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The Healing of Renal Wounds: I. Partial Nephrectomy
THE JOURNAL OF UROLOGY
Vol. 78, No. 5, November 1957
Printed in U.S.A.
THE HEALING OF RENAL WOUNDS: I. PARTIAL NEPHRECTOMY JOHN J. MURPHY
AND
RICHARD BEST
From the Department of Surgery, Division of Urology, Ho.~pital of the University of Pennsylvania, and the Harrison Department of Surgical Research, Schools of Medicine, University of Pennsylvania, Philadelphia, Pa.
Maximal conservation of functioning renal tissue is the major objective of surgical treatment for localized disease of the kidney. Wide application of the operation of partial nephrectomy has been somewhat limited because of serious complications such as secondary hemorrhage and urinary fistula. After the first partial nephrectomy by Czerny in 1887, 1 a number of these procedures were performed for tuberculosis and tumors. The high incidence of complications led to virtual abandonment of the procedure until about 1930 when it was revived for the treatment of renal calculi and localized cysts or caliectasis. In 1949, Dr. Carl Semb2 demonstrated that partial nephrectomy was feasible in carefully selected cases of renal tuberculosis and he reported an extremely low morbidity. A review of the available literature since 1930 reveals that complications of partial renal resection continue to occur despite improved surgical care and modern antibacterial therapy (table 1). In 819 cases of partial resection of the kidney for localized cysts, calculi, abscesses, hydronephrosis, caliectasis and benign tumors, the incidence of secondary hemorrhage was 3.4 per cent. Urinary fistula occurred in 3.9 per cent and secondary nephrectomy was necessary in 2.5 per cent. Thus a significant number of patients suffered severe complications or were subjected to the hazards and discomfort of a second major operation. Similarly, in 384 cases of partial nephrectomy for tuberculosis collected from the available literature for the same period, there was an incidence of urinary fistula of 5.5 per cent, of secondary hemorrhage of 2.9 per cent, and secondary nephrectomy had to be performed in 3.4 per cent. While the incidence of these complications is not high enough to prohibit the use of partial nephrectomy under certain conditions, it represents a constant threat which must be considered in selecting the best operation for a given case. If the 226 partial nephrectomies for renal tuberculosis which were reported by Semb3 are excluded, the incidence of urinary fistula in the tuberculosis series is 12.7 per cent, of secondary hemorrhage 7 per cent, and of secondary nephrectomy 8.2 per cent. The explanation for the discrepancy between Semb's results and those of others is probably due to his careful selection of cases and his utilization of a technique whereby the amount of ischemic tissue left behind to undergo necrosis and atrophy is minimized. The conventional type of wedge resection with approximation of the residual flaps by deep horizontal mattress or cobbler sutures must frequently result in necrosis of Read at annual meeting of American Urological Association, Pittsburgh, Pa .. May 6-9, , 1957. 1 Czerny: quoted by Goldstein, A. E. and Abeshouse, B. S., Partial resection of the kidney. J. Urol., 38: 15, 1937. 2 Semb, C.: Renal tuberculosis and its treatment by partial resection of the kidney. Acta. Chir. Scand., 98: 457, 1949. 3 Semb, C.: Partial resection of the kidney: Anatomical, physiological and clinical aspects. Ann. Roy. Coll. Surgeons Eng., 19: 137, 1956. 504
HEALING OF RENAL WOUNDS: PARTIAL NEPHRECTOMY TABLE
505
1. Complications following partial nephrectomy No. of Cases
Reason for Resection
:.l!
Trauma . . .. . . . .... Calculus .. Cysts ...... ... Hydronephrosis ... Anomalies ..... .. .. . ........ Benign tumors. . . . . . . . . . . . . . . . ......... Tuberculosis Total. .... .... . . . . . . . . . . . . . . . . . . . . . . After excluding Semb's cases. .. . . . . . .
.
