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Segmental calculus disease: Potential of partial nephrectomy
SEGMENTAL POTENTIAL ROBERT JOHN
CALCULUS
OF PARTIAL NEPHRECTOMY
J. BATES,
M.D.
A. HEANEY,
M.D.
WALTER
DISEASE:
S. KERR,
JR., M.D.
From the Urological Service, Massachusetts General Hospital and the Harvard Medical School, Boston, Massachusetts
ABSTRACT - Partial nephrectomy was performed on 71 renal units between 1962 and 1978 for segmental calculus disease. Parenchymal scarring associated with an infundibulocalyceal stone, which was usually branched, was the indication fw resection. Stone analysis demonstrated an equal incidence of idiopathic and struvite stones. Perioperative morbidity uxs minimal, but pyelocutaneous urinary drainage prolonged the hospitalization of 5 patients. In 2 cases, the cause was an obstructing retained calculus. Retained calculi occurred in 3 other patients, one requiring early nephrectomy for sepsis. Fifty-seven patients were followed fm longer than twelve months. Ips&teral calculi recurred in 12 per cent of kidneys, and contralateral new calculi developed in the same number. Ninety-four per cent of patients with preoperative urinary tract infections had sterile urine at follow-up. From the results of this and other series, partial nephrectomy compares f~~vorably with extended pyelolithotomy and anatrophic nephrotomy for segmental calculus disease associated with parenchymal scarring andlor a defonlzed collecting systenz.
The early use of partial nephrectomy was marred by the frequent occurrence of primary and secondary hemorrhage, urinary fistulas, delayed nephrectomy, and death. By the late 1930s with improvements in preoperative diagnosis, knowledge of renal anatomy and physiology, anesthesia, surgical techniques, and postoperative care, partial nephrectomy had become a reasonable surgical alternative. In 1937, Goldstein and Abeshouse’ reviewed 296 cases of partial nephrectomy, 58 of which were performed for stone disease. They concluded that with proper case selection and attention to anatomy, partial resection of the kidney was a satisfactory treatment for solitary serous or hemorrhagic cysts, hydatid cysts, localized hydronephrosis or pyonephrosis (with or without renal calculi), benign tumors, localized cortical abscesses, renal infarcts, and renal fistulas.
Read at -\nnual Meeting tion, Inc., San Francisco,
C’ROLOGY
i
MAY 1331
of American Urological AssociaCalifornia, May 19. 1980.
/
VOLUME
XVII,
NL’klBER
5
By 1950, 200 cases of partial nephrectomy for stone disease could be found in the literature.’ The work of Graves3 on the intrarenal arterial anatomy and its surgical significance and the reports of Semb” in treating renal tuberculosis were followed by an increased use of partial nephrectomy in segmental calculus disease. Several large series have been reported focusing on the indications for partial nephrectomy in stone disease and the recurrence rates as compared with other surgical techniques. 5-‘6 The indication usually has been the presence of a stone or multiple stones in a single calyx or group of calyces with accompanying parenchymal scarring and deformities of the pyelocalyceal anatomy. In addition, Stewart5 has suggested that a partial resection is applicable in the absence of calyceal deformity when roentgenograms of the explored kidney reveal parenchymal calcifications adjacent to the calyceal group. This report details our experiences with partial nephrectomy performed on 71 renal units
409
between 1962 and 1978. The procedure was used to treat segmental calculus disease and its resultant pathologic deformities. Material
and Methods
Seventy-one partial nephrectomies for segmental calculus disease were performed from 1962 through 1978. The clinical records were reviewed and attempts made to contact those patients not recently seen in follow-up visits. The length of the follow-up was determined by the most recent intravenous urogram or plain abdominal film. All patients had an intravenous urogram within six weeks of operation and the majority before discharge. All films were reviewed to assess details of the number and distribution of calculi, the functional and anatomic condition of the kidney before and after operation, and the presence of residual and recurrent calculi. Residual calculi were defined as any seen on the first postoperative x-ray film. A recurrent stone was documented by its passage and collection, surgical removal, or appearance on follow-up films. Patients with dysgenetic or horseshoe kidneys and complete duplex collecting systems were eliminated from review. Table I catalogues the pertinent medical and surgical history of the group. There were 29 males and 42 females ranging in age from eighteen to seventy-five years’ old, with a mean of forty-seven years (Fig. 1). The female mean age was fifty-two years, and the male forty-eight years. Parenchymal scarring and pyelocalyceal deformity associated with single or multiple infundibulocalyceal calculi indicated partial resection. Thirty-two patients had infected urine preoperatively. Hypercalcinuria (males > 300 mg./day, females > 250 mg./day) was present in 5 of 40 patients, and 1 patient had undergone resection of a parathyroid adenoma. Stone analysis revealed 30 struvite, 27 calcium, and 1 uric acid stone. Analysis was not performed on the remainder. The relationship between stone morphology, analysis, and location is summarized in Table II. Twenty-eight patients had no known history of renal ipsilateral stones, 23 had had ipsilateral colic and/or stone passage, and 20 had undergone ipsilateral nephrolithotomy, pyelolithotomy, and/or ureterolithotomy. Fifty-seven patients were followed for longer than twelve months (eighteen to 190 months) with a mean of eighty-six months.
