Vol. 115, February
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
RECOVERY OF RENAL FUNCTION AFTER PROLONGED UNILATERAL URETERAL OBSTRUCTION STEPHEN R. SHAPIRO
AND
ALAN H. BENNETT
From the Department of Surgery (Urology), Harvard Medical School, Boston, Massachusetts
ABSTRACT
Concepts of renal counterbalance and animal experiments have long supported nephrectomy for prolonged complete unilateral ureteral obstruction. The situation in humans has been clarified by only a few reported cases. Herein we report 3 cases with relief of obstruction after at least 28, 28 and 150 days. Evidence is presented to support renal preservation in similar cases. In the past the theories of renal counterbalance and of renal atrophy of disuse have considerably affected treatment of prolonged unilateral ureteral obstruction. 1 • 2 I; was commonly believed that once hypertrophy of the opposite kidney developed the damaged kidney would not regain some portion of its functional capacity. 3 Hydronephrotic atrophy was considered complete in 6 months and compensatory hypertrophy was considered complete in 4 to 6 weeks. More recently, it has been suggested in animal studies that recovery of renal function is unlikely after prolonged unilateral ureteral obstruction. 4 • 5 Most significantly, in dogs there was rarely any return of renal function with release of unilateral complete ureteral obstruction after 40 days.• However, the situation in humans is largely
Cystoscopy on July 3, 1974 was normal. On July 4 an open renal biopsy of the right kidney was performed and the specimen was obtained from the lower pole of the left kidney with a Vim-Silverman needle. Postoperatively, bleeding occurred and required 2 units of blood and drainage of a perirenal wound hematoma. An IVP 2 days postoperatively showed non-visualization of the right kidney. On July 24 the patient was transferred to the Peter Bent Brigham Hospital because of persistent hematuria and flank pain. Examination revealed a tender, full right flank. Laboratory examination revealed microscopic hematuria, hematocrit 36 per cent, blood urea nitrogen 16 mg. per cent and creatinine 1.6 mg. per cent. An IVP on July 26 again showed non-visualization of the right
FIG. 1. Case 1. A, preoperative IVP shows non-visualization of right kidney. B, selective right arteriogram demonstrates arteriovenous fistula in lower pole of right kidney.
unknown and limited to only a few case reports. 7 Herein we report 3 cases with complete ureteral obstruction from 4 to 21 weeks with partial but adequate recovery of renal function in each case. CASE REPORTS
Case 1. A 44-year-old man had microscopic hematuria 4 years prior to hospitalization. Evaluation at a local hospital was non-diagnostic. Excretory urography (IVP) was normal. Accepted for publication ,June 13, 1975. Read at annual meeting of American Urological Association, Miami Beach, Florida, May 11-15, 1975. 136
kidney (fig. 1, A). Delayed films failed to demonstrate visualization. A retrograde pyelogram on July 26 demonstrated right ureteral obstruction by multiple filling defects most likely representing clots. Arteriography on July 30 demonstrated an arteriovenous communication in the lower pole of the right kidney with early filling of the right renal vein (fig. 1, B). On July 31 a lower pole nephrectomy of the right kidney was performed with pyelotomy and drainage of clots, thereby relieving 28 days of ureteral obstruction. A postoperative hippuran scan demonstrated a 25 per cent return of function in the right kidney within 1 week (fig. 2). No further bleeding ensued. Case 2. A 56-year-old man was admitted to the hospital with
RECOVERY OF RENAL FUNCTION AFTER PROLONGED UNILATERAL URETERAL OBSTRUCTION
FIG.
137
2. Case 1. A, postoperative hippuran scan demonstrates return of function to right kidney. B, postoperative hippuran scan
F 1G. 3. Case 2. Non-visualization of right kidney with large calculus in right mid ureter.