Urinary Fistula
Secondary Hemorrhage
Secondary N ephrectomy
819
32 (3.9%)
28 (3.4%)
20 (2.5%)
384 158
21 (5.5%) 20 (12. 7%)
11 (2.8%) 11 (7%)
13 (3.4%) 13 (8.2%)
Fm. 1. Technique of wedge type resection. Note a) closure of collecting system; b) approximation of remaining parenchyma.
tissue. 4 The present study was designed to determine the normal course of healing after the conventional wedge type of partial nephrectomy and after another method which was thought likely to decrease the likelihood of tissue necrosis. Three groups of animals were operated upon in the course of this study. The wedge type of resection was utilized in the first group of seven dogs. The animals were anesthesized with intravenous pentobarbital and the kidney exposed through a flank incision. The renal capsule was incised over the upper pole of the kidney and reflected to the lower limit of the line of resection. Hemostasis was secured during the resection by placing a Crafoord clamp on the vascular pedicle. A wedge of renal parenchyma was excised (fig. 1), removing with it the upper pole calyces and infundibulum. The collecting system was closed with a continuous suture of 5-0 atraumatic catgut. Hemostasis was obtained by identifying bleeding points after release of the clamp and ligating them with transfixion sutures of 5-0 catgut. The flaps of renal parenchyma remaining after excision of the wedge were approximated by horizontal mattress sutures buttressed with tabs of perirenal fat. The capsule was closed over the incision with interrupted sutures of 3-0 catgut. 4 Herbst, R.H. and Polkey, H.J.: Renal resection; experimental study of postoperative function. Surg., Gynec. & Obst., 51: 213, 1930.
506
JOHN J. MURPHY AND RICHARD BEST
In the second group of animals, the renal parenchyma in the upper pole was sectioned transversely to the long axis of the kidney after reflection of the capsule (fig. 2, A). Approximately one-third of the kidney parenchyma including the same portion of the collecting system as removed by the wedge incision was excised The collecting system was carefully closed with a continuous 5-0 atraumatic catgut suture. Hemostasis was secured by individual suture-ligature of vessels visualized when the clamp on the renal pedicle was released. After hemostasis was
Fm. 2. Technique of transverse type of resection. Note a) method of obtaining hemostasis; b) closure of collecting system; c) closure of capsule.
Fm. 3. A, gross specimen of kidney, subjected to wedge-type resection, two we'eks after operation. Note necrosis of flaps. B, microscopic appearance of healing wedge resection at five weeks. Note extensive necrosis and atrophy.
HEALING OF RENAL WOUNDS: PARTIAL NEPHRECTOMY
507
accomplished a free graft of peritoneum was applied to the raw surface of the kidney by suturing the edges of the graft to the renal capsule. In the third group of animals, transverse resection of the renal parenchyma was accomplished exactly as in group 2, but the management of this group differed from group 2 in that no graft was utilized, the renal capsule (fig. 2, C) being loosely approximated across the cut surface. Animals in each series were sacrificed at weekly intervals so that gross and microscopic evidence concerning the course of healing could be obtained over a period of seven to eight weeks. Comparison of the wedge type of resection with the transverse method from the technical aspect emphasized the difficulty of closing accurately the renal collecting system when it was at the apex of a narrow wedge, whereas this was accomplished with ease on the broad, flat surface of the transverse section. Visualization of bleeding points and accurate placement of hemostatic suture ligatures was likewise more difficult in the wedge type of resection. RESULTS
Except for superficial wound infections, no complications developed in any of the animals. In the wedge resections examined one and two weeks after operation, the mattress sutures had cut deeply into the parenchyma and there was necrosis of the tissue distal to the sutures (fig. 3, A). Later in the course of healing, it was apparent that there was scarring and fibrosis of and between the flaps with an area of atrophy several millimeters wide on either side (fig. 3, B). In the kidneys resected by the transverse method and on which a peritoneal graft was placed, there was evidence of a small hematoma beneath the graft in all but two cases. Compression of the adjacent renal parenchyma was evidenced by a thin zone of atrophy just below the cut surface (fig. 4). Thus, the desired effect of the graft (that of sealing the raw surface and promoting early healing) was lost. In the group of animals in which the capsule was loosely applied across the cut surface of the kidney after hemostasis was secured, healing proceeded without difficulty. There was no evidence of necrosis or hematoma formation (fig. 5, A).
