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Staghorn Calculi
THE JOURNAL OF UROLOGY
Vol. 69, No. 3, March 1953 Printed in U.S.A.
STAGHORN CALCULI ELMER HESS, RUSSELL B. ROTH
AND
ANTHONY F. KAMINSKY
From the Department of Urology, St. Vincent's Hospital, Erie, Pa.
The management of the patient with staghorn renal calculi is usually an intriguing clinical experience. One frequently begins by marvelling at how these stones may achieve such impressive size and bring about such extensive destruction of the renal substance without giving rise to more in the way of subjective symptoms. It is not uncommon to find that the patient has actually had no discomforts at all, and that the diagnosis is made only in tracking down the cause of pyuria discovered in a routine physical examination, an insurance examination, or perhaps because the stone shadows were seen in x-ray studies made for some unrelated purpose. In a small percentage of cases, a careful history will elicit a story of what may have been previous episodes of renal colic due to the passage of lesser calculi. Had these episodes been adequately investigated, the fundamental problem might have been uncovered at an earlier date. The problems presented by staghorn calculi (renal) are diversified. The urologist is obliged to consider possible etiological factors, to assess the advisability of surgical removal, to evaluate medical measures for control, and to cope with the ever-present threat of recurrence. The patient who has once had staghorn calculi is an individual who requires urological supervision for life, and the length of that life may be peculiarly dependent upon the judgment of the physician. ETIOLOGY
Much that concerns the development of urinary calculi is still controversial or obscure, and it is not our purpose here to review the conflicting evidence Certain factors are of importance beyond a reasonable doubt First, there is the matter of heredity. We regard the tendency to form primary urinary tract calculi as a family characteristic in certain instances. Inasmuch as this factor is not one of much value in the management of any given case, we will not dwell on it except to remark that recently, after removing a staghorn calculus from the right kidney of a young man and learning that we had previously removed calculi from his father and that a brother was currently in an Army hospital for the removal of stones from both kidneys, we suggested that his remaining brother stop by for a check-up. He also showed asymptomatic renal calculi. Metabolic abnormalities are also of significance. Cystinuria is of importance, although our incidence of cystine stones has been extremely low. It follows, however, that the discovery of cystinuria materially affects the prognosis for the formation of future stones, and the medical measures taken to minimize the possibility of such recurrence. Much the same may be said of urate and uric acid stones occurring in persons who show a high blood uric acid. More intriguing is the problem of hyperparathyroidism and the formation of calcium stones. Read at annual meeting, South Central Section, American Urological Association, Houston, Texas, October 30, 1951. 347
348
ELMER HESS, RUSSELL B. ROTH AND ANTHONY F. KAMINSKY
Here it is an incontestable fact that the existence of a parathyroid adenoma may lead to hypercalcemia, hypercalcinuria, and the development of nephrocalcinosis or renal calculi. Whereas it has been our routine practice over the years to carry out blood calcium and phosphorus studies on all stone-forming patients, we must admit that we have felt only once that parathyroid exploration was desirable and in that instance no adenoma was found. Our lack of cases of hyperparathyroidism is not assignable to a negligence in looking for the condition. Since we are specifically discussing the so-called staghorn type of calculus, it seems necessary to admit that we have encountered a recognizable metabolic abnormality in only a handful of cases, and that when such abnormality has been recognized there has proved to be little modifiability of the situation. Of more practical importance is the matter of stasis of urine. When an obstructive factor can be identified, it must be dealt with accordingly, since simple removal of the stone will be followed by recurrence in virtually every instance if the obstruction persists. It should be emphasized that one must not conclude that there is no stasis simply because the ureteropelvic junction is not obstructive in character. The lower end of the ureter is a frequent offender in unilateral cases, and the vesical neck and the external urethral meatus must be regarded with suspicion in bilateral cases. The effect of prolonged recumbency and immobilization is also to be considered under the heading of stasis, and its role is usually obvious. Lastly, we must consider infection. At the present time, there are effective means of combating virtually every organism encountered in cases of calculous disease. The urea-splitting organisms are obviously of principal importance since, by their strong alkalinization of the urine, they favor the formation and rapid growth of stones. Among them have been some of the more troublesome organisms in terms of resistance to chemotherapeutic or antibiotic treatment. Now, under proper circumstances, it is possible to eradicate the urea-splitting staphylococci with a variety of medications. Bacillus proteus yields quite decently to gantrisin, and Bacillus pyocyaneus responds to polymixin and terramycin. These newer weapons in combating infection are of inestimable value in the management of staghorn calculi. THE DECISION TO OPERATE
