Vol. 115, January Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
O riginal Articles DISSOLUTION OF RESIDUAL RENAL CALCULI WITH HE ~ IACIJ?RIN STEPHEN C. JACOBS
AND
RUBEN F. GITTES*
~ e,,/4v,,v
From the Division of Urology , Department of Surgery, University Hospital , San Diego, California
ABST RA CT
Hemiacidrin irrigation of the renal collection system via nephrostomy for the dissolution of residual postoperative calculi is described in 14 cases. The irrigation successfully dissolved 13 to 16 caliceal calculi. It did not dissolve any parenchymal calcifications. No known stones of pure calcium o ~ r apatite have been dissolved. Residual stones can safely be dissolved with hem1ac1dnn irrigation via nephrostomy if~ar open drainage and scrupulously sterile urine are maintained. __ Residual renal calculi following pyelolithotomy for infected hemiacidrin infusion was begun. The patients were taught how stones represent an infected nidus for future regrowth of to disconnect the infusion at the first sign of flank discomfort , calculus, particularly struvite , and continuing pyelonephritis. assuring immediate cessation of the infusion if outflow obstrucMany investigators have attested to the desirability of com- tion or extravasation should occur (see figure). Renal calculus plete removal of all residual stone fragments for the prevention size was followed by plain roentgen films of the abdomen and of future infected calculi. However, surgical exploration does nephrotomography . During the hemiacidrin infusion daily not always result in the complete removal of calculi. In 1959 urine cultures were obtained and a positive urine culture led to Mulvaney reported on the dissolution of urinary tract calculi immediate cessation of the infusion . with local irrigation using 10 per cent hemiacidrin solution. t 1, 2 This solution is a mixture of gluconic and citric acid and their RESULTS mag~ unction pro ably b ma nesi -calData on the 14 patients are summarized in table 1. Only 3 ~ e~ g a rom:.e..§o u -les1!:lt. 3 We report on the use ofnem1acidrin renal pelvic irrigation as patients had not had previous renal calculi either passed or an adjunct to stone operations in an effort to free patients of removed surgically. The present operations to render these patients free of stone included 20 pyelolithotomies and 1 stones and infection. ureterolithotomy. One of the pyelolithotomies was performed at another institution and the patient was referred for irrigaMATERIALS AND METHODS tion . Nephroscopy was used as an adjunct in 13 of the Clinical material . Fourteen patients with renal calculi pyelolithotomies (65 per cent). underwent 20 stone operations, which included the placement Stone analysis. Nine patients had struvite (MgNH,PO, · of 15 nephrostomies to be used for postoperative irrigation 6H 2 0) stones, 2 had apatite (Ca 10 (P0,) 0 (0H) 2 ) stones, of the kidneys with hemiacidrin . All patients had symptoms of 1 had a mixed apatite and struvite stone and 2 had calcium upper urinary tract calculi (fever and/or flank pain) except 1 oxalate stones. Table 2 details the postoperative results. who had bilateral parotitis. All patients had renal stones on Residual stone fragments included 4 parenchymal and 16 plain roentgen films of the abdomen. Of the 14 patients 11 had caliceal stones. Of the 16 caliceal stones 13 were completely a Proteus species cultured from the urinary tract, while 2 had dissolved. Three of the 16 caliceal calculi could not be Escherichia coli isolated and 1 had sterile urine. dissolved-1 because azotemia contraindicated further irrigaAll patients first had open stone operations. Nephrostomy tion and 1 because its location in a caliceal