DOUBLE KIDNEY AS A SOURCE OF IMPAIRED DYNAMISM*

ITS SURGICAL TREATMENT BY HEMINEPHRECTOMY

ROBERT GUTIERREZ, M.D.

DipIomate of the American Board of UroIogy

NEW YORK, NEW YORK

0 F a11 anomalies of the upper uri- nary tract, double kidney is the most common. WhiIe many differ-

ent types of this anomaIy occur, the one most frequentIy observed consists of the presence of one Iarge kidney with two independent renaI peIves and two ureters. These double ureters may be united at any IeveI, from the Iower poIe of the kidney to the bIadder, or they may open separateIy into the bIadder in the region of the trigone. Sometimes the second ureter is found ectopic, opening at some point outside of the urinary bIadder, causing urinary incon- tinence, particuIarIy in the femaIe, and as a ruIe producing hydroureter and hydro- nephrosis in the corresponding haIf of the doubIe organ. It is aIso commonIy observed that the ectopic ureter corresponds to the upper poIe of the doubIe kidney. This dupIex condition, when associated with urinary incontinence, aIways demands sur- gica1 intervention for correction of the surgica1 maIformation. l

WhiIe it is freeIy admitted that not a11 doubIe kidneys give rise to symptoms or pathoIogic conditions, it is a fact that cIini- calIy and at postmortem more than haIf the cases of this congenita1 maIformation are found associated with one type or another of surgica1 pathoIogic Iesions, some of which demand reIief by surgica1 intervention.

The embryonic deveIopment and ana- tomic varieties of doubIe kidney and ureter have been thoroughIy discussed in the

literature and wiI1 not be gone into at this time. 2

AIthough it has been said that three kidneys might be expected to function better than two, cIinica1 experience has shown that such is not the case; and that the third kidney is in most instances an intruder, encroaching upon the rights of the two Iegitimate kidneys. In other words, it now appears that the supernumerary upper or Iower renaI peIvis of the double organ may be the source of a pathoIogic process, discovered uroIogicaIIy or uro- graphicaIIy, and that it is present more often than was ever suspected prior to the urographic era.

It has been observed cIinicaIIy and ana- tomopathoIogicaIIy that in the doubIe kid- ney with compIete bifurcation of the two ureters there is as a ruIe a crossing or even a doubIe crossing of these two ureters somewhere between the kidney and the bIadder and that the ureter corresponding to the upper renaI peIvis is invariabIy the one in ectopia. Since there is aIways in these cases a certain degree of nephroptosis, it can be readiIy understood that the doubIe ureters in crossing make pressure upon one another, and thus interfere with the drain- age of the doubIe kidney from which they issue, As a resuIt the dynamism of these crossed ureters becomes impaired; their rhythmic contractions are disturbed; the time of emptying is retarded. Owing to the intricate nerve connections between the kidney and ureter on the one hand

* Read before the Section of Genito-Urinary Surgery, New York Academy of Medicine, May 17, 1944.

256

NEW SERIES VOL. LXV. No. Y. Gutierrez-DoubIe Kidney American Journd of Surgery 257

and the chief gangIia of the abdomen on the other, the crises of pain arising in an

at operation. Since urography has been

overflIed ureter and renaI peIvis are readily routineIy used, conservatism in renaI sur- gery has been steadiIy on the increase.

FIG. I. Intravenous urogram revealing the presence of a rinht doubIe kidnev with double Delves and doublg ureters. The Iift kidney pel;is is we11 delineated and appears to be within normaI limits. The double ureters of the right side are dilated, demonstrating urinary stasis and dynamic dysfunction.

transmitted to the abdomina1 cavity, where they may give rise to indefinite abdomina1 pain with nausea and vomiting, frequentIy mistaken for appendicitis, espe- ciaIIy if the doubIe kidney and ureter are on the right side. These abdomina1 or gastrointestina1 symptoms may compIeteIy divert the attention from a doubIe kidney as the possibIe underIying cause of the surgica1 syndrome, and may thus misIead in diagnosis.

