Partial Resections of the Kidney

Partial Resections of the Kidney

PARTIAL RESECTIONS OF THE KIDNEY A REPORT OF 6 CASES AND A REVIEW OF THE LITERATURE A. E. GOLDSTEIN AND B. S. ABES,HOUSE From the Urological Servi...

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PARTIAL RESECTIONS OF THE KIDNEY A

REPORT OF

6

CASES AND A REVIEW OF THE LITERATURE

A. E. GOLDSTEIN AND B. S. ABES,HOUSE From the Urological Service, Sinai Hospital, Baltimore, Maryland

The first deliberate partial resection of a kidney was performed by Czerny in 1887, eighteen years after the first epoch-making nephrectomy by Simons. During the early period of renal surgery (1870-1900) extensive experimental studies by Tillman, Tuffier, Bardenheuer, Paoli and others established the feasibility of employing partial resections in the treatment of localized diseases of the kidney. The surgeons of this period employed partial resections in various types of clinical cases but the operation soon lost favor and was more or less abandoned for several reasons; viz., (a) an unwarranted fear of extensive hemorrhage at the time of operation and of delayed hemorrhage following operation, (b) the frequent occurrence of persistent urinary fistula following the operation, and (c) the poor results and recurrences following the injudicious use of this operation in the treatment of neoplasms and tuberculosis of the kidney. With the dawn of the new century, surgeons began to devote their efforts to conservative operations in the treatment of localized diseases of the kidney such as cysts, benign tumors, localized cortical abscesses, infarcts, carbuncles, localized hydro- or pyonephrosis, localized diseases of double kidney, etc., and as a result, the conservative partial resection has gradually but steadily supplanted in many instances the radical nephrectomy in the treatment of these conditions (De Rouville, Kuster, Von Schmieden, Berti, and Herbst and Polkey). We undertook a comprehensive review of the literature on partial resection of a kidney in order to establish the priority, nature and extent of the cases reported and have collected to date 296 cases which include 6 personal cases (tables 1 and 2) . In this paper the authors use the term partial resection of a kidney to designate the removal of a portion of a congenitally normal kidney in which some pathological change has taken place. The term-partial resection- is used synonymously with partial nephrectomy. A brief summary of the experimental studies is presented under the following headings : viz., (1) renal repair following resections; (2) com15

16

A. E. GOLDSTEIN AND B. S. ABESHOUSE

pensatory hypertrophy following resections; (3) renal function following resections; (4) changes in body functions following resections; and (5) the amount of renal tissue necessary for life. (1) Renal repair following resections. The healing of sutured or nonsutured wounds in the nephrotomized or partial nephrectomized animals is dependent upon the exuberant production of connective tissue derived from the capsule and interstitial tissue and reinforced by reticular tissue derived from the blood elements and by fibrous and fatty tissue. When a portion of the kidney is excised, the capsule dips downward and attaches TABLE

!.-Tabulation of cases of resection of the kidney including the authors' 6 cases NUMBER

PATHOLOGICAL CONDITION

OF CASES

SECONDARY URINARY HEMOR- FISTULA

RHAGE

SEC-

ONDARY RECOVNEPHREC-

ERED

TOMY

- - -- -- -- -- Solitary cysts ........... . .... .. . . ... Hydatid cysts .............. . . . . . .... Polycystic disease ....... . .. . . ....... Localized hydro- or pyonephrosis . ..... Generalized hydronephrosis .. . . . .. . ... Kidney injuries . ... . .. . . ... . .. . . . ... Infarct . .. ....... . . .. . .. . . . .. . . . . ... Renal abscess .. . ... . .... .. . .. .. .. ... Renal carbuncle ...... ... ..... .. ..... Perirenal sclerosis . ... .. .... .... . ..... Fistula . . ..... ................. Malignant tumors .... .. .. . ... .. ..... Benign tumors . ........... . . .... .... Pararenal tumors . .. . . . . . .. . . . ...... . Adrenal tumors . . . . . . . .. ... .. .. .. . . . . Tuberculosis . ..... .. ...... . . . . . . . . . .

32 22 10 80 4 22 13

16 11

3 1 21 13 6 1 41

Total. ... .. . . . . · · ·· · .... .... ...... 296

1 1

32 17 10 77 4 21 13 15

-

0 5 0 2 3 3 0 3 2 1 1 2 0 2 1 1 11 0 1 3 0 1 0 20 6 1 1 13 0 6 0 1 0 5 6 36 5 -- -- -- -- - 3 13 23 280 16 1

1 0

DIED

MORTALITY

-per cenl

22.7 3.7 4.5 6.6

4.7

12 .1 5.4

itself to the cut surface; The repair process along the line of incision or excision is more or less localized and in this localized area of connective tissue one finds only a few atrophied or degenerating glomeruli and tubules showing a varying amount of hyalinization. New capillaries can be demonstrated throughout the area of repair (Tuffier, Paoli, Carson and Goldstein, and others). (2) Compensatory hypertrophy following resections. Resections of small portions of one kidney, i.e., approximately one-seventh to one-third, with the opposite kidney intact are not accompanied by a compensatory

TABLE CASE

YEAR

SEX

--- - M I. W. B. H. 1933

AGE

---

PRE-OPERATIVE DIAGNOSIS

2.-Tabulation of authors' cases POST-OPERATIVE DIAGNOSIS

+

AMOUNT OF TISSUE REMOVED

OPE~TION

RESULT

42

Renal calculi (R)

solitary Same cyst (R upper pole)

Solitary cyst (size of walnut)

Partial resection of Recovered kidney and pyelolithotomy

35

Polycystic disease

Same

Lower third (R)

Partial resection and puncture of cysts

---

II. H.P.

1919

M

Recovered

~

--III. K. B.

1929

IV. M. Z.

1932

F

r:n.

45

V. E. H.

1935

--F

40

43

t,,J

Localized calculous Same pyonephrosis (L)

Lower fifth (L)

Partial resection of kidney

Recovered

Localized calculous Same pyonephrosis (R)

Lower pole (R)

Partial resection of kidney

Died 11 days (P.O.). Pneumonia

1-rJ

Localized calculous Same pyonephrosis (R)

Lower pole (R)

Partial resection of kidney

Recovered

~

Partial resection of kidney and pyelolithotomy

Recovered

--- --F

I (")

g zr:n.