‘410
TABLE I. Preoious medical and surgical history of patients undergoing partial nephrectomy
Number
History
2 1 1 3
Previous partial nephrectomy Cystectomy and ureterosigmoidostomy Ureteroneocystomy - ipsilateral Pyeloplasty - ipsilateral Nephrolithotomy Ipsilateral Contralateral Pyelolithotomy Ipsilateral Contralateral Ureterolithotomy Ipsilateral Contralateral Hyperparathyroidism Hyperthyroidism Medullary sponge kidney Multiple sclerosis with neurogenic bladder Single kidney
17 4 5 3 3 2 1 1 3 1 1
161412'; loul ii ,' 86-
1
42-
0
IO
1
FIGURE 1. Age distribution partial nephrectomy.
Operative
of patients
80
undergoing
Technique
Operative procedures were performed by the senior and resident staffs in a generally similar fashion. The majority of the dissections were retroperitoneal, and all approaches were through a flank incision. The exact surgical incision varied with the clinical situation and surgeon’s preference. The kidney was mobilized carefully to avoid injury to accessory or polar
UROLOGY
/ MAY 1981 / VOLUMEXVII,NUMBER5
II. Site of parenchyma resected by partial nephrectomy morphology and analysis of contained calculi
TABLE
Morphology Branched
No.
Analysis
25
Calcium oxalate/ phosphate (8) Struvite (14) Uric acid (1)
Males (12) Females (13)
Area of Partial Nephrectomy
No analysis (2)
S taghorn Males (4) Females (5)
Single
Struvite
16
Males (5) Females (11)
21
Multiple Males (7) Females (14)
UROLOGY
i MAY
1981
/
VOLUMEXVII.NUMBER5
(9)
Calcium oxalate/ phosphate (8) Struvite (2) No analysis (6)
Calcium oxalate/ phosphate (11) Struvite (5) No analysis (5)
vessels and the vascular pedicle isolated between umbilical tapes for control and identification. Segmental arteries were occluded or injected with methylene blue to demarcate the vascular supply of the region to be resected. Early in the series, the main artery was occluded temporarily for a variable length of time to obtain hemostasis, but this practice has been abandoned in more recent times. The capsule was sharply incised and stripped back off the parenchyma except when extensive inflammatory reaction from infection or previous surgery made this impossible. Extent of excisions were either wedge caliectomy (17), transverse polar (42), or heminephrectomy (12). Arterial vessels were transfixed with figure-ofeight chromic catgut sutures. The collecting system was closed in a watertight fashion with fine chromic catgut sutures, often after exploration of the residual collecting system for retained stones and calibration of the ureteropelvic junction. The closure was checked by inflation of the pyelocalyceal system by direct injection of fluid. The capsule was closed over the resected surface with or without intervening perinephric fat,
with
Left Upper Lower Lower mid Right Upper Lower Left Upper Lower Right Upper Lower Left Upper Lower Right Upper Lower Left Upper Lower Right Upper Lower
pole (7) pole (8) and pole (1) pole (3) pole (6) pole (1) pole (3) pole (2) pole (3) pole (4) pole (2) pole (3) pole (7) pole (1) pole (11) pole (3) pole (6)
and the kidney was usually sutured to the paraspinal musculature. Large Penrose drains were placed in the area of resection and brought out through a separate stab wound in the retroperitoneum. Partial nephrectomy was combined with one or more other procedures in 60 per cent of the cases (Table III). Nephrostomy tubes were placed in 5 cases associated with simultaneous pyeloplasty, nephrotomy, or pyelotomy. Pyelostomy tubes were placed in 4 cases after attempted extended pyelolithotomy. In 5 cases,
TABLE
III. Procedures performed concurrently with partial nephrectomy Procedure
Pyelotomy/pyelolithotomy Nephrotomy/nephrolithotomy Both pyelotomy and nephrotomy Ureterolithotomy Pyeloplasty Vesicolithotomy Closure of pyelocutaneous fistula
NO.
25 7 3 4 3 1 1
111
the partial resection ence of pyonephrosis; followed in one case.
was performed a deep
in the preswound infection
Results The complications which occurred are listed in Table IV. No deaths or secondary hemorrhages occurred. Six patients required more than four units of blood to replace intraoperative loss. Nineteen patients required no transfusions. The postoperative hospital stay averaged eleven days in 59 uncomplicated cases.
TABLE
I\'.
,tfujorcompkxtions
Comment
of pm-tid
nephrectorny Complication
Iu 0.
Pyelocutaneous fist&s Retained stones CTreteral injur) Wound infection Incidental splenectomy
5 5 1
2 1
Pyelocutaneous urinary drainage for longer than seven days prolonged the hospital stay of 5 patients. Two were associated with retained calculi, one requiring reoperation to remove an One closed following placeobstructing stone. ment of a ureteral catheter, while the remaining two closed spontaneously. Two delayed nephrectomies were performed: one for pyonephrosis due to a retained obstructing calculus and the other after irreparable damage to the remaining ureter in a partially duplicated collecting system. Two of the five retained stones required ‘operative intervention (pyelolithotomy and delayed nephrectomy), one passed without incident, and the remaining two were small flecks and have been asymptomatic in follow-up. Seven ipsilateral recurrences and seven contralateral new stones were seen in 12 of 57 patients followed for longer than twelve months. Ipsilateral recurrences were seen seventeen to 121 months (mean sixty-eight) after operation, and six of seven occurred in kidneys which had undergone at least one previous stone procedure before partial nephrectomy. All ipsilateral recurrences were in kidneys in which the partial resection had included the lower pole. One stone passed spontaneously, one was located in the pelvis, and five were found in the most dependent calyx. One patient died of other causes, 2 required nephrolithotomy, and 3
-112
remain asymptomatic. Contralateral new stones appeared at an average of forty months in follow-up. Urinary tract infections persisted in 2 of 32 patients with positive preoperative cultures. In 1 of these patients a &traiateral struvite stone subsequently developed. Flank pain was relieved in all but 1 of 12 patients in which this was a prominent presenting complaint. Blood urea nitrogen and/or serum creatinine determinations were performed on all patients. No significant differences were noted between the pre- and postoperative values.
