Leslie N. Pyrah

Renal Calculus Foreword by D. Innes Williams

With 55 Figures

Springer-Verlag Berlin Heidelberg New York 1979

Dr. Leslie N. Pyrah, Emeritus Professor of Urological Surgery at the University of Leeds, Past President of the British Association of Urological Surgeons, 55 Weetwood Lane, Leeds LS16 5NP, Great Britain

ISBN-13: 978-3-642-67126-5 DOl: 10.1007/978-3-642-67124-1

e-ISBN-13: 978-3-642-67124-1

Library of Congress Cataloging in Puhlication Data. Pyrah, Leslie Norman. Renal calculus. Bibliography: pp. Includes index. I. Kidneys-Calculi. I. Title. [DNLM: I. Kidney calculi. WJ356 P998rJ RC916.P95 616.6'22 78-23788

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2123/3321-543210

Contents

Foreword . . . .

Acknowledgements

Introduction . . .

Chapter 1: Epidemiology of Urolithiasis .

xv

xvi

1

3

I. Early Cases of Vesical Calculus 3 II. Ethnic Considerations . 4

1. The African Negro . 4 2. The American Negro 5

III. Climate . . . . . . 6 IV. Occupation. . . . . 7 v. Incidence of Stone in Countries with Different Degrees

of Economic Development 7 1. Great Britain . 8 2. Sweden. 8 3. Norway ... 4. Finland. . . 5. Czechoslovakia. 6. Israel. 7. Turkey ... 8. Sicily. . . . 9. United States.

10. India. . . . 11. Thailand

VI. The Stone Wave in Central Europe References . . . . . . . . . . .

Chapter 2: Pathology of the Stone-Bearing Kidney.

I. Theories of Renal Stone Formation 1. Colloid Material . . 2. Crystals . . . . . 3. Inhibitor Substances 4. Calcific Foci

II. General Structure of Renal Calculi 1. Crystalline Content. . . 2. Colloid Content . . . .

III. Components of Renal Calculi 1. Calcium Oxalate . 2. Phosphate . . . 3. Rare Components 4. Matrix Calculi. .

9 9

10 10 11 11 11 12 13 14 16

18

18 18 19 20 20 22 22 22 24 24 24 26 26

vi Contents

IV. Morbid Anatomy. 1. Infection. . .

27 27

2. Complications . 28 References . . . . . 30

Chapter 3: Intrarenal, Pararenal and Ureteric Disorders Complicated by Renal Calculi and Calcification 32

I. Renal and Ureteric Stone and Obstructive Conditions in the Urinary Tract. . 32

1. Hydrocalycosis . 32 2. Pelviureteric Hydronephrosis. 32 3. Retrocaval Ureter . 33 4. Horseshoe Kidney. 34 5. Ureterocele 38 6. Megaureter 41 7. Ureteric Stricture from Other Causes 42 8. Renal CaLyceal Diverticula 42 9. Ureteric Diverticula and Urolithiasis 42

10. Obstruction of the Lower Urinary Tract and Upper Tract Urolithiasis 43

II. Renal Calculi and Cystic Conditions of the Kidney 44 1. Pyelogenic Cysts . 44 2. Traumatic Cysts . 46 3. Polycystic Disease 48 4. Medullary Sponge Kidney 52

III. Renal and Ureteric Calculi Associated with Other Congenital Anomalies of the Urinary Tract 54

IV. Metaplastic Conditions and Tumours of the Kidney, the Ureter, and Calculi. 55 1. Metaplasia (Squamous and Glandular) and Leuko-

plakia . 55 2. Carcinoma of the Renal Parenchyma 55 3. Sarcoma of the Kidney 56 4. Epithelial Tumours of the Renal Pelvis 56 5. Epithelial Tumours of the Ureter 57

V. Renal Tubular Acidosis 57 1. In Infants (Lightwood's Syndrome) 57 2. In Adolescents and Adults 58 3. Acetazolamide (Diamox) and Renal Calculi. 61

VI. Infective Conditions of the Kidney and Calculous Disease 1. Renal Tuberculosis 2. Renal Actinomycosis 3. Typhoid Infections of the Kidney. 4. Bilharziasis of the Urinary Tract 5. Gonococcal Infection of the Kidney. 6. Renal Brucellosis. 7. Hyatid Disease of the Kidney

61 61 62 62 62 63 63 64

Contents VII

References 64

Chapter 4: Some Extrarenal Diseases Associated with Renal Stone or Nephrocalcinosis. . . . 69

I. Primary Hyperparathyroidism 1. Pathology . . . . . 2. Clinical Picture 3. Biochemical Diagnosis. 4. Treatment . . . . .

