Extracorporeal Renal Surgery and Autotransplantation for Complicated Stone Disease1
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Extracorporeal renal surgery and autotransplantation for complicated stone disease1 Andrew C. Novick, M.D. Most patients with extensive renal calculous disease can be managed satisfactorily by percutaneous or in situ surgical tech- niques. However, in selected patients with advanced nephrolithia- sis in whom prior surgical therapy has failed, extracorporeal renal lithotomy and/or autotransplantation may provide the best method of achieving complete stone removal and unobstructed urinary drainage from the upper urinary tract. The most common indica- tions for this approach are recurrent nephrolithiasis with stenosis of the renal pelvis or ureter, recurrent renal colic, and extensive ureteral loss following prior operative therapy. In all cases, close postoperative follow-up, with prevention of infection and treat- ment of metabolic disorders, is integral to successful long-term management. Index terms: Kidney calculi, therapy • Kidney, surgery • Kidney, transplantation Cleve Clin Q 52:21-26, Spring 1985 There is little doubt that most patients who require removal of renal calculi can be treated successfully with percutaneous or in situ surgical techniques. Nevertheless, extracorporeal surgery and autotransplantation may occa- sionally be useful in managing selected patients with ad- vanced renal calculous disease.1 In general, these are pa- 1 Section of Renal Transplantation, Department of tients with recurrent calculi and a history of surgical ther- Urology, The Cleveland Clinic Foundation. Submit- apy. In some cases, it is possible to remove the calculi while ted for publication Aug 1984; accepted Nov 1984. leaving the kidney in its native location and the primary 0009-8787/85/01/0021/06/$2.50/0 rationale for performing autotransplantation is to ensure Copyright © 1985, The Cleveland Clinic Foun- unobstructed drainage of urine and/or passage of recur- dation rent calculi from the upper urinary tract to the bladder. 21 Downloaded from www.ccjm.org on September 24, 2021. For personal use only. All other uses require permission. 1 22 Cleveland Clinic Quarterly Vol. 52, No. 1 Specific indications Recurrent nephrolithasis with stenosis of the renal pelvis or ureter Some patients with recurrent nephrolithasis will have associated fibrotic obstruction of the renal pelvis and/or upper ureter as the result of prior surgery. Proper management in such cases involves not only removal of calculi, but also upper urinary tract reconstruction to ensure free drainage, thereby eliminating stasis as a factor promoting recurrent calculi. These combined goals are most likely to be achieved with extra- corporeal renal lithotomy and autotransplanta- tion (Fig. 1). Fig. 1. A plain radiograph (left) shows a recurrent staghorn calculus in a 43-year-old man with a solitary left kidney. An intra- Complications secondary to stone surgery venous pyelogram (right) demonstrates a stricture of the upper ureter caused by fibrosis following a prior operation. Extracorpo- Ureteral obstruction and fistula formation are real pyelolithotomy and autotransplantation were performed. distressing complications of upper urinary tract surgery performed for stone disease. Extensive ureteral loss may be a sequela of such interven- The advantages of performing extracorporeal tion and, when in situ ureteral repair is not renal surgery include optimal exposure and illu- possible, autotransplantation provides an excel- mination, a bloodless surgical field, greater pro- lent method of urinary tract reconstruction.2 Al- tection of the kidney from ischemia, easier em- though ileal interposition has been the traditional ployment of microvascular techniques and optical method of ureteral replacement and has yielded magnification, facilitation of nephroscopy, supe- good results in properly selected patients, auto- riority of extracorporeal roentgenography for transplantation appears to offer several advan- detection of retained calculi, and the ability to tages. Most significantly, autotransplantation extract difficult stones under direct fluoroscopy. allows the integrity of the urinary tract to be In the case of repeat surgery involving extensive maintained, thereby avoiding problems such as perihilar fibrosis, the ureter and renal pelvis can mucous secretion and electrolyte reabsorption be dissected meticulously while preserving their which may result from ileal ureteral replacement. blood supply and avoiding injury to major arte- Postoperative bacteriuria occurs commonly with rial or venous branches. Also, removing and an ileal ureter and this can generally be pre- flushing the kidney causes it to contract, thereby vented by autotransplantation. Approximately facilitating more peripheral intrasinusoidal