the pelvis is effected with a running 5-zero atraumatic chromic catgut suture commencing at the Instruments, materials and techniques for intrarena! operations are quite similar to those used in operations on small vessels. A proper leaves all calices widely patent, completely and watertight. Closure of the renal incision is with a 4-zero atraumatic continuous chromic catgut suture in the renal No vertical mattress sutures, sutures or other parenchymal sutures are used for renal closure. The kidney is then returned to Gerota's space and surrounded with a fatty Vvhen this envelope is deficient omentum between the 0
Fro. 4. infundibular flaps have been sutured o-,e,· columns of pole calix has been opened for short distance. closure begins at superior pole. B, repair of single stenotic calix.
structures.
reconstruction of the internal ing system was 4.65 hours (table ::iJ. This total operating time commenced with anesthetic tion of the patient and terminated with removal the to the recovery area. Slush renal hypothermia was used in each case, average renal artery time of 69.8 minutes. silastic ureteral stent ,vas used in 77 left for an average of 8 tomy was necessary in l azotemia and obstruction d.ictatsd maximal renal
in table 4. The most common
en-
310
BOYCE AND ELKINS
The use of less flexible silastic stents has totally alleviated this problem. Transient drainage of urine from the incision was present postoperatively in 2 patients. The single death recorded in the immediate postoperative period occurred in a 47-year-old black woman, following a left nephrolithotomy for a staghorn calculus. A cardiac arrest occurred 3 days postoperatively with resultant irreversible brain damage. This patient died of pneumonia 2 months postoperatively. LONG-TERM RESULTS
FIG. 5. Surgical reconstruction of bifid collecting system with necessary caliceal repairs as indicated.
TABLE
3. Operation
Stone detail (staghorn or multiple) . Approach (flank) Average operating time (hrs.) . Average renal artery clamp time (mins.) .. Indwelling ureteral stent (No. pts.) . Average number of days stent indwelling . Patients requiring nephrostorny . Patients not requiring blood intraoperatively . Patients not requiring blood postoperatively Average hospital stay following surgery (days) .
TABLE
100 100 4.65 69.8 77 8 :J4 71
TABLE
5. Long-term followup data: 90 patients
10.7
4. Immediate complications
Hemorrhage . Pneumothorax . Retrograde migration of ureteral stent .. Flank drainage of urine . Wound infection . Death .
Our followup studies are based on patients who have been followed for more than 1 year postoperatively. The average length of followup is 3 years. Thirteen patients had an elevation of blood pressure during the preoperative evaluation and all had a history of hypertension (table 5). Postoperatively, 8 patients remained hypertensive. There was no evidence that a renal operation aggravated the pre-existent hypertension in any patient. Three patients with normal preoperative blood pressures were noted to have mild hypertension during followup. Two of these patients required no form of treatment. The third patient presented as normotensive but with a long history of antihypertensive therapy and it was necessary to continue this postoperatively. Seventy-three patients had normal blood urea nitrogen (BUN) determinations preoperatively, the remaining 17 patients having a BUN greater than 20 mg. per 100 ml. During the followup period 75 patients have had normal BUN. Thirteen patients with an elevated BUN preoperatively have continued with the same level of increase postoperatively. Two patients had continued progressive reduction of renal function postoperatively. One patient was found to have a non-functioning kidney postoperatively although the excre-
4
3 3
2 1 1
countered in the postoperative period occurred in 4 patients who required more than 5 units of blood for replacement. Each patient with renal bleeding postoperatively was treated conservatively and no complications were noted. Three patients had retrograde migration of the silastic ureteral stent, which necessitated open ureterotomy in 1 patient.
