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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 1997  |  Volume : 8  |  Issue : 4  |  Page : 423-427
Nephrectomy in Adults: Asir Hospital Experience


1 College of Medicine, King Saud University, Abha Branch, Asir Central Hospital, Saudi Arabia
2 College of Medicine, King Saud University, Abha Branch, Abha, Saudi Arabia

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   Abstract 

We retrospectively analysed the clinical data and investigations of 85 adult patients who underwent nephrectomy at a referral hospital in Asir region. The patients were fairly young with mean age of 44 years except those with transitional cell carcinoma of the upper urinary tract who had a mean age of 67 years. The male to female ratio was 1.9:1 and there was slight predominance of right sided lesions. Loin pain was the leading presenting feature with only a few cases presenting with hematuria and some with a loin mass. The leading indication for nephrectomy was chronic obstruction culminating in end-stage pyelonephritis (65%), followed by malignancy of kidneys and upper urinary tract (22%). Fifty six percent of the cases with obstruction had associated upper urinary tract stones. Ultrasonography and intravenous urography were excellent in the evaluation of clinically significant obstruction but many ancillary imaging procedure were needed to evaluate the nature of the obstructing lesion. We conclude that obstructive nephropathy is the main cause for nephrectomy in Asir, with urolithiasis implicated in more than half of the cases of obstruction.

Keywords: Nephrectomy, Obstructive nephropathy, Malignancy, Saudi Arabia.

How to cite this article:
El Malik EM, Memon SR, Ibrahim AL, Al Gizawi A, Ghali AM. Nephrectomy in Adults: Asir Hospital Experience. Saudi J Kidney Dis Transpl 1997;8:423-7

How to cite this URL:
El Malik EM, Memon SR, Ibrahim AL, Al Gizawi A, Ghali AM. Nephrectomy in Adults: Asir Hospital Experience. Saudi J Kidney Dis Transpl [serial online] 1997 [cited 2020 Jun 7];8:423-7. Available from: http://www.sjkdt.org/text.asp?1997/8/4/423/39342

   Introduction Top


Nephrectomy is a standard therapeutic urological procedure for malignancy of kidneys and upper urinary tract, and for damaged kidneys with little or no contribution to the overall renal function. The causes of loss of renal function, which lead tonephrectomy differ between the pediatric and adult patient population. Vesicoureteric reflux is the leading cause of nephrectomy in children [1] . Some reports list malignancy as the leading cause in adults [2] , while others implicate the sequelae of obstruction, collectively known as obstructive nephropathy, as the main culprit [3],[4] .

In this study, we review our experience of the indications, the clinical, the pathological and the radiological- features of patients undergoing nephrectomy.


   Material and Methods Top


During the nine year period from 1987 to 1995, 85 adults aged 13 years and above, underwent nephrectomy in our hospital. The clinical notes, histopathology reports and imaging investigations of these patients were reviewed. The clinical data retrieved included age, sex, nationality, mode of presentation, history of upper urinary tract surgery, clinical diagnosis, operative details and complications. A histopathological documentation of disease was available in every case. All 85 patients underwent ultrasound (U/S) examination while 84 had intravenous urograms (IVU). Twenty eight patients had antegrade pyelograms (AGP) or retrograde pyelograms (RGP), 20 had computerized tomography scans (CT Scan), six had angiograms and five had radionuclide scans.


   Results Top


[Table - 1] summarizes the patients characteristics and the site of pathology for the study group and for the pathological subgroups. The clinical data for the study group are summarized in [Table - 2]. The most prominent feature was isolated loin pain (69%), followed by hematuria with or without loin pain/mass (17%). Eight of the 10 patients with hematuria had malignant lesions, while only two out of five palpable kidneys turned out to be malignant. None of the patients had the classical triad of pain, hematuria and loin mass. Of the 12 patients with past history of pyelolithotomy, three had the operation bilaterally and one had two previous operations on the nephrectomized kidney.

Ultrasound (U/S) detected hydronephrosis and cortical thinning in 59 (69%) patients. In 18 (21%) patients the diagnosis was a solid mass; 10 renal carcinoma (RCC), four TCC, three xanthogranulomatous pyelonephritis (XGP) and one angiomyolipoma.

In five (6%) patients a cystic mass was identified by U/S; two hydatid, one intracystic RCC, one XGP and one congenital anomaly. The three remaining patients had suprarenal masses; one pheochromocytoma, one shattered kidney and one small contracted kidney.

Intravenous pyelogram detected non­functioning kidney in 41 (48%) patients, a poorly functioning kidney in 24 (28%), and a renal mass in 13 (15%). All the 59 cases with evidence of chronic obstruction on U/S had either poor or no function on IVU.