II. Immobilization Osteoporosis and Recumbency Uro­lithiasis. . . 1. Incidence 2. Causes 3. Special Characteristics. 4. Treatment . . . . .

III. Diseases of Other Ductless Glands 1. Cushing's Syndrome . . . . 2. Acromegaly . . . . 3. Multiple Endocrine Adenomatosis

IV. Sarcoidosis. . V. Paget's Disease VI. Myelomatosis. VII. Wilson's Disease VIII. Ureterocolic Anastomosis, Ileal Ureterostomy and

Cutaneous Ureterostomy. . . . . . . . IX. Renal Calculi Complicating Renal Transplants References . . . . . . . . . . . . . . .

Chapter 5: Renal Calculi and Nephrocalcinosis Contributed to by Ingestion of Certain ·Substances: Environmental Calculosis.

I. Silicate Calculi . 1. In Man 2. In Animals

II. The Sulphonamides III. Renal Papillary Necrosis: Phenacetin Addiction.

1. Experimental Renal Papillary Necrosis. 2. Clinical Picture 3. Diagnosis 4. Treatment

IV. Nephrolithiasis and Chronic Peptic Ulcer 1. Alkalosis from Ingestion of Excess Alkali . 2. Alkalosis from Simple or Malignant Pyloric Stenosis. 3. Nephrolithiasis and Peptic Ulcer in the Same Patient. 4. Milk-drinker's Syndrome.

V. Chronic Glomerulonephritis and Excessive Ingestion of Milk

VI. Beryllium Poisoning

69 69 70 75 76

78 78 79 82 83 83 83 85 85 86 86 87 89

89 90 90

95

95 95 97 99

101 103 103 105 107 108 109 110 111 112

118 122

viii Contents

VII. Cadmium Poisoning . VIII. Food Emulsifiers

122 124 124 References

Chapter 6: Levels of the Principal Crystalloids in the Urine of Patients with Calcium-Containing Calculi 128

I. Urinary Calcium . . . . 128 Relation to Type of Stone I . 130

II. Urinary Phosphate . 130 III. Urinary Oxalate . . 131 IV. Urinary Crystalluria. 132

1. Oxaluria. . 132 2. Phosphaturia 133

References . . . . 134

Chapter 7: Primary Hyperoxaluria and Related Conditions. 136

I. Primary Hyperoxaluria II. Related Conditions . . . . . . .

1. Vitamin B6 Deficiency. . . . . 2. Hyperoxaluria from Other Causes 3. Glycinuria; Hyperglycinaemia; Calcium

Calculi References

Oxalate

136 145 145 146

147 148

Chapter 8: Idiopathic Hypercalciuria 151

I. Clinical Features and Diagnosis 151 1. Biochemical Findings 152 2. Diagnosis . . . . 153

II. Pathogenesis . . . . 154 1. Renal Tubular Defect 154 2. Intestinal Absorption of Dietary Calcium. 155 3. Hyperfunction of Parathyroid Glands . . 157 4. Summary. . . . . . . . . .. . . 158

III. Treatment: Measures to Reduce Urinary Calcium . 159 1. Diet . . . . . 159 2. Intake of Fluids . 159 3. Specific Measures 160

References . . . . 163

Chapter 9: Chemical Substances in Urine Promoting or Preventing Renal Stone. . . . . . . . . .. 166

I. Some Chemical Substances and Their Relation to Renal Stone Formation . . . . 1. Citric Acid and Citrates . . . . 2. Urinary Magnesium. . . . . . 3. Urinary Sodium and Total Solutes 4. Urinary Amino Acids . . . . .