Once we have assessed to the best of our ability the reasons why staghorn calculi have developed in our patient, we are ready to consider what is to be done about the situation. The first question to answer is concerning the advisability of surgery. We may start in by saying that we have encountered patients with bilateral staghorn calculi who have minimal symptoms and after due consideration of all the factors involved it has been our feeling that they should be managed medically rather than surgically. From the point of view of surgical technique, it is quite possible to split the kidney adequately for complete removal of a solid staghorn stone. Appropriate measures may then be taken to minimize the chance of recurrence, and after successfully carrying this out on one side, it may be repeated on the other side. Several factors, how-
STAGHORN CALCULI
349
ever, should give one pause before setting out on such a course. If the kidneys have been previously operated upon and the staghorn calculi are recurrent the technique of operation is far more difficult and not to be undertaken lightly. If the stone is not solid but consists of multiple separate calyceal stones, or if it is of the friable or mushy calcareous variety, it may defy all reasonable attempts at complete removel. If the patient is a poor surgical risk for unrelated reasons, it must be remembered that two major surgical assaults are required. One may do well to advise the patient that the disadvantages of surgical removal outweigh the advantages and that medical management should be attempted first. If symptoms become too disturbing, it may later become mandatory to embark upon surgical removal. The surgical approach to the problem is the one of choice when symptoms are marked, when there is evidence of rapid progression of the disease, or when there is accompanying infection. If one kidney alone is involved, one must decide between removal of the calculus and removal of the kidney. This is not always a simple decision. N ephrectomy is usually safe, rapid, and attended by complete recovery. It may therefore be the procedure of choice when the patient is elderly, when the chances of complete surgical removal of the stone are not optimal, or when there is a valid financial objection to a long-drawn-out hospitalization and intensive aftercare. It may also be the most feasible approach when the stone is recurrent after prior attempt has been made at removal. The factor which militates against simple nephrectomy is the fact that a stone may possibly develop in the hitherto normal contralateral kidney. We have seen this happen. In the elderly patient, one does not attach so much importance to this, and the other factors enumerated may be reasonably easy to evaluate except for the financial factor. We feel that this is a very real consideration. For a simple nephrectomy our average patient is discharged from the hospital on the tenth postoperative day and may return to almost any type of employment short of heavy physical labor, in about one month. There is no necessity for numerous follow-up urological studies, treatments, or x-rays. For these reasons, hospital expenses, professional charges, and lost wages are all kept to a minimum. This must be contrasted to a relatively prolonged hospital stay when the kidney is opened, cleaned out, and intubated. The return to work is usually delayed, and the necessity for frequent recheck visits to the urologist, for cystoscopic treatments, and for follow-up x-rays is obvious. It is not sound medical judgment to be swayed unduly by financial considerations, but when a decision is to be made between radical removal and conservative repair, it is only fair to the patient to make clear the economic aspects of the choice. It is to be stressed, however, that when a patient has developed one staghorn calculus and has lost a kidney thereby, it is increasingly important for him to remain under close medical supervision with respect to the remaining kidney. Regular urinalyses and periodic plain films of the renal area become mandatory if early involvement of the solitary kidney is to be detected in time to be helpful. When one has made decision to perform conservative surgery-that is, to
350
ELMER HESS, RUSSELL B. ROTH AND ANTHONY F. KAMINSKY
remove the calculus and conserve the renal parenchyma, one must decide on the order of events; in bilateral cases, the degree of parenchymal destruction, the presence or absence of infection, and the amount of discomfort ascribable to each side. No rule of thumb, applicable to all cases, can be formulated. A few examples may illustrate the elements of the problem. M. S. had a large calculous pyonephrosis on the right side, with some small amount of renal function as measured by dye excretion. On the left, there was a large lower calyceal branching calculus which caused virtually no pain. We elected to remove the stone-bearing lower pole of the left kidney first. When this was satisfactorily accomplished and we were left with a well-functioning stone-free left kidney, we then felt free to do a nephrectomy on the right side, since the salvage value of that kidney seemed negligible. This philosophy, however, carries its perils. Another case in which the same plan was adopted turned out less favorably. The right kidney contained a large staghorn stone but appeared to have better function and more parenchyma than the left which also contained a