0

~ Kl

---

VI. L.B.

1919

M

55

Acute perinephritis Anemic infarct (L). Upper third (L) (L). PerineRenal calculus (L) phritic abscess (L)

,-.,. ~

18

A. E. GOLDSTEIN AND B. S. ABESHOUSE

hypertrophy in either the resected kidney (Valentin, Rosenstein) or nonoperated kidney (Wolff, Barth, Plaggemeyer and Cummings) but on the contrary Herbst and Polkey observed a relative atrophy of the resected kidney as indicated by some reduction in size, weight, and function. When a relatively large amount of renal tissue is removed, i.e., two-thirds to three-quarters of one kidney, and the opposite kidney is intact, a compensatory hypertrophy is manifested by the non-operated kidney (Tuffi.er, Di Paoli, Berti and others) but not in the resected kidney. When more than one-half of total renal tissue is removed (removal of one kidney and after an interval of time, resection of one-third to one-half of the other kidney) a compensatory hypertrophy was observed in the remaining segment by all investigators. Resection of one-half or less of a solitary kidney or the simultaneous removal of one kidney and less than one-half of the other kidney is also followed by compensatory hypertrophy in the remaining segment. (3) Renal function following resections. Experimental studies have shown that following partial resections, a decrease in renal function occurs approximately in proportion to the amount of renal tissue. Herbst and Polkey resected approximately one-seventh to one-third of a kidney with the opposite kidney intact and observed a reduction in the size, weight, and phthalein function in the resected kidney in each case whereas the non-operated kidney remained normal. They observed that the diminished function in the operated kidney was most marked the first two weeks after resection due to congestion and repair processes. A gradual restoration of function occurred in the third to the fifth week as was also observed by Plaggemeyer and Cummings but never reached a normal level. (4) Changes in body functions following resections. The experimental studies of Tuffier, Paoli and others showed that following the removal of small portions of one kidney, i.e., one-third to one-half of one kidney with the opposite kidney intact, no unusual change in body functions occurred which appreciably altered the life or health of the experimental animals-. When the total amount of renal tissue is reduced to a minimum compatible with life, signs and symptoms of a progressive renal insufficiency soon develop. Experimental studies reveal that the extensively resected kidney is similar to the partially diseased kidney in its response to diet. Mark, and Lundin and Scharf found that when the average laboratory diet was fed to dogs who had slightly less than 75 per cent of the total kidney tissue

PARTIAL RESECTIONS OF KIDNEY

19

removed and to goats with a reduction of 80 to ·90 per cent of the total kidney tissue, there resulted no disturbance of kidney function other than the appearance of traces of albumin and a restriction of the concentrating capacity for nitrogen in the urine. Animals with more than 75 per cent of the combined kidney tissue removed on an average diet developed severe disturbances in kidney functions and died of uremia. (5) The amount of kidney tissue necessary for life. The minimum amount of kidney tissue necessary to maintain life differs slightly in the various experimental animals. Dogs and cats require at least 25 per cent of the total renal tissue, i.e., one-half of one kidney (Tuffier, Paoli, Peters, Bradford). The rat can survive the removal of five-sixths of the total renal tissue (Chanutin and Ferris). The rabbit appears to require more kidney tissue than any other laboratory animal for it does not seem capable of surviving the removal of 60 to 70 per cent of the total kidney substance (Anderson). The goat requires the least amount of renal tissue, i.e., 10.- to 15 per cent of total renal tissue (Allen, Scharf and Lundin). Indications for partial resections of a kidney. There are certain affections occurring in the congenitally normal kidney which are amenable to resection. In this group are included the following conditions: viz., solitary cysts, hydatid cysts, benign tumors, localized infections, localized hydronephrosis or pyonephrosis with or without calculi, renal fistula, etc. A comprehensive preoperative study may lead the surgeon to plan a partial resection but the final decision as to the practicability of the procedure must be made at operation. Partial resection is the operation of choice in those cases in which the following criteria can be fulfilled; viz. (1) the disease process must be sharply confined to one area of a kidney as determined at operation; (2) operative removal of the affected portion of the kidney must be performed with ease and without undue risk to the patient; (3) the blood supply to the portion of the kidney remaining after resection must be adequate; and (4) the portion of kidney remaining after resection should be able to carry at least one-half or, if possible, more of the secretory burden of the affected kidney. In some cases, partial resection is an operation of necessity rather than choice. In!these cases, it is imperative to preserve as much renal tissue as possible. The following groups, which are fortunately rare, illustrate this type of case: viz., (1) when the disease process occurs in a congenital THE JOURNAL OF UROLOGY, VOL,

38,

NO,

1

20

A. E. GOLDSTEIN AND B . S. ABESHOUSE

solitary kidney or in the remaining kidney after nephrectomy and is a part of or in intimate association with the remaining functioning portion of renal tissue; (2) when traumatic injuries to both kidneys necessitate the removal of one kidney and part of the other as in the case reported by Franklin; (3) when the localized disease process occurs in a kidney whose mate is of the congenital hypoplastic or acquired atrophic type and hence is insufficient to carry the entire secretory burden alone in the event of nephrectomy of the diseased kidney; (4) in cases of bilateral renal disease, especially lithiasis and, less frequently, tuberculosis, pyonephrosis and cortical infections, the functional capacity of each kidney may be seriously impaired and surgical treatment should be directed toward the preservation of as much renal tissue as is possible; and (5) in cases where, for some reason or other, the presence of function of the opposite kidney is not known or cannot be determined at or before operation, as occurred in one of our cases, i.e., an emergency partial resection for an infarct of the kidney. Partial resection for solitary cysts. Conservative renal surgery, consisting of the complete removal of the cyst with or without a small portion of the adjacent kidney tissue, is generally accepted as the ideal form of treatment for solitary serous or hemorrhagic cysts. Resection of the cyst with a wedge-shaped portion of the underlying renal tissue was originally described by Tuffier in 1891 and in this country by Stamm in 1894. This is considered the operation of choice providing the functional capacity of the kidney is good. Hemostasis is obtained by approximating the edges of the incision with a continuous through and through suture or by mattress sutures. Partial resection is contraindicated in those cases where the cyst is very large and has destroyed a major portion of the renal parenchyma or where the cyst is situated at or near the hilum and encroaches upon the vascular pedicle. We have collected 31 cases of solitary cysts treated by partial resection and add one personal case. The authors have also had one case of solitary cyst treated by excision. There were no mortalities in this series. A postoperative fistula occurred in one case (Cahill), postoperative hemorrhage, one case (Walters) and secondary nephrectomy, one case (Walters). Case 1 (G. U. No. 1390). W. B. H., a male, aged 42 years, was admitted to the Sinai Hospital May 19, 1933 complaining of pain in the right lumbar region of seven days' duration. Right renal colic one year ago and again one

PARTIAL RESECTIONS OF KIDNEY

21

week ago. No urinary symptoms. Physical examination was negative except for tenderness in the right costo-vertebral angle. The urine showed a few pus cells and red blood cells. Cystoscopy and pyelography revealed a calculus in the upper third of the right ureter and two small calculi in the lower pole of the right kidney. On May 30, 1933, operation was performed under avertin anaesthesia. The two calculi in the kidney were removed through a pyelotomy incision. A small cyst, the size of a walnut, was found on the convex border of the upper pole of the kidney. The cyst was removed by sharp dissection using a wedgeshaped incision (fig. 1). A piece of muscle was placed in the cyst cavity and the edges of the incision were approximated with several mattress sutures = incision

FIG. 1 (Case 1). Drawing of the solitary cyst, the size of a walnut, found on convex border of right kidney at the upper pole. The cyst was removed by a wedge shaped incision. The operative defect was closed with mattress sutures after placing a piece of muscle in the wound.

(Beer-Hagenbach). The patient made an uneventful recovery and was discharged from the hospital on June 13, 1933. The patient was re-examined six months later and found to be in excellent condition.

