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ORIGINAL ARTICLE Nephrectomy An Overview

Muhammad Akmal, Khizar Ishtiaque Khan, Shahid Rana

Abstract Objectives: To find out the incidence of various benign conditions causing nonfunctioning kidney leading to nephrectomy Study Design: Descriptive study Setting and Duration: Armed Forces Institute of Urology (AFIU) Rawalpindi from Jan 2006 to Feb 2008 Methodology: All the patients who underwent nephrectomy during this period were included in this study. 189 patients underwent nephrectomy out of which 115 patients had nonfunctioning kidneys. Complete history was taken and all patients were thoroughly examined and investigated. Particular attention was given to assess the functions of the contra lateral kidney. Post operatively patients were followed up in OPD with serial ultrasound examinations & renal function tests for the contralateral kidney. Results: The incidence of nonfunctional kidney was 60.84 %. Most of the patients with non functioning kidneys have calculus disease 61 (53.04%) or congenital hydronephrosis 20 (17.39%). The reason for high number of nonfunctional kidneys was that patients reported to the hospital very late. Some of these patients were asymptomatic as in congenital hydronephrosis and stag horn calculus and others ignored their symptoms and some had prolonged treatment from quacks as it is a common problem in remote areas without proper medical facilities. Conclusion: Most of the kidneys can be saved and nephrectomy avoided by early diagnosis & appropriate treatment of the benign conditions leading to nonfunctional kidney. Keywords: Nephrectomy, Non functional kidney, Calculus, Hydronephrosis Introduction: Surgery for the kidney is more and more conservative and only a few patients require Nephrectomy for benign conditions like prolonged hydronephrosis with cortical atrophy, calculus disease, infection, reno-vascular hypertension, trauma etc. Surgery for malignant disease is radical. Even renal sparing surgery is required when the malignant disease is bilateral or the contra lateral kidney is poorly functioning. Donor nephrectomy is undertaken as a part of renal transplantation procedure. New technical advances have improved the operative technique of the kidney for example; angiography has improved understanding of the vascular anatomy of the kidney. Similarly, methods of preserving the kidney by cooling, has given surgeon enough time to operate without haste or loss of blood. It has opened the fields for renal transplantation preventing ischemia to the kidney. At the same time discovery of blood less plane1 and the technique of dealing with the cut surface of the kidney2 had made it possible to perform resection and reconstruction of the parenchyma without bleeding or loss of functions. Due to these advances, ablative surgery is today limited to nonfunctioning and tumor bearing kidneys only. Most of these patients with non

Baqai Medical University, Karachi M Akmal KI Khan S Rana Correspondence: Dr Khizar Ishtiaque Khan, Assistant Professor General Surgery, Baqai Medical University, Karachi email: khizarikhan@ yahoo.com Cell: 0333-3475867
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functional kidneys were discovered accidentally as in congenital asymptomatic hydronephrosis or staghorn calculi. However others patients presented with pain, recurrent urinary tract infection (UTI), hematuria and lower urinary tract symptoms (LUTS). Methodology: This study was carried out at AFIU Rawalpindi, from Jan 2006 Feb 2008. All patients who underwent nephrectomy for nonfunctioning kidney were included in the study. Patients in whom partial nephrectomy was done were excluded from the study. Complete history, clinical examination, laboratory investigations including blood complete picture, serum urea, creatinine, electrolytes, urine complete examination and cultures were done in all patients. Ultrasonography Kidney Ureter and Bladder (USG KUB) and Intravenous urography (I.V.U) were done to evaluate the functional status of the kidneys. Computerized tomographic (CT) Scan abdomen was done in patients with Space occupying lesion (SOL) of the kidney. Diethylenetriaminepentaacetic acid (DTPA) renal scan was also done in patients with nonfunctional kidneys. All the patients were explained about the procedure and related complications and informed consent was taken. Standard lumbar through 12th rib approach was carried out in all the patients with benign conditions, unless diagnosis was in doubt like in xanthogranulomatous pyelonephritis and in patient with multiple previous surgeries. However, transperitoneal approach was adopted for patients with tumor of the kidney. All resected specimens were sent for histopathological examination. Patients were discharged from the hospital when they were mobilized out of bed (4 -5th day) and followed up in OPD to assess renal functions and possible recurrence of disease on the contra lateral side by serial USG KUB and renal function tests. Results: 189 patients were included in this study that underwent nephrectomy. The patients included were of all age groups. The youngest patient was