diverticulum tubes were left in 15 kidneys-in 9 kidneys because residual probably did not allow sufficient access for the hemiacidrin. stone fragments were visible by x-ray and in 6 kidneys because One apatite stone failed to dissolve after 6 days of irrigation. residual Randall's plaques were noted at nephroscopy. Biochemical dissolution of stones . Postoperatively, nephros- This patient underwent a second successful pyelolithotomy. The parenchymal calcifications did not change despite 3 to 22 tomy drainage was maintained with appropriate antibiotics for days of irrigation. No known hard stones (100 per cent oxalate 3 to 25 days. Sterile nephrostomy urine cultures were mandaor apatite) have been dissolved. tory before irrigation of the renal pelvis. A nephrostogram was In 5 patients the hemiacidrin infusions were performed for obtained to ascertain patency of ureteral drainage and the residual Randall's plaques seen at nephroscopy . There was no absence of extravasation 2 days before the renal pelvic irrigaroentgenographic evidence of retained caliceal stones postopertions were to begin. Sterile normal saline infusion of the renal atively or since and, thus, there is no proof of the efficacy of the pelvis at 120 cc per hour was begun 24 hours prior to irrigation. infusion in these cases. If no leakage or flank pain occurred with the saline infusion Complications. One major and 7 minor complications occurred in 6 patients. The major complication was a rise in serum creatinine from 2.0 to 5.2 in patient M. H . This patient Accepted for publication June 20, 1975. Read at annual meeting of American Urological Association, Miami was started on kanamycin to assure a sterile urine 2 days before Beach, Florida, May 11-15, 1975. the hemiacidrin infusion was begun . After 12 days of infusion * Requests for reprints: Department of Urology, Peter Bent Brigham both drugs were discontinued because of a rise in the creatinine Hospital, Boston, Massachusetts 02115. t Renacidin, Guardian Chemical Corp., Hauppauge, New York from 2.0 to 2.3. The creatinine increase continued and reached 11787. a peak of 5.2, 5 days later. Nephrotomography showed no 2
3
DISSOLUTION OF RESIDUAL RENAL CALCULI WITH HEMIACIDIUN
change in the retained calculus. The creatinine level returned slowly to the preoperative level of 2.0 by 2 months postoperatively. No fever occurred in this patient during the entire postoperative course.
The minor complications included 3 transient temperature elevations as high as 100.6 degrees. The temperature elevations were treated with immediate cessation of the irrigation. Reculture of the nephrostomy urine to ascertain its continuing sterility was performed. After defervescence and the demonstration of a continuing sterile nephrostomy urine, the infusion was continued in 2 patients. In 1 patient a positive nephrostomy urine culture led to discontinuation of the infusion. Bladder irritability requiring transient Foley urethral catheterization or cessation of therapy occurred in 3 patients. The hemiacidrin infusion was stopped in 1 case when a small amount of blood appeared in the ilea! loop urine. Subsequently, a small calculus passed into the loop bag. Followup. Followup data are available on 12 of the 14 and all are doing have been followed for 3 to :30 months 17). No patient has had recurrent stones or enlargement of any residual stones. One has had recurrent lower tract infections. Of the ;i who v,ere not rendered free of stone l has undergone a 1 has had an of flank successful second pain and 1 has been lost to fo!lowup. DISCUSS!Ol\