ex- 25% of patients treated with an ileal ureter have posure for extended pyelolithotomy. This may experienced some degree of functional renal de- obviate the need for nephrotomy incisions that terioration3; however, this has not occurred fol- would otherwise be required to achieve complete lowing autotransplantation, suggesting that this stone removal in situ. procedure may provide a more effective long- Autotransplantation of kidneys with severe term method of preserving renal function. A final parenchymal disease should be avoided. Such advantage of autotransplantation is that opera- kidneys generally flush poorly following their tive repair can be performed in the iliac fossa, removal, which could result in irreversible is- away from previous scarring and inflammation. chemic damage with lack of function postopera- tively. Also, autotransplantation may not be pos- Recurrent renal colic sible when severe atherosclerotic disease renders In some patients, multiple recurrent renal cal- the iliac arteries unsuitable for anastomosis to the culi and repeated episodes of ureteral obstruction renal artery. This determination can be made occur despite optimum medical therapy. Recur- through preoperative pelvic arteriography, rent calculous disease in these patients is gener- which should be adjunctively performed with ally due to chronic pyelonephritis, renal tubular preliminary renal arteriography in such cases. acidosis, cystinuria, or primary hyperparathy- Downloaded from www.ccjm.org on September 24, 2021. For personal use only. All other uses require permission. Spring 1985 Surgery and autotransplantation for stone disease 23 A, B Fig. 2. A. Plain radiograph of a patient with renal tubular acidosis, bilateral recurrent renal calculi, and a calculus in the upper left ureter. Several operations had been performed for removal of ureteral calculi. B. A Boari bladder flap was anastomosed to the pelvis of the autotransplanted right kid- ney. C. Intravenous pyelogram obtained three months later demonstrates a wide bladder flap extending to the renal pelvis (arrows). (Fig. 2, A and C, is from: Novick AC, Straf- fon RA, Stewart BH. Experience with extra- corporeal renal operations and autotransplan- tation in the management of complicated uro- logic disorders. Surg Gynecol Obstet 1981; 153:10-18, with the kind permission of the publishers.) Downloaded from www.ccjm.org on September 24, 2021. For personal use only. All other uses require permission. 1 24 Cleveland Clinic Quarterly Vol. 52, No. 1 roidism. In this setting, autotransplantation with the kidney after its removal. The first step in pyelovesicostomy is performed to allow direct extracorporeal renal preservation is immediate passage of subsequent stones into the bladder. flushing of the removed kidney with a chilled This is accomplished by anastomosing the renal electrolyte solution (500 mL) instilled into the pelvis to a Boari bladder flap, which then func- renal artery. This achieves rapid and uniform tions as a nonrefluxing large-calibre urinary con- cooling of the kidney; removes blood, with its duit.4 Patients with renal calculous disease that is coagulation factors and isoagglutinins; and pre- refractory to medical therapy have benefited vents cell damage by virtue of the composition of from this approach, which is preferable to ileal the particular electrolyte solution being em- interposition for the reasons just discussed (Fig. ployed. The removed, flushed kidney is then 2). submerged in ice slush to achieve preservation by simple cold storage. Coexisting staghorn calculus and renovascular There are two types of electrolyte flushing disease solutions: extracellular (i.e., saline, Ringer's lac- Sullivan et al5 described the successful appli- tate) or intracellular. The various intracellular cation of bench surgery for stone disease in a solutions are all basically modifications of the patient with a staghorn calculus and renal artery original Collins' solution. With simple cold stor- stenosis in the same kidney. The coexistence of age preservation, both types of solution are these two renal disorders, although distinctly un- equally effective for ischemic periods lasting up common, is a valid indication for extracorporeal to five hours. For longer periods of cold storage, lithotomy and autotransplantation, as they are intracellular solutions are superior. In patients the most effective methods for achieving simul- undergoing bench surgery or autotransplanta- taneous stone removal and vascular reconstruc- tion for renal calculous disease, the period of tion. extracorporeal renal preservation invariably lasts considerably less than five hours; therefore, Recurrent staghorn calculus either an extracellular or intracellular flushing There have been reports of extracorporeal solution may be employed satisfactorily.8 removal