large stone. With the idea of reconditioning the better kidney first, operation was carried out and the postoperative course was complicated by severe infection and hemorrhage so that a nephrectomy became mandatory. The patient thus lost the better of two diseased kidneys and is now living, fortunately quite comfortably, on one impaired kidney which still contains its calculus. Since we must be realistic and admit that in such surgical procedures there is an ever-present risk of complications which may force nephrectomy, we must give weight to this possibility in our planning. In general, when it appears ideal that each kidney should be cleaned out, it impresses us as better judgment to do the less damaged kidney first. If this is carried out successfully, as it generally is, then whatever happens on the other side will not be disastrous. If the reverse plan is carried out and the poorer kidney is treated first, one may still be in considerable peril when operating on the second side. In any event, there is a calculated risk. The presence of severe pain from one side or the other, of course, will usually dictate that this side be handled first. SURGICAL TECHNIQUE
Adequate exposure is the sine qua non of successful conservative renal surgery. There is little need to fear generous incisions into the renal parenchyma to allow total removal of calculi and we have stressed elsewhere our conviction that massive through and through sutures for closure sacrifice too much of renal tissue that we are attempting to save to be justifiable. If one achieves complete removal of the calculus from the kidney, it would seem to be wise to utilize nephrostomy tube drainage with a splinting ureteral catheter in order to permit irrigation of the pelvis postoperatively with appropriate solvent solutions and such antibiotics as may be indicated by cultural studies. POSTOPERATIVE CARE
Preoperative urine cultures will have identified the type of organism which is present in infected cases. It is our practice to institute appropriate antibiotic or chemotherapeutic treatment just prior to operation. Since there is almost
STAGHORN CALCULI
35]
certain to be a period of a day or t,Yo during which the medication cannot be taken orally, we prefer to use parenteral administration. Penicillin, chloromycetin, or terramycin are particularly adaptable. In addition to parenteral administration, we have also found it helpful to use direct instillations of such solutions as terramycin or polymixin through the nephrostomy tube in the more severely infected cases. We have also used constant or intermittent irriga·tions of solutions calculated to dissolve any calcareous debris which may have been left !whind at operation. Since we are ordinarily dealing with calcium phosphate stones, the solution which we normally use is solution G made up in l: 20,000 zephiran. If solution G proves to be too irritating to the pelvic mucosa, we change to solu bon JVL It will be readily understood that our use of the 1rnphrostomy tube is more as an avenue of approach to the kidney than as a means of drainage. The length of time over which a nephrostomy tube and splinting catheter is left in place is, obviously, sllbject to the requirements of the individual ease. H ureteropelvic plastic: revisions have been carried out, the splinting catheter may be left for 3 or 4 weeks. If no such procedure has been necessary, the tube is removed as quickly as Lhe urinary drainage bespeaks recovery of the kidney. At the same time, we place the patient on a relatively low phosphorous diet and institute the aluminum hydroxide regimen described by Shorr. This sometimes complicates postoperative bowel regulation, since the aluminum hydroxide is constipating, but this can ordinarily be handled satisfactorily ·with mild laxatives. In short, every measure which promrnes to assist m mmrrmzmg recurrence is promptly instituted. MEDICAL MANAGEME;NT
The essential elements of medical management of staghorn calculi have been touched upon while discussing postoperative care. ·when used in place of surgical excision of the calculi, they become perhaps even more important. The spontaneous disappearance of a staghorn calculus formed during a long period of recumbency has been reported, but it must be admitted that, in general, we are not sanguine mwugh to hope for complete disappearance of the ralculi. Our aim is, if possible, to check further growth of the stones and, if luck is with us, to achieve some decrease in size. It is especially helpfnl in medical management if the composition of the stone may be ascertained. When no stone fragment is available for actual analysis. it is necessary to infer the composition from reports on the character of tho crystalline sediment of the urine. The overwhelming majority of cases, how-ever, will prove to be calcium phosphate stones, perhaps with admixtures of a few other ions such as ammonium, magnesium, or carbonate. In such cases, the absence of infection and the ability to acidify the urine may permit the u.tifomtion of an acidification regimen coupling the acid-ash diet ·with ammonium chloride, sodium acid phosphate, or some similar agent. When urea-splitting organisms are present, making it virtually impossible to acidify the urine of the renal pelvis, it is unwise to pursue such a. course of treatment since under these
352
ELMER HESS, RUSSELL B. ROTH AND ANTHONY F. KAMINSKY