Blood pressure: Normotensive (preop.) Elevated postop. Diastolic hypertension (preop.) Remain elevated postop. Normal postop. BUN: Preop. Normal Elevated Postop. Normal Elevated Greater than preop. Recurrent stones and/or infection: Stones with infection Stones without infection Infection without stones Residual stones Incisional hernia Nephrectomy Death
77 3 13 8
5
73 17 75 1:3 2 22 8
7 7 5 2 1
RECONSTRUCTIVE RENAL SURGERY FOLLOWING ANATROPHIC NEPHROLITHOTOMY
6. Patients with recurrent stones following anatrophic nephrolithotomy
TABLE
No. Pts.
Factors Conducive to Recurrent Stone Formation
8
Previous It. nephrolithotomy and partial nephrectomy, intractable intrarenal obstruction and infection
5:3*
lpsilat. pyelolithotomy. chronic UTl:j: (Pseudomonas) Urethral stricture, bilat. reflux, recurrent UTI (Pseudomonas) Prior bilat. nephrolithotomy-rt. x 4, It. x :3,
79t 85
intractable infection (Proteus) and obstruction
11
Exstrophy, ilea! conduit, chronic UT! (Pseudomonas/Proteus) prior ipsilat. nephrolithotomy X 2 Exstrophy, ilea! conduit, bladder stones, chronic UT! (Pseudomonas)
22 46*
Ca of cervix, pelvic exenteration, ileal conduit,
40t
chronic UT! (Pseudomonas, Proteus) Pyelolithotomy-rt. x 2, ureterolithotomv-lt. x 1, parathyroid adenoma removed aft;r bilat.
45
Nephrocalcinosis, parathyroid adenoma removed
55
Boeck's sarcoid, ipsilat. ureterolithotomy x 2,
61 t
Classical cystinuria, intractable intrarenal ob-
28!
struction and infection Congenital renal anomalies, absent posterior seg-
recurrences after recurrences
non~function rt. lower pole
ment, chronic UT! (Pseudomonas) recurrent stones rt. onlv
89 12*·
t
Medullary spor.;ge kidney nephrocalcinosis Chronic UT! (Proteus), ethiflex sutures, repeat bilat. procedures :\ICBH. 28 mos. followup. free of stones and infection
15*
Solitary It. kidney, lt. pyelonephrolithotomy, rt. nephrectorny at age l'.i for stones
* Currently free of stones after operation. t Bilateral anatrophic nephrolithotomy at NCBH.
t Urinary
tract infection.
tory urogram demonstrated a small shrunken kidney preoperatively. The kidney has remained non-functioning and asymptomatic. The second patient required nephrectomy. This patient's poorly functioning kidney failed to improve after the removal of an obstructing staghorn calculus. In addition, persistent infection with Proteus species responding but not clearing during 2 years of intensive antimicrobial therapy necessitated removal of the kidney. The patient is now asymptomatic with clear urine and no stones in the solitary kidney. Recurrent urinary tract infection persisted in 15 patients during the followup period. Five patients have had a single infection only but the remaining 10 patients have had multiple recurrent infections. Four of these 10 patients had previously undergone ilea! conduit diversionary procedures for exstrophy, cancer or congenital neurogenic disorders. Two patients had bilateral reflux, one requiring ureteral reimplantation. One additional patient had posterior urethral valves, hydronephrosis with reflux and required bilateral ureteroneocystostomy. The remaining 3 patients did not demon-
31
strate obvious obstructive or functional to explain the persistent infection. Fifteen patients have had recurrent stones during the period of followup. The information sented in table 6 demonstrates the complex lems presented by these patients. Five patients were found with residual stones in the postoperative period. These were removed months and '.'l years in 2 patients. The other patients still harbor their small residual stones. Nephrocalcinosis in :Z patient;; :rnd technical problems in 3 patients accounted for these residual calculi. Two deaths have occurred during the late foJ. lowup period. One occurred 1 year secondary to a documented coronary occiusion. The other death occurred in a woman approximately 3 years following bilatenil nephrolithotomy procedures. The preoperative BUN was 59 mg. per 100 ml. with 2c serun1 creatinine of 4.2. Postoperatively the BUN de creased to 35 mg. per ml. and the patient did on a Giovanetti diet before she died at home unknown causes. DISCUSSION
