Treatment of Staghorn Calculi by Pole Resection

Transcription

1 International Urology and Nephrology 3 (4), pp (1971) Treatment of Staghorn Calculi by Pole Resection M. FRYCZKOWSKI Department of Urology, Surgical Clinic No. I, Silesian Academy of Medicine, Zabrze, Poland (Received February 26, 1971) From 1964 to 197 at the Surgical Clinic No. I in Zabrze, 126 kidney pole operations were performed for lithiasis. In a period of 6 to 74 months, 25 ~ of recurrent staghorn calculi and 7.7 ~ of recurrent calyx lithiasis were detected, a total average of 16~ of renal stone recurrences. The high percentage of cases with systolic hypertension following kidney pole excision is still an inexplicable phenomenon. Staghorn calculosis treatment yielded poor results up till now [2, 3, 5, 8, 9, 11, 13]. This explains the existence of numerous controversial methods of treatment for staghorn stones [1, 5, 6, 7]. Many authors assume that the majority of sterile stones would not damage the renal parenchyma and therefore the kidneys work efficiently for a long time. On the basis of this assumption they do not undertake any operative interventions in case of lithiasis in this form [5, 11 ]. Others, however, favour surgery in such cases because statistically it gives better results. The old methods for removing staghorn calculi (pyelolithotomy and nephrolithotomy) result in a high percentage of recurrences [2, 3, 6, 12, 13]. To improve the results of surgery in lithiasis partial excision of kidney parenchyma with simultaneous removal of staghorn calculi have been recommended [2, 6, 7, 8]. Any resection of an urographically well functioning kidney or even a partial resection of its parenchyma is now regarded as inadequate. During operations on the solitary kidney or on kidneys with bilateral staghorn calculi, as well as in case of recurrent lithiasis, sparing the kidney parenchyma is not justified but often indispensable [1, 2, 3, 9, 11]. After the extraction of a stone by renal pelvis incisions recurrences were noted in ~ of the cases, while other methods of surgery in simple lithiasis have brought only 3-12~ of recurrences [1, 2, 3, 5, 7, 12]. Nonradical surgery for staghorn lithiasis or the so-called "nidus lithiasis" in the lower renal calyx is responsible for this, for the following reasons: 1. The extraction of a stone from the lower part of the calyx does not counteract urinary stasis in the extended calyx or inflammatory changes, epithelial or pericalyceal, nor does it eliminate calyx-cervix stenosis [1, 6, 7, 9, 14]. 2. Every "blind" operative method inside the calyx-pelvis system leads 2*

2 354 Fryczkowski: Treatment of staghorn calculi often to copious bleedings and there may remain some small stone fragments especially in case of dissected staghorn calculi [1, 2, 3, 5]. 3. In the remaining calyx there is a stasis cavity communicating with the rest of the calyx-pelvis system. This cavity is in the lowest part of the kidney and so components of urine settle in it. This, again, is a good environment for the recurrence of stones. Akillik [1 ] points out the similarity of this process to the inception of urinary bladder lithiasis, where adenoma of the prostate, bladder neck disease or any other obstacle to urine flow occur. The excision of a part of the kidney together with the stone theoretically prevents recurrences by elimination of the above mentioned causes. Thus, many authors are inclined to apply this method in the treatment of lithiasis. In the third decade of this century this method was introduced in the treatment of renal stone. Since then, many variations have been published and nowadays the operation does not represent any greater danger [9, 13]. Many reports on kidney pole resections for renal stone or tuberculosis show that complications such as bleedings and urinary fistulas are not more frequent than with any other operations on the urinary tract (6-1~o) [5, 7, 8, 14]. From the physiological point of view the following facts are worth pointing out: 1. The possibility of a compensatory hypertrophy of parenchyma in both kidneys. 2. The possibility of a satisfactory function on the remaining nephrons due to the newly created environments. Many animal experiments performed by Alan, Persky, Stewart and others, as well as the numerous reports on the longevity of individuals with half of a single kidney, indicate that the excision of a considerable part of the parenchyma does not lead to renal insufficiency [6, 9, 12]. There are two basic items which influence the successful course of this operation: 1. Blood supply to the remaining part of the renal parenchyma. 2. Efficient function of nerve-muscle mechanism in the renal pelvis and calyx. Anoxia of parenchyma which lasts for up to 25 minutes does not damage the kidney, but anoxia lasting (in normothermia) for more than one hour causes irreversible damage in the majority of cases [4, 1]. Stasis, being the result of reduced tension of the muscular coat of the renal pelvis and calyces, promotes chronic infection of the urinary tract with all its consequences. In our Department the technic of infracapsular, wedge-shaped resection of the kidney pole is being practised. The calyx-pelvis system is accurately blocked up with the thinnest catgut. Single stitches placed on parenchyma and fibrous capsule effect simultaneously haemostasis [6, 7, 14]. Kidney fistula is used only in exceptional cases. The average duration of ischemia does not exceed 2 minutes. From 1964 till the end of 197 in the Surgical Clinic No. I of the Silesian Academy of Medicine in Zabrze, we performed 126 kidney pole operations in 123