A variety of techniques for partial nephrectomy have evolved including wedge resection and closure of the renal parenchyma with mattress sutures, guillotine resections with or without closure of the renal capsule, and the mass suture ligation technique. Guillotine (transverse polar) resection would appear to be the more desirable approach since it results in less ischemic tissue and allows for more exact closure of the collecting system thus reducing the chance of fistulas, infection, and hypertension. Perinephric fat or muscle was used to cover the resected surface in some cases, but generally the renal capsule was loosely approximated over the resected surface, and there did not appear to be any complications which could be related directly to this practice. The routine use of nephrostomy or pyelostomy tube drainage is not necessary since urinary fistulas are not a problem when the collecting system is carefully closed and no retained calculi are present. However, if simultaneous pelviureteric reconstruction is undertaken, a nephrostomy tube or ureteral stent is recommended. Temporary renal arterial occlusion occasionally is indicated while bleeding points are brought under control, but we have found that the ligation of segmental branches allows equally good hemostasis in most cases without the risk of renal ischemia. If renal artery occlusion is to be prolonged, renal flushing and cooling is advisable. Stewart5 has emphasized the importance of avoiding the artery to the posterior segment which lies close to the posterosuperior aspect of the pelvicalyceal junction and the renal vein which lies directly anterior to the medial border of the upper pole, when doing an upper pole resection. Fortunately, upper pole and mid renal resections are less often required.
As with any form of stone surgery, careful preoperative and intraoperative radiographic investigation is a necessity to optimize operative and long-term results. The addition of operative nephroscopy,” coagulum pyelolithotomy. I8 ant 1 stone localization using real-time B-scan ultrasound’” should permit more complete stone removal and reduce operative time and morbidit!.. In the event of retained stru\.ite stones, postoperative hemiacidrin irrigations should he performed. ‘O The central objectives in the surgical treatment of renal stone disease are to remove completely all current calculi, to prevent recurrent stones and their coliiplications, and to preseme adequate renal function for the patient’s expected lifespan. In addition, an equal amomit of attention needs to he directed toward the correction of metabolic abnormalities, maintenance and pursuit of preventative of sterile urine, measures such as adequate fluid intake. Despite ollr best efforts, however, the recurrence rates after surgical treatment of nephrolithiasis are distressingly high and increase with the length of follow-up. 1221 Several f&tors may predispose a kidney to recurrent stones after surgical removal: persistent infection, persistence of calculi, and/or parenchymal calcifications in the form of Randall plaques and diminished peristaltic activity in scarred and distorted calyces. Although stone formation is fundamentally the consequence of urinary crystallization, anatomic factors may decide where this will occur. The removal of a stone from a calyx where it has caused localized pvelonephritis and obstruction, without repair of the calyceal neck stenosis and excision of SC~I tissue, leaves the pathologic anatomy intact and will likely result in further stone formation. In carefully selected cases, it is logical to remo\*e diseased adjacent renal tissue and deformed calyces with the stone to minimize the possibility of recurrence. Stewart” recommended excision of adjacent renal parenchyma (especially the lower pole) when it contains radiographically demonstrable calcifications even in the absence of significant parench~mal scarring. He reported a recurrence rate of 6.3 per cent after lower pole nephrectomy. Further long-term follow-up at the same institution revealed a true recurrence rate of 34 per cent at twenty years for both the ipsilateral and contralateral kidney. l2 These rates were half those found in a similar study of nephrolithotand ureterolithotomy lj! omgr, pyelolithotoln),
\\:illiuins.“’ Anderson ” has shown, however, that radiopque microcalculi in postniortein kidneys of stone forrners treated 1)~ partial nephrectomy are uniformly distributed throughout the parenchpnla and removal of heavily calcified hut otherwise normal parenchynia will leave behind tissue containing microcalculi. \Vith an a\.erage follow-up of eighty-six months, onr ipsilateral and contralateral recurrence rates were equal at 12 per cent. Ipsilateral recurrent stones were found characteristically in the most dependent calyx of kidneys which had undergone previous operative procedures prior to lower pole nephrectomy. n’ald, Caine, and Solomon” had observed a higher incidence of recurrence in those patients with a history of stone in the same or contralateral kidney, with multiple or scattered stones and with a histor? of pre\ious operations. In addition, these authors and StewartS noted a correlation between recurrences and a retained calyceal neck after lower pole nephrectomy. We M:ere unable to demonstrate a similar relationship in this series. Partial