166 166 167 169 171

Contents IX

5. Urinary Pyrophosphates and Orthophosphates . 173 6. Vitamin D (Calciferol). . . . . . . . . . 174

II. Inhibitors of Calcification. . . . . . . . . . 176 1. Experimental Calcification of Rachitic Rat Cartilage

and ofIsolated Tendon Bundles . . . . . . 176 2. Urinary Peptides and Crystallization Inhibitors. 179 3. Metallic Inhibitors of Crystallization 180

References . . . . . . . . . . . . . . . . . 181

Chapter 10: Clinical Picture of Renal and Ureteric Calculus 185

I. Etiological Factors . . . . . . . . 185 1. Incidence of Calcium Oxalate Stone . 185 2. Age and Sex 185 3. Familial Incidence . 185 4. Anatomical Position 186 5. Size of Stone . . . 186

II. Clinical Course of Renal Stone Relative to Time 186 1. Duration of Symptoms 187 2. The Single-Stone-Former . 188 3. Recurrence. . . . . . 189 4. Bilateral Stones . . . . 189

III. Clinical Course of Renal Stone and Associated Factors. 189 IV. Clinical Symptoms of Renal and Ureteric Calculi . 190

1. Silent Renal Calculi. . . . . . . . . . . 190 2. Non-infected Calculi in the Upper Urinary Tract 190 3. Infected Calculi in the Upper Urinary Tract. . 192 4. Less Common Symptoms of Renal Calculi . . 193

V. Clinical Differential Diagnosis of Renal and Ureteric Calculi. . . . . . . . . . 195 1. Acute Pyelonephritis 195 2. Embolism of the Renal Artery 195 3. Extrarenal Syndrome 195

VI. Investigation 196 1. Blood Tests. . 196 2. Urine Tests. . 197 3. Radiodiagnosis 197 4. Cystoscopic Examination 204 5. Isotope Renography 205

VII. Urolithiasis in Children. . . 205 VIII. Renal and Ureteric Calculus in Pregnancy. 207

1. Clinical Picture 207 2. Treatment 208

References 208

Chapter 11: Some General Considerations in the Surgical Treatment of Renal and Ureteric Stone . . . . . . 210

I. Blood Supply of the Kidney . . . . . . . . II. Amount of Renal Tissue Needed to Sustain Life

210 212

x Contents

III. Compensatory Hypertrophy of the Kidney Following Nephrectomy . . . . . . . 212 1. In the Experimental Animal. . . . . . . 213 2. In Man . . . . . . . . . . . . . . 214

IV. Recovery of Function After Ureteric Obstruction 214 1. In the Experimental Animal . 214 2. In Man . . . . . . . . 215

V. Prevention of Infection. . . . 216 VI. Temporary Control of Bleeding 217 VII. Cooling Techniques. . . . 218

1. The Experimental Animal 218 2. In Man . . . . . . . 219

VIII. Radiography of the Exposed Kidney. IX. Closure of the Wound

219 221 221 References

Chapter 12: The Conservative Treatment of Renal and Ureteric Calculi. . . . . . . . . . . . 224

I. Conservative Treatment . . . . . . 224 1. Spontaneous Disappearance of Some Renal Calculi 224 2. Spontaneous Voiding of Some Renal and Ureteric

Calculi . . . . . . . . . . . . 224 3. Expectant Treatment . . . . . . . 227

II. Attempted Dissolution of Renal Calculi .. 229 1. General Considerations . . . . . . 229 2. Irrigation Through an Indwelling Catheter 229 3. Sodium Citrate-Citric Acid Solution: Solution G 230 4. EDTA(Versene). . . 231 5. Renacidin . . . . . . . . . . . 231 6. Irrigation or Operation? . . . . . . 233 7. Encrusted (Alkaline) Phosphatic Cystitis 233

III. Perureteral Instrumental Methods for the Treatment of Ureteric Stone . . . . . . . . . . . . . . .. 234 1. General Considerations . . . . . . . . . .. 234 2. Passage of Ureteric Catheters and Dilators; Indwell-

ing Catheters . . . . . . . . . . . . . .. 235 3. Instruments for Extracting Ureteric Calculi . . .. 238 4. Stones in the Intramural Part of the Ureter and at

the Ureterovesical Orifice. . . . . . . . . 239 5. Injuries of the Ureter Following Instrumentation 241 6. Ultrasonic Fragmentation of Calculi. . . . 243 7. Summary of Results ofInstrumental Methods . 243

References . . . . . . . . . . . . . . . . . 244

Chapter 13: Operative Treatment of Renal and Ureteric Calculi . . . . . . . . . . . . . . . . . . 247

I. Simple Pyelolithotomy and Its Variants. . . . 1. For a Calculus in a Mainly Extrarenal Pelvis

247 248

Contents

2. In Situ . . . . . . . . . 3. Transparenchymal Extension. 4. Subcapsular Pyelolithotomy . 5. Extracapsular Extended Pyelolithotomy. 6. Conclusion of Operation 7. Associated Calyceal Calculi . 8. Anterior Pyelolithotomy 9. Transperitoneal Pyelolithotomy

10. Coagulum Pyelolithotomy . 11. Complications . .

II. Nephrolithotomy...... 1. For Calyceal Calculil. . . . 2. For a Small Solitary Calyceal Stone. 3. For a Medium-sized Stone in a Dilated Calyx 4. For Multiple Small or Medium-sized Calyceal Stones 5. The Bivalve Procedure. . . . . 6. Lateral Resection of Renal Tissue 7. Complications. . 8. Mortality. . . . . . . .