circumstances, no calcium salts are dissolved and the effect is merely to make more calcium ion available for precipitation. In the patient with poor renal function and a tendency toward azotemia and acidosis, the latter condition may be aggravated by such treatment. It is more productive, in our experience, to use the aluminum hydroxide routine. Basaljel, which has been especially designed for this purpose, is excellent when well tolerated, but almost 50 per cent of our patients have been unable to overcome nausea and vomiting. Most of these patients, however, prove capable of taking amphojel in adequate amounts. It is our practice to use 40 cc per dose 1 hour after meals and at bedtime. This effectively decreases the amount of phosphate ion available for precipitation in the urinary tract. In a few cases, we have also used estrogens, as advocated by Shorr, to increase citric acid output in the urine, but we do not feel qualified to pass on its value. vVe are firmly convinced, however, that the aluminum hydroxide routine is of real virtue. In our case which has been followed the longest, we have had dramatic proof of its efficacy. This patient had bilateral staghorn calculi and each kidney had been surgically cleaned out, but had become refilled with stone before we saw her first. Because of pain in the right renal region, we did a second right nephrolithotomy in December 1946. Despite all our precautions, we were horrified to see a minute fleck of stone begin to grow rapidly. When we first became aware of the work of Shorr, we instituted aluminum hydroxide therapy with estrogens. The rapid growth of the stone ceased and as long as she was on this treatment, the size remained constant. Therapy was stopped because of menorrhagia and metrorrhagia and marked constipation, but as soon as the treatment was discontinued, the stone resumed its growth. Treatment was started again and stone growth stopped. Over the years, for one reason or another she ha:; discontinued treatment from time to time. Each time she stops the aluminum hydroxide, the stone starts growing, but while on therapy, it stays substantially the same in character. We have since had numerous other demonstrations of the fact that this routine, which is subject to numerous objections and shortcomings, is an effective measure in the medical management of stone. It has been our experience that when stone and infection co-exist, there is nothing to be gained by attempting to eradicate infection without removing the stone. It is perfectly true that in acute flare-ups of pyelonephritis, with evidence of extension of the infection, the appropriate antibiotic or chemotherapeutic agent should be given liberally, but in the absence of such acute situations, it does no significant good to administer these medications. It is better to reserve them for such time as surgical removal of the stone may be attempted. Finally, it is to be stressed that a high fluid intake constitutes a valuable element of stone control. The patient is urged to make a habit of taking water far in excess of the dictates of thirst in order that stone-forming substances may be kept in solution and carried on out of the urinary tract without precipitation.
STAGHORN CALCULI
353
In the smaller number of cases in which staghorn stones are composed of other substances than calcium phosphate, we do not employ the aluminum hydroxide routine but follow the simple dictates of time-honored dieting and medical management of stone: Alkaline ash diet and sodium citrate for uric acid stones, diet low in foods of high oxalic acid content for oxalate stones, and so on through the roster. In these instances, the medical management seems less likely to be satisfactory. We have found it most helpful to take the time to be explicit to our patients concerning the nature of their difficulties, to show them their stones in the x-ray films, and to point out to them any changes in size which occur during the course of therapy. We have felt that they become more zealous in their pursuit of our directions and more faithful in reporting for follow-up care. Lastly, and perhaps most important, they become more understanding and co-operative whenever it appears that ground is being lost un.der a medical regimen and surgery must be embarked upon. SUMMARY
The complex factors in the management of patients with unilateral or bilateral staghorn calculi of the kidneys are reviewed. First, it is necessary to assess the etiological factors such as heredity, metabolic defects, urinary stasis, and infection in order to determine the proper therapeutic approach. Second, it is well to consider the possibility of medical management of the disease as a substitute for surgery in certain types of cases. Third, when surgery is decided upon, radical nephrectomy or conservative removal of the calculus may be possible alternatives. The choice is determined by the amount of renal damage, the degree of functional integrity, the status of the contralateral kidney, and certain economic considerations of importance. In bilateral cases, the order of events must be planned with proper caution. Fourth, immediately before and after surgical removal of these calculi, it is of the utmost importance to employ every reasonable measure to insure against recurrence. These measures are dissolution of any possible remaining calcareous fragments, and a vigorous assault on infective organisms, plus appropriate dietary and medical treatment. Fifth, the principal elements in the medical management of calculous disease are to be applied not only to those patients in whom surgery is regarded as undesirable, but also to those patients who have been subjected to nephrolithotomy.