nephrectomy has been reported to be particularly advantageous when multiple calculi ’’ Although are present, 30 per cent of our partial nephrectomies were performed for multiple stones. only one of seven ipsilateral recurrences occurred in this group. It has been argued that partial nephrectomy results in a lower incidence of recurrent ipsilatera1 stones than other procedures. The incidence of recurrent calculi in the ipsilateral kidney increases with time, as does development of calculi in the previously normal contralateral kidney.21 Pederson,” in a series followed for 3.9 years, reported an o\rer-all recurrence rate of 13.2 per cent. Howcl\rer, when the calculus u’ils confined to the resected pole, the rate was only 3.6 per cent. Rose and Fol10ws’~ reported that ipsilateral and contralateral recurrence rates were the same and increased with time up to 34 per cent at twentv years after partial nephrectomy. This was ah&‘~t one-half the recurrence rate after more consel72tive procedures in a similar population.“’ U’ald and associates’” in Israel had a true ipsilateral recurrence rate of 23 per cent after 3.8s years which paralleled that after pyelolithotom~. As a result of their stud!,, they have ad\rocated the llse of partial nephrectomy when a clearl!. diseased or deformed seglnent is associated with a stone. Partial nephrectomy often was not the initially intended procedure and \vas onl>, undertaken when a more conservati\,e approach was
41:3
not successful (Table III). Whether or not this has had an effect on our long-term recurrence rates is unclear. Nevertheless, partial nephrectomy was undertaken only when other conservative means had been considered, and this may have been a significant selection mechanism allowing our recurrence rates to be somewhat lower than others. This combined approach could result in a more complete removal of all calculus material. Comparisons of results of operations for stone disease must take into account the nature of the cases, the relative indications for the procedures, and the length and completeness of follow-up. Obviously, parallels drawn between operations as different as partial nephrectomy and pyelolithotomy and nephrolithotomy may be misleading. Despite this, it is reasonable to conclude from this and other studies that partial nephrectomy for segmental stone disease is indicated for stones associated with scarred, hydronephrotic, or poorly draining calyceal systems and that it can be accomplished with acceptable levels of morbidity and mortality. Partial nephrectomy is not indicated for all calyceal or staghorn stones, most of which can be removed by more conservative nephron-sparing procedures. Recurrence rates are as good if not better than pyelolithotomy and nephrolithotomy in the appropriate clinical setting. Boston, Massachusetts 02114 (DR. BATES) References 1. Goldstein AE, and Abeshouse kidney, J. Ural. 38: 15 (1937).
414
BS: Partial
resections
of the
2. Abeshouse BS, and Lerman S: Partial nephrectomy versus pyelolithotomy in the treatment of localized calculus disease of the kidney, with a report of 17 partial nephrectomies, lnt. Abstr. surg. 91: 209 (1960). 3. Graves RT: Anatomy of intrarenal arteries and its application to segmental resection of the kidney, Br. J. Surg. 42: 132 (1954). 4. Semb C: Renal tuberculosis and its treatment by partial resection of the kidney, Acta Chir. Stand. 98: 457 (1949). 5. Stewart HH: The surgery of the kidney in the treatment of renal stones, Br. J. Ural. 32: 392 (1960). 6. Puigvert A: Partial nephrectomy for renal lithiasis, lnt. Surg. 46: 555 (1966). 7. Papathanassiadis S, and Swenney J: Results of partial nephrectomy compared with pyelolitbotomy and nephrolithotomy, Br. J. Urol. 38: 403 (1966). 8. Myrvold H, and Fritjofsson A: Late results of partial nephrectomy for renal lithiasis, Stand. J. Urol. Nephrol. 5: 57 (1971). 9. Pederson JF: Partial nephrectomy for nephrolithiasis. ibid. 5: 171 (1971). 10. Gellman AC, and Malamet M: Partial nephrectomy in renal calculus disease, Urology 1: 355 (1973). 11. Marshall VR, Singh M, Tresidder GC, and Blandy JP: The place of partial nephrectomy in the management of renal and calyceal calculi, Br. J. Ural. 47: 759 (1976). 12. Rose MB, and Follows OJ: Partial nephrectomy for stone disease, ibid. 49: 605 (1977). 13. Wein AJ, Carpiniello VL, Mulholland SG, and Murphy JJ: Partial nephrectomy, Urology 10: 193 (1977). 14. Wald U, Caine M, and Solomon H: Partial nephrectomy in surgical treatment of calculus disease, ibid. 11: 338 (1978). 15. Coleman CH, and Witherington R: A review of 117 partial nephrectomies, J. Ural. 122: 11 (1979). 16. Leach GE, and Lieber MM: Partial nephrectomy: Mayo Clinic experience 1957- 1977, Urology 15: 219 (i9SO). 17. Gittes RF: Onerative nenhroscow. I. Ural. 116: 148 (1976). 18. Rathorne A,-and Harrison JH.: ‘Coagulum pyelolithotomy using autogenous plasma and bovine thrombin, ibid. 116: 8 (1976). 19. Cook JH III, and Lytton B: Intra-operative localization of renal calculi during nephrolithotomy by ultrasound scanning, ibid. 117: 543 (1977). 20. Jacobs S, and Gittes RF: Dissolution of residual renal calculi with hemiacidrin, ibid. 115: 2 (1976). 21. Williams RE: The results of conservative surgery for stone, Br. J, Ural. 44: 292 (1972). 22. Anderson CK: Partial nephrectomy, Proc. R. Sot. Med. 67: 459 (1974).