If recurrence of calculi be considered failure in patients then antecedent factors share a proportion of the responsibility. Programs of conservative therapy appear to be responsible for the majority of these factors. Two patients had primary parathyroid adenomas undiagnosed until renal failure had obscured the classical signs of the disorder. assay for parathormone should correct this type of failure. Three patients with cutaneous diversion oi urine had advanced urinary obstruction, intracta ble infection and massive calculus formation. The patient with cystinuria had massive hydronephrn sis, complete loss of functional renal reserve and intractable infection. Modern medical should obviate this type of problem. One had non-absorbable sutures which served as ,1 nidus for stone formation. Uncorrected ureternI reflux with massive hydronephrosis accounted for 1 failure. Combinations of post-surgical or diseaseinduced obstruction, either ureteral or caliceal. with persistent infection in devitalized renal tissue accounted for recurrences in 4 patients whose renai. anatomy defied functional reconstruction. Collectively, these 12 patients in retrospect could con ceivably have benefited from earlier and intensive surgical and medical therapy. The remaining 3 patients underwent surgical procedures designed to remove obstructive calculi since there is no effective medical or surgical correction for the basic disease. SUMMARY
Followup is presented on 100 consecutive ana trophic nephrolithotomies with complete
312
BOYCE AND ELKINS
reconstruction of the intrarenal collecting system. The surgical technique is described. The average period of followup is 3 years. Recurrent stones have formed in 17 .7 per cent of patients, many of whom continue with urinary infection refractory to outpatient therapy. Renal function has improved or remained stable postoperatively in all but 2 patients whose course is described.
Persistent infection, recurrent stone formation and reduced renal function in the majority of these patients are directly attributable to factors antecedent to the definitive operation. Recognition and proper management of these factors can be logically anticipated to further reduce the complications of a renal operation for large calculi.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1974 by The Williams & Wilkins Co.
RECONSTRUCTIVE RENAL SURGERY FOLLOWING ANATROPHIC NEPHROLITHOTOMY: FOLLOWUP OF 100 CONSECUTIVE CASES WILLIAM H. BOYCE* AND IRVING B. ELKINS From the Department of Urology, Bowman Gray School of Medicine, Winston-Salem, North Carolina
Surgical removal of renal calculi is an essential element in the successful management of the majority of patients with calculous disease. In some series extirpation alone has been associated with recurrence of calculi in 70 to 80 per cent of patients. 1 It has been our experience that the recurrences of calculi and the progressive attrition of renal function are inversely related to the restoration of anatomical and physiological normalcy to the affected kidney and the system in which it functions. Many technological developments have permitted the urologic surgeon to approach or achieve the ideal of renal reconstruction. These developments have included many diverse fields of science. Roentgenological techniques of tomography, angiography, magnification techniques and organ radiography permit accurate preoperative and operative localization of small calculi. An increasing number of effective antimicrobial agents and techniques have greatly enhanced the successful therapy of urinary infection. Local renal hypothermia, microsurgical instruments and sutures have permitted surgical techniques not previously possible. Metabolic surveys that screen patients for the endocrinologic, malignant, degenerative and other diseases associated with renal calculi have become technologically more sophisticated and increasingly effective. Supportive measures for the patient in extreme renal failure include not only dialysis but special programs of intravenous hyperalimentation designed to re-establish homeostasis of protein, carbohydrate and electrolyte metabolism. These and related technical procedures have been used with as much uniformity as possible in a consecutive series of patients with gross anatomical deformity of one or both kidneys. The primary objective in our series was a reconstructive renal operation and to this end no nephrectomy or partial nephrectomy was performed as a primary procedure.