Failure to remove all stone fragments and sterilize the utiJifu-_y__tract -leads to ·a high rate-or·recuiience-:--une of our patients h;r1Viirev1ousstone-o"peralioris~1he use of hemiacidrin renal irrigation is 1 method for removing residual fragments that often harbor urea splitting bacteria, usually Proteus. W~_l:t1:1ve found intraoperative nephroscopy to be an extremely -valuabie--aafu.i1cf-in- remo-ving as -m-any-i::aTculus particles as. possiliiebut we-tmve stilrenc-offnte-rea-case-s in wfiicn-flienep1iroscop-yraiTodlov1si.iaEze a sfone seen X-ray and removal orthe calculus was pos-sibie-wilhout excising valuable renal tissue. In our cases b.emiacidrin was successful frequently · m mssolvmg the roentgenographic evidence of stones that were in free communication with the collecting system if no complications intervened to prevent continued use of the infusion. The maintenance of a sterile urine was of prime considera· tion ln th.esepaEenE.· The T4 paTienfs naB an average of 2 anti5iotics during hospitalization. Two patients with renal pelvic yeast infection were treated with 10-day courses of 5 fluorocytosine to assure sterility before hemiacidrin was begun. Roe_n_tg~mographic and manometric proof of a freely draining
·on
Arrangement of nephrostomy irrigation, permittin,,; patient to open outlet clamp for immediate decompression of collecting system. TABLE
Pt.-No.-Sex-Age
Stone Location
1. Clinical summary Infecting Organism
Stone Analysis
PJ-544140-F-46
Bilat. staghorn
E.coli
Struvite
ApaMe 60% M ucoprotein 40% Struvite
PL-576079-F-41
Rt. pelvis
Proteus
JS-488591-M-30
Bilat. staghorn
DJ-584566-M-19
SB-65-255-M-2', ER-611.555-M-47
Bilat. multiple caliceal Bilat. multiple caliceal Rt. ureteropelvic branched Lt. staghorn Rt. pelvis Rt. distal ureter Lt. staghorn Bil at. staghorn
Proteus, E. coli. yeast Proteus
EG-496333-F-57 BL-580872-F-47 HJ-501827-M-:18 PL-608587-M-33 JP-61:l368-F -55
3 lt. caliceal Lt. staghorn 2 rt. caliceal Rt. pelvis Rt. staghorn
NB-560511-F-39 MH-448813-F-67 FM-577476-M-64
Operations Lt. and rt. pyelolithotomy Lt. and rt. partial ne. phrectomy Rt. pyelolithotomy
Struvite
Lt. and rt. pyelolithotomy Rt. ilea! ureter Rt. and lt. pyelolithotomy
Proteus, E. coli
Struvite
Bilat. pyelolithotomy
Proteus, E. coli
Struvite
Rt. pyelolithotomy
Proteus
Struvite
Proteus Proteus
Struvite Apatite'
E.coli Proteus Proteus Sterile Proteus
Oxalate Struvite Struvite Oxalate Struvite 60('( .Apatite 40%
Rt. ureterolithotomy Rt. and It. pyelolithotomy Rt. ureteroneocystos tomy Lt. pyelolithotomy Rt. nephrectumy Lt. pyelolithotomy Lt. pyelolithotomy Lt. pyelolithotomy Rt. pyelolithotomy Rt. pyelolithotom:i Rt. p:velolithotomy
4
JACOBS AND GITTES TABLE
Pt.
Residual Stone Size
PJ
Lt. 9 x 8 mm. caliceai Lt. parenchymal Rt. 12 x 3 mm. caliceal Lt. 10 X 5, 8 X 5 mm. caliceal
PL JS DJ
Hemiacidrin 6days 4days 72 hrs.
2. Postoperative results
PostIrrigation Size 0 Unchanged 0 0
9days
0
8days
Unchanged
Complications
Followup (mos.)
0
30
0
19 17
Temperature rise to 100 degrees, + urine culture, therapy stopped Hematuria, therapy stopped, passed stone Temperature rise to 100 degrees
Lost
NB
Lt. 10 X 7, 6 X 3, 4 X 3, 7 x 2 mm. caliceal Rt. parenchymal
22 days
0
MH
Lt. 12 X 7, 10 X 6, 15 X 6, 11 x 7 mm. caliceal Lt. parenchymal 31 x 6 mm. caliceal
12 days
Unchanged Unchanged
FM
15 x 11 mm. collection in caliceal diverticulum
8 days
Unchanged
SB ER
Lt. 5 x 5 mm. caliceal 10 x 8 mm. caliceal
5days 6days
0 Unchanged
0 0
21 3
EG BL HJ PL
Randall's plaques Randall's plaques Randall's plaques Randall's plaques Rt. 2 x 2 mm. parenchymal Randall's plaques
0 0 0 0 Unchanged 0
0 0 0
15 15 29
JP
48 hrs. 36 hrs. 48 hrs. 72 hrs. 72 hrs.
Results 2 lower urinary tract infections Excellent Good ?
24
Excellent
22
Fair: stone has not grown, creatinine 2.0, 1 episode of flank pain without fever ?