Fm. 4. Microscopic appearance of healing of transverse resection with application of free peritoneal graft at five weeks. Note atrophy of tissue below hematoma.
508
JOHN J. MURPHY AND RICHARD BEciT
Fm, 5. A, gross appearance of kidney, resected transversely, three weeks after operation. Note absence of necrosis and atrophy. B, microscopic appearance of healing transverse resection at seven weeks. Nate minimal atrophy of tissue.
Fm. 6. A, gross specimen of upper pole resected transversely for renal calculus. B, postoperative pyelogram reveals excellent function and normal appearance of resected right kidney.
HJDALI'\"G OF RI
~\1icroscopic examination of the tissue at various stages of healing after this procedure indicated minimal atrophy of the remaining renal parenehyma (Jig. 6, CLINICAL EXPERIEXCE
The technique of trarnwerse resection has been used in five patients in the past six months. It has proven to be entirely satisfactory in every respect. The time required for the procedure has been decreased and blood loss minimized. 6, A shows the resected upper pole specimen; figure 6, B the postoperative pyelograms of a recent case. SUMMARY AND COXCLCSIO'-:S
Partial nephrectomy by the conventional ,vedge type of resection appear:-1 to be likely to result in necrosis of renal parenchyma because of tension on the flaps of renal tissue caused the mattress type of suture. This necrosis may to complications of secondary hemorrhage and urinary fistula as well as resulting in delayed healing and eventual fibrosis and atrophy. The renal parenchyma surrounding the portion of the collecting ,vhich 1nust be removed in partial nephrectomy contributes nothing to total renal function. Removal of this tissue facilitates closure of the collecting and the securing of hemostasis while minimizing the likelihood of the complications mentioned above. The use of a free graft, of peritoneum to seal the raw surface of the recSeetecl kidney seemed attractive theoretically, but in practice resulted in hematoma formation between the graft and the cut surface of the kidney. This result,ed in pressure atrophy of the parenchyma beneath the graft. The transverse method of partial renal resection appears to facilitate the technical details of the operative procedure and permits rapid healing with minimal necrosis. The authors gratefully acknowledge the assistance of Dr. Howard Department of Pathology, University of Pennsylvania, in the evaluation of the microscopic sections in this study. REVIEW OF LITERATURE SINCE 1930 CAMPBELi,, M.: Resection of the solitary kidney. Tr. Southeast. Sect_ Am, UroL Assn., 19th meeting, pp. 124-138, 1955. SFJMB, C.: Partial resection of the kidney. Operative technique. Acta Chir. Scancl., 109: :mo, 1955, SEMB, C.: Selective principle in the treatment of renal tuberculosis. Acta Chir. Seand., 110: 1:32, 1955. N1c1,sox, R. E.: Calycectomy. N. York State J. Med., 54: 70, 1954. EBERHART, C. A. AND BANKS, R. _ Partial nephrectorny_ Am. Surgeon, 18: 684, 1D52. L,ruNGGRE~:, E. AND OBRAXT, 0.: Partial nephrectorn:v in renal tuberculosis. Act a Chir. Scand., 105: 319, 1953. HJORT, E. F_: Partial resection of the kidney in large hydronephrosis. Acta Chir Sc and, 106: 103, 1953. TnoREX, LARS: The cause and incidence of delayed nephrectomy after resections of the kidney_ Acta. Chir_ Scand., 101: 291, 1951. Ft;R1,oxG, J_ H.: Heminephrectomy for staghorn calcnlus in lower half of double kidney; case report. Delaware M. J., 23: 57, 1951. Jhiss, E., RoTH, R. B., KAMI:S:SKY, A. F. AND Sw1cK, H_ V.: Surgery for the conservation of renal parenchyrna_ J. Urol., 64: 175, 1950. KrnBY, E.W.; Con,gervative renal therapy. West Virginia M. ,L, 46: 2HJ, 19,50.