Solid masses were diagnosed by CT scan in 19 patients (19/20); of which 14 were malignant, four were benign and one was indeterminable. All the predictions of malignancy were correct, however, one lesion was diagnosed as a benign cyst but turned out later to be an intracystic RCC, and the indeterminable lesion was an XGP.

Angiography was performed in six cases (7%); five had a CT scan. In five patients, both modalities correctly diagnosed three lesions as malignant (RCCs) and one as benign (angiomyolipoma); while they differed in the diagnosis of a cystic lesion, which was correctly diagnosed as malignant by angiogram only (intracystic RCC). The 6th angiogram was performed on a hypertensive patient with a hypoplastic kidney for suspected renal artery stenosis.

Antegrade pyelogram was performed in 16 patients. All the patients had percutaneous nephrostomies inserted earlier for therapeutic purposes. Retrograde pyelogram was performed in 12 patients; eight with nonfunctioning kidneys, and four with renal masses.

A radioisotope scan was performed in five patients with poorly functioning kidneys to determine the percentage of contribution of the function of these kidneys to the overall renal function. This ranged between four and 13%.

The group of "other diagnoses" included traumatic rupture, hydatid disease, congenital anomalies and shrunken kidneys. Nineteen patients (21.8%) required radical nephrectomies. These included eight nephroureterectomies performed for transitional cell carcinoma (TCC) of the upper urinary tract.

The indications for nephrectomy in this study were: 55 cases (65%) due to complications secondary to obstruction, 19 (22%) due to renal or upper urinary tract cancer and 11 (13%) due to the various pathologies mentioned above.

[Table - 3] shows the data of the patients who had evidence of chronic obstruction as a main indication for nephrectomy. This group included 47 patients with chronic pyelonephritis and atrophy, three with XGP, three with nonspecific end-stage kidneys, and two with fibrosis and bilharzia. Three patients with TCC of the renal pelvis and one with traumatic rupture of kidney, who had hydronephrosis were included in this group.

The histopathology results of the excised kidneys are summarized in [Table - 4]. Of the eight TCCs; seven were pelvic, and one was ureteric. The miscellaneous group included; three non-specific end-stage kidneys, and two of each of the following: hydatid disease, congenitally hypoplastic, traumatic rupture and fibrosis with evidence of bilharzia. It also included one kidney with angiomyolipoma, and another associated with a pheochro-mocytoma.


   Discussion Top


Despite a whole range of technical and technological innovations dedicated to preserving renal tissue [3] , the total number of nephrectomies performed per decade in one large European center does not seem to have changed much over the three decades 1960-1990 [4] . Over the same period of time, chronic pyelonephritis and cancer (RCC plus TCC taken together) remain the leading indications for nephrectomy, despite the relative decrease in the former and the relative increase in the latter [4] . This fact holds true in our study. The age distribution was compatible with previous reports [3],[4] . Male predominance is particularly evident in the pyelonephritis group, Saudis constituted around 75% of the patients and there was a slight predominance in the right sided pathologies.

Loin pain was the leading presenting symptom in our study, as it was in almost all the previous reports [5],[6],[7] . In our study, hematuria came far below in order after loin pain, which, is not surprising due to the heterogeneity of the renal pathology, with a large proportion of obstructed kidneys. However, 80% of the cases presenting with hematuria had underlying malignancy. The classical triad of loin pain, hematuria and renal mass was not encountered in any of the renal malignancies in our study, a finding which is in agreement with a recent report on 43 renal tumors from Saudi Arabia where this triad was associated with only two [5] .

Pyelonephritis was the leading pathological entity in our nephrectomies (62%), which is compatible with the report by Kubba, et al [4] , but different from that of Schiff and Glazier [2] . In these latter studies, RCC and TCC combined were the leading pathology findings.

Thirty four (37%) of the removed kidneys in our series contained stones, which is a high figure compared to the 6% in a large adult series of nephrectomies [2] and 11% in a pediatric series [1] . Renal tuberculosis is an infection worth of mentioning for its absence in our study compared to the report of Kubba, et al [4] . Of 19 renal tumors in this series (excluding the ureteric TCC) only one (5%) was benign. This was an angiomyolipoma that occurred in a female Saudis with features of tuberous sclerosis. This is in marked contrast with a recent report on Saudi patients where 14% of renal tumors were benign [5] .

Ultrasonography (U/S) has long been hailed for its superiority in the diagnosis of hydronephrosis [6],[7] . In this study U/S proved its value in the diagnosis of chronic obstruction where it is usually superior to other investigations [8] .