III. Partial Nephrectomy . . . . 1. For Renal Calculous Disease 2. Exposure and Control of Bleeding 3. Wedge-Shaped Resection. 4. Guillotine Method 5. Blunt Dissection . . 6. Type of Operation . 7. Combined Procedures 8. Complications. . .

IV. Ureterolithotomy. . . 1. Indications for the Operative Removal of Ureteric

Calculi . . . . . . . 2. Upper Third of the Ureter 3. Middle Third of the Ureter 4. Lower Third of the Ureter 5. Complications. . . . .

V. Nephrectomy and N ephroureterectomy 1. Indications for Nephrectomy . . . 2. Indications for Nephroureterectomy . 3. Extracapsular Nephrectomy 4. Subcapsular Nephrectomy . . . . 5. Transperitoneal Nephrectomy for Stone 6. Nephroureterectomy 7. Complications. . . . . .

VI. Nephrostomy and Pyelostomy for Calculous Pyo­nephrosis 1. Nephrostomy 2. Pyelostomy .

References . . . .

Xl

249 249 250 250 251 252 252 253 253 253 255 256 256 257 257 257 259 259 261 261 262 263 263 264 265 266 267 267 268

269 269 271 272 278 278 279 279 280 280 283 283 284

287 287 288 288

xii Contents

Chapter 14: Special Groups of Cases of Stone and Their Treatment. . . . . . . . . . . . . .... 292

I. Treatment of Bilateral Renal and Ureteric Calculi 292 1. Bilateral Renal Calculi. . . . . . 292 2. Bilateral Ureteric Calculi. . . . . . . . 292

II. Treatment of Stone in a Solitary Kidney 292 III. Secondary Operations for Renal and Ureteric Calculi 293

1. Recurrent Renal Calculi . . . . . . . . .. 293 2. Recurrent Ureteric Calculi . . . . . . . .. 294

IV. Recurrence of Calcium-Containing Stone in the Upper Urinary Tract After Operation 295 1. True and False Recurrence . . . . . . . 295 2. Causes of Recurrence . . . . . . . . . 295 3. Incidence of Recurrence in the Author's Series 296

V. Serious Cases of Renal Calculous Disease. . . 301 1. Renal Failure from Advanced Calculous Disease

with Pyelonephritis . . . . . . . . . . . .. 301 2. Calculous Anuria . . . . . . . . . . . .. 307 3. Symptomatic Relief for Patients with Rapidly Recur-

ring Calculi. . . . . . . . . . . . . . .. 311 VI. Treatment ofInfection in the Calculous Urinary Tract. 312 VII. Medical Treatment of Calcium Phosphate-Containing

Calculi. . . . . . . . . . . . . . . 314 1. Aluminium Hydroxide. . . . . . . . 314 2. Acidogenic Diet and Ammonium Chloride 315

VIII. Earlier Non-surgical Measures 317 References . . . . . . . 317

Chapter 15: Uric Acid Calculi 320

I. Pathology 321 1. Uric Acid Stone 321 2. The Kidney. . 323

II. Clinical Picture 324 1. Uric Acid Calculi and Primary Gout 324 2. Uric Acid Calculi and Secondary Gout. 325 3. Idiopathic Uric Acid Calculi Associated with a

Family History of Stone . . . . . . . . .. 326 4. Uric Acid Calculi Without a History of Gout Nor a

Family History of Stone 327 5. Age and Sex Incidence. 327 6. Symptoms . . . . 328 7. Associated Diseases 328

III. Investigation . . . . 329 1. Serum Uric Acid. . 329 2. Urinary Excretion of Uric Acid 329 3. Radiodiagnosis 331 4. Diagnosis 332

Contents

IV. Treatment . . . . . . 1. Surgery . . . . . . 2. Conservative Treatment 3. Results of Treatment . 4. Drug Treatment for Gouty Patients

References . . . . . . . . . . . .