Partial resection for echinoccus cyst of the kidney. Partial resection is also considered the operation of choice in the treatment of hydatid cyst but unfortunately relatively few cases are amenable to such treatment. It is interesting to note that the first resection of the kidney was performed accidentally for a hydatid cyst by Spiegelberg in 1867. We have collected 22 cases of hydatid cysts treated by partial resection: there were 5 deaths (Spiegelberg, Jerasch, Aboulkav, Marion, Viannay). There were no post-operative fistula and only one secondary hemorrhage.which

22

A. E. GOLDSTEIN AND B. S. ABESHOUSE

occurred in Viannay's patient on the ninth post-operative day and resulted in death six days later. Partial resection for polycystic disease of the kidneys. The operative treatment of this disease is usually directed toward the conservation and preservation of functioning tissue and entails the use of such palliative operative procedures as the multiple puncture of cysts (Rosving) and a nephrocutaneous fistula (Goldstein). The indications for nephrectomy and partial resection are very limited. The latter is only applicable to those rare cases in which the cysts are limited to one pole of the kidney

lower pole re,m_o\Te,d

FIG. 2 (Case 2). Drawing of the right polycystic kidney showing the scant distribution of the cysts in the upper two-thirds and the marked involvement of the lower third. The dotted line represents the line of resection. A nephrotomy incision was made to expose the cysts in the deeper portion of the kidney.

and the opposite kidney being normal or sltghtly affected. The first partial resection for polycystic disease was reported by Tuffier in 1891 who successfully removed the inferior half of the affected organ. The patient was reported well two years after operation. We have collected 9 cases of polycystic disease treated by partial resection and add one personal case in which one or more cysts were resected in conjunction with other operative procedures on the kidney. There were no operative deaths in this series. Post-operative complications, i.e., fistula or hemorrhage, were not noted in any of the cases reviewed by the authors.

PARTIAL RESECTIONS OF KIDNEY

23

Case 2. H. P., male, aged about 35 years, single, was admitted to Sinai Hospital in the latter part of December, 1919. (His hospital record had been lost.) He complained of abdominal pain and loss of strength. Examination disclosed a mass in the right upper quadrant which was irregular and lobulated. Ballottement was present. The urine showed a heavy trace of albumin and a moderate number of red blood cells and pus cells. Cystoscopy and pyelography confirmed the pre-operative diagnosis of bilateral polycystic disease of the kidneys. Under gas anesthesia, the right kidney was exposed through a lumbar incision. The cysts were punctured. The entire kidney was split in half in order to puncture the cysts in the deeper portion of kidney. The lower third of the kidney, which contained several very large cysts with very little functioning interstitial tissue, was removed (fig. 2). The patient made an une-ventful recovery and was discharged from the hospital about one month later. The patient was followed for about 4 years during which time he appeared to be enjoying fairly good health and was then lost sight of. Microscopic study of the removed tissue showed the typical changes of polycystic disease.

Partial resections for localized hydronephrosis or pyonephrosis. A localized hydronephrosis is essentially a dilatation of a major calyx (hydrocalyx), caused either by a calculus or stricture in a calyx. When infection supervenes within the calyx or in the surrounding parenchyma, a localized pyonephrosis occurs. Fortunately, the localized disease process is practically always confined to either the upper or lower pole of the kidney and lends itself admirably to surgical treatment in the form of a wedge-shaped resection of the diseased area and a portion of the adjacent healthy tissue. Partial resection is particularly efficacious in the treatment of a localized hydronephrosis or pyonephrosis involving the lower caudal calyx. In such cases, resection of the diseased area decreases or eliminates complications, which usually develop as a result of inadequate drainage and urinary stasis following treatment of the sacculation by incision and drainage. The first partial resection for a localized pyonephrosis was reported by Bardenheuer in 1891 who removed the lower third of the left kidney including several calculi and drained a perinephritic abscess in a 45 year old woman. The patient recovered but developed a reno-colic fistula. In 1892, Tu.ffier reported a successful resection of the upper pole of the kidney for localized calculous pyonephrosis but one year later the remaining portion was removed for carcinoma. Kummell reported a case of resection for localized pyonephrosis in 1893 and in the following year

24

A. E. GOLDSTEIN AND B. S. ABESHOUSE

reported the successful simultaneous resection of the upper and lower pole for a localized pyonephrosis. We have collected 77 cases of localized hydronephrosis or pyonephrosis treated by partial resection and add 3 personal cases of localized calculous pyonephrosis. In this series, resection was performed for calculous pyonephrosis in 58 cases, pyonephrosis in 11, and hydronephrosis in 11. There were only 3 deaths following operation (Cummings (2), authors (1)); an operative mortality of 3.8 per cent. Secondary hemorrhage was not observed in a single case. Post-operative fistula was reported in only 2 cases (Bardenheuer, De Rouville and Soubeyran). A secondary nephrectomy was performed in 3 cases (Tuffi.er, Eisendrath and Cummings). Case 3. (Gyn. No. 3041). K. B., female, aged 45 years, married, was first seen July 29, 1929 complaining of pain in the right lumbar region. For the past year, she has had intermittent attacks of dull pain beginning in the right lumbar region and radiating to the right groin with occasional pain in the left lumbar region. No urinary symptoms. Physical examination was entirely negative. The urine showed 15 pus cells and an occasional red blood cell per high power field. Cystoscopy and pyelography revealed a calculus in the lower major calyx of the left kidney which showed a moderate degree of infection and a calculus in an infected congenital hypoplastic kidney on the right. Phthalein test revealed 3 per cent function from the right kidney and 12 per cent function from the left kidney in 15 minutes. On November 22, 1929, the left kidney was exposed through a lumbar incision under gas anesthesia. A stone was found in the lower major calyx above a stricture of the infundibular portion of the calyx. The lower fifth of the kidney was nodular and contained several cortical abscesses. This area was supplied by an aberrant polar artery which was ligated. The lower fifth of the kidney was removed by a cuneiform resection. The calyx was sutured with number 00 non-chromicized catgut. A piece of fat was placed in the incision and the edges were approximated with several mattress sutures of number 2 non-chromicized catgut (Beer-Hagenbach). The capsule was sutured over the incision (fig. 3). Drainage of the renal bed was instituted. The patient had an uneventful recovery except for an urinary fistula which persisted for 8 weeks. The wound was entirely healed on January 25, 1930 when the patient was discharged from the hospital. The patient returned on October 9, 1930 complaining of severe pain in the right lumbar region. Cystoscopy and pyelography showed the calculus in the right hypoplastic kidney to be larger. The right kidney urine contained a moderate amount of pus cells but the left kidney urine was negative. On

PARTIAL RESECTIONS OF KIDNEY

25

April 29, 1932, the right infected hypoplastic kidney was removed under gas anesthesia. The patient had an uneventful convalescence and was discharged from the hospital on May 18, 1932. The patient subsequently returned for an examination on August 8, 1932, July 6, 1934, and January 24, 1936. On the latter date, a catheterized specimen contained no pus cells and an intravenous phthalein showed 40 per cent excretion for one hour. A pyelogram

FIG. 3 (Case 3). Drawing of the wedge shaped resection of lower fifth of left kidney for localized calcalous pyonephrosis. A, the aberrant artery supplying the lower pole of the kidney has been ligated and the capsule retracted before making the wedge shaped excision. B, the operative defect is closed by placing a pad of fat in the wound and approximating the edges of the incision with mattress sutures underpinned with fat (Beer-Hagenbach method). C, the retracted capsule is drawn over the incision and closed with a continuous number 00 non-chromicized suture.

of the left kidney on January 24, 1936 showed a normal pelvis and calyces with no calculi. The excised portion of the kidney weighed 25.6 grams and measured 5 x 2 x 2 cm. The surface was irregular and nodular and studded with small cortical abscesses. On cross section, several large abscesses and fresh hemorrhagic infarcts were noted. Microscopic examination showed essentially the same findings.