510
JOHN J. MURPHY AND RICHARD BEST
LATTEHER, J. K.: Partial nephrectomy for tuberculosis. Am. Rev. Tuberc., 66: 744, 1952. CrnERT, J.: Partial nephrectomy in renal tuberculosis. Brit. J. Urol., 25: 89, 1953. GuRLY, R.: Deux ca de nephrectomie partielle pour traumatisme et pour lithiase pyelocalicielle. Acta Urol. Belg., 23: 263, 1955. lNGELRANS, p ., DELMONTE, M. AND POUPARD, B.: Apropos de deux heminephrectomies pour malformations reno-ureterales. Lille Chir., 10: 235, 1955. Kuss, R.: Stenose du collet sur rein unique tuberculeux; anastomose pyelo-ureterale et nephrectomie partielle. J. d'urol., 60: 275, 1954. FORET, A.: La nephrectomie partielle. Rev. Med. Liege, 7: 595, 1952. BARTHELEMY, H.: Nephrectomie partielle. Echec. Causes. J. d'urol., 58: 85, 1952. ALKEN, C. E.: lndikation Technik und Ergebnisse der Nierenteilresectionen. Arch. !din. Chir., 276: 289, 1953. MAY, F.: Die Keilresektion der Niere. Praxis, Bern, 40: 730, 1951. BORELLI, C., COLOMBO, G. AND GIRARDI, A.: Le resezioni segmentali de! rene. Arch. Ital. Urol., 27: 103, 1954. TERRUZZI, B. AND CALVI, F.: Indicazione ed esiti remoti della nefrectomia parziale. Arch. ital. Urol., 26: 263, 1953. Roccm, A.: Nefrectomia parcial por tuberculosis. Rev. Argent. Urol., 23: 7, 1954. BATALLA SABATE, L.: Nephrectomie partielle et pyelotomie pour lithiase chez une femme enceinte resultat dix mois apres l'accouchement. J. d'urol., 56: 893, 1950. CHAUVIN, E. AND CHAUVIN, H. F.: Nephrectomie partielle pour tuberculose renale. J. d'urol., 56: 950, 1950. RENON, C. AND ILLES: Sur la nephrectomie partielle pour tuberculose. J. d'urol., 57: 28, 1951. PETKOVIC, S.: La nephrectomie partielle dans le traitemen de la tuberculose renale. Helvet. Chir. Acta, 20: 107, 1953. STEINBOCK, A.: Partial nephrectomy for tuberculosis of the kidney. Ann. Chir. Gyn. Fenn., Supp., 4, 1954. LARGET, P.: Apropos de la nephrectomie partielle pour tuberculose renale. J. d'urol., 57: 163, 1951. HANEY, H. G.: Discussion on partial nephrectomy. Proc. Roy. Soc. Med. Lond., 43: 1027, 1950. GOLDSTEIN, A. E. AND ABEsr-rousE, B. S.: Partial resections of the kidney. J. Urol., 38: 15, 1937. ABEsnm;sE, B. S. AND LERMAN, S.: Partial nephrectomy versus pyelolithotomy and nephrolithotomy in the treatment of localized calculous disease of the kidney, with a report of 17 partial nephrectomies. Surg., Gynec. & Obst., 91: 209, 1950. CLARK, F. B., CHUTE, R. AND RUDY, H. A.: Partial nephrectomy. J. Urol., 72: 6, 1954. Kusi::NCKI, T.: Partial nephrectomy. Urol. Internat., Basel, 1: 243, 1955. PurnvERT, A.: La nefrectomia partial. Rev. Brasil Cirurg., 29: 413, 1955. AzAGARA, L.: Traumatismo renal nefrectomia parcial. Arch. Espafi. Urol., 11: 126, 1955.