8 E. 12th St., Erie, Pa.
Vol. 69, No. 3, March 1953 Printed in U.S.A.
STAGHORN CALCULI ELMER HESS, RUSSELL B. ROTH
AND
ANTHONY F. KAMINSKY
From the Department of Urology, St. Vincent's Hospital, Erie, Pa.
The management of the patient with staghorn renal calculi is usually an intriguing clinical experience. One frequently begins by marvelling at how these stones may achieve such impressive size and bring about such extensive destruction of the renal substance without giving rise to more in the way of subjective symptoms. It is not uncommon to find that the patient has actually had no discomforts at all, and that the diagnosis is made only in tracking down the cause of pyuria discovered in a routine physical examination, an insurance examination, or perhaps because the stone shadows were seen in x-ray studies made for some unrelated purpose. In a small percentage of cases, a careful history will elicit a story of what may have been previous episodes of renal colic due to the passage of lesser calculi. Had these episodes been adequately investigated, the fundamental problem might have been uncovered at an earlier date. The problems presented by staghorn calculi (renal) are diversified. The urologist is obliged to consider possible etiological factors, to assess the advisability of surgical removal, to evaluate medical measures for control, and to cope with the ever-present threat of recurrence. The patient who has once had staghorn calculi is an individual who requires urological supervision for life, and the length of that life may be peculiarly dependent upon the judgment of the physician. ETIOLOGY
Much that concerns the development of urinary calculi is still controversial or obscure, and it is not our purpose here to review the conflicting evidence Certain factors are of importance beyond a reasonable doubt First, there is the matter of heredity. We regard the tendency to form primary urinary tract calculi as a family characteristic in certain instances. Inasmuch as this factor is not one of much value in the management of any given case, we will not dwell on it except to remark that recently, after removing a staghorn calculus from the right kidney of a young man and learning that we had previously removed calculi from his father and that a brother was currently in an Army hospital for the removal of stones from both kidneys, we suggested that his remaining brother stop by for a check-up. He also showed asymptomatic renal calculi. Metabolic abnormalities are also of significance. Cystinuria is of importance, although our incidence of cystine stones has been extremely low. It follows, however, that the discovery of cystinuria materially affects the prognosis for the formation of future stones, and the medical measures taken to minimize the possibility of such recurrence. Much the same may be said of urate and uric acid stones occurring in persons who show a high blood uric acid. More intriguing is the problem of hyperparathyroidism and the formation of calcium stones. Read at annual meeting, South Central Section, American Urological Association, Houston, Texas, October 30, 1951. 347
348
ELMER HESS, RUSSELL B. ROTH AND ANTHONY F. KAMINSKY
Here it is an incontestable fact that the existence of a parathyroid adenoma may lead to hypercalcemia, hypercalcinuria, and the development of nephrocalcinosis or renal calculi. Whereas it has been our routine practice over the years to carry out blood calcium and phosphorus studies on all stone-forming patients, we must admit that we have felt only once that parathyroid exploration was desirable and in that instance no adenoma was found. Our lack of cases of hyperparathyroidism is not assignable to a negligence in looking for the condition. Since we are specifically discussing the so-called staghorn type of calculus, it seems necessary to admit that we have encountered a recognizable metabolic abnormality in only a handful of cases, and that when such abnormality has been recognized there has proved to be little modifiability of the situation. Of more practical importance is the matter of stasis of urine. When an obstructive factor can be identified, it must be dealt with accordingly, since simple removal of the stone will be followed by recurrence in virtually every instance if the obstruction persists. It should be emphasized that one must not conclude that there is no stasis simply because the ureteropelvic junction is not obstructive in character. The lower end of the ureter is a frequent offender in unilateral cases, and the vesical neck and the external urethral meatus must be regarded with suspicion in bilateral cases. The effect of prolonged recumbency and immobilization is also to be considered under the heading of stasis, and its role is usually obvious. Lastly, we must consider infection. At the present time, there are effective means of combating virtually every organism encountered in cases of calculous disease. The urea-splitting organisms are obviously of principal importance since, by their strong alkalinization of the urine, they favor the formation and rapid growth of stones. Among them have been some of the more troublesome organisms in terms of resistance to chemotherapeutic or antibiotic treatment. Now, under proper circumstances, it is possible to eradicate the urea-splitting staphylococci with a variety of medications. Bacillus proteus yields quite decently to gantrisin, and Bacillus pyocyaneus responds to polymixin and terramycin. These newer weapons in combating infection are of inestimable value in the management of staghorn calculi. THE DECISION TO OPERATE
