Simplified Operative Nephroscopy

SIMPLIFIED OPERATIVE NEPHROSCOPY STEPHEN A. KOFF, M.D. From the Department of Surgery, Section of Urology, University of Michigan Medical Center, Ann Arbor, Michigan ABSTRACT - Zntraoperative nephroscopy is a valuable and practical adjunct to renal surgery. A simpli$ed methodology is described usingfamiliar cystoscopic equipment and techniques. Its particular usefulness in the definition of small radiolucent defects of the renal collecting system is illustrated. Intraoperative nephroscopy is a technique for en- The instrument ordinarily used is a 24 F doscopic visualization of the renal pelvis and McCarthy panendoscope with a straight sheath calyceal system. When operation is indicated, it fitted with water and lighting conduits in a fashion can be a valuable means of assisting in the diag- identical to that used during cystoscopy. Biopsy nosis and treatment of calculi and lesions in the forceps and fulgurating electrodes are available as renal collecting system. As originally described needed. by Trattner,’ standard endoscopic equipment and At operation the kidney is exposed and maneuvers were used to perform the intrarenal mobilized completely. The instrument is care- inspection and manipulations. Modifications of fully inserted through a small pyelotomy incision this equipment and technique have generated a on either the anterior or posterior surface of the more elaborate procedure and may have reduced pelvis. No attempt is made to prevent leakage of its practicability for routine use.2-4 irrigating fluid, but the wound is carefully packed We have found intraoperative nephroscopy to with pads, and the fluid is suctioned off as soon as be a valuable and practical adjunct to open renal it appears. Inspection of the pelvis, infundibula, surgery. By using routine cystoscopic equipment and calyces is performed while low pressure irri- and techniques, the method has been simplified gation into the pelvis provides for a clear view. and is adaptable to a number of operative situa- The movements of the instrument are similar to tions. It is particularly helpful in the definition of those performed during cystoscopy and are in small radiolucent filling defects of the renal col- concert with maninulationL of the kidney to permit lecting system in which there is a suspicion of inspection of all the collecting system ramifica- neoplasm. The following cases are presented to tions. Biopsy and fulguration capabilities are illustrate this usefulness and to describe the sim- utilized as needed. plified technique. Case Reports Operative Nephroscopic Technique Case 1 At the University of Michigan Medical Center, intraoperative nephroscopy has proved to be a A fifty-nine-year-old woman was admitted for valuable adjunct to the diagnosis and treatment of evaluation of gross hematuria and right flank pain. renal pelvic and collecting system lesions. Believ- Urologic history was negative except for previous ing that a simplified system would be most practi- urinary tract infection. Physical examination re- cal, we have streamlined the techniques de- vealed costovertebral angle tenderness on the scribed by Trattner and utilize only the instru- right but was otherwise normal. Results of renal ments and irrigating system that are standard for function tests were normal. Urine analysis cystoscopy and with which we are most familiar. showed numerous red blood cells but no white 260 UROLOGY / MARCH 1976 I VOLUME VII, NUMBER 3 FIGURE 1. (A) lntravenous pyelogram demonstrates two radiolucent defects along superior margin of right renal pelvis; left ureteropelvic junction obstruction is present. (B) Laminagraphy confirms renal pelvic lesions. (C) Selective renal arteriogram normal. FIGURE 2. (A) lntravenous pyelogram suggests sessile lesion along superior margin of left renal pelvis. (B) Lesion confkned by laminagraphy. (C) Normal left selective renal angiogram. blood cells or bacteria per high-power field. Case 2 Intravenous pyelography demonstrated two A fifty-five-year-old man with urinary retention radiolucent filling defects near the superior mar- was admitted. Physical examination was normal gin of the right renal pelvis. A left ureteropelvic except for an enlarged bladder. Laboratory data junction obstruction unchanged from previous revealed urinary infection and normal renal func- films was also noted (Fig. 1A). These filling de- tion studies. Intravenous pyelogram dem- fects were confirmed by laminagraphy and retro- onstrated a sessile lesion along the superior mar- grade pyelography (Fig. 1B). Cystoscopy was gin of the left renal pelvis (Fig. 2A). Laminag- normal. Results of urinary cytologic study were raphy (Fig. 2B) and retrograde pyelography cor- suspicious but not diagnostic for a transitional cell roborated the presence of this