0
Creatinine rise from 2.0 to 5.2 on kanamycin and hemiacidrin, bladder irritability Bladder irritability, temperature rise to 100.6 degrees
Lost
Excellent Required repeat pyelolithotomy Excellent Excellent Excellent
Bladder irritability 0
6 3
Excellent Excellent
collecting system without extravasation was demanded before REFERENCES Tnfusion was begun. ~ 1. Mulvaney, W. P.: A new solvent for certain urinary calculi: a Rosen and associates gave intravenous hemiacidrin to dogs preliminary report. J. Urol., 82: 546, 1959. and determined that serum magnesium rose in proportion to 2. Mulvaney, W. P.: The clinical use ofrenacidin in urinary calcificathe rate of infusion.• Death from hypermagnesemia occurred tions. J. Urol., 84: 206, 1960. only at infusion rates equivalent to 280 cc per hour intrave- 3. Nemoy, N. J. and Stamey, T. A.: Surgical, bacteriological, and biochemical management of "infection stones". J.A.M.A., 215: nously for 70 kg. man. Infu · s via ne hrostomy have not 1470, 1971. exceeded 120 cc per hour in our series or any of t e ot er published series·· 8·" and certamly only a fraction of tiu; 4. Rosen, D. I., Nemoy, N. J., Wolf, P. L. and Stamey, T. A.: Intravenous infusion of renacidin in dogs. Invest. Urol., 9: 31, infusion could be absorbed via elovenous backfl w. Other 1971. deran emen s note with intravenous hemiacidrin h a v ~ 5. Ries, S. W. and Malament, M.: Renacidin: a urinary calculi ransient elevations o creatmme, serum g u am1c oxa oacetic solvent. J. Ural., 87: 657, 1962. transammase and white blood count at 24 hours wtuch rapialy 6. Auerbach, S., Mainwaring, R. and Schwarz, F.: Renal and ureteral returned to normaI. • H)'Qfil'.magnesem1a lias not been a pro~ damage following clinical use of renacidin. J.A.M.A., 183: 61, 1963. lem in the re2orted series. Serum magnesium levels did not change in tile 4patients in whom we made determinations. We 7. Fostvedt, G. A. and Barnes, R. W.: Complications during lavage therapy for renal calculi. J. Urol., 89: 329, 1963. do recommend following creatinine levels in view of our patient 8. Kohler, F. P.: Renacidin and tissue reaction. J. Urol., 87: 102, 1962. with azotemia. Currently this drug remains withdrawn for use in the renal COMMENT pelvis by the Food and Drug Administration, chiefly because of The authors have reported a series of patients in whom fragments of 4 reported deaths occurring in patients undergoing treatment.•-• Nemoy and-£tamey ~viewed the reported struvite calculi but not other types that could not be removed at operation were dissolved by irrigation with hemiacidrin. Struvite cases and found that sterile uri e was not ascertained in th · e dissolves much more readily in an acid medium than does apatite or se sis eared to have been the cause f calcium oxalate and the efficacy of the irrigation procedure was cases an t e rrigation of the renal pelvis via ureteral catheters has undoubtedly more dependent on the acidity (pH 4.0) of the hemiacibeen used by other investigators.• Because of the frequent drin solution than its complement of citrate, which has relatively little obstruction of these catheters 2 • 5 and, thus, of all renal pelvic ability to complex magnesium or calcium at this low pH. Less drainage we believe that the use of ureteral catheter irrigation hypertonic solutjons or other organic acids might also be effective in of the renal pelvis should be limited to those patients in whom dissolving struvite stone fragments but the authors and others have again demonstrated that with adequate precautions hemiacidrin may a nephrostomy cannot be placed. We conclude that residual stones can safely be dissolved be used safely and effectively in this demanding therapeutic situation. with hemiacidrin irrigation via nephrostomy if clear open W.C.T. drainage and scrupulously sterile urine are maintained. Dr. G. W. Kaplan provided care of patient S. B.