3 Fryczkowski: Treatment of staohorn calculi 355 patients with kidney lithiasis, including 61 cases of staghorn calculi and 62 cases of kidney calyx lithiasis (i.e. the so called "nidus lithiasis"). 63 cases of staghorn calculi were operated on. In 53 cases the lower pole and in 8 cases the upper pole of the kidney was resected. 3 operations were performed on the right kidney and 33 on the left one. In two cases the lower parts of both kidneys were resected. 6 patients operated on for staghorn calculi were followed up. The average age of the patients was 45 years, ranging from 7 to 67. Check examinations were carried out within the period of six to 74 months. The average postoperative period of check examinations amounted to 33 months. The following table represents the age groups. Table 1 Age up to 2 21 to 5 over 5 Total Men Women The results were as follows: There were 11% of considerable and 13 % of slight stone recurrences with a possibility of conservative treatment. Slight recurrences meant concretions, the diameter of which did not exceed.4 mm. The alleged renewals referred to five cases (1/3 of stone recurrences). Three cases represented slight recurrences in which the stone was situated in the ureter. In five cases stones were found in the calyx-pelvis system of the kidney. Out of 15 recurrences 1 were stones in the lower, previously resected pole. In six cases stasis was found in the lower part of the calyx. Nine patients had a single staghorn calculus and six of them had some dissected staghorn stones. Before operation pyuria, as a symptom of infection, appeared in 42 cases and after operation only in nine of them. In eight cases of recurrent lithiasis and in nine cases of the stasis in the calyx-pelvis system pyuria lasted for more than six months. This fact confirms the observation that infection of the urinary tract increases the frequency of recurrences of lithiasis and prolongs the duration of stasis in the infected kidney. Stasis in the calyx-pelvis system was present in 31 cases before operation. It increased postoperatively in three cases (5 %), and in 28 cases (48 %) it diminished or disappeared completely. In four cases one kidney was urographically completely inactive before operation. Postoperatively in one case only the previously inactive kidney did not show urographic function. Table 2 shows postoperative complications. It is worth pointing out that in all cases the size of a non-resected kidney increased diagonally and longitudinally. The severity of hypertrophy varied considerably. The average hypertrophy of the kidney amounted to eight millimetres in length and four millimeters in width.

4 356 Fryczkowski." Treatment of staghorn calculi Complications Table 2 Number of cases Wound early (up to 1 days) bleedings I 1ate (after 1 days) Urinary temporary (up to 21 days) fistulae constant (over 4 days) Secondary bleedings from urinary tract Pyuria Arterial blood increase pressure fall Lithiasis considerable recur~re~a~e slight Secona'a~y excision of the kidney Died It was noted that in 11 cases the systolic blood pressure increase oscillated from 3 to 7 mm Hg, and in two cases the systolic pressure dropped by more than 4 mm Hg. An increase of systolic blood pressure exceeding 4 mm Hg was noted in five cases. As regards other cases the increase remained within the limits of 3-4 mm Hg. In four cases the postoperative complications were the most probable cause of this increase, as it was later shown by radiography. Haematuria with more than 5 blood corpuscles per field of vision was regarded as urinary tract bleeding. In the examined cases secondary resection of the kidney had to be performed, once on account of haemorrhage which had appeared some hours after operation and ~n another case because of recurrent lithiasis in the urographically inactive kidney. The latter occurred in a young woman with arterial hypertension around 2/11 mm Hg, where renal arteriography demonstrated cirrhosis of the kidney. Discussion The success of kidney lithiasis operation depends on the percentage of recurrences and of the functional results. The postoperative recurrences of staghorn calculi after pyelolithotomy amount approximately to 55 % [1, 2, 3, 12, 13]. Even worse results were stated following nephrolithotomy where the recurrences were as high as 69% (Balogh), 75% (Jordan) and 69% (Williams). Staghorn calculosis operations following various non-radical measures led to less than 4 % of stone recurrences (Papathassidias: 37 %; Williams: 37 %; Suterlend : 47 ~o). Thus, the 25 % recurrences, as compared with 13 % of nonoperative successful treatment, seem to be quite a passable result. Partial loss of renal parenchyma is not so decisive if a compensatory growth of parenchyma in the nonoperated kidney is taken into consideration (this has been proved in the examined cases).