26

A. E. GOLDSTEIN AND B. S. ABESHOUSE

Partial resection for localized calculous pyonephrosis. Case 4 (Gyn. No. 3919). M. Z., aged 40 years, married, was first seen October 14, 1930, complaining of urinary frequency and dysuria. For the past nine months she had complained of diurnal frequency, nocturia, urgency, hesitancy, and burning. She also complained of intermittent pain in the right loin radiating to right groin. There had been no haematuria or gravel. Physical examination was negative except for slight tenderness on deep palpation in the right loin. A catheterized specimen of urine was negative except for four to five pus cells per high power field. Cystoscopy and pyelography revealed a small calculus in the lower pole of the right kidney and a moderate ptosis of same kidney. Phthalein test revealed a normal function in each kidney. On January 22, 1932, the right kidney was exposed through a lumbar incision under spinal anesthesia. An anomalous artery was found supplying the lower pole of the kidney which contained a small oval stone (12 mm. x 4 mm.). This artery was ligated and the devascularized renal tissue was excised by a cuneiform incision which left a tongue-like piece of tissue on the convex border. The lower major calyx was cut during the resection and closed with a continuous number 00 non-chromicized catgut. The tongue-like piece of renal tissue was approximated to the edges of the cuneiform incision by means of several interrupted mattress sutures (Beer-Hagenbach type) after inserting a piece of muscle in the incision. The capsule was resutured over the incision (fig. 4). A nephropexy (Kelly method) was performed. The renal bed was drained. The patient developed bronchopneumonia and died on the 11th post-operative day. A post mortem examination showed the kidney to be healing per primam with no evidence of intra or extra-renal infection. A diffuse bronchopneumonia was found in both lungs. Histological study of the resected tissue showed a chronic pyelonephritis. Case 5 (Gyn. No. 5011). E. H., aged 43 years, female, married, was first seen on May 10, 1933 complaining of pain in right abdomen. The past history was essentially negative except for an attack of non-colicy pain on right side accompanied by fever about 18 years ago. Since the latter attack, pain has occurred practically daily especially after being up and about on her feet. No urinary symptoms. Physical examination was negative except for tenderness on palpation in the right lumbar region, right upper and lower abdominal quadrants. A catheterized specimen of urine showed a moderate number of pus cells. Cystoscopic and pyelographic studies on May 10, 1933 showed (a) a calculus about the size of a marble in the lower major calyx of the right kidney; (b) right hydronephrosis, infected; (c) right nephroptosis and (d) an obstruction at the uretero-pelvic junction. Phenolsulphonphthalein test revealed a normal

PARTIAL RESECTIONS OF KIDNEY

27

function in each kidney. Operation was advised but refused. The patient returned on March 9, 1935 for re-examination and the findings revealed a small calculus in each kidney and a hydronephrosis on the right.

FrG. 4 (Case 4). Drawing of the wedge shaped exci;ion of the lower third of the right kidney for a localized calculous pyonephrosis. A, ligation of the aberrant artery and vein to the lower pole and the resulting devascularized zone. B, the operative defect resulting from wedge shaped excision of devascularized tissue after retracting the capsule. The opened lower major calyx is closed with a continuous suture of number 00 non-chromicized catgut. C, a piece of muscle is placed in the wound and the edges of incision are approximated with mattress sutures underpinned with fat (Beer-Hagenbach method). The capsule is closed over the incision with a continuous number 00 non-chromicized suture.

On March 19, 1935, the right kidney was exposed through a lumbar incision under avertin anesthesia. The lower pole of the kidney including a small stone about 1.5 cm. in diameter was removed. A cuneiform incision was made. The opened calyx was closed with a continuous suture of number 00 nonchromicized catgut. The edges of the wound were approximated with a

28

A. E . GOLDSTEIN AND B. S. ABESHOUSE

continuous suture of number 2 non-chromicized catgut with underpinning of fat (Beer-Hagenbach). A piece of muscle was placed in the incision before closing it. The capsule was sutured over the incision (fig. 5). A plastic operation was done on the renal pelvis by removing a portion of the pelvis and resuturing same. A nephropexy (Kelly method) was also performed.

FIG. 5 (Case 5). Drawing of the wedge shaped resection of the lower third of the right kidney for localized calculous pyonephrosis. A, the dotted line represents the upper limit of the resected tissue. A diamond shaped portion of the dilated pelvis was removed to correct the hydronephrosis. B, operative defect resulting from the wedge shaped excision of renal tissue. The severed lower major calyx is closed with a continuous suture of number 00 nonchromicized catgut. The edges of the wound are approximated by a continuous through and through suture of the number 2 non-chromicized catgut underpinned with fat. C, a piece of muscle is placed in t he wound before approximating the edges of the wound. The capsule is closed with a continuous number 00 non-chromicized suture.

The patient had a rather stormy convalescence due to a post-operative wound infection and a wide spread furunculosis. She continued to drain urine from the wound until May 7, 1935 and the wound was ehtirely healed on May 13, 1935. On January 16, 1936 patient was re-examined and found to be in excellent health.

PARTIAL RESECTIONS OF KIDNEY

29

Pathological examination of removed renal tissue revealed a mild diffuse nephritis with necrotic and :fibrotic changes suggestive of an old infarct. Orthopedic resection for hydronephrosis. In 1905, Albarran proposed his operation of orthopedic resection for the treatment of hydronephrosis. The operation consisted of resecting the dependent portion of the pelvis together with the lower pole of the kidney. He had successfully performed the operation on 4 females. Partial resections for injuries of the kidney. Partial resection has been successfully performed for kidney injuries confined to one portion of the kidney as in cases reported by Keelty in 1890 and Bardenheuer in 1891. Partial resection is also indicated in unusually severe injuries to both kidneys requiring bilateral operations as in the case reported by Franklin who performed a simultaneous left nephrectomy and right partial resection. We have collected 22 cases of resections for kidney injuries. There was one death following operation (Redi), an operative mortality, 4.5 per cent. Post-operative urinary :fistula developed in 3 cases (Cunningham 2, Simonin). Secondary nephrectomy was necessary in 2 cases because of post-operative suppuration (Link, Atkinson). Partial resections for localized non-tuberculous disease in or about the kidney. A brief consideration of the role of partial resection in the treatment of the non-tuberculous diseases in and about the kidney is presented under the following headings: (a) infarcts of the kidney; (b) acute pyelonephritis with abscesses; (c) renal carbuncle; (d) perirenal adhesions or sclerosis; (e) renal fistula. (a) Infarcts of the kidney. While the indications for surgical intervention in this condition are by no means clearly defined, conservative treatment by resection is indicated if an infarct is encountered during an exploratory operation on the kidney providing the amount of renal tissue involved is not too extensive to render such an operation impractical or hazardous. Partial resection for renal infarct was successfully performed for an anemic infarct by us. We have collected 12 cases where resection was performed for an infarct and add one personal case. Post-operative hemorrhage occurred in one case and required secondary nephrectomy (Cummings). A secondary nephrectomy was also performed by Barney because of persistence of infection following operation. There were no post-operative urinary fistulae. Case 6 (G. U. No. 69). L.B., 55 years, a male, cap maker, was admitted to Sinai Hospital on August 1, 1919 with a complaint of sharp pain in left lumbar

30

A. E. GOLDSTEIN AND B . S. ABESHOUSE

region of 5 days duration. The patient passed a calculus about 6 years ago and again about 9 months ago. The present trouble manifested itself about 5 days ago with sudden sharp pain in left lumbar region lasting 48 hours. The,pain radiated around in front and into the testicle and was accompanied by nausea, vomiting, chills and fever. He also complained of frequency, dysuria, urgency, straining but no hematuria. Two days ago, a similar attack of pain recurred which persisted on admission to the hospital. Physical examination was negative except for exquisite superficial and deep tenderness in the left lumbar region and a benign enlargement of the prostate (1st degree). The patient appeared very toxic and the temperature varied

-~\__/\ ~~?~ ~1' J)~ {~

·~~.