*11~~~( M ~ ~'\,ili
~ 1f - ~~ c rJS ~ ~1.e )1,1,\2., v l,~l r1-i
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
O riginal Articles DISSOLUTION OF RESIDUAL RENAL CALCULI WITH HE ~ IACIJ?RIN STEPHEN C. JACOBS
AND
RUBEN F. GITTES*
~ e,,/4v,,v
From the Division of Urology , Department of Surgery, University Hospital , San Diego, California
ABST RA CT
Hemiacidrin irrigation of the renal collection system via nephrostomy for the dissolution of residual postoperative calculi is described in 14 cases. The irrigation successfully dissolved 13 to 16 caliceal calculi. It did not dissolve any parenchymal calcifications. No known stones of pure calcium o ~ r apatite have been dissolved. Residual stones can safely be dissolved with hem1ac1dnn irrigation via nephrostomy if~ar open drainage and scrupulously sterile urine are maintained. __ Residual renal calculi following pyelolithotomy for infected hemiacidrin infusion was begun. The patients were taught how stones represent an infected nidus for future regrowth of to disconnect the infusion at the first sign of flank discomfort , calculus, particularly struvite , and continuing pyelonephritis. assuring immediate cessation of the infusion if outflow obstrucMany investigators have attested to the desirability of com- tion or extravasation should occur (see figure). Renal calculus plete removal of all residual stone fragments for the prevention size was followed by plain roentgen films of the abdomen and of future infected calculi. However, surgical exploration does nephrotomography . During the hemiacidrin infusion daily not always result in the complete removal of calculi. In 1959 urine cultures were obtained and a positive urine culture led to Mulvaney reported on the dissolution of urinary tract calculi immediate cessation of the infusion . with local irrigation using 10 per cent hemiacidrin solution. t 1, 2 This solution is a mixture of gluconic and citric acid and their RESULTS mag~ unction pro ably b ma nesi -calData on the 14 patients are summarized in table 1. Only 3 ~ e~ g a rom:.e..§o u -les1!:lt. 3 We report on the use ofnem1acidrin renal pelvic irrigation as patients had not had previous renal calculi either passed or an adjunct to stone operations in an effort to free patients of removed surgically. The present operations to render these patients free of stone included 20 pyelolithotomies and 1 stones and infection. ureterolithotomy. One of the pyelolithotomies was performed at another institution and the patient was referred for irrigaMATERIALS AND METHODS tion . Nephroscopy was used as an adjunct in 13 of the Clinical material . Fourteen patients with renal calculi pyelolithotomies (65 per cent). underwent 20 stone operations, which included the placement Stone analysis. Nine patients had struvite (MgNH,PO, · of 15 nephrostomies to be used for postoperative irrigation 6H 2 0) stones, 2 had apatite (Ca 10 (P0,) 0 (0H) 2 ) stones, of the kidneys with hemiacidrin . All patients had symptoms of 1 had a mixed apatite and struvite stone and 2 had calcium upper urinary tract calculi (fever and/or flank pain) except 1 oxalate stones. Table 2 details the postoperative results. who had bilateral parotitis. All patients had renal stones on Residual stone fragments included 4 parenchymal and 16 plain roentgen films of the abdomen. Of the 14 patients 11 had caliceal stones. Of the 16 caliceal stones 13 were completely a Proteus species cultured from the urinary tract, while 2 had dissolved. Three of the 16 caliceal calculi could not be Escherichia coli isolated and 1 had sterile urine. dissolved-1 because azotemia contraindicated further irrigaAll patients first had open stone operations. Nephrostomy tion and 1 because