UROLOGY
/
MAY 1981
/
VOLUME
XVII, NUMBER
5
CALCULUS
OF PARTIAL NEPHRECTOMY
J. BATES,
M.D.
A. HEANEY,
M.D.
WALTER
DISEASE:
S. KERR,
JR., M.D.
From the Urological Service, Massachusetts General Hospital and the Harvard Medical School, Boston, Massachusetts
ABSTRACT - Partial nephrectomy was performed on 71 renal units between 1962 and 1978 for segmental calculus disease. Parenchymal scarring associated with an infundibulocalyceal stone, which was usually branched, was the indication fw resection. Stone analysis demonstrated an equal incidence of idiopathic and struvite stones. Perioperative morbidity uxs minimal, but pyelocutaneous urinary drainage prolonged the hospitalization of 5 patients. In 2 cases, the cause was an obstructing retained calculus. Retained calculi occurred in 3 other patients, one requiring early nephrectomy for sepsis. Fifty-seven patients were followed fm longer than twelve months. Ips&teral calculi recurred in 12 per cent of kidneys, and contralateral new calculi developed in the same number. Ninety-four per cent of patients with preoperative urinary tract infections had sterile urine at follow-up. From the results of this and other series, partial nephrectomy compares f~~vorably with extended pyelolithotomy and anatrophic nephrotomy for segmental calculus disease associated with parenchymal scarring andlor a defonlzed collecting systenz.
The early use of partial nephrectomy was marred by the frequent occurrence of primary and secondary hemorrhage, urinary fistulas, delayed nephrectomy, and death. By the late 1930s with improvements in preoperative diagnosis, knowledge of renal anatomy and physiology, anesthesia, surgical techniques, and postoperative care, partial nephrectomy had become a reasonable surgical alternative. In 1937, Goldstein and Abeshouse’ reviewed 296 cases of partial nephrectomy, 58 of which were performed for stone disease. They concluded that with proper case selection and attention to anatomy, partial resection of the kidney was a satisfactory treatment for solitary serous or hemorrhagic cysts, hydatid cysts, localized hydronephrosis or pyonephrosis (with or without renal calculi), benign tumors, localized cortical abscesses, renal infarcts, and renal fistulas.
Read at -\nnual Meeting tion, Inc., San Francisco,
C’ROLOGY
i
MAY 1331
of American Urological AssociaCalifornia, May 19. 1980.
/
VOLUME
XVII,
NL’klBER
5
By 1950, 200 cases of partial nephrectomy for stone disease could be found in the literature.’ The work of Graves3 on the intrarenal arterial anatomy and its surgical significance and the reports of Semb” in treating renal tuberculosis were followed by an increased use of partial nephrectomy in segmental calculus disease. Several large series have been reported focusing on the indications for partial nephrectomy in stone disease and the recurrence rates as compared with other surgical techniques. 5-‘6 The indication usually has been the presence of a stone or multiple stones in a single calyx or group of calyces with accompanying parenchymal scarring and deformities of the pyelocalyceal anatomy. In addition, Stewart5 has suggested that a partial resection is applicable in the absence of calyceal deformity when roentgenograms of the explored kidney reveal parenchymal calcifications adjacent to the calyceal group. This report details our experiences with partial nephrectomy performed on 71 renal units
409
between 1962 and 1978. The procedure was used to treat segmental calculus disease and its resultant pathologic deformities. Material
and Methods
Seventy-one partial nephrectomies for segmental calculus disease were performed from 1962 through 1978. The clinical records were reviewed and attempts made to contact those patients not recently seen in follow-up visits. The length of the follow-up was determined by the most recent intravenous urogram or plain abdominal film. All patients had an intravenous urogram within six weeks of operation and the majority before discharge. All films were reviewed to assess details of the number and distribution of calculi, the functional and anatomic condition of the kidney before and after operation, and the presence of residual and recurrent calculi. Residual calculi were defined as any seen on the first postoperative x-ray film. A recurrent stone was documented by its passage and collection, surgical removal, or appearance on follow-up films. Patients with dysgenetic or horseshoe kidneys and complete duplex collecting systems were eliminated from review. Table I catalogues the pertinent medical and surgical history of the group. There were 29 males and 42 females ranging in age from eighteen to seventy-five years’ old, with a mean of forty-seven years (Fig. 1). The female mean age was fifty-two years, and the male forty-eight years. Parenchymal scarring and pyelocalyceal deformity associated with single or multiple infundibulocalyceal calculi indicated partial resection. Thirty-two patients had infected urine preoperatively. Hypercalcinuria (males > 300 mg./day, females > 250 mg./day) was present in 5 of 40 patients, and 1 patient had undergone resection of a parathyroid adenoma. Stone analysis revealed 30 struvite, 27 calcium, and 1 uric acid stone. Analysis was not performed on the remainder. The relationship between stone morphology, analysis, and location is summarized in Table II. Twenty-eight patients had no known history of renal ipsilateral stones, 23 had had ipsilateral colic and/or stone passage, and 20 had undergone ipsilateral nephrolithotomy, pyelolithotomy, and/or ureterolithotomy. Fifty-seven patients were followed for longer than twelve months (eighteen to 190 months) with a mean of eighty-six months.
