THE ,]U\,RNAL OF UROLOG\
Vol. 115, ,ianuar
Copynght © 1976 by The Williams & Wilkins Co.
Printed in U.S A
SURGICAL MANAGEMENT OF RENAL LESIONS USING IN SITU HYPOTHERMIA AND ISCHEMIA ROBERT P. GIBBONS, ROY J. CORREA, JR., KENNETH B. CUMMINGS
AND
J. TATE MASON
From the Division of Urology, The Virginia Mason Medical Center, Seattle, Washington
ABSTRACT
Many renal lesions that were once treated by nephrectomy now lend themselves to surgical correction. The value of in situ hypothermia and ischemia produced by occlusion of the renal artery is detailed. This technique has proved to be a simple, safe and effective surgical approach to the management of most difficult renal lesions. Many difficult renal lesions that were once treated by nephrectomy are now surgically correctable with a minimal loss of renal function. We have found that the majority of these lesions can be safely, easily and effectively managed by using the surgical technique of in situ hypothermia and renal ~rtery,. occlusion.
(fig. 1). Afler-25..gm ruannitol are given intravenill!filY,J3J;i:L10 cc heparin (20 units per cc) are injected into the main =al artery._.Th@ rn1u1L artery is immedia~ occluded with a vascular clamp, wj_th care_ being tak_en to ensure that the renal
FIG. 1. After mobilization rubber sheet is folded around kidney and pedicle with clamps placed where necessary to contain iced saline. Care must be taken not to kink renal vein. FIG. 2. Technique of in situ hypothermia with iced saline; ischemia produced by occlusion of renal artery.
TECHNIQUE
The kidney and vascular pedicle are entirely mobilized through any incision that provides good exposure of these structures. The kidney is then surrounded by a rubber sheet
'{©.ill. is not occluded by kinking. The space between the rubber dam ~ w i t h iced saline to completely immerse the kidney (fig. 2). If the kidney must be exposed during the D.p.e.rative procedureit is first allowed to coolfur.20 rI;:inutes, at which time ren.al...core temperature will reach the d~sired level of 15 to 20C. 1 ·• If most of the kidney can be ke])t
Accepted for publication June 13, 1975. Read at annual meeting of American Urological Association, Miami Beach, Florida, May 11-15, 1975.
12
SURGICAL MANAGEMENT OF RENAL LESIONS
13
Fm. :J. Simple method for maintaining available supply of iced electrolyte solutions
FIG. 4. Case 1. A, aortogram demonstrates intrarenal arteriovenous fistula (arrow) resulting in marked dilation of renal vein. B, postoperative aortogram with arrow at site of prior arteriovenous fistula.
igJ!i.!:_i.c!) ~J:h dmin_gJbe !2!:QC.l?_Q1,!re_o1-__i(0nephrotomy isJ;Q .Q~ ~rforme,;h clel(!Y.js not_nece_ssary because C()_CJlii,gyil!coaj,inue as the operation progress,_~,;;.. Duringlhe operative procedure the k{dney is kept with the iced saline solution. We have found that the easiest way to make saline slush is to
1noisf
take the intravenous or irrigation solutions of saline cornrneravailable in soft vinyl bags,* and sterilize them immersion for 10 hours in a solution. t The are then
14
GIBBONS AND ASSOCIATES
double wrapped on a sterile field and stored in the freezer. At the time of the operation the sterile bag can be opened on the surgical table and the ice can be broken with an orthopedic hammer into usable sizes (fig. 3).
FIG. 5. Doppler localization of intrarenal arteriovenous fistula used as adjunct to in situ hypothermia and ischemia.