its location in a caliceal diverticulum tubes were left in 15 kidneys-in 9 kidneys because residual probably did not allow sufficient access for the hemiacidrin. stone fragments were visible by x-ray and in 6 kidneys because One apatite stone failed to dissolve after 6 days of irrigation. residual Randall's plaques were noted at nephroscopy. Biochemical dissolution of stones . Postoperatively, nephros- This patient underwent a second successful pyelolithotomy. The parenchymal calcifications did not change despite 3 to 22 tomy drainage was maintained with appropriate antibiotics for days of irrigation. No known hard stones (100 per cent oxalate 3 to 25 days. Sterile nephrostomy urine cultures were mandaor apatite) have been dissolved. tory before irrigation of the renal pelvis. A nephrostogram was In 5 patients the hemiacidrin infusions were performed for obtained to ascertain patency of ureteral drainage and the residual Randall's plaques seen at nephroscopy . There was no absence of extravasation 2 days before the renal pelvic irrigaroentgenographic evidence of retained caliceal stones postopertions were to begin. Sterile normal saline infusion of the renal atively or since and, thus, there is no proof of the efficacy of the pelvis at 120 cc per hour was begun 24 hours prior to irrigation. infusion in these cases. If no leakage or flank pain occurred with the saline infusion Complications. One major and 7 minor complications occurred in 6 patients. The major complication was a rise in serum creatinine from 2.0 to 5.2 in patient M. H . This patient Accepted for publication June 20, 1975. Read at annual meeting of American Urological Association, Miami was started on kanamycin to assure a sterile urine 2 days before Beach, Florida, May 11-15, 1975. the hemiacidrin infusion was begun . After 12 days of infusion * Requests for reprints: Department of Urology, Peter Bent Brigham both drugs were discontinued because of a rise in the creatinine Hospital, Boston, Massachusetts 02115. t Renacidin, Guardian Chemical Corp., Hauppauge, New York from 2.0 to 2.3. The creatinine increase continued and reached 11787. a peak of 5.2, 5 days later. Nephrotomography showed no 2
3
DISSOLUTION OF RESIDUAL RENAL CALCULI WITH HEMIACIDIUN
change in the retained calculus. The creatinine level returned slowly to the preoperative level of 2.0 by 2 months postoperatively. No fever occurred in this patient during the entire postoperative course.
The minor complications included 3 transient temperature elevations as high as 100.6 degrees. The temperature elevations were treated with immediate cessation of the irrigation. Reculture of the nephrostomy urine to ascertain its continuing sterility was performed. After defervescence and the demonstration of a continuing sterile nephrostomy urine, the infusion was continued in 2 patients. In 1 patient a positive nephrostomy urine culture led to discontinuation of the infusion. Bladder irritability requiring transient Foley urethral catheterization or cessation of therapy occurred in 3 patients. The hemiacidrin infusion was stopped in 1 case when a small amount of blood appeared in the ilea! loop urine. Subsequently, a small calculus passed into the loop bag. Followup. Followup data are available on 12 of the 14 and all are doing have been followed for 3 to :30 months 17). No patient has had recurrent stones or enlargement of any residual stones. One has had recurrent lower tract infections. Of the ;i who v,ere not rendered free of stone l has undergone a 1 has had an of flank successful second pain and 1 has been lost to fo!lowup. DISCUSS!Ol\