‘410
TABLE I. Preoious medical and surgical history of patients undergoing partial nephrectomy
Number
History
2 1 1 3
Previous partial nephrectomy Cystectomy and ureterosigmoidostomy Ureteroneocystomy - ipsilateral Pyeloplasty - ipsilateral Nephrolithotomy Ipsilateral Contralateral Pyelolithotomy Ipsilateral Contralateral Ureterolithotomy Ipsilateral Contralateral Hyperparathyroidism Hyperthyroidism Medullary sponge kidney Multiple sclerosis with neurogenic bladder Single kidney
17 4 5 3 3 2 1 1 3 1 1
161412'; loul ii ,' 86-
1
42-
0
IO
1
FIGURE 1. Age distribution partial nephrectomy.
Operative
of patients
80
undergoing
Technique
Operative procedures were performed by the senior and resident staffs in a generally similar fashion. The majority of the dissections were retroperitoneal, and all approaches were through a flank incision. The exact surgical incision varied with the clinical situation and surgeon’s preference. The kidney was mobilized carefully to avoid injury to accessory or polar
UROLOGY
/ MAY 1981 / VOLUMEXVII,NUMBER5
II. Site of parenchyma resected by partial nephrectomy morphology and analysis of contained calculi
TABLE
Morphology Branched
No.
Analysis
25
Calcium oxalate/ phosphate (8) Struvite (14) Uric acid (1)
Males (12) Females (13)
Area of Partial Nephrectomy
No analysis (2)
S taghorn Males (4) Females (5)
Single
Struvite
16
Males (5) Females (11)
21
Multiple Males (7) Females (14)
UROLOGY
i MAY
1981
/
VOLUMEXVII.NUMBER5
(9)
Calcium oxalate/ phosphate (8) Struvite (2) No analysis (6)
Calcium oxalate/ phosphate (11) Struvite (5) No analysis (5)
vessels and the vascular pedicle isolated between umbilical tapes for control and identification. Segmental arteries were occluded or injected with methylene blue to demarcate the vascular supply of the region to be resected. Early in the series, the main artery was occluded temporarily for a variable length of time to obtain hemostasis, but this practice has been abandoned in more recent times. The capsule was sharply incised and stripped back off the parenchyma except when extensive inflammatory reaction from infection or previous surgery made this impossible. Extent of excisions were either wedge caliectomy (17), transverse polar (42), or heminephrectomy (12). Arterial vessels were transfixed with figure-ofeight chromic catgut sutures. The collecting system was closed in a watertight fashion with fine chromic catgut sutures, often after exploration of the residual collecting system for retained stones and calibration of the ureteropelvic junction. The closure was checked by inflation of the pyelocalyceal system by direct injection of fluid. The capsule was closed over the resected surface with or without intervening perinephric fat,
with
Left Upper Lower Lower mid Right Upper Lower Left Upper Lower Right Upper Lower Left Upper Lower Right Upper Lower Left Upper Lower Right Upper Lower
pole (7) pole (8) and pole (1) pole (3) pole (6) pole (1) pole (3) pole (2) pole (3) pole (4) pole (2) pole (3) pole (7) pole (1) pole (11) pole (3) pole (6)
and the kidney was usually sutured to the paraspinal musculature. Large Penrose drains were placed in the area of resection and brought out through a separate stab wound in the retroperitoneum. Partial nephrectomy was combined with one or more other procedures in 60 per cent of the cases (Table III). Nephrostomy tubes were placed in 5 cases associated with simultaneous pyeloplasty, nephrotomy, or pyelotomy. Pyelostomy tubes were placed in 4 cases after attempted extended pyelolithotomy. In 5 cases,
TABLE
III. Procedures performed concurrently with partial nephrectomy Procedure
Pyelotomy/pyelolithotomy Nephrotomy/nephrolithotomy Both pyelotomy and nephrotomy Ureterolithotomy Pyeloplasty Vesicolithotomy Closure of pyelocutaneous fistula
NO.
25 7 3 4 3 1 1
111
the partial resection ence of pyonephrosis; followed in one case.
was performed a deep
in the preswound infection
Results The complications which occurred are listed in Table IV. No deaths or secondary hemorrhages occurred. Six patients required more than four units of blood to replace intraoperative loss. Nineteen patients required no transfusions. The postoperative hospital stay averaged eleven days in 59 uncomplicated cases.
TABLE
I\'.
,tfujorcompkxtions
Comment
of pm-tid
nephrectorny Complication
Iu 0.
Pyelocutaneous fist&s Retained stones CTreteral injur) Wound infection Incidental splenectomy
5 5 1
2 1
Pyelocutaneous urinary drainage for longer than seven days prolonged the hospital stay of 5 patients. Two were associated with retained calculi, one requiring reoperation to remove an One closed following placeobstructing stone. ment of a ureteral catheter, while the remaining two closed spontaneously. Two delayed nephrectomies were performed: one for pyonephrosis due to a retained obstructing calculus and the other after irreparable damage to the remaining ureter in a partially duplicated collecting system. Two of the five retained stones required ‘operative intervention (pyelolithotomy and delayed nephrectomy), one passed without incident, and the remaining two were small flecks and have been asymptomatic in follow-up. Seven ipsilateral recurrences and seven contralateral new stones were seen in 12 of 57 patients followed for longer than twelve months. Ipsilateral recurrences were seen seventeen to 121 months (mean sixty-eight) after operation, and six of seven occurred in kidneys which had undergone at least one previous stone procedure before partial nephrectomy. All ipsilateral recurrences were in kidneys in which the partial resection had included the lower pole. One stone passed spontaneously, one was located in the pelvis, and five were found in the most dependent calyx. One patient died of other causes, 2 required nephrolithotomy, and 3
-112
remain asymptomatic. Contralateral new stones appeared at an average of forty months in follow-up. Urinary tract infections persisted in 2 of 32 patients with positive preoperative cultures. In 1 of these patients a &traiateral struvite stone subsequently developed. Flank pain was relieved in all but 1 of 12 patients in which this was a prominent presenting complaint. Blood urea nitrogen and/or serum creatinine determinations were performed on all patients. No significant differences were noted between the pre- and postoperative values.