Intravenous pyelogram (IVU) helped evaluating the level of renal function in the affected kidneys. Neither the cause nor the level of obstruction were apparent in many cases after U/S and IVU and hence the need for additional contrast imaging procedures (AGP and RGP).

CT scan gave a correct diagnosis in 18 out of 20 patients. In one case no conclusion could be reached as to the nature of the lesion which proved to be an XGP. This is a lesion notorious for its elusive nature and is rarely diagnosed pre-operatively [9] . The second lesion was a cyst diagnosed as benign on CT but tiny tumor blushes could be seen on angiography. This proved to be a sarcomatoid RCC in a renal cyst wall.

Radionuclide renal scan was not optimally used in our study because of inadequate availability.

Many complications are associated with nephrectomy. These include 2% death and 2% general complications rate [10] , 10% pleural injury [11] , 12% wound complication rate [12] , 2.3% splenectomy and 1% bowel obstruction requiring laparotomy [13] . In our study, we had two deaths; both were males above 70 years of age following radical nephrectomies for RCC However, there were no deaths from nephrectomies of kidneys with benign lesions [3] . Three patients (7%) had wound infection; two of them occurred in abdominal incision.

We conclude that obstructive nephropathy was the main cause of nephrectomy in this series from Asir, followed by malignancy of the kidney and upper urinary tract. Urolithiasis was by far the leading pathology associated with obstruction. It remains to be seen whether the recent introduction of ESWL in this region and the adoption of endourological stone management techniques will have their long-term impacts on this complication.

 
   References Top

1.Adamson AS, Nadjmaldin AS, Atwell JD. Total nephrectomy in children: a clinicopathological review. Br J Urol 1992;70:550-3.  Back to cited text no. 1  [PUBMED]  
2.Schiff M Jr, Glazier WB. Nephrectomy: indications and complications in 347 patients. J Urol 1997;118:930-l.  Back to cited text no. 2    
3.Wickham JE. Intrarenal surgery. Edinburgh, Churchill Livingston 1984.  Back to cited text no. 3    
4.Kubba AK, Hollins GW, Deane RF. Nephrectomy: changing indication, 1960-1990. Br J Urol 1994;74:274-8.  Back to cited text no. 4  [PUBMED]  
5.Talic RF, EL Faqih SR. Renal tumours in adult Saudi patients: a review of 43 cases. Ann Saudi Med 1996;16(5):517­-20.  Back to cited text no. 5    
6.St Lezin M, Hofmann R, Stollcr ML. Pyonephrosis: diagnosis and treatment. Br J Urol 1992;70:360-3.  Back to cited text no. 6    
7.Malave SR, Neirnan HL, Spies SM, Cisternino SJ, Adamo G. Diagnosis of hydronephrosis: comparison of radionuclide scanning and sonography. Am J Roentgenol 1980; 135:1179-85.  Back to cited text no. 7    
8.Webb JA. Ultras on ography in the diagnosis of renal obstruction. BMJ 1990;301:944-6.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.D'Costa GF, Nagle SB, Waghoiikar UL, Nathani RR. Xanthogranulomatous pyelonephritis in children and adults-an 8 year study. Indian J Pathol Microbiol 1990;33(3):224-9.  Back to cited text no. 9    
10.Novick AC, Streem SB. Surgery of kidney. In: Campbell's Urology 6th ed. Walsh PC, Retik AB, Stamey TA, Vaughan ED Jr. eds. Philadelphia: WP Saunders Co. 1992;2428-48.  Back to cited text no. 10    
11.Riehle RA Jr, Steckler R, Naslund EB, Riggio R, Cheigh J, Stubenbord W. Selection criteria for the evaluation of living related donors. J Urol 1990;144:845-8.  Back to cited text no. 11  [PUBMED]  
12.Weinstein SH, Navarre RJ Jr, Loening SA, Corry RJ. Experience with live donor nephrectomy. J Urol 1980;124:321-3.  Back to cited text no. 12  [PUBMED]  
13.Scott RF Jr, Selzman HM. Complications of nephrectomy: review of 450 patients and a description of a modification of the transperitoneal approach. J Urol 1966;95:307-12.  Back to cited text no. 13  [PUBMED]  

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Correspondence Address:
El Fadil M.A El Malik
College of Medicine, King Saud University-Abha Branch, P.O. Box 641, Abha
Saudi Arabia
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    Abstract
    Introduction
    Material and Methods
    Results
    Discussion
    References
    Article Tables
 

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