Vol. 78, No. 5, November 1957
Printed in U.S.A.
THE HEALING OF RENAL WOUNDS: I. PARTIAL NEPHRECTOMY JOHN J. MURPHY
AND
RICHARD BEST
From the Department of Surgery, Division of Urology, Ho.~pital of the University of Pennsylvania, and the Harrison Department of Surgical Research, Schools of Medicine, University of Pennsylvania, Philadelphia, Pa.
Maximal conservation of functioning renal tissue is the major objective of surgical treatment for localized disease of the kidney. Wide application of the operation of partial nephrectomy has been somewhat limited because of serious complications such as secondary hemorrhage and urinary fistula. After the first partial nephrectomy by Czerny in 1887, 1 a number of these procedures were performed for tuberculosis and tumors. The high incidence of complications led to virtual abandonment of the procedure until about 1930 when it was revived for the treatment of renal calculi and localized cysts or caliectasis. In 1949, Dr. Carl Semb2 demonstrated that partial nephrectomy was feasible in carefully selected cases of renal tuberculosis and he reported an extremely low morbidity. A review of the available literature since 1930 reveals that complications of partial renal resection continue to occur despite improved surgical care and modern antibacterial therapy (table 1). In 819 cases of partial resection of the kidney for localized cysts, calculi, abscesses, hydronephrosis, caliectasis and benign tumors, the incidence of secondary hemorrhage was 3.4 per cent. Urinary fistula occurred in 3.9 per cent and secondary nephrectomy was necessary in 2.5 per cent. Thus a significant number of patients suffered severe complications or were subjected to the hazards and discomfort of a second major operation. Similarly, in 384 cases of partial nephrectomy for tuberculosis collected from the available literature for the same period, there was an incidence of urinary fistula of 5.5 per cent, of secondary hemorrhage of 2.9 per cent, and secondary nephrectomy had to be performed in 3.4 per cent. While the incidence of these complications is not high enough to prohibit the use of partial nephrectomy under certain conditions, it represents a constant threat which must be considered in selecting the best operation for a given case. If the 226 partial nephrectomies for renal tuberculosis which were reported by Semb3 are excluded, the incidence of urinary fistula in the tuberculosis series is 12.7 per cent, of secondary hemorrhage 7 per cent, and of secondary nephrectomy 8.2 per cent. The explanation for the discrepancy between Semb's results and those of others is probably due to his careful selection of cases and his utilization of a technique whereby the amount of ischemic tissue left behind to undergo necrosis and atrophy is minimized. The conventional type of wedge resection with approximation of the residual flaps by deep horizontal mattress or cobbler sutures must frequently result in necrosis of Read at annual meeting of American Urological Association, Pittsburgh, Pa .. May 6-9, , 1957. 1 Czerny: quoted by Goldstein, A. E. and Abeshouse, B. S., Partial resection of the kidney. J. Urol., 38: 15, 1937. 2 Semb, C.: Renal tuberculosis and its treatment by partial resection of the kidney. Acta. Chir. Scand., 98: 457, 1949. 3 Semb, C.: Partial resection of the kidney: Anatomical, physiological and clinical aspects. Ann. Roy. Coll. Surgeons Eng., 19: 137, 1956. 504
HEALING OF RENAL WOUNDS: PARTIAL NEPHRECTOMY TABLE
505
1. Complications following partial nephrectomy No. of Cases
Reason for Resection
:.l!
Trauma . . .. . . . .... Calculus .. Cysts ...... ... Hydronephrosis ... Anomalies ..... .. .. . ........ Benign tumors. . . . . . . . . . . . . . . . ......... Tuberculosis Total. .... .... . . . . . . . . . . . . . . . . . . . . . . After excluding Semb's cases. .. . . . . . .
.
