Urology & Kidney Disease News - Cleveland Clinic

32 Urology & Kidney Disease News
Kidney
Auto-Transplantation for Intractable Nephrolithiasis
Alvin Wee, MD, Stuart Flechner, MD, Ho Y. Tiong, MD, Ray
Littleton, MD, and Mark J. Noble, MD
Auto-transplantation historically has been used to treat a
variety of disorders including bench surgical reconstruction
of the renal artery for aneurism; bench excision of a malignant
tumor; therapeutic intervention for Loin-Pain,
Hematuria Syndrome; and preservation of a kidney when
the ureter must be excised for a variety of reasons (e.g., long
strictures or ureteral tumors). There are few reports of
auto-transplantation to treat medically refractory stone
disease, and even fewer reports of bilateral treatment. Yet,
the literature suggests that the procedure is generally successful
in both preserving the kidney(s) and also helping
the patient to pass stones more easily (via pyelovesicostomy).
We believe this procedure should be offered to more
patients despite its complexity, as it has a high success rate
in reducing the inevitable dependence on narcotics seen in
many recurrent stone patients. It also seems to greatly
reduce the tendency to form new stones. We present our
results to date in a combined series with Henry Ford
Hospital.
The basic surgical technique involves removal of a kidney
(donor nephrectomy technique), flushing with preservation
solution, bench removal of stones if needed, then transplantation
into the ipsilateral iliac fossa with
pyelovesicostomy (Fig. 1). There were 6 renal units in 4
patients in this series through a midline abdominal incision.
Two females underwent bilateral staged
auto-transplantation 2-3 months apart (Fig. 2). One renal
unit (female patient) was transplanted for intractable uric
acid nephrolithiasis; the other 5 kidneys were in 3 individuals
with medically refractory cystinuria. Patients averaged
more than 3 years of a variety of stone treatments including
ESWL, ureteroscopy, percutaneous surgery, or combinations
and all had completely failed medical management in
spite of good compliance. Two patients averaged three UTIs
per year, and all patients were on continuous narcotics
preoperatively.
Mean pre-op creatinine was 1.08 and mean post-op creatinine
was 0.90. All kidneys exhibited normal function
postoperatively. There were no major complications.
Patients were all off narcotics by the eighth postoperative
week, and frequency of UTIs was reduced by 50%. Stone
events per year were reduced by more than 100%.
Our series demonstrates the feasibility of auto-transplantation
with direct pyelovesicostomy for treatment of
medically refractory stone disease. The reflux (“washing
machine effect”) helps remove small crystals before they
grow into large stones, and any stones that do form can
pass far more easily than if they needed to traverse a ureter.
Key Point:
We believe auto-transplantation for intractable nephrolithiasis
should be offered to highly selected patients despite its
complexity, as it has a high success rate in reducing the
inevitable dependence on narcotics seen in many recurrent
stone patients. It also seems to greatly reduce the tendency
to form new stones.
There is no ureteral colic from gravel or stones < 8 mm.
Larger stones that don’t pass can be lasered through a flexible
cystoscope passed transurethrally, which is far less
invasive than ureteroscopy or percutaneous stone removal.
Figure 1. Unilateral auto-transplant with (inset) anastamosis of a
bladder flap (Boari) to the longitudinally-opened upper ureter and
renal pelvis.
Figure 2. Bilateral auto-transplant with pyelovesicostomy,
completed result.