CASE REPORTS
Case 1. A 50-year-old woman was found to be hypertensive during an evaluation for pedal edema. A bruit was heard in the left upper quadrant radiating into the flank. The arteriogram revealed an intrarenal arteriovenous fistula arising from a 1 cm. aneurysm in a tertiary branch of the renal artery (fig. 4, A). During the operation a Doppler flowmeter was used as an adjunct to the described technique to localize the fistula exactly and to confirm that it was closed after ligation of the aneurysm (fig. 5). 5 Total artery occlusion time was 87 minutes. An arteriogram 6 weeks postoperatively confirmed that the lesion has been repaired successfully with virtually no loss of renal tissue (fig. 4, B). Case 2. A 56-year-old man had a mass lesion in the right kidney and a hypoplastic left kidney (fig. 6, A). An arteriogram suggested that the lesion was a renal cell carcinoma (fig. 6, B). Differential renal function studies demonstrated insufficient function from the left hypoplastic kidney (creatinine clearance 9.9 cc per minute) to sustain life without dialysis or transplantation. We decided to perform a partial nephrectomy. 6 - 12 The mid-pole hypernephroma was excised using the technique of selective renal hypothermia and renal artery occlusion (fig. 7). The renal artery was occluded for 120 minutes. The creatinine level increased to a high of 2.3 mg. per dl. 1 day postoperatively but returned to the normal preoperative level of 1.1 mg. per dl. 4 days postoperatively. The excised neoplasm was a grade II, stage IA renal cell carcinoma with surgical margins free of tumor. Followup excretory urograms (IVPs) demonstrated little loss of renal tissue and differential function studies compared favorably to the preoperative values (fig. 8). Case 3. A 56-year-old woman had a branching calculus filling the intrarenal collecting system of the left kidney (fig. 9, A). During 2 years of observation the calculus continued to enlarge and to produce symptoms of fever, pain and urinary infection despite therapy with specific suppressive antibiotics. A calculus that had been in the right kidney passed spontaneously. The branching calculus was removed by using anatrophic nephrotomy and nephroscopy with water-pik irrigation as adjuncts to the described technique (fig. 9, B). 13 • 14 The renal
FIG. 6. Case 2. A, mass lesion in right kidney with hypoplastic left kidney. B, selective renal right arteriogram (subtraction study) compatible with renal cell carcinoma.
SURGICAL MANAGEMENT OF RENAL LESIONS
15
FIG. 7. Case 2. A, appearance of carcinoma during hypothermia. B, electrosurgical excision of hypernephroma. C, collecting system defects closed with 4-zero plain catgut. Blood vessels individually suture ligated with 4-zero chromic catgut. Defect filled with pararenal fat.
artery was occluded for 78 minutes. Blood loss was not sufficient to require transfusion. An IVP 12 postoperatively demonstrated prompt excretion of from the operated kidney. DISCUSSION
A surgical approach to any renal lesion should permit that lesion to be corrected with a minimal loss of nephron units and minimum morbidity to the patient. The surgical herein described is not new. H. 13 · 15 - 17 However, its value needs to be re-emphasized at this time bee a use -;;-yffieTurfenf more recenfii/aescrihed te€Q!}_i.._cui~~:~0L~£i:ac.orpiifiliil~iivm.:.krumr!:il surgery. with aulotransplantation. 18 · 22 We believe that the latte'"i;technique has be-eTCover=us'ed- and has been associated with too many technical failures resulting in dialysis or The effects of
mteres11n Tne
resection is bothersome. One must remember that the operabecause a radical norm.al ci.rcum-
stances< When faced -r1it.h this situation ·we
the uperative
16
GIBBONS AND ASSOCIATES
FIG. 8. Case 2. Postoperative IVP
FIG. 9. Case 3. A, symptomatic and enlarging branched calculus in left kidney. B, anatrophic nephrotomy as adjunct to in situ hypothermia and ischemia.
17
SURGICAL MANAGEMENT OF RE.'JAL LESIONS
' I-
!