operation. The 100 cases include those done resident house staff, postgraduate fellows private staff physicians. Followup has been tained on these patients through January 197:'l. All patients had either a large multiple large calculi of such nature as to an operation equivalent to that for a calculus (table 2). Forty-six per cent of patients had a previous ipsilateral open for stones. Fifteen patients had previously had ipsilateral nephrolithotomy. Twenty per cent the patients were asymptomatic at the time hospitalization, the remaining presenting with history of urinary tract infection, pain or hematuria. Parathyroid adenomas had been removed from patients and 3 patients had classical cystinuria unresponsive to medical therapy. Seven had a solitary kidney, a nephrectomy done for calculous disease at other institutions. At the time of hospitalization 60 (6'7 '7 per cent) had urinary infection documented culture (fig. 1). Proteus species and/or Pseudomo· nas were the predominant organisms in ~-m pa tients, with Escherichia coli and/or Klebsiella present in another 19 patients. Antimicrobial therapy initiated before hospitalization is considered account for failure to isolate organisms from a.n indeterminate number of the :30 patients with sterile urine. The persistence of bacteria calculi after the urine has become sterile is documented. 2 Sixty-four patients (71 per received intensive parenteral antibiotic fm at least 36 hours prior to an operation. Our pres(--mt philosophy is to continue this high dose antibiotic treatment throughout the intraoperative and postoperative period. Antibiotic therapy in remaining 26 patients was initiated at the time of the operation and continued throughout the operative period. SURGICAL TECHNIQUE
The surgical technique remains as 3 described by Smith and Figure demonstrates the planned site of incision between the anterior and posterior vascular segments. Thi:o site is demonstrated at the time of the operation the peripheral intravenous administration of meth ylene blue while the anterior segmental circulation is occluded with a rubber-shod clamp. Surgical
CHARACTERISTICS OF THE PATIENT POPULATION
Between January 1967 and January 1972, 90 patients underwent 100 anatrophic nephrolithotomies with reconstruction of the intrarenal collecting system (table 1). During this time no patient with obstructing calculous disease was refused an Accepted for publication ,July 6 1973. * Requests for reprints: Department of Urology, Bowman Gray School of Medicine, Winston-Salem, ;\/orth Carolina 27103. 1 Williams, R. E.: The results of conservative surgery for stone. Brit. J. Urol., 44: 292, 1972.
2 Stamey, T. A.: Urinary Infections, 1st ed. Baltimore: The Williams & Wilkins Co., p. 218, 1972. 3 Smith, M. J. V. and Boyce. W. H.: nephrotomy and plastic calyrhaphy. J. Urol., 99: 1968.
307
308
BOYCE AND ELKINS
entrance into the pelvis is just anterior to the posterior row of calices (fig. 2, B). The primary objective in the reconstructive phase of the procedure is to convert the infunTABLE
Affected Kidney Rt.
1. Patient characteristics for 100 consecutive anatrophic nephrolithotomies* Sex
32
M 18
48
Bilat.
10
Totals
90t
Total Procedures for White Followup
Race
No. Pts.
Lt.
dibulum of each calix into a widely patent channel. After removal of the pelvic calculi and the more accessible caliceal stones, an infundibulotomy is performed on each calix in which the papilla is not visualized (fig. 3). This procedure opens the anterior surface of the posterior row of calices and the posterior surface of the anterior row of calices. All
Black 1 2 0 4 0
F 14 M25 F 23 M 3 F 7 M46 F 44
17 12 25 19 3 6 45 37
7
TABLE
No.(%)
:l2
Previous ipsilateral nephrolithotomy Previous ipsilateral open stone procedure Asymptomatic Urinary tract infection Pain (ipsilateral)
48 20 100
Hematuria (gross)
* January 1967 to January 1972; followup through ,January 1973. t Average age 42.4 years, range 19 to 65 years.