-l.~o/tR ~~frJ ziu,J, -

~) {Jyt; r~,.\ -~~;{r3 )

,.. ~ \ 1

'

r-

(~JS~ \ 2.~r-&f ) FIG. 6 (Case 6). Diagram illustrating the usual type of lumbar incision (Israel) employed in resections of the kidney. The dotted area represents the upper pole of the left kidney resected for an infarct.

between 100° and 103.2°F. and the pulse varied between 90-102. The leucocyte count was 18,000 and 86 per cent polymorphonuclear leucocytes. The blood 'urea was 48 mgm. per cent. The urine showed a faint trace of albumin but no pus or red blood cells. The patient was kept under observation for 2 days but the condition became progressively worse. He was considered too ill to risk cystoscopy although a plain roentgenogram of the genito-urinary tract showed no unusual findings. A tentative diagnosis of acute perinephritis with perinephritic abscess was made and operation advised. On August 3, 1919, the left kidney was exposed through the usual Israel

PARTIAL RESECTIONS OF KIDNEY

31

lumbar incision. No inflammatory or suppurative process was found in the perinephritic tissues. The kidney appeared normal. No stones were palpated in the pelvis or through the kidney parenchyma. Following the operation, pus and red blood cells were found in the urine. The elevated temperature persisted and the toxicity and pain appeared to be more severe. The impression prevailed that we were dealing either with a liver abscess or some obscure renal lesion. A second operation was advised and performed on August 20, 1919. Through a right mid rectus incision the liver and its surrounding area were exposed and carefully examined but showed no pathological changes. The left lumbar incision was re-opened and the left kidney was exposed. The kidney appeared to be enlarged and presented numerous small abscesses on the anterior and posterior surface of the upper third of the kidney. This portion of the kidney was of a greyish color and sharply demarcated from the lower two-thirds which had a normal appearance (fig. 6). A small calculus, about the size of a pea, was palpated in the pelvis and removed through a pyelotomy incision. Inasmuch as there had been no opportunity to determine the presence or function of the opposite kidney, it was decided to resect the upper third of the kidney. A transverse incision was made about 1 cm. below the sharply demarcated grey area through healthy tissue. The upper major calyx was exposed. The renal wound was closed with a continuous number 2 chromic catgut suture (fig. 7). As the patient's condition at this stage appeared very alarming, the lumbar incision was closed with through and through sutures of silkworm gut and restorative measures were quickly instituted. Following this operation, the temperature gradually declined and maintained a normal level after 16 days. A moderate amount of pus and urine drained from the wound for 10 days. While dressing the wound, the remaining portion of the kidney could be seen and gradually decreased in size, appearing to be the size of a pecan on the 21st post-operative day (fig. 8). The kidney was soon covered with granulation tissue. The wound closed and the patient was discharged from the hospital 40 days after the second operation. At this time, the urine contained 15 pus cells per high power field and colon bacilli. The intravenous phthalein test showed 35 per cent excretion for 1 hour and 5 minutes. Three months after operation, the patient was re-examined. There was a post-operative hernial defect in the left lumbar region with a tiny pin-point opening through which an occasional discharge of urine was observed. The urinary fistula closed entirely after 6 months. Cystoscopic studies showed normal urine from the right kidney but no urine from the left. In March 1924 (4½ years after operation), cystoscopy was repeated and normal urine was obtained from both kidneys. An intravenous phthalein test showed 14 per

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A. E. GOLDSTEIN AND B. S. ABESHOUSE

FIG. 7 (Case 6). Drawing showing the wound resulting from the transverse excision of upper pole of the left kidney for an infarct. The renal wound is closed with a continuous through and through suture of number 2 non-chromicized catgut. The retracted capsule is later utilized to close over the operative defect.

FIG. 8 (Case 6). Drawing made on the 21st post-operative day to show the protrusion into the wound of the portion of kidney remaining after resection. The kidney appeared to be the size of a pecan.

PARTIAL RESECTIONS OF KIDNEY

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cent excretion from the right kidney and 7 per cent from the left kidney for 30 minutes. A pyelogram of the left kidney showed the left pelvis and lower calyces to be smaller than normal. The patient was again examined April 1927 (7½ years after operation) and found to be in e.xcellent shape. The cystoscopic findings were essentially the same as above. The hernial defect was still present in the operative region. Examination made October 1936, seventeen years after the operation shows the patient to be in excellent condition. Pathological report: Specimen consists of a portion of a kidney removed at operation measuring 4 x 2 x 2 cm. The kidney tissue except for 0.5 cm. at the cut end has the greyish color characteristic of an anemic infarct. Numerous pin point abscesses are seen over the entire surface of the specimen and in the parenchyma on cross section. Histological examination reveals widespread areas of coagulation necrosis with an occasional area showing an accumulation of polymorphonuclear leucocytes. Pathological diagnosis : Anemic infarct of the kidney with acute pyelonephritis. (b) Abscesses of the kidney. Nephrecto'm y was considered the only treatment for this condition until Lennander in 1901 reported 4 cases successfully treated by splitting the kidney throughout its entire length and resecting portions of the infected kidney. Subsequently this operation was supplanted by decapsulation with excision or resection of the localized abscesses whenever possible. We have collected 16 cases of abscess of the kidney treated by excision or resection. Post-operative fistula was observed in 2 cases (Cunningham). No secondary hemorrhage was reported. A secondary nephrectomy was required in one case (Morris). (c) Renal carbuncle. The first successful resection for renal carbuncle was reported by Israel in 1891. Excision or partial resection is applicable to cases of carbuncle which are sharply localized and unaccompanied by an extensive infection in the remaining portion of the kidney. The excision or resection of the septic mass should be done with the electrosurgical knife whenever possible. We have collected 11 cases of renal carbuncle treated by excision or partial resection; all of which recovered following operation. (d) Perirenal sclerosis or adhesions. We found 3 cases (Berti, O'Conor 2) of successful partial resections of the kidney for perirenal sclerosis. In 1921 Berti reported the successful removal of the upper third of the right kidney in a 49 year old man for adhesions following a nephropexy. In 1925, O'Conor reported 2 cases of p ~rirenal abscess in men 34 and 24