a history of right flank pain several weeks in duration. An IVP 1 month prior to hospitalization revealed non-visualization on the right side with a large calculus appearing in the mid ureter. The patient had been free of pain for 2 weeks and presented for a second opinion regarding the necessity of an operation. Examination was within normal limits. Laboratory evaluation revealed a normal complete blood count and urinalysis. IVP on June 27, 1974 again demonstrated non-visualization of the right kidney with a 1.5 cm. calculus in the right mid ureter (fig. 3). A hippuran scan on June 28 showed only background activity on the right side (fig. 4). On July 2 a right ureterolithotomy was performed, relieving a minimum of 28 days of right ureteral obstruction. Postoperative IVP (fig. 5, A) and a hippuran renal scan (fig. 5, B) on July 8 demonstrated a significant return of function to the right kidney. Case 3. A 56-year-old man was admitted to the hospital with increasing left lower quadrant pain 6 weeks in duration. Approximately 5 months previously he had undergone left ureterolithotomy elsewhere for a calculus noted on an IVP as part of an evaluation for back pain. The stone was near the left ureterovesical junction. The patient had experienced discomfort in the left flank and left lower quadrant since the previous operation. Examination showed a healed left lower quadrant scar but was otherwise within normal limits. Laboratory values revealed a normal complete blood count and urinalysis. An IVP on June 25, 1974 demonstrated non-visualization of the left kidney (fig. 6, A) and this was confirmed a hippuran scan 6, B). A retrograde showed complete obstruction at the site of the en vL1cuvvuu1y 6, C). On June 26 a
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SHAPIRO AND BENNETT
Fm. 4. Case 2. A, preoperative hippuran scan shows only background activity on right side. B, preoperative hippuran scan
Fm. 5. Case 2. A, postoperative IVP demonstrates significant return of function to right kidney. B, postoperative hippuran scan
metal clip on the side wall of the ureter. Reim plantation of the remaining ureter was aided by a psoas hitch of the bladder. An IVP 3 weeks postoperatively demonstrated visualization of the left kidney (fig. 7, A) and this was confirmed by a hippuran renal scan (fig. 7, B). An IVP 6 months postoperatively demonstrated even further improvement (fig. 7, C). This was the result after relief of approximately 150 days of left ureteral obstruction.
DISCUSSION
In view of more recent experimental evidence it may now be accepted that the damaged kidney can recover in the presence of a healthy contralateral kidney. 8 The 3 cases reported herein demonstrate the recovery of renal function in humans after at least 28, 28 and 150 days of apparently complete unilateral ureteral obstruction. IVP and renal scanning were used to
RECOVERY OF RENAL FUNCTION AFTER PROLONGED UNILATERAL URETERAL OBSTRUCTION
139
FIG. 6. Case 3. A, preoperative IVP demonstrates non-visualization of left kidney. B, preoperative hippuran scan. C, retrograde pyelogram shows complete obstruction of left ureter at site of previous ureterolithotomy.
FIG. 7. Case 3. A, postoperative IVP demonstrates visualization of left kidney. B, postoperative hippuran scan. C, IVP 6 months postoperatively.
document the presence or absence of renal function before and after the operation but the decision to relieve obstruction in an attempt to save a renal unit should not be made on the basis of a poor renal scan or IVP. In all 3 cases good cortex was present and possibly should be a major determining factor in renal preservation in such cases. Although experimental data in animals suggest that recovery of renal function should not
occur after 40 days of complete unilateral ureteral obstruction, this may not be exactly comparable to the situations in humans. Return of function has occurred in clinical cases after more than 100 of obstruction in a number of cases. 9 The reason for the lack of correlation between the experimental data and the clinical situation is not entirely clear. The be that the occlusion of the ureter
140
SHAPIRO AND BENNETT
ligation obtained in animals is probably not comparable to the incomplete occlusions (even with non-functioning kidneys) t~at are more likely to occur in clinical types of hydronephros1s. In view of these facts and because of the surprisingly good results in many other reported cases, a plea is made for renal preservation in cases similar to those presented. REFERENCES
1. Hinman, F.: The condition of renal counterbalance and the theory of renal atrophy of disuse. J. Ural., 49: 392, 1943. 2. Orr, L. M. and Kundert, P.R.: Renal counterbalance in relation to conservative renal surgery. South. Med. J., 35: 723, 1942. 3. Schulhof, M. G. and Cabot, H.: Effect of surgical drainage on kidneys declared functionless by present tests of renal function. Surg., Gynec. & Obst., 65: 188, 1937. 4. Widen, T.: Restitution of kidney function after induced urinary stasis of varying duration. Acta Chir. Scand., 113: 507, 1957. 5. Kerr, W. S., Jr.: Effect of complete ureteral obstruction in dogs on kidney function. Amer. J. Physiol., 184: 521, 1956. 6. Vaughan, E. D., Jr. and Gillenwater, J. Y.: Recovery following complete chronic unilateral ureteral occlusion: functional, radiographic and pathologic alterations. J. Ural., 106: 27, 1971. 7. Earlam, R. J.: Recovery of renal function after prolonged ureteric obstruction. Brit. J. Ural., 39: 58, 1967. 8. Vaughan, E. D., Jr., Sweet, R. E. and Gillenwater, J. Y.: Unilateral ureteral occlusion: pattern of nephron repair and compensatory response. J. Ural., 109: 979, 1973. 9. Everett, H. S. and Williams, T. J.: Urology in the female. In: Urology, 3rd ed. Edited by M. F. Campbell and J. H. Harrison. Philadelphia: W. B. Saunders Co., p. 1977, 1970.