Once we have assessed to the best of our ability the reasons why staghorn calculi have developed in our patient, we are ready to consider what is to be done about the situation. The first question to answer is concerning the advisability of surgery. We may start in by saying that we have encountered patients with bilateral staghorn calculi who have minimal symptoms and after due consideration of all the factors involved it has been our feeling that they should be managed medically rather than surgically. From the point of view of surgical technique, it is quite possible to split the kidney adequately for complete removal of a solid staghorn stone. Appropriate measures may then be taken to minimize the chance of recurrence, and after successfully carrying this out on one side, it may be repeated on the other side. Several factors, how-
STAGHORN CALCULI
349
ever, should give one pause before setting out on such a course. If the kidneys have been previously operated upon and the staghorn calculi are recurrent the technique of operation is far more difficult and not to be undertaken lightly. If the stone is not solid but consists of multiple separate calyceal stones, or if it is of the friable or mushy calcareous variety, it may defy all reasonable attempts at complete removel. If the patient is a poor surgical risk for unrelated reasons, it must be remembered that two major surgical assaults are required. One may do well to advise the patient that the disadvantages of surgical removal outweigh the advantages and that medical management should be attempted first. If symptoms become too disturbing, it may later become mandatory to embark upon surgical removal. The surgical approach to the problem is the one of choice when symptoms are marked, when there is evidence of rapid progression of the disease, or when there is accompanying infection. If one kidney alone is involved, one must decide between removal of the calculus and removal of the kidney. This is not always a simple decision. N ephrectomy is usually safe, rapid, and attended by complete recovery. It may therefore be the procedure of choice when the patient is elderly, when the chances of complete surgical removal of the stone are not optimal, or when there is a valid financial objection to a long-drawn-out hospitalization and intensive aftercare. It may also be the most feasible approach when the stone is recurrent after prior attempt has been made at removal. The factor which militates against simple nephrectomy is the fact that a stone may possibly develop in the hitherto normal contralateral kidney. We have seen this happen. In the elderly patient, one does not attach so much importance to this, and the other factors enumerated may be reasonably easy to evaluate except for the financial factor. We feel that this is a very real consideration. For a simple nephrectomy our average patient is discharged from the hospital on the tenth postoperative day and may return to almost any type of employment short of heavy physical labor, in about one month. There is no necessity for numerous follow-up urological studies, treatments, or x-rays. For these reasons, hospital expenses, professional charges, and lost wages are all kept to a minimum. This must be contrasted to a relatively prolonged hospital stay when the kidney is opened, cleaned out, and intubated. The return to work is usually delayed, and the necessity for frequent recheck visits to the urologist, for cystoscopic treatments, and for follow-up x-rays is obvious. It is not sound medical judgment to be swayed unduly by financial considerations, but when a decision is to be made between radical removal and conservative repair, it is only fair to the patient to make clear the economic aspects of the choice. It is to be stressed, however, that when a patient has developed one staghorn calculus and has lost a kidney thereby, it is increasingly important for him to remain under close medical supervision with respect to the remaining kidney. Regular urinalyses and periodic plain films of the renal area become mandatory if early involvement of the solitary kidney is to be detected in time to be helpful. When one has made decision to perform conservative surgery-that is, to
350
ELMER HESS, RUSSELL B. ROTH AND ANTHONY F. KAMINSKY
remove the calculus and conserve the renal parenchyma, one must decide on the order of events; in bilateral cases, the degree of parenchymal destruction, the presence or absence of infection, and the amount of discomfort ascribable to each side. No rule of thumb, applicable to all cases, can be formulated. A few examples may illustrate the elements of the problem. M. S. had a large calculous pyonephrosis on the right side, with some small amount of renal function as measured by dye excretion. On the left, there was a large lower calyceal branching calculus which caused virtually no pain. We elected to remove the stone-bearing lower pole of the left kidney first. When this was satisfactorily accomplished and we were left with a well-functioning stone-free left kidney, we then felt free to do a nephrectomy on the right side, since the salvage value of that kidney seemed negligible. This philosophy, however, carries its perils. Another case in which the same plan was adopted turned out less favorably. The right kidney contained a large staghorn stone but appeared to have better function and more parenchyma than the left which also contained a large stone. With the idea of reconditioning the better kidney first, operation was