50
37.5
2. Presenting history
15 (16.6) 42 (46.6) 18 (20.0) 55 (61.0) 58(64.4) 12 (1:l.O)
Primary hyperparathyroidism (adenoma removed) Cystinuria
:l (3.3)
Previous contralateral nephrectomy
7 (7.7)
4 (4.4)
~
>-
%
33.3%
32.2%
NO GROWTH
PROTEUS SP
PATIENTS
25
,..
125
-
12.2% E.COLI
10% PSEUDOMONAS
8.8% KLEBSIELLA
I 33%
IENTERO- ,
coccus
FIG. 1. Initial urine bacteriology in 90 patients
A
ct: 0
ct:
w
1-
z
of incision
B
ct: 0
ct:
w IC/)
0 0...
Renal artery
FIG. 2. A, demonstration ofnephrotomy incision between anterior and posterior vascular segments. B, cross-section of kidney demonstrates surgical entrance into pelvis. Note large anterior caliceal calculus and opened posterior calix with its papilla.
RECONSTRUCTIVE RENAL SURGERY FOLLOWING ANATROPHIC NEPHROLITHOTOMY
FIG. :3. lnfundibulotomy is which papilla is not visible. opened anterior calix.
stones and concretions can be removed, the papillae inspected and the calices thoroughly irrigated. Repair of the calices may be achieved a number of surgical other than primary resuture. The infundibular of adjacent calices may be approximated over the columns of Bertin with a running 6-zero atraumatic chromic catgut suture 4, A). The upper and lower pole calices may be for a lesser distance and sutured to the adjacent anterior and In some cases only a calix is stenotic and a calyrhaphy need only be done on this calix. After infundibulotomy the caliceal neck is shortened markedly partial closure of the infundibulotomy incision. The nnnn°,, flap is then tented during the closure and sutured to the remaining free edge of the infundibular (fig. 4, B). The presence of stones in a bifid collecting system may require another variation of the techniques presented. The 2 systems are opened in the same plane and converted into one larger collecting unit 5). ca!iceal repairs may also be accompl.ished. closure of the pelvis is effected with a running 5-zero atraumatic chromic catgut suture commencing at the Instruments, materials and techniques for intrarena! operations are quite similar to those used in operations on small vessels. A proper leaves all calices widely patent, completely and watertight. Closure of the renal incision is with a 4-zero atraumatic continuous chromic catgut suture in the renal No vertical mattress sutures, sutures or other parenchymal sutures are used for renal closure. The kidney is then returned to Gerota's space and surrounded with a fatty Vvhen this envelope is deficient omentum between the 0
Fro. 4. infundibular flaps have been sutured o-,e,· columns of pole calix has been opened for short distance. closure begins at superior pole. B, repair of single stenotic calix.
structures.
reconstruction of the internal ing system was 4.65 hours (table ::iJ. This total operating time commenced with anesthetic tion of the patient and terminated with removal the to the recovery area. Slush renal hypothermia was used in each case, average renal artery time of 69.8 minutes. silastic ureteral stent ,vas used in 77 left for an average of 8 tomy was necessary in l azotemia and obstruction d.ictatsd maximal renal
in table 4. The most common
en-
310
BOYCE AND ELKINS
The use of less flexible silastic stents has totally alleviated this problem. Transient drainage of urine from the incision was present postoperatively in 2 patients. The single death recorded in the immediate postoperative period occurred in a 47-year-old black woman, following a left nephrolithotomy for a staghorn calculus. A cardiac arrest occurred 3 days postoperatively with resultant irreversible brain damage. This patient died of pneumonia 2 months postoperatively. LONG-TERM RESULTS
FIG. 5. Surgical reconstruction of bifid collecting system with necessary caliceal repairs as indicated.
TABLE
3. Operation
Stone detail (staghorn or multiple) . Approach (flank) Average operating time (hrs.) . Average renal artery clamp time (mins.) .. Indwelling ureteral stent (No. pts.) . Average number of days stent indwelling . Patients requiring nephrostorny . Patients not requiring blood intraoperatively . Patients not requiring blood postoperatively Average hospital stay following surgery (days) .
