The Need of Conservatism in Renal Surgery1

The Need of Conservatism in Renal Surgery1

THE NEED OF CONSERVATISM IN RENAL SURGERY1 ARTHUR L. CHUTE Boston Received for publication June 15, 1925 Certain experiences, as well as observation...

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THE NEED OF CONSERVATISM IN RENAL SURGERY1 ARTHUR L. CHUTE

Boston Received for publication June 15, 1925

Certain experiences, as well as observations, have led me to wonder whether the time has not come for us to begin a campaign for conrnrvatism in renal surgery; whether in this field of surgery the pendulum has not swung too far toward the side of radical operation. I will admit that I have no conclusive evidence to offer but simply certain points that I believe have some suggestive value. At first I wish to report briefly some personal cases in which I believe too radical a course was followed. Observation has led me to believe that my experience is not unique. An instance that is particularly clear in my mind is that of a young woman whose left kidney I removed for a rather moderate degree of hydronephrosis and hydrometer five years ago. She had suffered from severe pain in her left loin and an attack or two of temperature. I have been unable to find in the hospital record the figures as to the functional value of the left kidney, but my recollection is that I took her kidney out because it was giving discomfort and because I felt that she had a good kidney on her other side. This patient returned a few weeks ago with a stone in her remain:ng kidney. To my mind this represents an instance of renal surgery that was probably not truly conservative in that I removed a kidney which although it was giving trouble, still had some considerable value. It is fair, I believe, to assume that the extra work thrown on the right kidney predisposed it to stone formation. As the stone in this instance was the size of a 1 Read at the annual meeting of the American Association of Genito Urinary Surgeons, Washington, D . C., May, 1925. 231

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small white bean, was in the lower calyx, and was accompanied by an infection, I fear this patient has a process started which is going to be steadily progressive. Two somewhat similar instances have come to my notice within the last few years where a nephrectomy had been done a few years before and in which at the time I saw these patients there was a hydronephrosis on the remaining side; the presumption is that it was there at the time of operation. One of these patients has died of uraemia; the other had, a short time ago when last seen, an infection of his remaining hydronephrosis but showed no evidence of failing renal function. In 1911 I saw a woman of forty-nine with bleeding from her right kidney. The bleeding had extended over twelve months. After a further period of six months, during which time she bled for all but two weeks, her hemoglobin was down to 60 per cent; she had a rather poor color, and a systolic blood pressure of 100 mm. Hg. I was able to get practically no phenolsulphonephthalein from her bleeding kidney but got 37 per cent from her good kidney. Her urine had a specific gravity of 1020; a urea of 2.34 per cent; the urine from her left kidney showed no evidence of renal disease. On that score I cut down and removed her right kidney which weighed 185 grams instead of about 150 grams. This kidney showed changes in the glomeruli and in the intertubular tissue. One pathologist said he felt sure the other kidney must be diseased; another said that he was not sure about it. This patient made a slow convalescence. Several months later her hemoglobin had risen to 85 per cent. I lost sight of this patient until 1923 when her doctor told me that she had a systolic blood pressure of 250 mm. at times and all the evidence of an advanced chronic nephritis in the remaining kidney; her condition was much the same on M ay 1, 1925; I do not doubt that simple decapsulation of the bleeding kidney or at most nephrostomy would have stopped her hematuria and would have allowed the saving of sufficient renal tissue to have carried this patient along comfortably for a longer period, perhaps a considerably longer period. Some years ago a man of twenty-six came to see me complain-

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ing of rather severe pain in his left loin. As a considerable number of previous x-rays had not given anything definite, I congratulated myself upon finding a very small shadow, perhaps 2 to 3 mm. wide in this man's left kidney and I advised its removal. In my search for this very small stone I injured the kidney to such an extent that I did not dare to leave it. One may say in this instance that an accident of surgery led to this misfortune, but I believe that my misguided enthusiasm in attempting to operate upon a stone which was still too small to be really operable, my failure to get an accurate surgical perspective, was the trouble. When last seen this man showed no evidence of renal insufficiency, and I trust that he never will, but we know that in a considerable proportion of cases there is a tendency to the bilateral formation of renal stone and that with one kidney doing all the work, the tendency is probably somewhat increased. I regret to say that a similar experience happened in still another case. As I have gone over my own cases and some others that have come under my observation, I have come to the conclusion that there are two factors that incline us toward radicalism in renal surgery. The first is our knowledge that one normal kidney is more than adequate to carry on the work of urinary excretion; this, combined with our desire to give complete relief and our experience that our conservative operations have not always done this, tend to make us willing to sacrifice a little renal tissue in the interest of a quick recovery: the second is that our more accurate methods of diagnosis of renal disease, methods by which we are able to recognize much lesser lesions than it was possible to do formerly, have rather distorted our perspective, causing us to put an over-great importance on relatively slight variations from the normal and at times to attempt a surgical idealism that is not true conservatism. There are certain conditions in which there need be no thought of conservatism as for instance in the presence of any form of malignant disease of the kidney, whether it be hypernephroma, papillary carcinoma, or sarcoma. A tuberculous involvement, limited so far as we can determine to one kidney, is in my opinion a definite indication for nephrec-