standard operating rooms. There is ample exposure for a precise and bloodless dissection as well as ample protection against ischemia and blood loss. When compared to the workbench technique less operating time is required and there are fewer potential complications since the process avoids an additional incision, 2 vascular anastomoses and a possible ureterovesical anastomosis. REFERENCES
l. Kerr, W. K., Kyle, V. N .. Keresteci. A.G. and Smvthe, C. A.· Renal hypothermia. J. Uro!., 84: 236, 1960. · 2. Graves, F. T.: Renal hypothermia: an aid to partial nephrectomy. Brit. J. Surg., 50: 362, 1963. 3. Wilson, G. S. M.· Clinical experience in renal hypothermia. J. UroL 89: 666. 196:l. 4. Pahner. iJ. M., Guernsey) ,J. IVI. and Connolly, J. E: An experirnental study of selective renal hypothermia. Amer. rJ. Surg., 106: 224, 1963. 5 Gibbons. R. P., Correa, R. ,J.. eJr. and Tremann, A · Manag2ment of intrarenal vascular rr1alformations. Urology, l: L-36, 1973. 6. Grabstald, H. and Aviles. E.: Renal cell cancer in the solitary or sole-functioning kidney. Cancer, 22: 97:l, 1968. 7. Malek, R. S., Utz, D. C., Culp. 0. S., Kelalis, P. P. and Vlarren. IVI. M.: lVlalignant tumors of solitary kidneys. Mayo Clin. Proc., 47: 180, 1972. 8. Stackpole, R. H.: Treatment of carcinoma in a solitary kidney: case report and review of the literature. ,J. UroL 9:3: 35:l, 1965. 9. Parker, R. M., Timothy, R. P. and Harrison, H.: Neoplasia of the solitary kidney. J. Urol.. Hll: 28:l, 1969. 10. Kaufman, J. ,J., Chaffey, B. T. and Goodwin, W. E.: Renal cell carcinoma in the solitary kidney: report of six cases. Brit. J _ Urol., 40: 12, 1968. 11. Belzer, F. 0., Schweizer, R. T., Kountz, S. L. and deLorimier. A. A.: Malignancy and immunosuppression. Renal homotransplantation in patients with primary renal neoplasms. Transplantation, 13: 164, 1972. 12. Penn, I. and Starzl, T. E.: Immunosuppression and cancer. Transplant. Proc .. 5: 94:3, 197:3. 13. Smith, M. J. V. and Boyce, W. H.: Anatrophic nephrotomy and plastic calyrhaphy. J. Urol., S9: 521, 1968. 14. Gibbons, R. P., Correa, R. J., Jr., Cummings, K. B. and Mason, J.
T.: Use of water-pik and nephroscope. Urology, 4: 605, 1974. 15. Semb, C.: Partial resection of the kidney, operative technique. Acta Chir. Scand., 109: 360, 1955. 16. Semb, C.: Partial resection of the kidney: anatomical, physiological and clinical aspects. Ann. Roy. Coll. Surg., 19: 137, 1956. 17. Wickham, J. E. A. and Mathur, V. K.: Hypothermia in the conservative surgery of renal disease. Brit. ,J. Urol., 43: 648, 1971. 18. Ota, K., Mori, S., Awane, Y. and Ueno. A.: Ex situ repair of renal artery for renovascular hypertension. Arch. 94: :l70, 1967. B.: Total 19. Gel in, L-E., Claes, G., Gustafsson, A. and bloodlessness for extracorporeal organ repair. Rev. Surg .. 28: 30fi, 1971. 20. Hodges, C. ., Lawson, R. K., Pearse, H. D. and Stranburg, C. 0.: Autotransplantation of the kidney. ,J. Urol.. HO: 20. 197:3. 21. 11/Iilsten, R, Neifield. J., ,Jr. and Koontz, W. W., ,Jr.: Extracorporeal renal surgery. ,J. Ural.. H2: 425, 1974. 22. Gil-Vernet, J. IV!., Caralps. A., Revert, L., Andreu, ,J., Carretero, P. and Extracorporeal renal surgery. Work bench surgery. 5: 444, 1915. 2'' Schloerb, ?. R., Vlaldorf, R. D. and VVe!sh, J. S.: The protective effect of kidney hypothermia on total renal ischemia. Surg. Forum, 8: 633, 1957. 24. Mitchell, R M. and Woodruff, M. F. A.: The effects of local hypothermia in increasing tolerance of the kidney to ischernia. Transplant. Bull., 4: 15. 19fi7. 25. Steuber, P .. Kovacs. S .. Persky. L. and Koletsky, S.: Regional hypothermia. Surgery, 44: 77, 1958. 26. Birkeland, S .. Vogt, A., Krog, J. and Semb, C.: Renal circulatory occlusion and local cooling. ,J. Appl. Physiol., 14: 227, 19,59. 27. Cockett, A. T .. The kidney and regional hypothermia. Surgery, 50: 905, 1961. 28_ Boyce, W. H.: Radiology in the diagnosis and surgery of renal calculi. Radio!. Clin. N. Amer., 3: 89, 1965. COMMENT These investigators have elegantly illustrated and discussed the value of in situ hypothermia for the surgical management of difficult intrarenal lesions. Although recently workbench surgery has been enthusiastically endorsed as the preferred treatment for such problems, this timely publication should make us pause and reconsider the decision. P.C W.