Urinary Fistula
Secondary Hemorrhage
Secondary N ephrectomy
819
32 (3.9%)
28 (3.4%)
20 (2.5%)
384 158
21 (5.5%) 20 (12. 7%)
11 (2.8%) 11 (7%)
13 (3.4%) 13 (8.2%)
Fm. 1. Technique of wedge type resection. Note a) closure of collecting system; b) approximation of remaining parenchyma.
tissue. 4 The present study was designed to determine the normal course of healing after the conventional wedge type of partial nephrectomy and after another method which was thought likely to decrease the likelihood of tissue necrosis. Three groups of animals were operated upon in the course of this study. The wedge type of resection was utilized in the first group of seven dogs. The animals were anesthesized with intravenous pentobarbital and the kidney exposed through a flank incision. The renal capsule was incised over the upper pole of the kidney and reflected to the lower limit of the line of resection. Hemostasis was secured during the resection by placing a Crafoord clamp on the vascular pedicle. A wedge of renal parenchyma was excised (fig. 1), removing with it the upper pole calyces and infundibulum. The collecting system was closed with a continuous suture of 5-0 atraumatic catgut. Hemostasis was obtained by identifying bleeding points after release of the clamp and ligating them with transfixion sutures of 5-0 catgut. The flaps of renal parenchyma remaining after excision of the wedge were approximated by horizontal mattress sutures buttressed with tabs of perirenal fat. The capsule was closed over the incision with interrupted sutures of 3-0 catgut. 4 Herbst, R.H. and Polkey, H.J.: Renal resection; experimental study of postoperative function. Surg., Gynec. & Obst., 51: 213, 1930.
506
JOHN J. MURPHY AND RICHARD BEST
In the second group of animals, the renal parenchyma in the upper pole was sectioned transversely to the long axis of the kidney after reflection of the capsule (fig. 2, A). Approximately one-third of the kidney parenchyma including the same portion of the collecting system as removed by the wedge incision was excised The collecting system was carefully closed with a continuous 5-0 atraumatic catgut suture. Hemostasis was secured by individual suture-ligature of vessels visualized when the clamp on the renal pedicle was released. After hemostasis was
Fm. 2. Technique of transverse type of resection. Note a) method of obtaining hemostasis; b) closure of collecting system; c) closure of capsule.
Fm. 3. A, gross specimen of kidney, subjected to wedge-type resection, two we'eks after operation. Note necrosis of flaps. B, microscopic appearance of healing wedge resection at five weeks. Note extensive necrosis and atrophy.
HEALING OF RENAL WOUNDS: PARTIAL NEPHRECTOMY
507
accomplished a free graft of peritoneum was applied to the raw surface of the kidney by suturing the edges of the graft to the renal capsule. In the third group of animals, transverse resection of the renal parenchyma was accomplished exactly as in group 2, but the management of this group differed from group 2 in that no graft was utilized, the renal capsule (fig. 2, C) being loosely approximated across the cut surface. Animals in each series were sacrificed at weekly intervals so that gross and microscopic evidence concerning the course of healing could be obtained over a period of seven to eight weeks. Comparison of the wedge type of resection with the transverse method from the technical aspect emphasized the difficulty of closing accurately the renal collecting system when it was at the apex of a narrow wedge, whereas this was accomplished with ease on the broad, flat surface of the transverse section. Visualization of bleeding points and accurate placement of hemostatic suture ligatures was likewise more difficult in the wedge type of resection. RESULTS
Except for superficial wound infections, no complications developed in any of the animals. In the wedge resections examined one and two weeks after operation, the mattress sutures had cut deeply into the parenchyma and there was necrosis of the tissue distal to the sutures (fig. 3, A). Later in the course of healing, it was apparent that there was scarring and fibrosis of and between the flaps with an area of atrophy several millimeters wide on either side (fig. 3, B). In the kidneys resected by the transverse method and on which a peritoneal graft was placed, there was evidence of a small hematoma beneath the graft in all but two cases. Compression of the adjacent renal parenchyma was evidenced by a thin zone of atrophy just below the cut surface (fig. 4). Thus, the desired effect of the graft (that of sealing the raw surface and promoting early healing) was lost. In the group of animals in which the capsule was loosely applied across the cut surface of the kidney after hemostasis was secured, healing proceeded without difficulty. There was no evidence of necrosis or hematoma formation (fig. 5, A).