34

A. E. GOLDSTEIN AND B. S. ABESHOUSE

years of age respectively in whom it was necessary to remove a portion of the kidney. There were no post-operative complications reported. (e) Renal fistula. In an occasional case, a fistulous tract is confined to a particular localized portion of the kidney leaving the remaining kidney tissue in a healthy condition. In such cases resection of the involved renal area with excision of the entire fistulous tract will effect a cure. In 1891, Tuflier successfully resected a kidney for fistula formation following a previous nephrotomy for pyonephrosis. In 1901, Berti reported a successful case of renal resection for a fistula and perirenal adhesions developing after a nephropexy. Partial resections for tumors of the kidney. It is generally agreed that the only effectual treatment of malignant tumors of the kidney is total nephrectomy. Wells in 1884 accidentally removed a third of a kidney during the enucleation of a perirenal fibrolipoma and Czerny in 1887 performed the first deliberate resection of the kidney for an angiosarcoma. Rosenstein has recently employed partial nephrectomy in the palliative symptomatic treatment of a case of hypernephroma with satisfactory results and urged that this operation be utilized in similar cases where pre-operative studies, especially by urea tolerance test, show that the contra-lateral kidney is insufficient and incapable of satisfactory function following nephrectomy. Small tumors, accidentally discovered during the course of any renal operation, and tumors of moderate size situated at one of the poles of the kidney, may be removed by partial resection. Large growths, which have produced a marked atrophy or destruction of the kidney, are best treated by nephrectomy. Any growth situated at or near the hilum of the kidney and in intimate contact with the vascular pedicle also requires nephrectomy. In 1921, Berti collected 8 partial resections for benign tumors with 6 cures, one death and one secondary nephrectomy. We have collected 21 resections for malignant tumors with one death (Lotheisen) and 13 resections for benign tumors with no deaths. There were no cases of secondary hemorrhages or urinary fistula reported. Partial resections for pararenal and adrenal tumors. When the primary growth is very adherent to the kidney but has not penetrated the fibrous capsule, the primary growth may be detached from the kidney by performing a cuneiform resection. We have collected 6 partial nephrectomies for pararenal tumors and one for adrenal tumors. There were no deaths or post-operative complications in this series. Partial resections for tuberculosis. In the early period of renal surgery,

PARTIAL RESECTIONS OF KIDNEY

35

several surgeons (Renger, Israel, Kelly) employed partial resections in the treatment of localized tuberculous lesions of the kidney but the results were very disappointing. Ravich recently reported a successful resection in an unusually rare type of unilateral tuberculosis, i.e., a multilocular tuberculous cyst involving the upper pole of the kidney. Partial nephrectomy is indicated in renal tuberculosis only when the disease is sharply confined to one portion of a congenital or acquired solitary kidney. Even in these cases, non-operative treatment should be tried :first and partial resection resorted to after all other measures have failed. We have collected 41 cases of partial resection for tuberculosis with 5 deaths. Post-operative fistula occurred in 5 cases and secondary nephrectomy was required in 6 cases. How much renal substance is necessary to maintain life in the human? As a result of his experiments on dogs, Tu:ffier estimated that the adult could maintain life on 80 to 100 grams of healthy renal tissue (slightly more than one-half of one kidney) the normal kidney weighing between 165 to 170 grams. However, calculations and deductions based on the experimental removal of large amounts of renal substance (two-thirds to three-quarters of the total kidney substance) are not fully applicable to man inasmuch as in animals these operations were carried out on healthy kidneys whereas in man one is dealing with diseased kidneys. Furthermore, one must take into consideration that in cases of localized disease in a solitary kidney or severe bilateral diseases in the human the portion of functioning tissue, which will remain following operation, may have undergone a compensatory hypertrophy during the clinical course of the disease. In the determination of how much renal tissue is necessary to maintain life in the human we are forced to draw our conclusions from the clinical reports of (1) resections of one kidney before or after the removal of the other kidney; (2) simultaneous resection of one kidney and the removal of the other kidney; and (3) extensive bilateral resections (see table 3 in au tho rs' reprints). A careful analysis of these interesting cases permits the following conclusions: 1. Extensive operative reduction of the total renal substance (removal of one kidney and one-third to one-half of the other kidney) may be successfully employed in the treatment of severe bilateral disease of the kidneys.

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A. E. GOLDSTEIN AND B. S. ABESHOUSE

2. The minimum amount of renal substance necessary to maintain life in the human is one-fourth of the total renal substance (one-half of one kidney). 3. Two-thirds of the total renal substance (removal of one kidney and one-third of the other kidney) was successfully accomplished in 10 cases. 4. Although the simultaneous removal of one kidney and one-third of the other kidney has been accomplished with satisfactory results in 3 cases, the authors do not approve of this method of treatment except in the gravest emergencies, i.e., bilateral rupture of the kidney as in Franklin's case. 5. We strongly advocate waiting at least 4 to 8 weeks between operations in cases entailing resection of one kidney and removal of the other or bilateral resections in order to permit the development of a compensatory hypertrophy in the resected kidney and to minimize or obviate the danger of post-operative shock and ure~ia. 6. It is difficult to state which kidney should be operated upon first in cases with severe bilateral renal disease. The surgeon must be guided by (a) the condition of the patient, (b) the extent of pathological process in each kidney, and (c) the functional capacity of each kidney. In the majority of cases, especially those with a non-functioning kidney on one side, it may be advisable to remove this kidney first thereby lessening the secretory burden on the kidney to be resected and permitting the development of a compensatory hypertrophy in the latter kidney. In other cases, especially those with a localized disease process in each kidney, it may be advisable to resect the better or least affected kidney first in order to take advantage of whatever secretory function is possessed by the other kidney which is more seriously damaged and may require a nephrectomy. Mortality and morbidity. We are cognizant of the limited value of general mortality statistics representing the combined efforts of many surgeons in evaluating the merits of any operative procedure. However, we are forced to resort to this method of study in evaluating partial resections due to the fact that there are no large series of partial resections reported by individual surgeons. The largest series of partial resections are reported by Cummings's 17 cases (2 deaths), Kretschmet's 16 cases (no deaths), and our present report of 6 cases. We have collected 296 cases of partial resections of the kidney with 16 deaths. Unfortunately there is not available a similar review of the total number of nephrectomies for the same period. The mortality rate of 5.4 per cent for partial resection is very low and compares very favor-