Failure to remove all stone fragments and sterilize the utiJifu-_y__tract -leads to ·a high rate-or·recuiience-:--une of our patients h;r1Viirev1ousstone-o"peralioris~1he use of hemiacidrin renal irrigation is 1 method for removing residual fragments that often harbor urea splitting bacteria, usually Proteus. W~_l:t1:1ve found intraoperative nephroscopy to be an extremely -valuabie--aafu.i1cf-in- remo-ving as -m-any-i::aTculus particles as. possiliiebut we-tmve stilrenc-offnte-rea-case-s in wfiicn-flienep1iroscop-yraiTodlov1si.iaEze a sfone seen X-ray and removal orthe calculus was pos-sibie-wilhout excising valuable renal tissue. In our cases b.emiacidrin was successful frequently · m mssolvmg the roentgenographic evidence of stones that were in free communication with the collecting system if no complications intervened to prevent continued use of the infusion. The maintenance of a sterile urine was of prime considera· tion ln th.esepaEenE.· The T4 paTienfs naB an average of 2 anti5iotics during hospitalization. Two patients with renal pelvic yeast infection were treated with 10-day courses of 5 fluorocytosine to assure sterility before hemiacidrin was begun. Roe_n_tg~mographic and manometric proof of a freely draining
·on
Arrangement of nephrostomy irrigation, permittin,,; patient to open outlet clamp for immediate decompression of collecting system. TABLE
Pt.-No.-Sex-Age
Stone Location
1. Clinical summary Infecting Organism
Stone Analysis
PJ-544140-F-46
Bilat. staghorn
E.coli
Struvite
ApaMe 60% M ucoprotein 40% Struvite
PL-576079-F-41
Rt. pelvis
Proteus
JS-488591-M-30
Bilat. staghorn
DJ-584566-M-19
SB-65-255-M-2', ER-611.555-M-47
Bilat. multiple caliceal Bilat. multiple caliceal Rt. ureteropelvic branched Lt. staghorn Rt. pelvis Rt. distal ureter Lt. staghorn Bil at. staghorn
Proteus, E. coli. yeast Proteus
EG-496333-F-57 BL-580872-F-47 HJ-501827-M-:18 PL-608587-M-33 JP-61:l368-F -55
3 lt. caliceal Lt. staghorn 2 rt. caliceal Rt. pelvis Rt. staghorn
NB-560511-F-39 MH-448813-F-67 FM-577476-M-64
Operations Lt. and rt. pyelolithotomy Lt. and rt. partial ne. phrectomy Rt. pyelolithotomy
Struvite
Lt. and rt. pyelolithotomy Rt. ilea! ureter Rt. and lt. pyelolithotomy
Proteus, E. coli
Struvite
Bilat. pyelolithotomy
Proteus, E. coli
Struvite
Rt. pyelolithotomy
Proteus
Struvite
Proteus Proteus
Struvite Apatite'
E.coli Proteus Proteus Sterile Proteus
Oxalate Struvite Struvite Oxalate Struvite 60('( .Apatite 40%
Rt. ureterolithotomy Rt. and It. pyelolithotomy Rt. ureteroneocystos tomy Lt. pyelolithotomy Rt. nephrectumy Lt. pyelolithotomy Lt. pyelolithotomy Lt. pyelolithotomy Rt. pyelolithotomy Rt. pyelolithotom:i Rt. p:velolithotomy
4
JACOBS AND GITTES TABLE
Pt.
Residual Stone Size
PJ
Lt. 9 x 8 mm. caliceai Lt. parenchymal Rt. 12 x 3 mm. caliceal Lt. 10 X 5, 8 X 5 mm. caliceal
PL JS DJ
Hemiacidrin 6days 4days 72 hrs.
2. Postoperative results
PostIrrigation Size 0 Unchanged 0 0
9days
0
8days
Unchanged
Complications
Followup (mos.)
0
30
0
19 17
Temperature rise to 100 degrees, + urine culture, therapy stopped Hematuria, therapy stopped, passed stone Temperature rise to 100 degrees
Lost
NB
Lt. 10 X 7, 6 X 3, 4 X 3, 7 x 2 mm. caliceal Rt. parenchymal
22 days
0
MH
Lt. 12 X 7, 10 X 6, 15 X 6, 11 x 7 mm. caliceal Lt. parenchymal 31 x 6 mm. caliceal
12 days
Unchanged Unchanged
FM
15 x 11 mm. collection in caliceal diverticulum
8 days
Unchanged
SB ER
Lt. 5 x 5 mm. caliceal 10 x 8 mm. caliceal
5days 6days
0 Unchanged
0 0
21 3
EG BL HJ PL
Randall's plaques Randall's plaques Randall's plaques Randall's plaques Rt. 2 x 2 mm. parenchymal Randall's plaques
0 0 0 0 Unchanged 0
0 0 0
15 15 29
JP
48 hrs. 36 hrs. 48 hrs. 72 hrs. 72 hrs.
Results 2 lower urinary tract infections Excellent Good ?
24
Excellent
22
Fair: stone has not grown, creatinine 2.0, 1 episode of flank pain without fever ?