TABLE
100 100 4.65 69.8 77 8 :J4 71
TABLE
5. Long-term followup data: 90 patients
10.7
4. Immediate complications
Hemorrhage . Pneumothorax . Retrograde migration of ureteral stent .. Flank drainage of urine . Wound infection . Death .
Our followup studies are based on patients who have been followed for more than 1 year postoperatively. The average length of followup is 3 years. Thirteen patients had an elevation of blood pressure during the preoperative evaluation and all had a history of hypertension (table 5). Postoperatively, 8 patients remained hypertensive. There was no evidence that a renal operation aggravated the pre-existent hypertension in any patient. Three patients with normal preoperative blood pressures were noted to have mild hypertension during followup. Two of these patients required no form of treatment. The third patient presented as normotensive but with a long history of antihypertensive therapy and it was necessary to continue this postoperatively. Seventy-three patients had normal blood urea nitrogen (BUN) determinations preoperatively, the remaining 17 patients having a BUN greater than 20 mg. per 100 ml. During the followup period 75 patients have had normal BUN. Thirteen patients with an elevated BUN preoperatively have continued with the same level of increase postoperatively. Two patients had continued progressive reduction of renal function postoperatively. One patient was found to have a non-functioning kidney postoperatively although the excre-
4
3 3
2 1 1
countered in the postoperative period occurred in 4 patients who required more than 5 units of blood for replacement. Each patient with renal bleeding postoperatively was treated conservatively and no complications were noted. Three patients had retrograde migration of the silastic ureteral stent, which necessitated open ureterotomy in 1 patient.
Blood pressure: Normotensive (preop.) Elevated postop. Diastolic hypertension (preop.) Remain elevated postop. Normal postop. BUN: Preop. Normal Elevated Postop. Normal Elevated Greater than preop. Recurrent stones and/or infection: Stones with infection Stones without infection Infection without stones Residual stones Incisional hernia Nephrectomy Death
77 3 13 8
5
73 17 75 1:3 2 22 8
7 7 5 2 1
RECONSTRUCTIVE RENAL SURGERY FOLLOWING ANATROPHIC NEPHROLITHOTOMY
6. Patients with recurrent stones following anatrophic nephrolithotomy
TABLE
No. Pts.
Factors Conducive to Recurrent Stone Formation
8
Previous It. nephrolithotomy and partial nephrectomy, intractable intrarenal obstruction and infection
5:3*
lpsilat. pyelolithotomy. chronic UTl:j: (Pseudomonas) Urethral stricture, bilat. reflux, recurrent UTI (Pseudomonas) Prior bilat. nephrolithotomy-rt. x 4, It. x :3,
79t 85
intractable infection (Proteus) and obstruction
11
Exstrophy, ilea! conduit, chronic UT! (Pseudomonas/Proteus) prior ipsilat. nephrolithotomy X 2 Exstrophy, ilea! conduit, bladder stones, chronic UT! (Pseudomonas)
22 46*
Ca of cervix, pelvic exenteration, ileal conduit,
40t
chronic UT! (Pseudomonas, Proteus) Pyelolithotomy-rt. x 2, ureterolithotomv-lt. x 1, parathyroid adenoma removed aft;r bilat.
45
Nephrocalcinosis, parathyroid adenoma removed
55
Boeck's sarcoid, ipsilat. ureterolithotomy x 2,
61 t
Classical cystinuria, intractable intrarenal ob-
28!
struction and infection Congenital renal anomalies, absent posterior seg-
recurrences after recurrences
non~function rt. lower pole
ment, chronic UT! (Pseudomonas) recurrent stones rt. onlv
89 12*·
t
Medullary spor.;ge kidney nephrocalcinosis Chronic UT! (Proteus), ethiflex sutures, repeat bilat. procedures :\ICBH. 28 mos. followup. free of stones and infection
15*
Solitary It. kidney, lt. pyelonephrolithotomy, rt. nephrectorny at age l'.i for stones
* Currently free of stones after operation. t Bilateral anatrophic nephrolithotomy at NCBH.