AdmittedIy, conservative operation for relief of associated disorders in one-haIf of a doubIe kidney has been performed even prior to the urographic era, but onIy in cases in which the diagnosis was made

FIG. 2. Plain roentgenogram showing ureteral catheters and instrument in position. There is no shadow indicative of stone anywhere in the urinary tract. The right ureteral catheter meets obstruction at the IeveI of the Iast lumbar vertebra. The shadow of the right kidney is enlarged and Iow in position.

However, it is to be noted that conserva- tive surgery dehberateiy undertaken for the correction of the impaired dynamism and faulty mechanics of the doubIe kidney has been seIdom if ever carried out. UsuaIIy the doubIe kidney has been Ieft to go on its way, as a harmIess maIformation of no surgica1 or pathoIogic interest, unIess a gross pathoIogic Iesion is visuaIized in the urogram.

The main purpose of this presentation is, accordingly, to discuss this very modern idea of the importance of the orthopedic surgical correction of tbe double kidney, witb a sole view to its restoration to normal function.

258

It is not uncommon to see a patient with maIformation per se, with a view to a his tory of abdomina1 pain who has been permanent reIief of symptoms for WI oper; zted upon for so-caIIed chronic ap- it is chiefly responsibIe.

American Journal of Surgery Gutierrez-DoubIe Kidney AUGUST, 1944

the lich

FIG. 3. Right retrograde pyelo-ureterogram FIG. 4. BiIateraI retrograde pyelo-uretero- disclosing beautifully the presence of a gram. The right doubIe kidney with right double kidney with double peIves double pelves and double ureters is ob- and double ureters. The double ureters viousIy dilated, discIosing urinary stasis appear to be united into one at the level and dynamic dysfunction. The doubIe of the promontory of the sacrum. They are ureters are crossed, and there seems to be seen to be dilated, revealing urinary stasis a narrowing at the point of their union. and evidence of pyelitis and pyelonehp- The Ieft kidney pelvis and Ieft ureter are ritis. we11 deIineated and within normal Iimits.

pendicitis without reIief of symptoms, and in whom, after uroIogic and urographic examination, a doubIe kidney with doubIe ureter in one or both sides of the body is discovered, with evidence of urinary stasis, marked pyeIectasis, caIyectasis and retard- ation of the dynamic physioIogic emptying time of one or both pelves of the doubIe organ. This doubIe kidney then proves to be the underIying cause of the entire syndrome, and it obviousIy demands sur- gica1 intervention for the correction of the

Heminephrectomy, or partia1 resection of the kidney, has been performed in many congenita1 maIformations of the kidney, notabIy in the horseshoe kidney and other types of ectopic fused kidney, and even in a singIe norma kidney with associated pathoIogy in the upper or Iower caIyx in which doubIe poIar resection can be carried out. However, it is my intention here to disc&s onIy the appIicabiIity of this con- servative operation to the orthopedic restoration of the dynamism and correct

NEW SERIES VOL. LXV, No. z Gutierrez-DoubIe Kidney American Journal of Surgery 259

function of the doubIe kidney with doubIe ureter. I am referring to the group of cases

case with compIeteIy satisfactory resuIts,

in which the presence of the doubIe organ and I am presenting at the sanie time the technic that I have successfuIIy empIoyed.

FIG. 5. Operative technic for heminephrectomy in a double kidney: A, drawing of oblique Iumbo-abdominal incision; a, the double kidney and double ureters are readily,exposed and drawn out of the wound. The double ureters are seen diIated, crossed and united into one at the IeveI of the sacro-iIiac synchrondrosis.

has caused persistent crises of indefinite abdomina1 pain, without visuaIization of gross pathoIogic conditions, cases in which many errors of diagnosis have been made, incIuding those in which an unavaiIing appendectomy has aIready been performed, and in which the patient, after being properIy diagnosed uroIogicaIIy and uro- graphicaIIy, has at Iong Iast been submitted to an operation pIanned and successfuIIy carried out soIeIy for such functiona resto- ration, with conservation of renal tissue, achieving permanent cure with disappear- ance of a11 symptoms.

