International Urology and Nephrology 13 (1), pp. 51--54 (1981)

Bivalve Nephrotomy in the Management of Staghorn Calculi in the Solitary Kidney

E. PROCA

Department of Urology, Fundeni Hospital, Bucharest

(Received October 21, 1979)

An analysis of 17 patients who had undergone bivalve anatrophic nephrotomy for staghorn calculi in the solitary kidney is presented.

The postoperative course was uneventful in all cases but one. This technique is thought to be mandatory for removal of branched stones even in the solitary kidney, to prevent development of renal failure or improve the already existing one.

For obvious reasons the urological surgeon reluctantly embarks on surgical removal of a branched calculus in the solitary kidney.

The technique is difficult and time consuming. Renal failure may complicate the postoperative course or aggravate the existing renal deficiency. Stone frag- ments may perpetrate urinary infection and obstruct urinary passage, leading to prolonged fistulas.

Nevertheless,,the most frightening outcome is the uncontrollable haemorrhage which may require salvage nephrectomy. Consequently, arguments are looked for with a view to avoid operation: (a) the calculus is a so-called silent one and the patient has come too early for surgery; (b) uraemia and other compli- cations indicate that he came to late for it.

In either case, the surgeon remains in this "wise" neutral position, favouring conservative therapy. However, such a conception can no longer be held. The staghorn calculus is always aggressive for the kidney. Sooner or later, with clinical evidence or silently, renal parenchyma comes under pressure with subsequent scarring and atrophy.

Superimposed infection may hasten renal failure to a point of irreversibility. Surgical removal of stone remains the only possibility to stop parenchymal damage. Many techniques have been devised for this purpose, such~as extended intrasinusal pyelocalycotomy, pyelotomy associated with multiple small nephro- tomies, tactical polar nephrectomyand the great bivalve nephrotomy, Here we present our experience with tiffs last technique.

We consider the staghorn calculus to be a stone that entirely fills the renal pelvis and has mushroom components in all calyces forming one piece all together.

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52 Proca; Bivalve nephrotomy

Material and method

During the years 1976-1978, 138 patients with large branched calculi were operated upon at the Urological Department of Fundeni Hospital. The cases are presented in Table 1.

Table 1

No. of cases

Extended pyelocalycotomy Nephrolithotomy Pyelotomy -q- nephrotomy Pyelotomy + tactical lower

pole nephrectomy Total nephrectomy Bivalve nephrotomy

Total

48 5

24

2 23 36

138

Among the patients, 17 had a single kidney, the opposite kidney having been removed for nephrolithiasis. Four patients had previous pyelotomies on their solitary kidneys.

Renal function was normal in 6 patients, While 11 patients had uraemia of various degrees, with a mean blood urea value of 112 m g ~ and plasma creatinine of 4.9 mg ~.

The preoperative urine culture was sterile in 9 patients and positive in 8 (E. coli in 5 cases, and B. proteus in 3 cases). In all 17 cases surgical removal of the multibranched calculus was accomplished through extended bivalve nephro- tomy performed under renal artery clamping and cooling of the kidney with sterile ice chips. The kidney was approached through a lumbar incision with rib resection and fully mobilized, great care being taken to preserve the renal capsule. The upper ureter was taped to prevent stone fragments sliding into the conduit. The renal artery was dissected free, and either tourniquet-taped or clamped with the Satinsky clamp. Abnormal polar arteries were identified and clamped. The ischaemic time averaged 14 minutes, with a range of 9 to 32 minutes.

During surgery, renal temperature was thoroughly monitored with a thermo- probe (Siemens theater monitor with thermic module) and varied between 16 and 24~ (mean 22~

The renal parenchyma was largely incised from one pole to another, nephro- tomy being done along the relative avascular plane, as recommended by Boyce [5], which corresponds to the anterior aspect of the posterior calyces. No methylene blue injection or thermographic paper has been used, as suggested by Grdgoir and Osterlinck. The inferior calyx was opened first for better orientation of ex- tended nephrostomy. To make stone removal easier, in all cases but one the stag-

International Urology and Nephrology 13, 1981

Proca: Bivalve nephrotomy 53

horn calculus was fractured to smaller pieces, separate small incisions being made for fragments located in the calyces.

The renal cavities were then thoroughly irrigated with cool fluid from melting ice and a control Rx-film was taken.