carried out and the postoperative course was complicated by severe infection and hemorrhage so that a nephrectomy became mandatory. The patient thus lost the better of two diseased kidneys and is now living, fortunately quite comfortably, on one impaired kidney which still contains its calculus. Since we must be realistic and admit that in such surgical procedures there is an ever-present risk of complications which may force nephrectomy, we must give weight to this possibility in our planning. In general, when it appears ideal that each kidney should be cleaned out, it impresses us as better judgment to do the less damaged kidney first. If this is carried out successfully, as it generally is, then whatever happens on the other side will not be disastrous. If the reverse plan is carried out and the poorer kidney is treated first, one may still be in considerable peril when operating on the second side. In any event, there is a calculated risk. The presence of severe pain from one side or the other, of course, will usually dictate that this side be handled first. SURGICAL TECHNIQUE
Adequate exposure is the sine qua non of successful conservative renal surgery. There is little need to fear generous incisions into the renal parenchyma to allow total removal of calculi and we have stressed elsewhere our conviction that massive through and through sutures for closure sacrifice too much of renal tissue that we are attempting to save to be justifiable. If one achieves complete removal of the calculus from the kidney, it would seem to be wise to utilize nephrostomy tube drainage with a splinting ureteral catheter in order to permit irrigation of the pelvis postoperatively with appropriate solvent solutions and such antibiotics as may be indicated by cultural studies. POSTOPERATIVE CARE
Preoperative urine cultures will have identified the type of organism which is present in infected cases. It is our practice to institute appropriate antibiotic or chemotherapeutic treatment just prior to operation. Since there is almost
STAGHORN CALCULI
35]
certain to be a period of a day or t,Yo during which the medication cannot be taken orally, we prefer to use parenteral administration. Penicillin, chloromycetin, or terramycin are particularly adaptable. In addition to parenteral administration, we have also found it helpful to use direct instillations of such solutions as terramycin or polymixin through the nephrostomy tube in the more severely infected cases. We have also used constant or intermittent irriga·tions of solutions calculated to dissolve any calcareous debris which may have been left !whind at operation. Since we are ordinarily dealing with calcium phosphate stones, the solution which we normally use is solution G made up in l: 20,000 zephiran. If solution G proves to be too irritating to the pelvic mucosa, we change to solu bon JVL It will be readily understood that our use of the 1rnphrostomy tube is more as an avenue of approach to the kidney than as a means of drainage. The length of time over which a nephrostomy tube and splinting catheter is left in place is, obviously, sllbject to the requirements of the individual ease. H ureteropelvic plastic: revisions have been carried out, the splinting catheter may be left for 3 or 4 weeks. If no such procedure has been necessary, the tube is removed as quickly as Lhe urinary drainage bespeaks recovery of the kidney. At the same time, we place the patient on a relatively low phosphorous diet and institute the aluminum hydroxide regimen described by Shorr. This sometimes complicates postoperative bowel regulation, since the aluminum hydroxide is constipating, but this can ordinarily be handled satisfactorily ·with mild laxatives. In short, every measure which promrnes to assist m mmrrmzmg recurrence is promptly instituted. MEDICAL MANAGEME;NT
The essential elements of medical management of staghorn calculi have been touched upon while discussing postoperative care. ·when used in place of surgical excision of the calculi, they become perhaps even more important. The spontaneous disappearance of a staghorn calculus formed during a long period of recumbency has been reported, but it must be admitted that, in general, we are not sanguine mwugh to hope for complete disappearance of the ralculi. Our aim is, if possible, to check further growth of the stones and, if luck is with us, to achieve some decrease in size. It is especially helpfnl in medical management if the composition of the stone may be ascertained. When no stone fragment is available for actual analysis. it is necessary to infer the composition from reports on the character of tho crystalline sediment of the urine. The overwhelming majority of cases, how-ever, will prove to be calcium phosphate stones, perhaps with admixtures of a few other ions such as ammonium, magnesium, or carbonate. In such cases, the absence of infection and the ability to acidify the urine may permit the u.tifomtion of an acidification regimen coupling the acid-ash diet ·with ammonium chloride, sodium acid phosphate, or some similar agent. When urea-splitting organisms are present, making it virtually impossible to acidify the urine of the renal pelvis, it is unwise to pursue such a. course of treatment since under these
352
ELMER HESS, RUSSELL B. ROTH AND ANTHONY F. KAMINSKY