PARTIAL RESECTIONS OF KIDNEY

37

ably with that reported for nephrectomies performed at the various clinics over specific periods. For example, in 1912 Gerster reported 112 nephrectomies performed by the general surgeons at the Mt. Sinai Hospital in New York City in the preceding 16 years with a mortality of 21.33 per cent. In 1920, Beer and Hyman reported 207 nephrectomies performed by the urological surgeons at the same hospital in the period of 1912-1920 with a mortality of only 3.8 per cent. In 1928, Hunt collected 1119 nephrectomies performed at the Mayo Clinic between 19221927 and found 157 nephrectomies for malignant tumors with 11 deaths, an operative mortality of 7 per cent and 962 nephrectomies for benign diseases with 20 deaths, an operative mortality of 2 per cent. The morbidity factors attending partial resections are essentially limited to the development of post-operative complications, i.e., secondary hemorrhage and urinary fistula. In the series of 296 cases collected by us, there were 13 cases of fistula and 3 cases of secondary hemorrhage. These complications occurred more frequently in the early period of renal surgery as a result of faulty methods of hemostasis and improper closure of the renal wound. We found 23 cases in which a secondary nephrectomy was necessary. Operative technique. A successful partial resection demands an orderly plan of operation as outlined below. When these operative procedures are performed in a careful and precise manner, the end results are so uniformly satisfactory that the surgeon is more than amply rewarded for his painstaking efforts. Insufficient attention to any of the important steps in this operation may lead to unpleasant post-operative complications. However, in an occasional case, certain anatomical and pathological changes may exist, i.e., abnormally fixed kidney, abnormal vascular pedicle, etc., that may interfere with the execution of one or more steps in this operative plan. The importance and value of this operative plan merits mention of the various steps. 1. Proper surgical approach (lumbar route). 2. Preparation and isolation of the vascular pedicle and temporary compression of the nutrient vessels to the segment to be removed to determine the amount of renal tissue supplied by the vessels. 3. Decapsulation of the kidney in the operative area and utilization of this portion of the capsule in the closure of the renal wound. 4. Incision through healthy renal tissue and avoiding, if possible, opening of the pelvis or calyces. 5. Accurate closure of operative wound. The importance of the first four steps is readily apparent and requires TUE JOVB.NAL OF UROLOGYi VOL. 38~ NO. 1

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A. E. GOLDSTEIN AND II. S. ABESHOUSE

no further elaboration. Inasmuch as the success of this operation is often dependent upon the type of closure employed, this phase of the operation merits consideration and discussion. Some authors prefer an inner suture of continuous catgut to control internal bleeding and an outer layer of continuous or interrupted sutures or both to approximate the parenchyma and serve as a hemostatic suture. Others depend entirely upon interrupted mattress sutures or a continuous through suture to control bleeding and approximate the edges of the wound. In their experimental studies on resections of the kidney, Herbst and Polkey made an extensive painstaking investigation of the various methods of closure and found that their best results were obtained when the simple continuous through and through suture of Tuffier was used after the stripped capsule has been replaced. They observed that mattress sutures were highly destructive to the parenchyma and produced a maximum amount of atrophy. The final step in the closure of the renal wound is replacing and suturing the previously stripped capsule over the approximated edges or raw surface resulting from the resection. This not only serves to seal over the raw edges or surfaces and check late oozing but also aids in the closure and healing of the wound by holding the sutures in place. Some authors (Lichtenberg, Papin) prefer a circular suture of the capsule over the cut surface while others use interrupted sutures in single or double layers with or without imbrication of the two leaves. When mattress sutures or a continuous through sutt1re is employed to control bleeding from the cut surfaces of any type of renal incision, their efficiency can be increased by underpinning the sutures on both sides with small pieces of fat after the method of Beer and Hagenbach. Herbst and Polkey found that the use of straight needles with catgut fused in their heads (atraumatic sutures) produced a minimum amount of trauma especially when well greased with sterile vaseline. Kolischer and Feodoroff advocated placing a pad of fat from subcutaneous or perirenal fatty tissue in the wound or on top of the wound and anchoring the fat transplant with superficial catgut sutures. Ciminata and Joseph and others proposed the use of a nonviable muscle graft (as originally described by Cushing) in a similar manner. Ockerblad has had excellent results in his experiments with viable muscle grafts. Rubaschow implanted fascia lata and fragments of muscle in his experimental nephrotomy wounds. Kummell and Cirillio employed tamponade by making a tissue of resorbable catgut threads which had

PARTIAL RESECTIONS OF KIDNEY

39

great hemostatic powers in experimental animals but has not been used in humans. Carson and Goldstein have reported excellent results i:r;i. controlling hemorrhage from the nephrotomy incisions in animals and humans by manual compression of the edges of the incision for a period of five to eight minutes. Lowsley recently described the successful use in experimental animals and humans of a flat ribbon catgut for closing wounds of the kidney without inserting a needle or suture through the kidney substance. Mastrosimone implanted a fresh autoplastic graft of adjacent renal tissue in wounds following nephrotomy and resection with excellent results. In every partial resection, drainage of the renal bed should be instituted to forestall the development of an infection about the operative .site. One or two Penrose drains usually suffice, although some surgeons prefer to use a rubber tube eight to ten µiillimeters in diameter. The question of intrarenal drainage following resection has been the subject of discussion. Some writers, especially Lichtenberg, strongly advocate intrarenal drainage of the remaining portion in order to facilitate healing by relieving tension on the suture line. This is accomplished by inserting a small rubber tube or catheter (eight to ten millimeters in diameter) through the parenchyma into the pelvis at some distance from the operative site usually in the lower pole or middle third of the kidney in order to obtain dependent drainage. Some authors prefer to insert the drainage tube through the opened calyx when the renal wound is at either pole of the kidney especially the lower pole. The drainage tube is usually removed after six to eight days. The advisability and practicability of intrarenal drainage is strongly questioned as this procedure does not completely relieve tension on the suture line but, on the contrary, lllay interfere with primary healing, particularly when the drainage tube 11\fs inserted through the opened calyx at the site of resection. We are of the opinion that intrarenal drainage is not necessary in those cases of partial resection in which tl:le pelvis or calyces of the remaining portion of the kidney have not been opened but may be employed in those cases in which the pelvis or calyces have been opened. In the latter cases, drainage should be at some distance from the operative site preferably in the lower or middle third of the kidney. We wish to emphasize the beneficial effects of performing a simple nephropexy on the remaining portion of kidney in order to insure good drainage through the normal channels and suggest the Deming method of nephropexy which is easy to carry out and avoids the use of intrarenal sutures.

40

A. E. GOLDSTEIN AND B. S. ABESHOUSE CONCLUSIONS

We have reviewed the literature on resections of the kidney and have collected 296 cases which include 6 personal cases. Partial resection of a kidney is the operation of choice in the treatment of the following localized diseases of the kidney: viz., solitary serous or hemorrhagic cysts, hydatid cysts; localized hydronephrosis or pyonephrosis, with or without renal calculi, benign tumors, localized cortical abscesses, renal carbuncles, renal infarct and renal fistula. Partial resection of a kidney is contra-indicated in the treatment of tuberculosis or malignant tumors of the kidney in the presence of a healthy kidney on the opposite side. Partial resection is occasionally indicated in the treatment of extensive bilateral disease, i.e., tuberculosis, calculous pyonephrosis, and rupture of the kidney. Under such circumstances, it becomes an operation of necessity. In operations requiring an extensive reduction of the total kidney substance (the removal of one kidney and one-half to one-third of the. other kidney or bilateral resections) it is advisable to perform the operations at two settings with an interval of at least 4 to 8 weeks between operations. The minimum amount of renal substance necessary to maintain life in the human is one-fourth of the total renal substance (one-half of one kidney). A successful partial resection demands an orderly plan of operation which include the following steps: (1) proper surgical approach; (2) preparation of the vascular pedicle and ligation of the nutrient vessels to the segment to be removed; (3) decapsulation of the kidney in the operative area and utilization of this portion of the capsule in the closure of the wound; (4) incision through healthy tissue; and (5) accurate hemostasis and approximation of the wound.