COMMENT As the authors have illustrated with these cases, "the decision to relieve obstruction in an attempt to save a renal unit should not be made on the basis of a poor renal scan or urogram". In addition, it is probable that one cannot accurately and quantitatively extrapolate data obtained in animals to the clinical situation. However, several factors must be borne in mind in assessing these cases as a demonstration of recovery of renal function after 28 to 150 days of apparently complete unilateral ureteral obstruction. It is possible and perhaps highly probable that these cases (especially patient 3 who experienced 5 months of left flank pain) represent instances of a high degree of incomplete ureteral occlusion. In addition, an IVP and hippuran renal scan cannot document the absence of renal function. An IVP can only be interpreted as showing non-visualization and the findings will be dependent upon the interval of the delayed films, the amount of contrast material used and the functional capacity of the contralateral renal unit. The hippuran scan measures only proximal tubular function and cannot be equated with non-function or complete lack of glomerular filtration. McDougal and Wright have demonstrated a back leak of inulin from the proximal tubule into the peritubular capillaries during obstruction and such a situation would make interpretation of renal scans difficult.' Although these cases cannot be proved to be examples of complete unilateral obstruction or non-function the authors can be commended for their management, which pro~ides support for attempts to preserve renal parenchyma even in the face of long periods of obstruction with a poor renal scan or IVP. These cases demonstrate our lack of adequate tools to assess renal function or to provide an index of the potential return of function in obstructed kidneys. R.M. W. 1. McDougal, W. S. and Wright, F. S.: Defect in proximal and distal sodium transport in post-obstructive diuresis. Kidney Int., 2: 304, 1972.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
RECOVERY OF RENAL FUNCTION AFTER PROLONGED UNILATERAL URETERAL OBSTRUCTION STEPHEN R. SHAPIRO
AND
ALAN H. BENNETT
From the Department of Surgery (Urology), Harvard Medical School, Boston, Massachusetts
ABSTRACT
Concepts of renal counterbalance and animal experiments have long supported nephrectomy for prolonged complete unilateral ureteral obstruction. The situation in humans has been clarified by only a few reported cases. Herein we report 3 cases with relief of obstruction after at least 28, 28 and 150 days. Evidence is presented to support renal preservation in similar cases. In the past the theories of renal counterbalance and of renal atrophy of disuse have considerably affected treatment of prolonged unilateral ureteral obstruction. 1 • 2 I; was commonly believed that once hypertrophy of the opposite kidney developed the damaged kidney would not regain some portion of its functional capacity. 3 Hydronephrotic atrophy was considered complete in 6 months and compensatory hypertrophy was considered complete in 4 to 6 weeks. More recently, it has been suggested in animal studies that recovery of renal function is unlikely after prolonged unilateral ureteral obstruction. 4 • 5 Most significantly, in dogs there was rarely any return of renal function with release of unilateral complete ureteral obstruction after 40 days.• However, the situation in humans is largely
Cystoscopy on July 3, 1974 was normal. On July 4 an open renal biopsy of the right kidney was performed and the specimen was obtained from the lower pole of the left kidney with a Vim-Silverman needle. Postoperatively, bleeding occurred and required 2 units of blood and drainage of a perirenal wound hematoma. An IVP 2 days postoperatively showed non-visualization of the right kidney. On July 24 the patient was transferred to the Peter Bent Brigham Hospital because of persistent hematuria and flank pain. Examination revealed a tender, full right flank. Laboratory examination revealed microscopic hematuria, hematocrit 36 per cent, blood urea nitrogen 16 mg. per cent and creatinine 1.6 mg. per cent. An IVP on July 26 again showed non-visualization of the right
FIG. 1. Case 1. A, preoperative IVP shows non-visualization of right kidney. B, selective right arteriogram demonstrates arteriovenous fistula in lower pole of right kidney.