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tomy although the frequency with which, some years later, we find tuberculous disease appearing in the remaining kidney raises occasional doubts in one's mind. Totally destroyed pus kidneys are definite indications for nephrectomy, as are large hydronephrotic sacs. With the above conditions the kidney is either doomed to destruction or is already destroyed; no conservative measures will be of the slightest avail. Several of the types of renal disease unfortunately show a tendency to be bilateral or if the disease is not bilateral when first seen shows a tendency for the same condition to develop in the second kidney at a somewhat later period. This I believe makes it incumbent on us to conserve to the greatest degree possible any renal tissue that a patient with this condition possesses. We must, if possible, make the patient comfortable but there is a point beyond which we are not justified in sacrificing renal tissue for mere comfort. vVe must recognize that freedom from discomfort, possibly even freedom from renal pain, may at times be purchased only at a price in renal tissue that is greater than the individual can afford to pay. I remember some years ago being greatly shocked by an amputation of the lower leg that was done simply and solely to avoid the care of a varicose ulcer. The mutilation seemed to me greater than the discomfort warranted and yet the patient's loss in that case was really small when compared with that of a patient who has been subjected to an unnecessary loss of renal tissue. An amputated leg may be replaced after a fashion by an artificial limb; renal tissue, however, cannot be replaced and while one starts life with an adequate supply, one has none to waste. The cases in which I think there is a tendency to do radical · renal surgery, and in which it is especially important that we try to develop conservatism are the suppurations, the calculus cases, .cases of hydronephrosis, the so-called causeless hematurias and the rare instances of nephralgia. An important step has already been taken in the conservation of renal tissue in that now one almost never hears any one advise nephrectomy in those very acute inflammations of the kidney, the so-called hematogenous infections, for which nephrectomy

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was so strongly advocated a few years ago. It is pretty generally conceded that most of these patients get well without any operative treatment although decapsulation or nephrostomy may occasionally be indicated. In the case of the non-tuberculous renal suppurations, it is impossible to say just where we should draw the line between the cases that should be treated conservatively and those that should be subjected to nephrectomy. I do believe, however, that we should be very slow to remove any suppurating kidney that has a fair function without a thorough try at conservative measures, irrigations perhaps in the lesser degrees, and drainage through the loin in the more advanced stages. Double renal suppurations are very common and if there is suppuration in the second kidney, no matter how little, one should be especially cautious about doing a nephrectomy. I have little confidence in the tradition that the removal of a suppurating kidney will cause a slight suppuration in the other kidney to clear up. More often a condition of this sort will indicate the beginning in the second kidney of a suppuration similar to that in the side first involved and should be taken as a contraindication to nephrectomy under anything but most unusual conditions. With kidney stones, even when these are not very large, and in instances where the kidney shows a fair functional ability, there seems to be a tendency to radical operation. The frequency with which stones recur might seem to justify this. On the other hand, the frequency with which renal stones are bilateral (in 18 per cent of some cases I went over a year or two ago) makes it imperative that the patient with a fair renal function first be given the advantage of a nephro-lithotomy, resorting to the radical operation only when palliative measures have proved ineffective. While it is very important to remove a renal stone before it becomes large enough to produce any considerable destruction of kidney tissue by pressure or if possible before infection has taken place, yet attempts to get very small stones are often unsuccessful and when one persists in one's search for them he may injure the kidney to such an extent that it has to be removed.

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Another condition which is very apt to tempt us to radical operation is a moderate degree of hydronephrosis or hydronephrosis and hydroureter. One reason for this is that on the whole our plastic operations in cases of hydronephrosis have not been unqualified successes and nephrectomy offers an easy and sure way to rid the patient of his pain. Unfortunately hydronephrosis is found to be bilateral in an increasing number of cases and in the instances where this condition is of slight or moderate degree we should exhaust our means of conservative treatment before doing nephrectomy. In the great hydronephrotic sac conservation is impossible. The cases of so-called "causeless" or "idiopathic" hematuria offer a considerable field for the exercise of conservation. These hematurias are usually the result of a nephritis of some sort. At times this nephritic process involves the kidney generally, at other times but a part of it; in rare instances the bleeding is the r!:)sult of an infarct. Decapsulation, or at most nephrostomy, will in my experience almost invariably control this condition. The clinical case that I reported in the first part of this paper illustrates the undesirability of nephrectomy in cases of this sort. From time to time we see patients who complain of great renal pain without showing any considerable kidney lesion. These cases occasionally are submitted to nephrectomy in sheer desperation. Such cases as I have seen have been in neurotic women and decapsulation has given temporary relief, at least: in one case that I followed, this relief had lasted for some years at the time the patient disappeared from sight. I perfectly well appreciate that my suggestions are decidedly utopian in character, that there are many limitations to our diagnostic ability, and that many factors interfere with our ability to estimate accurately the worth, to a patient, of a given kidney. I also appreciate that many patients have renal conditions which make the prolongation of their lives for any length of time quite impossible, no matter what course one pursues, but I believe that there are others and quite a considerable number, in whom the wise conservation of renal tissue may prolong life for perhaps an appreciable period. It is true that at times this prolongation of

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life may have to be purchased at some loss of comfort, perhaps even at some more or less degree of invalidism. If we will keep before us the importance of saving as much renal tissue as possible and approach all renal operations with this in view, we will, in many cases, effect a definite lengthening of life. Naturally the more we attempt conservative measures the more expert we shall become in their use and the more successful they will be.