PRELIMINARY COMMUNICATION

DISSOLUTION IRRIGATION THROUGH ARTHUR PAUL

DONOVAN

CALCULI

BY

WITH ACETYLCYSTEINE PERCUTANEOUS

D. SMITH,

H. LANGE,

ROBERT

OF CYSTINE

NEPHROSTOMY

M.D. M.D.

P. MILLER, B. REINKE,

M.D. M.D.

From the Departments of Urology and Radiology, Veterans Administration Hospital, and the Department of Urologic Surgery, University of Minnesota College of Health Sciences, Minneapolis, Minnesota

ABSTRACT - Cystine calculi in the renal pelvis of a patient with cystinuria were dissolved by irrigation with a saline solution of acetylcysteine and bicarbonate through percutaneous nephrostomu.

Patients with cystinuria have a marked propensity for recurrent stone formation, which often necessitates multiple operations on the upper urinary tract. Prophylactic treatment with hydration, alkalinization of the urine, and at times D-penicillamine often reduces the incidence of recurrence; but even with careful treatment, new cystine calculi may form. Thus the urologic surgeon often is called on to relieve acute obstruction in a way that will preserve as much renal function as possible. Any treatment that avoids open procedures and further distortion of the renal architecture is therefore desirable. Case Report A forty-five-year-old man had an episode of renal colic in 1955 and passed a stone spontaneously. He was found to have cystinuria. After that, he passed many stones and had stones basketed in one or both ureters on at least 50 occasions. A left nephrolithotomy was performed in 1956 and a right nephrolithotomy in 1961. The patient took 0.5 Gm. of D-penicillamine and 10 ml. of oral citrate mixture (Polycitra Syrup) four times a day. He presented at Veterans Administration Hospital with acute renal colic caused by a 1.5-

422

cm. radiolucent calculus at the left ureteropelvic junction. There were three other, smaller calculi in the left collecting system. To avoid still another major operation, we performed a left percutaneous nephrostomy, with prompt decompression of the renal pelvis. A second angiogram catheter was inserted antegrade into the bladder. The portion of this catheter remaining in the renal pelvis had side holes, and thus continuous irrigation with a double catheter system could be achieved easily (Fig. 1). Irrigation was begun the next day with a solution of 300 mEq. of sodium bicarbonate per liter of saline at a rate of 110 ml./hr. The patient continued to take D-penicillamine and the citrate mixture. After seventeen days of irrigation, the size of the large calculus appeared to be unchanged. The patient still was eager to avoid another operation, and therefore irrigation was begun with bicarbonate solution to which 60 ml. of a 20-per cent solution of N-acetyl-L-cysteine (Mucomyst)* had been added, for a final concentration of approximately 1 per cent. Within five days the stone appeared to be smaller. In view of the *Mead

UROLOGY

Johnson

i

Laboratories,

APRIL

1979

Evansville,

/

VOLUME

Illinois.

XIII,

NUMBER

4

FIGURE 1. One polythene angle-tip angiogram catheter in left renal pelvis f~ irrigation; stone visible at its tip. Another angiogram catheter with side holes in renal pelvis has been passed down into bladder.

lack of side effects from the acetylcysteine, we doubled its concentration in the irrigation solution to achieve more rapid results. An intravenous urogram four days later showed no residual calculi. However, irrigation with the 1 per cent solution of acetylcysteine was maintained for two more days to dissolve any calculi that might remain undetected. The nephrostomy tube was removed, and a urogram showed no further obstruction. The patient has been asymptomatic since. Comment Acetylcysteine is thought to act by opening disulfide bonds and thus reducing the dimer cystine to the far more soluble monomer cysteine. D-penicillamine, which apparently bonds

UROLOGY

/

APRIL

1979

/

VOLUME

XIII,

NUMBER

4

with cysteine to form penicillamine-cysteine disulfide, may contribute to this effect by lowering the amount of cysteine available for oxidation to cystine. However, it is difficult to determine exactly what happens in vivo because of the technical difficulty in measuring the forms of cysteine in the urine and because the amount of cystine excreted even by normal persons varies greatly from day to day. L Mulvaney, Quilter, and Mortera3 administered 0.7 Gm. of acetylcysteine orally four times a day to 6 patients with cystinuria, none of whom was taking D-penicillamine. The patients were treated for as long as seven years, and none suffered side effects. In all patients, the frequency of stone recurrence was lowered, and in one patient calculi present at the start of treatment dissolved. Although the alkalinizing agent and Dpenicillamine that our patient was taking may have contributed to the disappearance of his cystine stones, we believe that acetylcysteine dissolved them. The patient had been taking systemic agents for some time; and during that time, the stones formed. Also, the renal pelvis had been irrigated with a bicarbonate solution, but in two weeks this produced no visible change in the size of the stones. However, there was a dramatic response within four days to pelvic irrigation with acetylcysteine. Moreover, small cystine calculi in the renal pelvis had been dissolved by irrigation with acetylcysteine through retrograde ureteral catheters.4 We believe that irrigation of the renal pelvis through a percutaneous nephrostomy may become an invaluable adjunct to the classic treatments for cystinuric stone disease. Our case is another example of the benefits that percutaneous nephrostomy and its applications have in the practice of urology. Department

of Urologic Surgery, Box 394 420 Delaware Street S.E. Minneapolis, Minnesota 55455 (DR. SMITH) References

1. Collini WR, et al: Methods of diminishing cystine excretion in cystinuria, J. Urol. 93: 729 (1985). 2. Kallistrators G, and Malorny G: Experimentelle Untersuchungen zur Frage der chemischen AuflGsung van Cystinsteinen, Arzneim. Forsch. 22: 1434 (1972). 3. Mulvaney WP, Quilter T, and Mortera A: Experience with acetylcysteine in cystinuric patients, J. Urol. 114: 107 (1975). 4. Mulvaney WP: Personal communication, August 8, 1978.

423

Dissolution of cystine calculi by irrigation with acetylcysteine through percutaneous nephrostomy.

PRELIMINARY COMMUNICATION DISSOLUTION IRRIGATION THROUGH ARTHUR PAUL DONOVAN CALCULI BY WITH ACETYLCYSTEINE PERCUTANEOUS D. SMITH, H. LANGE, R...
780KB Sizes 0 Downloads 0 Views