M Akmal, KI Khan, S Rana

6 years old and oldest was 78 years old. 110 patients were male and 79 were female. Majority of the patients were young belonging to 4th decade of life. The age wise distribution is given in table I. The causes leading to nephrectomy are given in table II, whereas the causes of nonfunctioning kidney are given in table III. Discussion: Nephrectomy is a procedure which is rarely performed now days because of improved surgical techniques and early diagnosis and appropriate treatment of most of the benign disorders which ultimately require nephrectomy. Ablative surgery today is limited to nonfunctioning and tumor bearing kidneys. Various conditions which require simple nephrectomy are: Non functional kidneys secondary to Calculus disease Pyelonephritis Xanthogranulomatous nephritis TB Hydronephrosis(congenital/acquired) Vascular disorders Acquired cystic disease Non functional dysplastic kidney (congenital) Sclerotic kidneys in renal hypertension Pyonephrosis Grade V injury Simple nephrectomy is indicated in patients with an irreversible damaged kidney because of symptomatic chronic infection, obstruction, calculus disease, or severe traumatic injury. It is occasionally appropriate to remove a functioning kidney involved with one of these conditions when the patients age or general condition is very poor to permit a reconstructive procedure and provided that the opposite kidney is normal. Nephrectomy may also be indicated to treat renovascular hypertension owing to non-correctable renal artery disease or severe unilateral parenchymal damage owing to nephrosclerosis, pyelonephritis, reflux, dysplasia, or congenital dysplasia. Reconstructive surgery is clearly preferable to nephrectomy, particularly when the kidney is healthy apart from the abnormality in the rePak J Surg 2012; 28(2): 102-105

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Frequency 11 18 35 30 21 Percentage 9.56 15.65 30.43 26.08 18.26

Table 1: Age Distribution (N=115)

Age Group < 10 10-20 20-30 30-40 > 40

cessful in retraining renal functions or decreasing patient morbidity. 18 (15.06%) patients had unilateral simple nephrectomy because of chronic pyelonephritis. The management of nonfunctioning or severely diseased tuberculous kidney is indisputable, and nephrectomy is mandatory7, 8. A number of other studies had also shown that 89.3% of all nonfunctioning kidneys had been destroyed and required nephrectomy9, 10, 11, in only 3 out of 28 cases reconstruction was possible. We had 16 cases of renal tuberculosis out of these 3 patients underwent nephrectomy. In congenital hydronephrosis a quantitative renal scan using technetium-99-labeled Dimercaptosuccinic acid (DMSA) that determines individual renal function is sometimes helpful in deciding whether to perform a nephrectomy or pyeloplasty, especially when the excretory urogram reveals a kidney with poor concentrating ability and nonvisualization on delayed post-injection films. 20 (17.39%) patients had massive hydronephrosis with cortical atrophy and differential renal functions were less than 10%12, 13, 14. All these patients underwent nephrectomy. Nephrectomy is indicated rarely for management of renal calculi15. It does have a role, however, in well defined patients. Specifically, if the stone is associated with a nonfunctioning or poorly functioning kidney that is unlikely to recover adequate functions with removal of the stone alone, nephrectomy may be the best option. This is especially true for older patients with significant concomitant medical problems in whom the contralateral kidney is normal. Most of the patients presented in AFIU Rawalpindi had long standing calculus disease 61(53.04%) with severe renal damage. Majority of these patients belonged to poor socioeconomic group and they had history of treatment from quakes or hakims. Out of 189 patients, 115 (60.84%) patients had non functioning kidneys. There is high percentage of cases of nonfunctioning kidneys which required nephrectomy. The reasons for end stage of the disease are due to ignorance by the

Table 2: Nephrectomy [Total] (N=189)

Cause Non Functioning Kidney Space Occupying lesion of kidney Donor Nephrectomy Renal Vascular Hypertension Trauma Tuberculosis Frequency 115 27 29 9 4 3 Percentage 60.84 14.08 15.34 1.05 4.76 2.11 1.58

Chronic Renal Failure (Transplant Recipient) 2

Table 3: Benign Conditions Requiring Nephrectomy (Non Functional Kidney) (N=115)

Cause Pyelonephritis Calculus Disease Glomerulonephritis Hydronephrosis Xanthogranulomatous Nephritis Frequency 18 61 1 20 5 Percentage 15.65 53.04 0.86 17.39 9.69 4.34