lesion. Cystoscopy neoplasm. A renal arteriogram was normal (Fig. revealed a trabeculated bladder with outlet 1C). obstruction but no neoplasm. Urinary cytologic The patient underwent flank exploration at study was positive for transitional cell carcinoma. which time the external appearance of the kidney Selective left renal arteriography was normal was normal. After mobilization of the kidney a (Fig. 2C). number 24 F panendoscope was inserted through The left kidney was grossly normal at the time a posterolateral pyelotomy. Inspection of the area of left flank exploration. After adequate mobiliza- in question showed it to be free of tumor and tion a number 24 F panendoscope was inserted stone, but two arterial pulsations were seen to through a posterior pyelotomy. An exophytic le- account for the filling defects. The pyelotomy in- sion, atypical for transitional cell carcinoma, was cision was closed, and the patient made an un- identified endoscopically. Using the biopsy for- eventful recovery. ceps, tissue fragments were removed and sent for UROLOGY / MARCH 1976 / VOLUMEVII, NUMBER3 261 FIGURE 3. (A) Retrograde ureteropyelography utilizingfiberoptic pediatric gastroscope demonstrates papillary mass projectingfi-om upper pole infundibulum. (B) Selective left renal arteriogram is normal. Pyelographic phase confirms filling defect in upper pelvis. pathologic study. The lesion proved to be an revealed a small exophytic mass at the origin of exudative and proliferative benign inflammatory the upper pole infundibulum which was not typi- mass with no evidence of neoplasm. Further en- cal for transitional cell tumor. Frozen sections of doscopic inspection of the pelvis was unremark- biopsy material revealed inflammatory tissue and able. The pyelotomy was closed, and the patient a fibrinopurulent exudate without evidence of had an uneventful postoperative course. The pa- neoplasm. The procedure was terminated, and tient has been followed endoscopically and pyelo- the patient was treated with antibiotics. He is graphically at three monthly intervals; urinary currently free of neoplasm. cytologic specimens have been negative, and no Case 4 evidence for neoplasm exists. A fifty-five-year-old woman underwent cystec- Case 3 tomy and ileal loop diversion for invasive transitional cell carcinoma of the bladder. Three A sixty-nine-year-old man was admitted for months postoperatively an intravenous pyelo- evaluation of gross hematuria. Four years prior to gram demonstrated the interval appearance of a admission he underwent cystectomy and ileal left renal intrapelvic mass. Repeat intravenous loop urinary diversion for invasive transitional cell pyelogram performed one month later was again carcinoma of the bladder. The patient was other- abnormal, and recurrent transitional cell car- wise asymptomatic and free of metastatic disease. cinoma was suspected. Results of urinary Renal function tests were normal. Intravenous cytologic study were negative. Renal function pyelogram with laminagraphy suggested a filling studies and hemogram were normal. defect in the left renal pelvis. Using a fiberoptic Exploration of the left kidney was performed, pediatric gastroscope to catheterize the left ure- and nephroscopy through a posterior pyelotomy teral orifice, retrograde pyelography disclosed a revealed no neoplasm. Prominent arterial pulsa- small papillary mass projecting from the upper tions were seen within the pelvis, and contiguous pole infundibulum (Fig. 3A). Left renal arterio- mucosal erosions with submucosal hemorrhage gram showed the renal vasculature to be normal were noted. The procedure was terminated, and and confirmed the presence of a pelvic filling the patient has since been asymptomatic and free defect during pyelographic phase (Fig. 3B). Re- of tumor. sults of urinary cytologic study were negative. The patient underwent exploration of the left Comment kidney which appeared normal to external inspec- Endoscopic visualization of the renal pelvis and tion Nephroscopy through a posterior pyelotomy collecting system is not a new technique. In 1941 262 UROLOGY / MARCH 1976 / VOLUME VII, NUMBER 3 Rupel and Brown5 introduced a method of endo- criminating evidence, and renal exploration is scopic examination of the renal pelvis and de- deemed necessary to exclude a neoplasm. To wait scribed its usefulness in extracting stone frag- and watch for growth or evidence of invasion is ments from the collecting system. Trattner’ unacceptable in that the chance for cure may be elaborated on this and in 1948 presented both the significantly compromised. Equally unacceptable instrument and the operative methodology nec- is radical surgery for a benign inflammatory le- essary to visualize the entire intrarenal collecting sion, calculi,

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