Fm. 4. Microscopic appearance of healing of transverse resection with application of free peritoneal graft at five weeks. Note atrophy of tissue below hematoma.
508
JOHN J. MURPHY AND RICHARD BEciT
Fm, 5. A, gross appearance of kidney, resected transversely, three weeks after operation. Note absence of necrosis and atrophy. B, microscopic appearance of healing transverse resection at seven weeks. Nate minimal atrophy of tissue.
Fm. 6. A, gross specimen of upper pole resected transversely for renal calculus. B, postoperative pyelogram reveals excellent function and normal appearance of resected right kidney.
HJDALI'\"G OF RI
~\1icroscopic examination of the tissue at various stages of healing after this procedure indicated minimal atrophy of the remaining renal parenehyma (Jig. 6, CLINICAL EXPERIEXCE
The technique of trarnwerse resection has been used in five patients in the past six months. It has proven to be entirely satisfactory in every respect. The time required for the procedure has been decreased and blood loss minimized. 6, A shows the resected upper pole specimen; figure 6, B the postoperative pyelograms of a recent case. SUMMARY AND COXCLCSIO'-:S
Partial nephrectomy by the conventional ,vedge type of resection appear:-1 to be likely to result in necrosis of renal parenchyma because of tension on the flaps of renal tissue caused the mattress type of suture. This necrosis may to complications of secondary hemorrhage and urinary fistula as well as resulting in delayed healing and eventual fibrosis and atrophy. The renal parenchyma surrounding the portion of the collecting ,vhich 1nust be removed in partial nephrectomy contributes nothing to total renal function. Removal of this tissue facilitates closure of the collecting and the securing of hemostasis while minimizing the likelihood of the complications mentioned above. The use of a free graft, of peritoneum to seal the raw surface of the recSeetecl kidney seemed attractive theoretically, but in practice resulted in hematoma formation between the graft and the cut surface of the kidney. This result,ed in pressure atrophy of the parenchyma beneath the graft. The transverse method of partial renal resection appears to facilitate the technical details of the operative procedure and permits rapid healing with minimal necrosis. The authors gratefully acknowledge the assistance of Dr. Howard Department of Pathology, University of Pennsylvania, in the evaluation of the microscopic sections in this study. REVIEW OF LITERATURE SINCE 1930 CAMPBELi,, M.: Resection of the solitary kidney. Tr. Southeast. Sect_ Am, UroL Assn., 19th meeting, pp. 124-138, 1955. SFJMB, C.: Partial resection of the kidney. Operative technique. Acta Chir. Scancl., 109: :mo, 1955, SEMB, C.: Selective principle in the treatment of renal tuberculosis. Acta Chir. Seand., 110: 1:32, 1955. N1c1,sox, R. E.: Calycectomy. N. York State J. Med., 54: 70, 1954. EBERHART, C. A. AND BANKS, R. _ Partial nephrectorny_ Am. Surgeon, 18: 684, 1D52. L,ruNGGRE~:, E. AND OBRAXT, 0.: Partial nephrectorn:v in renal tuberculosis. Act a Chir. Scand., 105: 319, 1953. HJORT, E. F_: Partial resection of the kidney in large hydronephrosis. Acta Chir Sc and, 106: 103, 1953. TnoREX, LARS: The cause and incidence of delayed nephrectomy after resections of the kidney_ Acta. Chir_ Scand., 101: 291, 1951. Ft;R1,oxG, J_ H.: Heminephrectomy for staghorn calcnlus in lower half of double kidney; case report. Delaware M. J., 23: 57, 1951. Jhiss, E., RoTH, R. B., KAMI:S:SKY, A. F. AND Sw1cK, H_ V.: Surgery for the conservation of renal parenchyrna_ J. Urol., 64: 175, 1950. KrnBY, E.W.; Con,gervative renal therapy. West Virginia M. ,L, 46: 2HJ, 19,50.