A variety of techniques for partial nephrectomy have evolved including wedge resection and closure of the renal parenchyma with mattress sutures, guillotine resections with or without closure of the renal capsule, and the mass suture ligation technique. Guillotine (transverse polar) resection would appear to be the more desirable approach since it results in less ischemic tissue and allows for more exact closure of the collecting system thus reducing the chance of fistulas, infection, and hypertension. Perinephric fat or muscle was used to cover the resected surface in some cases, but generally the renal capsule was loosely approximated over the resected surface, and there did not appear to be any complications which could be related directly to this practice. The routine use of nephrostomy or pyelostomy tube drainage is not necessary since urinary fistulas are not a problem when the collecting system is carefully closed and no retained calculi are present. However, if simultaneous pelviureteric reconstruction is undertaken, a nephrostomy tube or ureteral stent is recommended. Temporary renal arterial occlusion occasionally is indicated while bleeding points are brought under control, but we have found that the ligation of segmental branches allows equally good hemostasis in most cases without the risk of renal ischemia. If renal artery occlusion is to be prolonged, renal flushing and cooling is advisable. Stewart5 has emphasized the importance of avoiding the artery to the posterior segment which lies close to the posterosuperior aspect of the pelvicalyceal junction and the renal vein which lies directly anterior to the medial border of the upper pole, when doing an upper pole resection. Fortunately, upper pole and mid renal resections are less often required.
As with any form of stone surgery, careful preoperative and intraoperative radiographic investigation is a necessity to optimize operative and long-term results. The addition of operative nephroscopy,” coagulum pyelolithotomy. I8 ant 1 stone localization using real-time B-scan ultrasound’” should permit more complete stone removal and reduce operative time and morbidit!.. In the event of retained stru\.ite stones, postoperative hemiacidrin irrigations should he performed. ‘O The central objectives in the surgical treatment of renal stone disease are to remove completely all current calculi, to prevent recurrent stones and their coliiplications, and to preseme adequate renal function for the patient’s expected lifespan. In addition, an equal amomit of attention needs to he directed toward the correction of metabolic abnormalities, maintenance and pursuit of preventative of sterile urine, measures such as adequate fluid intake. Despite ollr best efforts, however, the recurrence rates after surgical treatment of nephrolithiasis are distressingly high and increase with the length of follow-up. 1221 Several f&tors may predispose a kidney to recurrent stones after surgical removal: persistent infection, persistence of calculi, and/or parenchymal calcifications in the form of Randall plaques and diminished peristaltic activity in scarred and distorted calyces. Although stone formation is fundamentally the consequence of urinary crystallization, anatomic factors may decide where this will occur. The removal of a stone from a calyx where it has caused localized pvelonephritis and obstruction, without repair of the calyceal neck stenosis and excision of SC~I tissue, leaves the pathologic anatomy intact and will likely result in further stone formation. In carefully selected cases, it is logical to remo\*e diseased adjacent renal tissue and deformed calyces with the stone to minimize the possibility of recurrence. Stewart” recommended excision of adjacent renal parenchyma (especially the lower pole) when it contains radiographically demonstrable calcifications even in the absence of significant parench~mal scarring. He reported a recurrence rate of 6.3 per cent after lower pole nephrectomy. Further long-term follow-up at the same institution revealed a true recurrence rate of 34 per cent at twenty years for both the ipsilateral and contralateral kidney. l2 These rates were half those found in a similar study of nephrolithotand ureterolithotomy lj! omgr, pyelolithotoln),
\\:illiuins.“’ Anderson ” has shown, however, that radiopque microcalculi in postniortein kidneys of stone forrners treated 1)~ partial nephrectomy are uniformly distributed throughout the parenchpnla and removal of heavily calcified hut otherwise normal parenchynia will leave behind tissue containing microcalculi. \Vith an a\.erage follow-up of eighty-six months, onr ipsilateral and contralateral recurrence rates were equal at 12 per cent. Ipsilateral recurrent stones were found characteristically in the most dependent calyx of kidneys which had undergone previous operative procedures prior to lower pole nephrectomy. n’ald, Caine, and Solomon” had observed a higher incidence of recurrence in those patients with a history of stone in the same or contralateral kidney, with multiple or scattered stones and with a histor? of pre\ious operations. In addition, these authors and StewartS noted a correlation between recurrences and a retained calyceal neck after lower pole nephrectomy. We M:ere unable to demonstrate a similar relationship in this series. Partial nephrectomy has been reported to be particularly advantageous when multiple calculi ’’ Although are present, 30 per cent