unknown and limited to only a few case reports. 7 Herein we report 3 cases with complete ureteral obstruction from 4 to 21 weeks with partial but adequate recovery of renal function in each case. CASE REPORTS
Case 1. A 44-year-old man had microscopic hematuria 4 years prior to hospitalization. Evaluation at a local hospital was non-diagnostic. Excretory urography (IVP) was normal. Accepted for publication ,June 13, 1975. Read at annual meeting of American Urological Association, Miami Beach, Florida, May 11-15, 1975. 136
kidney (fig. 1, A). Delayed films failed to demonstrate visualization. A retrograde pyelogram on July 26 demonstrated right ureteral obstruction by multiple filling defects most likely representing clots. Arteriography on July 30 demonstrated an arteriovenous communication in the lower pole of the right kidney with early filling of the right renal vein (fig. 1, B). On July 31 a lower pole nephrectomy of the right kidney was performed with pyelotomy and drainage of clots, thereby relieving 28 days of ureteral obstruction. A postoperative hippuran scan demonstrated a 25 per cent return of function in the right kidney within 1 week (fig. 2). No further bleeding ensued. Case 2. A 56-year-old man was admitted to the hospital with
RECOVERY OF RENAL FUNCTION AFTER PROLONGED UNILATERAL URETERAL OBSTRUCTION
FIG.
137
2. Case 1. A, postoperative hippuran scan demonstrates return of function to right kidney. B, postoperative hippuran scan
F 1G. 3. Case 2. Non-visualization of right kidney with large calculus in right mid ureter.
a history of right flank pain several weeks in duration. An IVP 1 month prior to hospitalization revealed non-visualization on the right side with a large calculus appearing in the mid ureter. The patient had been free of pain for 2 weeks and presented for a second opinion regarding the necessity of an operation. Examination was within normal limits. Laboratory evaluation revealed a normal complete blood count and urinalysis. IVP on June 27, 1974 again demonstrated non-visualization of the right kidney with a 1.5 cm. calculus in the right mid ureter (fig. 3). A hippuran scan on June 28 showed only background activity on the right side (fig. 4). On July 2 a right ureterolithotomy was performed, relieving a minimum of 28 days of right ureteral obstruction. Postoperative IVP (fig. 5, A) and a hippuran renal scan (fig. 5, B) on July 8 demonstrated a significant return of function to the right kidney. Case 3. A 56-year-old man was admitted to the hospital with increasing left lower quadrant pain 6 weeks in duration. Approximately 5 months previously he had undergone left ureterolithotomy elsewhere for a calculus noted on an IVP as part of an evaluation for back pain. The stone was near the left ureterovesical junction. The patient had experienced discomfort in the left flank and left lower quadrant since the previous operation. Examination showed a healed left lower quadrant scar but was otherwise within normal limits. Laboratory values revealed a normal complete blood count and urinalysis. An IVP on June 25, 1974 demonstrated non-visualization of the left kidney (fig. 6, A) and this was confirmed a hippuran scan 6, B). A retrograde showed complete obstruction at the site of the en vL1cuvvuu1y 6, C). On June 26 a
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SHAPIRO AND BENNETT
Fm. 4. Case 2. A, preoperative hippuran scan shows only background activity on right side. B, preoperative hippuran scan
Fm. 5. Case 2. A, postoperative IVP demonstrates significant return of function to right kidney. B, postoperative hippuran scan
metal clip on the side wall of the ureter. Reim plantation of the remaining ureter was aided by a psoas hitch of the bladder. An IVP 3 weeks postoperatively demonstrated visualization of the left kidney (fig. 7, A) and this was confirmed by a hippuran renal scan (fig. 7, B). An IVP 6 months postoperatively demonstrated even further improvement (fig. 7, C). This was the result after relief of approximately 150 days of left ureteral obstruction.
DISCUSSION
In view of more recent experimental evidence it may now be accepted that the damaged kidney can recover in the presence of a healthy contralateral kidney. 8 The 3 cases reported herein demonstrate the recovery of renal function in humans after at least 28, 28 and 150 days of apparently complete unilateral ureteral obstruction. IVP and renal scanning were used to
RECOVERY OF RENAL FUNCTION AFTER PROLONGED UNILATERAL URETERAL OBSTRUCTION
139
FIG. 6. Case 3. A, preoperative IVP demonstrates non-visualization of left kidney. B, preoperative hippuran scan. C, retrograde pyelogram shows complete obstruction of left ureter at site of previous ureterolithotomy.