To this end I am reporting an iIIustrative

ILLUSTRATIVE CASE OF A RIGHT DOUBLE

KIDNEY WITH DOUBLE URETER CAUSING

INDEFINITE ABDOMINAL PAIN AND

URINARY DISTURBANCES FROM

BIRTH-CURED BY

HEMINEPHRECTOMY

Miss F. T., twenty-four years of age, an o&e secretary, was referred to me October 7,

1941, complaining of pain in the right lumbar region, frequency of urination day and night, and marked dysuria. She gave a history of having had an attack of pain on the right side of the abdomen for which she was operated upon about a year ago and an appendectomy carried out, but without relief of symptoms.

260 American Journal of Surgery Gutierrez-DoubIe Kidney AUGUST, ~944

Attacks of this kind were repeated on severa abdomen was cIearIy observed. The right occasions after the appendectomy operation, kidney was enIarged on paIpation, Iow in and incapacitated her for work. About three position, tender and easily paIpabIe. The Ieft

FIG. 6. Operative technic for heminephrectomy in a doubIe kidney: A, the ureter corresponding to the upper kidney peIvis is doubIy clamped at its junction with the ureter corresponding to the Iower kidney pelvis, and divided and Iigated. A rubber tourniquet is apptied around the line of demar- cation between the two parts of the double kidney to serve as a landmark for their separation and for better hemostasis. B, the stump of the divided upper ureter is dissected free in order to visuaIize the pedicIe of the kidney and the blood suppIy of the upper poIe of the double organ. The retropyelic renaI artery of the upper kidney, which was here a branch of the main renal artery, is exposed, clamped, excised and ligated. c, the capsule of the upper pole is incised IongitudinaIIy, freeIy separated and retracted to expose the renaI parenchyma.

weeks previous to coming to the offIce she awoke with another such attack which kept her in bed for severa weeks, during which time she stated that she had been taking sulfa drugs without reIief of symptoms. From her parents I then learned that when the chiId was three years oId she had begun to have these attacks off and on, and had suffered frequently ever since with gas pains, chronic constipation and marked abdomina1 distention. The voided specimen of urine was cloudy and contained pus and traces of albumen.

0 h’ n p yslca1 examination the abdomen was distended, and the scar of the appendectomy operation in the lower median Iine of the

kidney couId not be paIpated. Examination of the externa1 genitaIs was normaI. Recta1 examination was negative. The impression was of right nephroptosis with definite dis- turbance in the right kidney, for which a compIete uroIogic and urographic examination was carried out.

Intravenous urograms discIosed the presence of a right doubIe kidney with doubIe ureters, with pyeIitis and pyeIonephritis and evidence of pyeIectasis, caIyectasis and Iack of drainage. In fact the ninety-minute fiIm discIosed marked retardation of the emptying time of the doubIe kidney and doubIe ureters. (Fig. I.) The Ieft kidney was cIearIy visualized and within

New SERIES VOL. LXV, No. 2 Gutierrez-DoubIe Kidney American Journal of Surgery 261

normaI Iimits. In view of these findings singIe ureter which opened normaIIy into the retrograde studies were carried out, incIuding bladder. There was aIso mechanical obstruction cystoscopy, catheterization of ureters, differ- at the point of their union, more marked in the

FIG. 7. Operative technic for heminephrectomy in a doubIe kidney: A, the rubber tourniquet has been replaced by a rubber-shod clamp applied to the pedicle for better anatomic exposure and complete hemostasis. The upper pole of the decapsulated doubIe kidney is resected with its entire upper ureter. B, the raw cut surface of the kidney Bfter resection is seen with the retracted renaI capsuIe. c, a cushion of fat is, transplanted to cover the raw surface of the kidney to prevent bIeeding and is fixed in position with pIain catgut sutures. D, the capsuIe of the remaining portion of the resected doubIe kidnev, which is aIreadv covered with the cushion of fat, is drawn together

I-

and cIosed with mattress sutures.

ential renaI functional tests and biIatera1 retrograde pyeIo-ureterograms to determine the separate function of the three kidneys, and aIso to discover whether the two ureters of the fused organ opened normaIIy into the bIadder or were united outside of the bladder. A speci- men was sent to the Iaboratory for cuIture, urea estimation and microscopic ex8mination.

