Endourological renal salvage in patients with calculus nephropathy and advanced uraemia

To document our experience with percutaneous nephrolithotripsy (PCNL) for the treatment of calculus nephropathy and advanced renal failure.

Between October 1989 and April 1996, 78 patients with calculus nephropathy (51 males and 27 females, mean age 42 years, range 16-67; mean serum creatinine level 663.8 micromol/L, range 282.8-1449.7) were treated in our department. Forty-six of the patients had bilateral upper urinary calculi, while the remaining 32 had a solitary functioning kidney obstructed by stone. Thirty-two patients had a normal urine output, 26 were oliguric and 20 presented with anuria. A preliminary percutaneous nephrostomy (PCN) was performed under local anaesthesia in 64 patients, and stone retrieved subsequently through the same nephrostomy track after improvement in their uraemic status. In the remaining 14 patients, the stones were removed at the first session. Of the 46 patients with bilateral stones, 21 underwent stone retrieval by PCNL on the contralateral side after an interval of 2-3 weeks, while 25 patients underwent simultaneous JJ stenting on the contralateral side, followed, after improvement in uraemic status, by delayed PCNL or extracorporeal shock wave lithotripsy on that side.

There were three deaths, caused by overwhelming sepsis; 64 of the remaining 75 patients recovered well from uraemia, while 11 showed no improvement, suggesting irreversible renal damage. Complications included five patients with nonfatal sepsis and five with secondary haemorrhage. At the last follow-up 2.5-9 years after presentation, the mean serum creatinine level (271.3 micromol/L) was significantly better than the mean preoperative level. Six patients are on maintenance haemodialysis.

It is not uncommon in developing countries for patients with urolithiasis to present with advanced uraemia caused by long-standing obstruction, almost invariably complicated by infection. A percutaneous endourological approach offers the best hope for these patients, and in our experience a significant percentage of these cases can be salvaged.