Vol. 115, ,ianuar
Copynght © 1976 by The Williams & Wilkins Co.
Printed in U.S A
SURGICAL MANAGEMENT OF RENAL LESIONS USING IN SITU HYPOTHERMIA AND ISCHEMIA ROBERT P. GIBBONS, ROY J. CORREA, JR., KENNETH B. CUMMINGS
AND
J. TATE MASON
From the Division of Urology, The Virginia Mason Medical Center, Seattle, Washington
ABSTRACT
Many renal lesions that were once treated by nephrectomy now lend themselves to surgical correction. The value of in situ hypothermia and ischemia produced by occlusion of the renal artery is detailed. This technique has proved to be a simple, safe and effective surgical approach to the management of most difficult renal lesions. Many difficult renal lesions that were once treated by nephrectomy are now surgically correctable with a minimal loss of renal function. We have found that the majority of these lesions can be safely, easily and effectively managed by using the surgical technique of in situ hypothermia and renal ~rtery,. occlusion.
(fig. 1). Afler-25..gm ruannitol are given intravenill!filY,J3J;i:L10 cc heparin (20 units per cc) are injected into the main =al artery._.Th@ rn1u1L artery is immedia~ occluded with a vascular clamp, wj_th care_ being tak_en to ensure that the renal
FIG. 1. After mobilization rubber sheet is folded around kidney and pedicle with clamps placed where necessary to contain iced saline. Care must be taken not to kink renal vein. FIG. 2. Technique of in situ hypothermia with iced saline; ischemia produced by occlusion of renal artery.
TECHNIQUE
The kidney and vascular pedicle are entirely mobilized through any incision that provides good exposure of these structures. The kidney is then surrounded by a rubber sheet
'{©.ill. is not occluded by kinking. The space between the rubber dam ~ w i t h iced saline to completely immerse the kidney (fig. 2). If the kidney must be exposed during the D.p.e.rative procedureit is first allowed to coolfur.20 rI;:inutes, at which time ren.al...core temperature will reach the d~sired level of 15 to 20C. 1 ·• If most of the kidney can be ke])t
Accepted for publication June 13, 1975. Read at annual meeting of American Urological Association, Miami Beach, Florida, May 11-15, 1975.
12
SURGICAL MANAGEMENT OF RENAL LESIONS
13
Fm. :J. Simple method for maintaining available supply of iced electrolyte solutions
FIG. 4. Case 1. A, aortogram demonstrates intrarenal arteriovenous fistula (arrow) resulting in marked dilation of renal vein. B, postoperative aortogram with arrow at site of prior arteriovenous fistula.
igJ!i.!:_i.c!) ~J:h dmin_gJbe !2!:QC.l?_Q1,!re_o1-__i(0nephrotomy isJ;Q .Q~ ~rforme,;h clel(!Y.js not_nece_ssary because C()_CJlii,gyil!coaj,inue as the operation progress,_~,;;.. Duringlhe operative procedure the k{dney is kept with the iced saline solution. We have found that the easiest way to make saline slush is to
1noisf
take the intravenous or irrigation solutions of saline cornrneravailable in soft vinyl bags,* and sterilize them immersion for 10 hours in a solution. t The are then
14
GIBBONS AND ASSOCIATES
double wrapped on a sterile field and stored in the freezer. At the time of the operation the sterile bag can be opened on the surgical table and the ice can be broken with an orthopedic hammer into usable sizes (fig. 3).
FIG. 5. Doppler localization of intrarenal arteriovenous fistula used as adjunct to in situ hypothermia and ischemia.