Medical Arts Building, Baltimore, Maryland. REFERENCES1 ABOULKAV: Quoted by Nicaise, V.- Assoc. franc. d'urol., 11: 506, 1907. ALBARRAN, J.: Arch. de med., July 26, 1898. Medecine operatoire des voies urinaires. Masson et Cie., Paris, 1909; pp. 231; idem, quoted by Eliot, H.-J. d'urol., 3: 161, 1913; idem, quoted by Kroiss, F.-Beitr. z. klin. chir., 58: 423, 1908. ALLEN, F . M., SCHARF, R., AND LUNDIN, H.: Jour. Amer. Med. Assoc., 85: 1698, 1925. ANDERSON; H.: Jour. Exper. Med., 39: 707, 1924. ANDERSON, H.: Arch. Int. Med., 37: 297, 1926. 1

The complete bibliography will be found in the author's reprints.

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ATKINSON, J. L.: Brit. Med. Jour., 2: 468, 1914. BARDENHEUER: Arch. f. klin. chir., 42: 370, 1891. BARNEY, J. D.: Trans. New England Branch Am. Urological Assoc., May 17, 1932, pp. 6; idem, Barney, J. D. and Mintz, E. R.: Jour. Amer. Med. Assoc., 100: 1, 1933. BARTH: Arch. f. klin. chir., 40: 418, 1893. BEER, E.: Surg., Gynec., and Obstet., 37: 694, 1923. BEER, E. AND HYMAN, A.: Jour. Amer. Med. Assoc., 76: 180, 1920. BERTI, G.: Policlinico (sez. chir.), 28: 261, 1921. BRADFORD, J. R.: Jour. Physiol., 23: 415, 1898-99. CAmLL, G. F.: Amer. Jour. Surg., 8: 129, 1930. CARSON, w. s. AND GOLDSTEIN, A. E.: Jour. UroL, 16: 506, 1926. CHANUTEN, A. AND FERRIS, E. B., JR.: Arch. Int. Med., 49: 767, 1932. CIMINATE, A.: Ztschr. f. urol. chir., 16: 37, 1924. CIRILLO, N.: Policlinico (sez chir.), 39: 65, 1932. CUMMINGS, R. E.: Personal communication, 1935. CUNNINGHAM, J. H.: Ann. Surg., 66: 918, 1912. CZERNY, H. E.: Operation in 1887; quoted by von Herczel, E.-Ueber neirenexstirpation. Aus der Heidelberger chirurgischen klinik des Prof. Dr. Czerny. Beitr. z. klin. chir., 6: 511, 1890. DE RouvILLE, G.: Des nephrectomies partielles. These de Paris, 1894---1895. DE RouVILLE AND SOUBEYRAN: Arch. provinc. de chir., 11: 624, 1902. EISENDRATH: In discussion of article by Scholl-Jour. Urol., 21: 243, 1929. FENGER, C.: Ann. Surg., 22: 804, 1895. FRANKLIN, A. L.: Amer. Jour. Surg., 20: 309, 1906. GOLDSTEIN, A. E.: Jour. Urol., 34: 536, 1935. HAGENBACH, E.: Ztschr. f. urol. chir., 12: 40, 1923. HERBST, R.H. AND PoLKEY, H.J.: Surg., Gynec., and Obstet., 51: 213, 1930. ISRAEL, J.: Operation in 1901; quoted by Israel, J. and Israel, W.: Chirurgie der niere und des Harnleiters g. Thieme, Leipzig, 1925; pp. 197. JERASCH, W.: Inaug. Dissertation, Greifswald, 1899; pp. 6; idem, Centralbl. f. chir., 1899; pp. 1056; idem, quoted by Nicaise, 1905. JosEPH, E.: Ztschr. f. urol. chir., 17: 659, 1923. KEELTY, E. B.: Brit. Med. Jour., 1: 147, 1890; idem, Lancet, 1: 134, 1890. KuMMELL, H.: Arch. f. klin. chir., 46: 310, 1893. KuMMELL, H.: Nierenresektion; in Voelcker and Wossidloo Urologische operationslehre, 2: 432, 1922. KELLY, H. A. AND BURNAM, C. T.: Diseases o~ the kidneys, ureters and bladder. D. Appleton and Co., N. Y., 1914; 2: 84. KusTER, E.: Die chirurgie der nieren. F. Enke, Stuttgart, 1896-1902. LENNANDER, K. G. AND SUNDBERG, C.: Upsala Lak, 29: 384, 1895; idem, Centralbl. f. chir., pp. 1183, 1895. LINK: Wien. med. wchnschr., 48: 481, 1898. LUNDIN, H. AND SCHARF, R.: Jour. Metab. Research, 7-8: 259, 1925-26. LoTHEISEN: Arch. f. klin. chir., 62: 721, 1896. LICHTENBERG, A.: Quoted by Lewis, B. and Carroll, G.-Urol. and Cutan. Rev., 38: 185, 1934. MARK, R. E.: Klin. wchnschr., 4: 676, 1925. MARK, R. E. AND LUNDIN, H.: Jour. Metab. Research, 7-8: 221, 1925. MARION: Quoted by Legueu-Traite chirurgical d'Urologie, Paris, F. Akan, 1910. MORRIS, H.: On the origin and progress of renal surgery. P. Blakiston's Son & Co., Philadelphia, 1898; pp. 11-14. PAOLI, E.: Verhandl. d. X, Internat. Med. Congress, Berlin; 3: 7, 1890. PAPIN, E.: Resections of the kidney. Chir. de Rein, 2: 511. PETERS, W.: Beitr. z. klin. chir., 129: 716, 1923. OcKERBLAD, F.: Southern Med. Jour., Jan., 27: 1, 1924. O'CoNoR, V. J.: Jour. Amer. Med. Assoc., 86: 1118, 1925. PLAGGEMEYER, H. N. AND CUMMINGS, R. E.: Trans. sect. urol. Amer. Med. Assoc., 1922; p. 125. ROSENSTEIN, P.: Zentralbl. f. chir., 59: 1138, 1932. REDI, R.: J. d'Urol., Sept., 28: 231, 1934. SIMONIM: Bull. et roem. de la Soc. de chir., May 21, 1918; 17: 866; idem, J. d'Urol., 8: 82, 1919-20. SIMON, G.: Edinburg Med. Jour., May, 1871.

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SPIEGELBERG, 0.: Operation in 18~7; Arch. f. gynak., 1: 146, 1870. STAMM, M. : Columbus Med. Jour., 13: 285, 1894-95. ScHMIEDEN, V.: Deutsche-ztschr. f. chir., 62: 205, 1901. TILLMAN: Virchow's Arch., 1879; p. 437. TuFFIER, T.: Etudes experimentale sur la chirurgie du rien. These de doct., Steinheil, G., Paris, 1889. TUFFIER, T .: Arch. gen. de med., July 1891; p. 1. VALENTIN: These de Doct., Paris, 1893. VIANNAY, C. : J. d'urol., 18: 144, 1924. VIANNAY: Operation in 1914; quoted by Guyotat- These de Lyons, 1933 ; p. 38. WALTERS, W. : Surg., Gynec., and Obstet., 60: 473, 1930. WELLS, S. : Brit. Med. Jour., 1: 758, 1884. WOLFF, M. : Die neirenresection und ihre folgen. These de doct., Hirschwald Berlin, 1900.