Chapter 16: Cystinuria and Cystine Lithiasis

I. Incidence of Cystinuria. . . . . . II. Cystinuria and Cystine Urolithiasis in Childhood III. Pathology

1. Cystine Stone . . . . . . . . . 2. The Kidney. . . . . . . . . .

IV. Pathogenesis and Genetics of Cystinuria 1. Renal Transport Defect . 2. Intestinal Transport Defect 3. Genetic Considerations

V. Clinical Picture . . . . . 1. Spontaneous Dissolution of Cystine Calculi 2. Associated Diseases

VI. Treatment . . . . . 1. Dietary Measures 2. Medicinal Measures . 3. Surgery . . . .

VII. Cystinuria in Animals References . . . . . .

Chapter 17: Xanthine Calculi and Xanthinuria

I. Xanthin uri a and Xanthine Oxidase II. Xanthine Stone III. Clinical Picture IV. Genetic Considerations V. Treatment References

Subject Index

xiii

333 333 333 335 335 336

339

339 340 340 340 342 342 342 343 344 345 347 347 347 348 349 351 351 352

355

355 356 357 358 358 359

361

Foreword

Stone in the urinary tract has fascinated the medical profession from the earliest times and has played an important part in the development of surgery. The earliest major planned operations were for the removal of vesical calculus; renal and ureteric calculi provided the first stimulus for the radiological investigation of the viscera, and the biochemical investigation of the causes of calculus formation has been the training ground for surgeons interested in metabolic disorders. It is therefore no surprise that stone has been the subject of a number of monographs by eminent urologists, but the rapid development of knowledge has made it possible for each one of these authors to produce something new. There is still a technical challenge to the surgeon in the removal of renal calculi, and on this topic we are always glad to have the advice of a master craftsman; but inevitably much of the interest centres on the elucidation of the causes of stone formation and its prevention.

Professor Pyrah has had a long and wide experience of the surgery of calculous disease and gives us in this volume something of the wisdom that he has gained thereby, but he has also been a pioneer in the setting up of a research department largely concerned with the investigation of this complex group of disorders, so that he is able to present in terms readily intelligible to the general medical reader the results of extensive biochemical investigation in this area.

The urologist in practice, the urologist in training, the nephrologist and the physician with a metabolic interest should study calculous disease, not only for the practical benefits that such study will bring to their patients but also as an example of the methods of medical investigation and as a stimulus to undertake something further. Almost always the facts newly discovered pose as many questions as they answer and there is still in this field ample opportunity for further research, taking the investigator sometimes away from his original objective to other areas of medical science.

A feature of this work is the extensive lists of references, which should provide a stimulus to the post-graduate student to undertake wider reading. It is perhaps a criticism of modern medicine that too many papers are written and that the repetition of well known facts in many articles discourages the student i'rom a prolonged study of the literature, but equally it is a criticism of surgical training in Britain as opposed to the United States that relatively little attention is given to background reading. The natural inclination of surgeons is to get on with the practical work, but the complexity of contemporary scientific medicine is such that a regular study of the journals is obligatory if the best service is to be offered to the patient. The habit of reading must be instilled into our post-graduate students; perhaps indeed if they were

XVI Foreword

more familiar with what had already been written, they would not always find it necessary to publish yet another paper on what they believe to be rare conditions.

This book presents the results of a great many clinical, radiological and biochemical investigations: let us hope it will also prove to be the starting point of even more searching investigation.

Autumn 1978 D. INNES WILLIAMS

Acknowledgements

It is a pleasure to acknowledge the help I have received in discussions on the subject of stone with former colleagues in the Department, especially Or. A. Hodgkinson and Dr. F.W. Heaton. Dr. W.E. Robertson helped in the preparation of the chapter dealing with idiopathic hypercalciuria. Mr. Irvine Smith was responsible for much of the information and script incorporated in the section dealing with recumbency calculi. I would like to thank Miss Mary D. Brown for some of the half-tone drawings, so carefully executed by her. I thank those friends and colleagues who have allowed me to reproduce illus­trations and tables and also the publishers in whose journals such illustrations have appeared. Finally I thank my secretary, Miss M. Hart, for the enormous amount of work which she has done in col­lating and assessing the literature and in the preparation of the drafts and final typescript. To all these the author is very grateful. Finally, I thank my wife for her encouragement and forbearance during the period of preparation of the book.