Congenital Dysplastic Kidney/Acquired Cystic Disease 10

nal vasculature because both atherosclerosis and mural dysplasia are potentially bilateral entities3, 4. However, nephrectomy may be indicated in older patients or patients at high risk. Nephrectomy may also be indicated when arterial reconstruction has failed, or when there is uncontrolled hemorrhage from unilateral renal infarction. Nephrectomy may also be indicated for severe unilateral parenchymal disease and for stenosis or poor flow through a previous vascular repair that has been unresponsive to balloon angioplasty5. In our study 9 (4.76%) patients underwent nephrectomy for renovascular hypertension. In all these patients the affected kidney was atrophic and poorly functioning whereas post operative control of blood pressure was satisfactory. Pyelonephritis is treated medically unless patient is not responding to treatment6. Surgical treatment must be complete extirpation because most attempts at renal sparing have been unsucPak J Surg 2012; 28(2): 102-105

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patient and self medication for initial symptoms and failure on the part of medical attendants to suspect kidney disease, investigate and follow up the patients properly. Conclusion: Even in this advanced medical era very high number of patients undergoes nephrectomy due to benign kidney disease in developing world. The main reason is lack of medical facilities in remote areas as well as ignorance on part of patients. Above all, treatment by quacks and hakims delays seeking of appropriate medical management of the patients. The number of the non functional kidneys due to benign conditions and hence nephrectomy can be decreased markedly by timely and appropriate diagnosis and treatment of the patients. The message of this study is that patients with urological symptoms should not be ignored and every patient should be thoroughly investigated, appropriately managed & followed up to prevent this ablative surgery. It also requires public awareness and provision of medical facilities in remote areas. References:
1. Gil-Vernet JM. New Surgical concepts in removing renal calculi. Urol. Internat 1965; 20;255.

M Akmal, KI Khan, S Rana 2. Semb C, Madden JP. Surgery of staghorn calculus. Brit J Urol 1967; 39:323. 3. Libertion JA, Beckmann CG. Surgery and percutaneous angioplasty in the management of renovascular hypertension. Urol Clin North Am 1994; 21:235-243. 4. Libertion JA, Bosco PJ, Ying CY. Renal revascularization to preserve and restore renal functions. J Urol 1992; 147: 14851487. 5. Libertino JA, Zinman L. Surgery for renovascular hypertension..In: Libertino JA. Pediatric and Adult Reconstructive Urologic Surgery. 2nd ed. Baltimore: Williams & Wilkins Company 1987: 119-161. 6. Davies AG, McL Achlan MS, Asscher AW. Progressive kidney damage after non- obstructive urinary tract infection. Br Med J 1972; 4:406. 7. Kerr WK, Gale GL, Peterson KSS. Reconstructive surgery for genitourinary tuberculosis. J Urol 1969; 101 : 254. 8. Kerr WK, Gale GL, Struthers NW. Prognosis in reconstructive surgery for urinary tuberculosis. Br J Urol 1970; 42:672. 9. Wong SH, Lan WY. The surgical management of non-functioning tuberculous kidneys. J Urol 1980; 124 : 187. 10. Flechner SM, Cow JG. Role of nephrectomy in the treatment of non functioning or very poorly functioning unilateral tuberculous kidney. J Urol 1980; 123:822. 11. Stanford JL, Grange JM. New concepts for the control of tuberculosis in the twenty- first century. JR Coll Phys London 1993; 27:218-223. 12. Dejter SR Jr, Eggli DF, Gibbons MD. Delayed management of neonatal hydronephrosis. J Urol 1988; 140: 1305. 13. Williams DI, Karlasftis CM. Hydronephrosis due to pelviureteric obstruction in the newborn. Br J Urol 1966; 38:138. 14. Schaeffer AJ, Grayheck JT. Surgical management of ureteropelvic junction obstruction. In: Walsh PC, Gittes RF, Perlmutter AD, Stamey TA. Campbells Urology. 5th ed. Phildelphia, W.B. Saunders 1986; 2505-2533. 15. Roth RA , Findlayson B. Partial nephrectomy and nephrectomy for stones. In: Roth RA , Findlayson B. Stones: Clinical management of Urolithiasis. Baltimore; Williams & Wilkins Company 1983.

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