510
JOHN J. MURPHY AND RICHARD BEST
LATTEHER, J. K.: Partial nephrectomy for tuberculosis. Am. Rev. Tuberc., 66: 744, 1952. CrnERT, J.: Partial nephrectomy in renal tuberculosis. Brit. J. Urol., 25: 89, 1953. GuRLY, R.: Deux ca de nephrectomie partielle pour traumatisme et pour lithiase pyelocalicielle. Acta Urol. Belg., 23: 263, 1955. lNGELRANS, p ., DELMONTE, M. AND POUPARD, B.: Apropos de deux heminephrectomies pour malformations reno-ureterales. Lille Chir., 10: 235, 1955. Kuss, R.: Stenose du collet sur rein unique tuberculeux; anastomose pyelo-ureterale et nephrectomie partielle. J. d'urol., 60: 275, 1954. FORET, A.: La nephrectomie partielle. Rev. Med. Liege, 7: 595, 1952. BARTHELEMY, H.: Nephrectomie partielle. Echec. Causes. J. d'urol., 58: 85, 1952. ALKEN, C. E.: lndikation Technik und Ergebnisse der Nierenteilresectionen. Arch. !din. Chir., 276: 289, 1953. MAY, F.: Die Keilresektion der Niere. Praxis, Bern, 40: 730, 1951. BORELLI, C., COLOMBO, G. AND GIRARDI, A.: Le resezioni segmentali de! rene. Arch. Ital. Urol., 27: 103, 1954. TERRUZZI, B. AND CALVI, F.: Indicazione ed esiti remoti della nefrectomia parziale. Arch. ital. Urol., 26: 263, 1953. Roccm, A.: Nefrectomia parcial por tuberculosis. Rev. Argent. Urol., 23: 7, 1954. BATALLA SABATE, L.: Nephrectomie partielle et pyelotomie pour lithiase chez une femme enceinte resultat dix mois apres l'accouchement. J. d'urol., 56: 893, 1950. CHAUVIN, E. AND CHAUVIN, H. F.: Nephrectomie partielle pour tuberculose renale. J. d'urol., 56: 950, 1950. RENON, C. AND ILLES: Sur la nephrectomie partielle pour tuberculose. J. d'urol., 57: 28, 1951. PETKOVIC, S.: La nephrectomie partielle dans le traitemen de la tuberculose renale. Helvet. Chir. Acta, 20: 107, 1953. STEINBOCK, A.: Partial nephrectomy for tuberculosis of the kidney. Ann. Chir. Gyn. Fenn., Supp., 4, 1954. LARGET, P.: Apropos de la nephrectomie partielle pour tuberculose renale. J. d'urol., 57: 163, 1951. HANEY, H. G.: Discussion on partial nephrectomy. Proc. Roy. Soc. Med. Lond., 43: 1027, 1950. GOLDSTEIN, A. E. AND ABEsr-rousE, B. S.: Partial resections of the kidney. J. Urol., 38: 15, 1937. ABEsnm;sE, B. S. AND LERMAN, S.: Partial nephrectomy versus pyelolithotomy and nephrolithotomy in the treatment of localized calculous disease of the kidney, with a report of 17 partial nephrectomies. Surg., Gynec. & Obst., 91: 209, 1950. CLARK, F. B., CHUTE, R. AND RUDY, H. A.: Partial nephrectomy. J. Urol., 72: 6, 1954. Kusi::NCKI, T.: Partial nephrectomy. Urol. Internat., Basel, 1: 243, 1955. PurnvERT, A.: La nefrectomia partial. Rev. Brasil Cirurg., 29: 413, 1955. AzAGARA, L.: Traumatismo renal nefrectomia parcial. Arch. Espafi. Urol., 11: 126, 1955.