5 Fryczkowski: Treatment of staghorn calculi 357 The other important result of the operation is the compensatory functional activity of the operated kidney. The incidence of postoperative complications (which is a reliable yardstick of surgical hazard) does not exceed 1 ~, nor does it differ from the similar data obtained by various authors [1, 2, 3, 5, 8]. However, late complications, especially bieedings after scarification of parenchyma, occur in 16 ~ to 2~ [3, 5, 12]. Thorough examinations show that some technical factors may influence the percentage of postoperative recurrences. Of 15 cases, in 1 stones recurred in the lower, previously resected pole of the kidney. At least a part of the recurrences were due to the calcification on catgut stitches. In six cases out of 15 stasis in the lower part of the operated kidney with the renewal in the place, might have been due to perfunctory calyx excision. Too large stumps of the excised calyx could have been responsible for it. The exact execution of this part of the operation may improve the results, which may be comparable to those obtained in the so-called "lithiasis nidus" in a lower part of the kidney pole. In 62 cases where the lower part of a kidney had been resected for this reason, late recurrences (6 to 76 months) were noted in 7.7~ of the cases (Piguert 5~, Stewart 9~, Williams 15~, Balogh 18 ~). This means that of 126 pole resections renal stones recurred in 16 ~. Reduction of the kidney parenchyma mass in case of normal blood flow may improve the circulation in the remaining part of the parenchyma. Our results, compared with those of other authors, clearly show a considerable rise in blood pressure after the resection of kidney poles. Laender and Riba noted an increase of blood pressure in 27 ~, Stewart in 22 ~ and Ruchenwald in 11 ~ of their cases. The results, which have been obtained up till now, do not solve the problem of postoperative complications such as: a haematoma in the region of the hilum, changes of the kidney axis, injury to renal endothelial vessels by clamps, scars obstructing blood flow or urine flow, and so on. These cannot be the only factors responsible for the increase of blood pressure after a pole resection. Such cases require renal arteriographic examinations and tests for renin activity in blood serum, which may yield some new evidence concerning the background of the complications. It may be presumed that the prolonged parenchymal disease, during which infection develops, may influence the change of blood pressure after operation. In numerous cases the consequences of prolonged lithiasis process cannot be eliminated by an operation, and the changes of blood supply to kidney parenchyma do not bring desirable results. Surgical intervention in the early stage of disease may permanently lower blood pressure, especially in those cases where it had been increased before operation.

6 358 Fryczkowski: Treatment of staghorn calculi Conclusions 1. Kidne-y-pote resection is the most radical surgical method of staghornlithiasis treatment. It leaves a large part of active parenchyma and simultaneously results in the lowest percentage of recurrences. 2. Kidney pole resection is a safe method yielding good functional results. This is evident from the improvement of urographical activity of the operated kidney as well as from the hypertrophy of the nonoperated one. 3. The total excision of the calyx of the kidney and stitching the parenchyma with an appropriate absorptive material may have considerable influence on the frequency of recurrences. 4. The high percentage of cases with postoperative increase of systolic blood pressure cannot be attributed to the postoperative complications alone, which lead to disturbances in the blood supply to the operated kidney. References 1. Akillik, M. : Unsere Ergebnisse der parietalen Nephrectomie bei Nierensteinen. Z. Urol. 68, 843 (1965). 2. Balogh, F., Kelemen, Zs., Czvalinga, I., K6ves, S.: Polresektion der Niere und Steinrecidive. Z. Urol. 62, 439 (1969). 3. Balogh, F., Kelemen, Zs., K/Sves, S., Czvalinga, I.: Ober den Weft der Nephrotomieu. Z. Urol. 62, 51 (1969). 4. Donohue, J. P.: Acute versus chronic experimental hypertension. Difference in pressor response to partial nephrectomy. J. Urol. 11, 21 (1969). 5. Janosz, F., Zielifiski, J. : The results of surgical treatment of staghorn calculi. Pol. Przegl. chit. loa, 1236 (1966). 6. Michatowski, E., Modelski, W. : Partial resection of a kidney. Pol. Przegl. ehir. 32, 453 (196). 7. Putassa, E. P.: Partial nephrectomy, new technique approach, operative indications and review of 51 cases. J. Urol. 88, 153 (1962). 8. Piguert, A.: Partial nephrectomy for renal lithiasis; experience with 28 cases. Int. Surg. 46, 555 (1956). 9. Piguert, A., Gittes, R. : Partial nephrectomy in the solitary kidney. Results in 1 cases of renal lithiasis. J. Urol. 1, 238 (1968). 1. Ruchenwald, K.: Nierenresektionen und renaler Hochdruck. Z. Urol. 59, 191 (1968). 11. Stromenger, P.: Pyelolithotomie mit transureteraler Dauersptilung als organerhaltende Behandlung von Korallensteinen der Niere. Z. Urol. 58, 96 (1966). 12. Semb, C., H/Seg, K., Vogt, A.: Die Teilresektion der Niere und die Nierenfunktion. Urologe 2, 131 (1963). 13. Taupitz, A. : Ober die Ergebnisse der Nierenteilresektion bei Urolithiasis, mit besonderer Beriicksichtigung der Steinpathogenese. Urolooe 2, 219 (1963). 14. Zielifiski, J. Szkodny, A.: Partial nephrectomy. Pol. Przegl. chit. loa, 1179 (1966).