LONG-TERM RESULTS OF INTRARENAL SURGERY FOR BRANCHED CALCULI - IS SUCH SURGERY STILL VALID

Objective To evaluate whether intrarenal surgery for branched calculi remains valid in the light of current new techniques, e.g. percutaneou s nephrolithotomy and extracorporeal shockwave lithotripsy, Patients a nd methods Between January 1978 and October 1984, 44 patients (24 male and 20 female, mean age 42.5 years, range 14-66) underwent complex su rgery for large stones, requiring opening of the renal pelvis and a tr ansparenchymal approach to the calices; 47 renal units were operated i n 49 procedures. The evaluation before surgery included creatinine and blood nitrogen levels, blood pressure measurement, urine culture, abd ominal plain X-ray (44 patients), intravenous urography (42) and isoto pic renography with renal scintigraphy (five). Renal lithiasis was cat egorized and all patients underwent extended pyelolithotomy with a tra nsparenchymal approach, achieved by partial nephrectomy (six patients) , radial paravascular nephrotomy (10), posterior lower nephrolithotomy (29), resection of the posterior segment (two), and posterior segment otomy and reconstruction (2); 16 operations were performed under ischa emia. In October 1996, the patients were clinically evaluated by serum creatinine levels (42), urine cultures (42), abdominal plain X-ray (4 2), TW (34), isotopic renography (eight), renal ultrasonography (eight ) and blood pressure measurement (44). The mean follow-up was 14.8 yea rs. Results The major postoperative complications were; residual stone s (six patients), fistula with ureteric stenosis (one, with a permanen t nephrostomy), toxic temporary hepatic failure (one), femoral arteria l embolism (one, resolved using a Fogarty catheter) and recurrent larg e stones (two, operated 1 and 5 years later). From 1984 to 1996, 19 pa tients had recurrent stones and two underwent dialysis. In October 199 6, the renal function of 47 renal units was stable or normal in 36 (77 %), reduced in seven (15%) and lost in four (8%); 24 patients were hyp ertensive (12 preoperatively), nine have urinary tract infection, thre e are positive for hepatitis B or C virus, and lithiasis has recurred in 15 renal units. Conclusions Intrarenal surgery, conducted using mod ern anatomical guidelines, was an effective treatment for renal branch ed stones. The long-term results are satisfactory after appropriate co rrection of the urinary tract, with the consequent prevention of stasi s and chronic infection. The definitive comparison between surgical an d combined endoscopic/extracorporeal methods will only become clear wh en there is a comparable follow-up, Currently, surgery remains prefera ble in patients with giant calculi, a small pelvis and prevalent calyc eal development.