CASE REPORTS
Case 1. A 50-year-old woman was found to be hypertensive during an evaluation for pedal edema. A bruit was heard in the left upper quadrant radiating into the flank. The arteriogram revealed an intrarenal arteriovenous fistula arising from a 1 cm. aneurysm in a tertiary branch of the renal artery (fig. 4, A). During the operation a Doppler flowmeter was used as an adjunct to the described technique to localize the fistula exactly and to confirm that it was closed after ligation of the aneurysm (fig. 5). 5 Total artery occlusion time was 87 minutes. An arteriogram 6 weeks postoperatively confirmed that the lesion has been repaired successfully with virtually no loss of renal tissue (fig. 4, B). Case 2. A 56-year-old man had a mass lesion in the right kidney and a hypoplastic left kidney (fig. 6, A). An arteriogram suggested that the lesion was a renal cell carcinoma (fig. 6, B). Differential renal function studies demonstrated insufficient function from the left hypoplastic kidney (creatinine clearance 9.9 cc per minute) to sustain life without dialysis or transplantation. We decided to perform a partial nephrectomy. 6 - 12 The mid-pole hypernephroma was excised using the technique of selective renal hypothermia and renal artery occlusion (fig. 7). The renal artery was occluded for 120 minutes. The creatinine level increased to a high of 2.3 mg. per dl. 1 day postoperatively but returned to the normal preoperative level of 1.1 mg. per dl. 4 days postoperatively. The excised neoplasm was a grade II, stage IA renal cell carcinoma with surgical margins free of tumor. Followup excretory urograms (IVPs) demonstrated little loss of renal tissue and differential function studies compared favorably to the preoperative values (fig. 8). Case 3. A 56-year-old woman had a branching calculus filling the intrarenal collecting system of the left kidney (fig. 9, A). During 2 years of observation the calculus continued to enlarge and to produce symptoms of fever, pain and urinary infection despite therapy with specific suppressive antibiotics. A calculus that had been in the right kidney passed spontaneously. The branching calculus was removed by using anatrophic nephrotomy and nephroscopy with water-pik irrigation as adjuncts to the described technique (fig. 9, B). 13 • 14 The renal
FIG. 6. Case 2. A, mass lesion in right kidney with hypoplastic left kidney. B, selective renal right arteriogram (subtraction study) compatible with renal cell carcinoma.
SURGICAL MANAGEMENT OF RENAL LESIONS
15
FIG. 7. Case 2. A, appearance of carcinoma during hypothermia. B, electrosurgical excision of hypernephroma. C, collecting system defects closed with 4-zero plain catgut. Blood vessels individually suture ligated with 4-zero chromic catgut. Defect filled with pararenal fat.
artery was occluded for 78 minutes. Blood loss was not sufficient to require transfusion. An IVP 12 postoperatively demonstrated prompt excretion of from the operated kidney. DISCUSSION
A surgical approach to any renal lesion should permit that lesion to be corrected with a minimal loss of nephron units and minimum morbidity to the patient. The surgical herein described is not new. H. 13 · 15 - 17 However, its value needs to be re-emphasized at this time bee a use -;;-yffieTurfenf more recenfii/aescrihed te€Q!}_i.._cui~~:~0L~£i:ac.orpiifiliil~iivm.:.krumr!:il surgery. with aulotransplantation. 18 · 22 We believe that the latte'"i;technique has be-eTCover=us'ed- and has been associated with too many technical failures resulting in dialysis or The effects of
mteres11n Tne
resection is bothersome. One must remember that the operabecause a radical norm.al ci.rcum-
stances< When faced -r1it.h this situation ·we
the uperative
16
GIBBONS AND ASSOCIATES
FIG. 8. Case 2. Postoperative IVP
FIG. 9. Case 3. A, symptomatic and enlarging branched calculus in left kidney. B, anatrophic nephrotomy as adjunct to in situ hypothermia and ischemia.
17
SURGICAL MANAGEMENT OF RE.'JAL LESIONS
' I-
!