The renal pelvis and calyces were closed with interrupted 000 catgut and the renal valves were approximated with a few deep sutures, complemented by a running capsular suture.

The kidneys retained uniformly their consistency and colour after declamping the renal artery.

All patients received postoperatively ampicillin or penicillin derivatives. Blood was transfused according to the degree of intraoperative blood loss or anaemia. For the first few days the necessary fluid and electrolytes were given intravenously.

The postoperative course was uneventful in all cases. There was no post- operative death or anuria. In all cases but one hematuria was mild and the urine cleared during the first 3-5 days. One patient had haematuria for 9 days.

In 15 patients the operative wound closed "per primam intentionem'. One patient had urinary leak for three weeks through the drainage tube and dried up after 24 hours of ureteral catheterization.

Another patient had wound disrupture with "per secundam" healing. Six patients with normal preoperative renal function left the hospital with normal values for blood urea and plasma creatinine, although in three of them there were mild temporary rises during the first postoperative week.

Of 11 patients with preoperative renal failure, 9 significantly improved (5 to normal blood urea level), the condition of one patient remained unchanged and one deteriorated (now under dialysis).

Among 8 patients with preoperatively infected urine, infection cleared in 3, while 2 of the 9 uninfected patients had positive urine culture on discharge.

In 2 cases small calyceal fragments remained undetected. All patients were followed up to a minimum of 5 months. The dialysed patient died during the follow-up period.

Discussion

In 1976, Blandy et al. [7] pointed out that staghorn stones are not silent and should always be removed. In their series 10 patients had solitary kidney.

The same aggressive approach is recommended by Stubbs et al. [2], after retrospective analysis of 30 stone patients with solitary kidney.

Our experience goes back to 1970, when we published a small series of 15 calculous cases complicated with advanced renal failure operated upon without kidney cooling. The results were disappointing, since 8 patients died postoperatively due to uraemia, infection or a combination of these.

With the advent of anatrophic nephrolithotomy under local hypothermia the results have dramatically changed, since the risks of haemorrhage and ischae-

International Urology and Nephrology 13, 1981

54 Peoca : Bivalve nephrotomy

mic atrophy of the renal parenchyma are minimized. Under such circumstances this technique may be reasonably indicated even for patients with branched calculi in a solitary kidney.

Improvement after stone removal has already been reported after anatrophic nephroli thotomy; our above results may be considered in this way.

However, we do not intend to be overenthusiastic. Patients with advanced renal failure must be carefully selected. Those with small contracted kidney, severely infected, or in terminal state may have little benefit, if any. Although local cooling provides effective protection against ischaemia, our policy is to shorten this period as much as possible, especially in uraemic patients. We take off the occluding arterial clamp immediately after closure of the renal cavities. This also helps in the identification of bleeding vessels.

Conclusions

Our experience is too limited for a definite conclusion with anatrophic nephroli thotomy in the solitary kidney, but the results are encouraging. Removal of such a calculus is mandatory for curtailing parenchymal damage and to prevent renal failure. Under special circumstances, including haemodialysis facilities, even uraemic patients are amenable to operation.

References

1. Osterlinck, W. : Experimental and preliminary clinical experience with thermography for avascular nephrotomy. J. Urol., 120, 528 (1978).

2. Stubbs, A. J., Resnick, M. I., Boyce, W. N.: Anatrophic nephrolithotomy in the solitary kidney. J. Urol., 119, 457 (1978).

3. Smith, M. J. V., Boyce, W. N. : Anatrophic nephrotomy and plastic eolyrhphy. J. UroL, 99, 521 (1968).

4. Maddern, J. P. : Surgery of the staghorn calculus. Brit. J. tyrol., 39, 237 (1967). 5. Boyce, W. N., Elkins, I. B. : Reconstructive renal surgery following anatrophic nephro-

lithotomy: follow-up of 100 consecutive cases. J. Urol., 111, 307 (1974). 6. Proca, E. : Despre tratamentul nefrolitiazei bilaterale asociate cu insuficientfi renal~t.

Chirurgia, Buc., 7, 617 (1970). 7. Blandy, J. P., Singh, M.: The case for a more aggressive approach to staghorn stones.

J. Urol., 115, 505 (1976).

International Urology and Nephrology 13, 1981