0
Creatinine rise from 2.0 to 5.2 on kanamycin and hemiacidrin, bladder irritability Bladder irritability, temperature rise to 100.6 degrees
Lost
Excellent Required repeat pyelolithotomy Excellent Excellent Excellent
Bladder irritability 0
6 3
Excellent Excellent
collecting system without extravasation was demanded before REFERENCES Tnfusion was begun. ~ 1. Mulvaney, W. P.: A new solvent for certain urinary calculi: a Rosen and associates gave intravenous hemiacidrin to dogs preliminary report. J. Urol., 82: 546, 1959. and determined that serum magnesium rose in proportion to 2. Mulvaney, W. P.: The clinical use ofrenacidin in urinary calcificathe rate of infusion.• Death from hypermagnesemia occurred tions. J. Urol., 84: 206, 1960. only at infusion rates equivalent to 280 cc per hour intrave- 3. Nemoy, N. J. and Stamey, T. A.: Surgical, bacteriological, and biochemical management of "infection stones". J.A.M.A., 215: nously for 70 kg. man. Infu · s via ne hrostomy have not 1470, 1971. exceeded 120 cc per hour in our series or any of t e ot er published series·· 8·" and certamly only a fraction of tiu; 4. Rosen, D. I., Nemoy, N. J., Wolf, P. L. and Stamey, T. A.: Intravenous infusion of renacidin in dogs. Invest. Urol., 9: 31, infusion could be absorbed via elovenous backfl w. Other 1971. deran emen s note with intravenous hemiacidrin h a v ~ 5. Ries, S. W. and Malament, M.: Renacidin: a urinary calculi ransient elevations o creatmme, serum g u am1c oxa oacetic solvent. J. Ural., 87: 657, 1962. transammase and white blood count at 24 hours wtuch rapialy 6. Auerbach, S., Mainwaring, R. and Schwarz, F.: Renal and ureteral returned to normaI. • H)'Qfil'.magnesem1a lias not been a pro~ damage following clinical use of renacidin. J.A.M.A., 183: 61, 1963. lem in the re2orted series. Serum magnesium levels did not change in tile 4patients in whom we made determinations. We 7. Fostvedt, G. A. and Barnes, R. W.: Complications during lavage therapy for renal calculi. J. Urol., 89: 329, 1963. do recommend following creatinine levels in view of our patient 8. Kohler, F. P.: Renacidin and tissue reaction. J. Urol., 87: 102, 1962. with azotemia. Currently this drug remains withdrawn for use in the renal COMMENT pelvis by the Food and Drug Administration, chiefly because of The authors have reported a series of patients in whom fragments of 4 reported deaths occurring in patients undergoing treatment.•-• Nemoy and-£tamey ~viewed the reported struvite calculi but not other types that could not be removed at operation were dissolved by irrigation with hemiacidrin. Struvite cases and found that sterile uri e was not ascertained in th · e dissolves much more readily in an acid medium than does apatite or se sis eared to have been the cause f calcium oxalate and the efficacy of the irrigation procedure was cases an t e rrigation of the renal pelvis via ureteral catheters has undoubtedly more dependent on the acidity (pH 4.0) of the hemiacibeen used by other investigators.• Because of the frequent drin solution than its complement of citrate, which has relatively little obstruction of these catheters 2 • 5 and, thus, of all renal pelvic ability to complex magnesium or calcium at this low pH. Less drainage we believe that the use of ureteral catheter irrigation hypertonic solutjons or other organic acids might also be effective in of the renal pelvis should be limited to those patients in whom dissolving struvite stone fragments but the authors and others have again demonstrated that with adequate precautions hemiacidrin may a nephrostomy cannot be placed. We conclude that residual stones can safely be dissolved be used safely and effectively in this demanding therapeutic situation. with hemiacidrin irrigation via nephrostomy if clear open W.C.T. drainage and scrupulously sterile urine are maintained. Dr. G. W. Kaplan provided care of patient S. B.
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