t Urinary
tract infection.
tory urogram demonstrated a small shrunken kidney preoperatively. The kidney has remained non-functioning and asymptomatic. The second patient required nephrectomy. This patient's poorly functioning kidney failed to improve after the removal of an obstructing staghorn calculus. In addition, persistent infection with Proteus species responding but not clearing during 2 years of intensive antimicrobial therapy necessitated removal of the kidney. The patient is now asymptomatic with clear urine and no stones in the solitary kidney. Recurrent urinary tract infection persisted in 15 patients during the followup period. Five patients have had a single infection only but the remaining 10 patients have had multiple recurrent infections. Four of these 10 patients had previously undergone ilea! conduit diversionary procedures for exstrophy, cancer or congenital neurogenic disorders. Two patients had bilateral reflux, one requiring ureteral reimplantation. One additional patient had posterior urethral valves, hydronephrosis with reflux and required bilateral ureteroneocystostomy. The remaining 3 patients did not demon-
31
strate obvious obstructive or functional to explain the persistent infection. Fifteen patients have had recurrent stones during the period of followup. The information sented in table 6 demonstrates the complex lems presented by these patients. Five patients were found with residual stones in the postoperative period. These were removed months and '.'l years in 2 patients. The other patients still harbor their small residual stones. Nephrocalcinosis in :Z patient;; :rnd technical problems in 3 patients accounted for these residual calculi. Two deaths have occurred during the late foJ. lowup period. One occurred 1 year secondary to a documented coronary occiusion. The other death occurred in a woman approximately 3 years following bilatenil nephrolithotomy procedures. The preoperative BUN was 59 mg. per 100 ml. with 2c serun1 creatinine of 4.2. Postoperatively the BUN de creased to 35 mg. per ml. and the patient did on a Giovanetti diet before she died at home unknown causes. DISCUSSION
If recurrence of calculi be considered failure in patients then antecedent factors share a proportion of the responsibility. Programs of conservative therapy appear to be responsible for the majority of these factors. Two patients had primary parathyroid adenomas undiagnosed until renal failure had obscured the classical signs of the disorder. assay for parathormone should correct this type of failure. Three patients with cutaneous diversion oi urine had advanced urinary obstruction, intracta ble infection and massive calculus formation. The patient with cystinuria had massive hydronephrn sis, complete loss of functional renal reserve and intractable infection. Modern medical should obviate this type of problem. One had non-absorbable sutures which served as ,1 nidus for stone formation. Uncorrected ureternI reflux with massive hydronephrosis accounted for 1 failure. Combinations of post-surgical or diseaseinduced obstruction, either ureteral or caliceal. with persistent infection in devitalized renal tissue accounted for recurrences in 4 patients whose renai. anatomy defied functional reconstruction. Collectively, these 12 patients in retrospect could con ceivably have benefited from earlier and intensive surgical and medical therapy. The remaining 3 patients underwent surgical procedures designed to remove obstructive calculi since there is no effective medical or surgical correction for the basic disease. SUMMARY
Followup is presented on 100 consecutive ana trophic nephrolithotomies with complete
312
BOYCE AND ELKINS
reconstruction of the intrarenal collecting system. The surgical technique is described. The average period of followup is 3 years. Recurrent stones have formed in 17 .7 per cent of patients, many of whom continue with urinary infection refractory to outpatient therapy. Renal function has improved or remained stable postoperatively in all but 2 patients whose course is described.
Persistent infection, recurrent stone formation and reduced renal function in the majority of these patients are directly attributable to factors antecedent to the definitive operation. Recognition and proper management of these factors can be logically anticipated to further reduce the complications of a renal operation for large calculi.