FIG. 7. Case 3. A, postoperative IVP demonstrates visualization of left kidney. B, postoperative hippuran scan. C, IVP 6 months postoperatively.
document the presence or absence of renal function before and after the operation but the decision to relieve obstruction in an attempt to save a renal unit should not be made on the basis of a poor renal scan or IVP. In all 3 cases good cortex was present and possibly should be a major determining factor in renal preservation in such cases. Although experimental data in animals suggest that recovery of renal function should not
occur after 40 days of complete unilateral ureteral obstruction, this may not be exactly comparable to the situations in humans. Return of function has occurred in clinical cases after more than 100 of obstruction in a number of cases. 9 The reason for the lack of correlation between the experimental data and the clinical situation is not entirely clear. The be that the occlusion of the ureter
140
SHAPIRO AND BENNETT
ligation obtained in animals is probably not comparable to the incomplete occlusions (even with non-functioning kidneys) t~at are more likely to occur in clinical types of hydronephros1s. In view of these facts and because of the surprisingly good results in many other reported cases, a plea is made for renal preservation in cases similar to those presented. REFERENCES
1. Hinman, F.: The condition of renal counterbalance and the theory of renal atrophy of disuse. J. Ural., 49: 392, 1943. 2. Orr, L. M. and Kundert, P.R.: Renal counterbalance in relation to conservative renal surgery. South. Med. J., 35: 723, 1942. 3. Schulhof, M. G. and Cabot, H.: Effect of surgical drainage on kidneys declared functionless by present tests of renal function. Surg., Gynec. & Obst., 65: 188, 1937. 4. Widen, T.: Restitution of kidney function after induced urinary stasis of varying duration. Acta Chir. Scand., 113: 507, 1957. 5. Kerr, W. S., Jr.: Effect of complete ureteral obstruction in dogs on kidney function. Amer. J. Physiol., 184: 521, 1956. 6. Vaughan, E. D., Jr. and Gillenwater, J. Y.: Recovery following complete chronic unilateral ureteral occlusion: functional, radiographic and pathologic alterations. J. Ural., 106: 27, 1971. 7. Earlam, R. J.: Recovery of renal function after prolonged ureteric obstruction. Brit. J. Ural., 39: 58, 1967. 8. Vaughan, E. D., Jr., Sweet, R. E. and Gillenwater, J. Y.: Unilateral ureteral occlusion: pattern of nephron repair and compensatory response. J. Ural., 109: 979, 1973. 9. Everett, H. S. and Williams, T. J.: Urology in the female. In: Urology, 3rd ed. Edited by M. F. Campbell and J. H. Harrison. Philadelphia: W. B. Saunders Co., p. 1977, 1970.
COMMENT As the authors have illustrated with these cases, "the decision to relieve obstruction in an attempt to save a renal unit should not be made on the basis of a poor renal scan or urogram". In addition, it is probable that one cannot accurately and quantitatively extrapolate data obtained in animals to the clinical situation. However, several factors must be borne in mind in assessing these cases as a demonstration of recovery of renal function after 28 to 150 days of apparently complete unilateral ureteral obstruction. It is possible and perhaps highly probable that these cases (especially patient 3 who experienced 5 months of left flank pain) represent instances of a high degree of incomplete ureteral occlusion. In addition, an IVP and hippuran renal scan cannot document the absence of renal function. An IVP can only be interpreted as showing non-visualization and the findings will be dependent upon the interval of the delayed films, the amount of contrast material used and the functional capacity of the contralateral renal unit. The hippuran scan measures only proximal tubular function and cannot be equated with non-function or complete lack of glomerular filtration. McDougal and Wright have demonstrated a back leak of inulin from the proximal tubule into the peritubular capillaries during obstruction and such a situation would make interpretation of renal scans difficult.' Although these cases cannot be proved to be examples of complete unilateral obstruction or non-function the authors can be commended for their management, which pro~ides support for attempts to preserve renal parenchyma even in the face of long periods of obstruction with a poor renal scan or IVP. These cases demonstrate our lack of adequate tools to assess renal function or to provide an index of the potential return of function in obstructed kidneys. R.M. W. 1. McDougal, W. S. and Wright, F. S.: Defect in proximal and distal sodium transport in post-obstructive diuresis. Kidney Int., 2: 304, 1972.