of our partial nephrectomies were performed for multiple stones. only one of seven ipsilateral recurrences occurred in this group. It has been argued that partial nephrectomy results in a lower incidence of recurrent ipsilatera1 stones than other procedures. The incidence of recurrent calculi in the ipsilateral kidney increases with time, as does development of calculi in the previously normal contralateral kidney.21 Pederson,” in a series followed for 3.9 years, reported an o\rer-all recurrence rate of 13.2 per cent. Howcl\rer, when the calculus u’ils confined to the resected pole, the rate was only 3.6 per cent. Rose and Fol10ws’~ reported that ipsilateral and contralateral recurrence rates were the same and increased with time up to 34 per cent at twentv years after partial nephrectomy. This was ah&‘~t one-half the recurrence rate after more consel72tive procedures in a similar population.“’ U’ald and associates’” in Israel had a true ipsilateral recurrence rate of 23 per cent after 3.8s years which paralleled that after pyelolithotom~. As a result of their stud!,, they have ad\rocated the llse of partial nephrectomy when a clearl!. diseased or deformed seglnent is associated with a stone. Partial nephrectomy often was not the initially intended procedure and \vas onl>, undertaken when a more conservati\,e approach was
41:3
not successful (Table III). Whether or not this has had an effect on our long-term recurrence rates is unclear. Nevertheless, partial nephrectomy was undertaken only when other conservative means had been considered, and this may have been a significant selection mechanism allowing our recurrence rates to be somewhat lower than others. This combined approach could result in a more complete removal of all calculus material. Comparisons of results of operations for stone disease must take into account the nature of the cases, the relative indications for the procedures, and the length and completeness of follow-up. Obviously, parallels drawn between operations as different as partial nephrectomy and pyelolithotomy and nephrolithotomy may be misleading. Despite this, it is reasonable to conclude from this and other studies that partial nephrectomy for segmental stone disease is indicated for stones associated with scarred, hydronephrotic, or poorly draining calyceal systems and that it can be accomplished with acceptable levels of morbidity and mortality. Partial nephrectomy is not indicated for all calyceal or staghorn stones, most of which can be removed by more conservative nephron-sparing procedures. Recurrence rates are as good if not better than pyelolithotomy and nephrolithotomy in the appropriate clinical setting. Boston, Massachusetts 02114 (DR. BATES) References 1. Goldstein AE, and Abeshouse kidney, J. Ural. 38: 15 (1937).
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BS: Partial
resections
of the
2. Abeshouse BS, and Lerman S: Partial nephrectomy versus pyelolithotomy in the treatment of localized calculus disease of the kidney, with a report of 17 partial nephrectomies, lnt. Abstr. surg. 91: 209 (1960). 3. Graves RT: Anatomy of intrarenal arteries and its application to segmental resection of the kidney, Br. J. Surg. 42: 132 (1954). 4. Semb C: Renal tuberculosis and its treatment by partial resection of the kidney, Acta Chir. Stand. 98: 457 (1949). 5. Stewart HH: The surgery of the kidney in the treatment of renal stones, Br. J. Ural. 32: 392 (1960). 6. Puigvert A: Partial nephrectomy for renal lithiasis, lnt. Surg. 46: 555 (1966). 7. Papathanassiadis S, and Swenney J: Results of partial nephrectomy compared with pyelolitbotomy and nephrolithotomy, Br. J. Urol. 38: 403 (1966). 8. Myrvold H, and Fritjofsson A: Late results of partial nephrectomy for renal lithiasis, Stand. J. Urol. Nephrol. 5: 57 (1971). 9. Pederson JF: Partial nephrectomy for nephrolithiasis. ibid. 5: 171 (1971). 10. Gellman AC, and Malamet M: Partial nephrectomy in renal calculus disease, Urology 1: 355 (1973). 11. Marshall VR, Singh M, Tresidder GC, and Blandy JP: The place of partial nephrectomy in the management of renal and calyceal calculi, Br. J. Ural. 47: 759 (1976). 12. Rose MB, and Follows OJ: Partial nephrectomy for stone disease, ibid. 49: 605 (1977). 13. Wein AJ, Carpiniello VL, Mulholland SG, and Murphy JJ: Partial nephrectomy, Urology 10: 193 (1977). 14. Wald U, Caine M, and Solomon H: Partial nephrectomy in surgical treatment of calculus disease, ibid. 11: 338 (1978). 15. Coleman CH, and Witherington R: A review of 117 partial nephrectomies, J. Ural. 122: 11 (1979). 16. Leach GE, and Lieber MM: Partial nephrectomy: Mayo Clinic experience 1957- 1977, Urology 15: 219 (i9SO). 17. Gittes RF: Onerative nenhroscow. I. Ural. 116: 148 (1976). 18. Rathorne A,-and Harrison JH.: ‘Coagulum pyelolithotomy using autogenous plasma and bovine thrombin, ibid. 116: 8 (1976). 19. Cook JH III, and Lytton B: Intra-operative localization of renal calculi during nephrolithotomy by ultrasound scanning, ibid. 117: 543 (1977). 20. Jacobs S, and Gittes RF: Dissolution of residual renal calculi with hemiacidrin, ibid. 115: 2 (1976). 21. Williams RE: The results of conservative surgery for stone, Br. J, Ural. 44: 292 (1972). 22. Anderson CK: Partial nephrectomy, Proc. R. Sot. Med. 67: 459 (1974).
UROLOGY
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MAY 1981
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VOLUME
XVII, NUMBER
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