circumstances, no calcium salts are dissolved and the effect is merely to make more calcium ion available for precipitation. In the patient with poor renal function and a tendency toward azotemia and acidosis, the latter condition may be aggravated by such treatment. It is more productive, in our experience, to use the aluminum hydroxide routine. Basaljel, which has been especially designed for this purpose, is excellent when well tolerated, but almost 50 per cent of our patients have been unable to overcome nausea and vomiting. Most of these patients, however, prove capable of taking amphojel in adequate amounts. It is our practice to use 40 cc per dose 1 hour after meals and at bedtime. This effectively decreases the amount of phosphate ion available for precipitation in the urinary tract. In a few cases, we have also used estrogens, as advocated by Shorr, to increase citric acid output in the urine, but we do not feel qualified to pass on its value. vVe are firmly convinced, however, that the aluminum hydroxide routine is of real virtue. In our case which has been followed the longest, we have had dramatic proof of its efficacy. This patient had bilateral staghorn calculi and each kidney had been surgically cleaned out, but had become refilled with stone before we saw her first. Because of pain in the right renal region, we did a second right nephrolithotomy in December 1946. Despite all our precautions, we were horrified to see a minute fleck of stone begin to grow rapidly. When we first became aware of the work of Shorr, we instituted aluminum hydroxide therapy with estrogens. The rapid growth of the stone ceased and as long as she was on this treatment, the size remained constant. Therapy was stopped because of menorrhagia and metrorrhagia and marked constipation, but as soon as the treatment was discontinued, the stone resumed its growth. Treatment was started again and stone growth stopped. Over the years, for one reason or another she ha:; discontinued treatment from time to time. Each time she stops the aluminum hydroxide, the stone starts growing, but while on therapy, it stays substantially the same in character. We have since had numerous other demonstrations of the fact that this routine, which is subject to numerous objections and shortcomings, is an effective measure in the medical management of stone. It has been our experience that when stone and infection co-exist, there is nothing to be gained by attempting to eradicate infection without removing the stone. It is perfectly true that in acute flare-ups of pyelonephritis, with evidence of extension of the infection, the appropriate antibiotic or chemotherapeutic agent should be given liberally, but in the absence of such acute situations, it does no significant good to administer these medications. It is better to reserve them for such time as surgical removal of the stone may be attempted. Finally, it is to be stressed that a high fluid intake constitutes a valuable element of stone control. The patient is urged to make a habit of taking water far in excess of the dictates of thirst in order that stone-forming substances may be kept in solution and carried on out of the urinary tract without precipitation.
STAGHORN CALCULI
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In the smaller number of cases in which staghorn stones are composed of other substances than calcium phosphate, we do not employ the aluminum hydroxide routine but follow the simple dictates of time-honored dieting and medical management of stone: Alkaline ash diet and sodium citrate for uric acid stones, diet low in foods of high oxalic acid content for oxalate stones, and so on through the roster. In these instances, the medical management seems less likely to be satisfactory. We have found it most helpful to take the time to be explicit to our patients concerning the nature of their difficulties, to show them their stones in the x-ray films, and to point out to them any changes in size which occur during the course of therapy. We have felt that they become more zealous in their pursuit of our directions and more faithful in reporting for follow-up care. Lastly, and perhaps most important, they become more understanding and co-operative whenever it appears that ground is being lost un.der a medical regimen and surgery must be embarked upon. SUMMARY
The complex factors in the management of patients with unilateral or bilateral staghorn calculi of the kidneys are reviewed. First, it is necessary to assess the etiological factors such as heredity, metabolic defects, urinary stasis, and infection in order to determine the proper therapeutic approach. Second, it is well to consider the possibility of medical management of the disease as a substitute for surgery in certain types of cases. Third, when surgery is decided upon, radical nephrectomy or conservative removal of the calculus may be possible alternatives. The choice is determined by the amount of renal damage, the degree of functional integrity, the status of the contralateral kidney, and certain economic considerations of importance. In bilateral cases, the order of events must be planned with proper caution. Fourth, immediately before and after surgical removal of these calculi, it is of the utmost importance to employ every reasonable measure to insure against recurrence. These measures are dissolution of any possible remaining calcareous fragments, and a vigorous assault on infective organisms, plus appropriate dietary and medical treatment. Fifth, the principal elements in the medical management of calculous disease are to be applied not only to those patients in whom surgery is regarded as undesirable, but also to those patients who have been subjected to nephrolithotomy.
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