standard operating rooms. There is ample exposure for a precise and bloodless dissection as well as ample protection against ischemia and blood loss. When compared to the workbench technique less operating time is required and there are fewer potential complications since the process avoids an additional incision, 2 vascular anastomoses and a possible ureterovesical anastomosis. REFERENCES
l. Kerr, W. K., Kyle, V. N .. Keresteci. A.G. and Smvthe, C. A.· Renal hypothermia. J. Uro!., 84: 236, 1960. · 2. Graves, F. T.: Renal hypothermia: an aid to partial nephrectomy. Brit. J. Surg., 50: 362, 1963. 3. Wilson, G. S. M.· Clinical experience in renal hypothermia. J. UroL 89: 666. 196:l. 4. Pahner. iJ. M., Guernsey) ,J. IVI. and Connolly, J. E: An experirnental study of selective renal hypothermia. Amer. rJ. Surg., 106: 224, 1963. 5 Gibbons. R. P., Correa, R. ,J.. eJr. and Tremann, A · Manag2ment of intrarenal vascular rr1alformations. Urology, l: L-36, 1973. 6. Grabstald, H. and Aviles. E.: Renal cell cancer in the solitary or sole-functioning kidney. Cancer, 22: 97:l, 1968. 7. Malek, R. S., Utz, D. C., Culp. 0. S., Kelalis, P. P. and Vlarren. IVI. M.: lVlalignant tumors of solitary kidneys. Mayo Clin. Proc., 47: 180, 1972. 8. Stackpole, R. H.: Treatment of carcinoma in a solitary kidney: case report and review of the literature. ,J. UroL 9:3: 35:l, 1965. 9. Parker, R. M., Timothy, R. P. and Harrison, H.: Neoplasia of the solitary kidney. J. Urol.. Hll: 28:l, 1969. 10. Kaufman, J. ,J., Chaffey, B. T. and Goodwin, W. E.: Renal cell carcinoma in the solitary kidney: report of six cases. Brit. J _ Urol., 40: 12, 1968. 11. Belzer, F. 0., Schweizer, R. T., Kountz, S. L. and deLorimier. A. A.: Malignancy and immunosuppression. Renal homotransplantation in patients with primary renal neoplasms. Transplantation, 13: 164, 1972. 12. Penn, I. and Starzl, T. E.: Immunosuppression and cancer. Transplant. Proc .. 5: 94:3, 197:3. 13. Smith, M. J. V. and Boyce, W. H.: Anatrophic nephrotomy and plastic calyrhaphy. J. Urol., S9: 521, 1968. 14. Gibbons, R. P., Correa, R. J., Jr., Cummings, K. B. and Mason, J.
T.: Use of water-pik and nephroscope. Urology, 4: 605, 1974. 15. Semb, C.: Partial resection of the kidney, operative technique. Acta Chir. Scand., 109: 360, 1955. 16. Semb, C.: Partial resection of the kidney: anatomical, physiological and clinical aspects. Ann. Roy. Coll. Surg., 19: 137, 1956. 17. Wickham, J. E. A. and Mathur, V. K.: Hypothermia in the conservative surgery of renal disease. Brit. ,J. Urol., 43: 648, 1971. 18. Ota, K., Mori, S., Awane, Y. and Ueno. A.: Ex situ repair of renal artery for renovascular hypertension. Arch. 94: :l70, 1967. B.: Total 19. Gel in, L-E., Claes, G., Gustafsson, A. and bloodlessness for extracorporeal organ repair. Rev. Surg .. 28: 30fi, 1971. 20. Hodges, C. ., Lawson, R. K., Pearse, H. D. and Stranburg, C. 0.: Autotransplantation of the kidney. ,J. Urol.. HO: 20. 197:3. 21. 11/Iilsten, R, Neifield. J., ,Jr. and Koontz, W. W., ,Jr.: Extracorporeal renal surgery. ,J. Ural.. H2: 425, 1974. 22. Gil-Vernet, J. IV!., Caralps. A., Revert, L., Andreu, ,J., Carretero, P. and Extracorporeal renal surgery. Work bench surgery. 5: 444, 1915. 2'' Schloerb, ?. R., Vlaldorf, R. D. and VVe!sh, J. S.: The protective effect of kidney hypothermia on total renal ischemia. Surg. Forum, 8: 633, 1957. 24. Mitchell, R M. and Woodruff, M. F. A.: The effects of local hypothermia in increasing tolerance of the kidney to ischernia. Transplant. Bull., 4: 15. 19fi7. 25. Steuber, P .. Kovacs. S .. Persky. L. and Koletsky, S.: Regional hypothermia. Surgery, 44: 77, 1958. 26. Birkeland, S .. Vogt, A., Krog, J. and Semb, C.: Renal circulatory occlusion and local cooling. ,J. Appl. Physiol., 14: 227, 19,59. 27. Cockett, A. T .. The kidney and regional hypothermia. Surgery, 50: 905, 1961. 28_ Boyce, W. H.: Radiology in the diagnosis and surgery of renal calculi. Radio!. Clin. N. Amer., 3: 89, 1965. COMMENT These investigators have elegantly illustrated and discussed the value of in situ hypothermia for the surgical management of difficult intrarenal lesions. Although recently workbench surgery has been enthusiastically endorsed as the preferred treatment for such problems, this timely publication should make us pause and reconsider the decision. P.C W.