The retrograde studies, carried out on October 16th, reveaIed beautifully in the fiIm of the right pyeIo-ureterogram the presence of a doubIe kidney with doubIe renaI peIvis and ureters (Figs. 3 and 4), the Iatter crossing each other at the IeveI of the fourth lumbar vertebra and interfering with the dynamism and emptying time of both right renaI peIves. The two ureters were united at the IeveI of the right sacro-iIiac synchondrosis to continue as a

pyeIograms taken in the erect posture, thereby revealing aIso a certain degree of nephroptosis. There was dilatation of the calyces and both peIves and ureters throughout, indicating the presence of urinary stasis, pyeIitis, pyelo- nephlritis and marked ureterectasis. The upper peIvis of the double kidney was T-shaped, whiIe the Iowerone appeared to be that of a fairly nor- ma1 kidney pelvis. The two right renaI pelves were definiteIy separated from one another and were cIearIy without intercommunication.

The impression, therefore, was that of a doubIe kidney on the right side with dupIication of rehaI peIves and ureters, with evidence of marked urinary stasis, nephroptosis, Iack of drairiage and obstruction at the union of the two ureters, a11 these combining to cause

262 American Journal of Surgery Gutierrez-DoubIe Kidney AUGUST, 1944

dynamic dysfunction, responsible for the entire peIvis was cIamped at its junction with the syndrome. ureter corresponding to the Iower peIvis.

The patient was accordingly admitted to (Fig. 6~.) The upper ureter was excised, its

FIG. 8. Drawing from the postoperative specimen removed at operation: A, the heminephrectomized upper poIe of the double kidney is shown with its peIvis and ureter, and its corresponding renal artery and renal vein. B, the same specimen Iaid open, showing a diIated renaI pelvis and ureter, and reveaIing norma parenchyma with pye- Iitis and pyelonephritis.

the Murray Hi11 HospitaI October 16, 1941, for operation on a double kidney. It was expIained to her that the Iack of dynamism and the fauIty drainage were the cause of a11 her troubles and that these no doubt wouId con- tinue to cause a gastro-enterorena1 syndrome, which couId be permanentIy cured only by carrying out a heminephro-ureterectomy under genera1 anesthesia.

Operation was performed on October 18, 1941, under cycIopropane anesthesia. With the patient lying on her Ieft side, an oblique incision about 15 inches long was made running obIiqueIy downward from the right costo- vertebra1 angIe through McBurney’s point to the midline. (Fig. 5~.) Fascia and muscle were cut and retracted; bIeeding points were cIamped and ligated ; the peritoneum was retracted. The fatty capsule of the kidney was cIamped and opened from behind; the kidney, which was somewhat adherent, was freeIy exposed and Iiberated from its surround- ing attachments by bhmt dissection. Its two ureters, running to the two separate kidney pelves, were identified and exposed down to the point where they united at the IeveI of the sacro-iIiac synchondrosis. (Fig. EB.) The ureter corresponding to the upper kidney

stump cauterized with carboIic acid and aIcoho1, and then Iigated with chromic catgut. The doubIe kidney was then properIy exposed out of the wound and the pedicle dissected from behind to identify the blood suppry of the organ. By retracting the cut ureter of the upper ‘kidney peIvis and by bIunt dissection, the retropyelic renaI artery of the upper kidney, which was a branch of the main renaI artery, was exposed, cIamped, excised and ligated. (Fig. 6~.) A rubber-shod cIamp was appIied to the pedicIe of the kidney to prevent bleeding and to obtain better exposure. A soft rubber catheter was tied around the kidney as a tourniquet in between the two renaI peIves and about the Iine of demarcation between the two parts of the doubIe kidney. (Fig. 6~.) The capsuIe of the upper poIe was incised and dissected from its attachment to the kidney, thus accompIishing its decapsuIation. (Fig. 6c.) The upper kidney was then excised and removed, with its attached ureter, leaving the retracted capsule. (Fig. 7~ and B.) There was practicaIIy no bIeeding, but a piece of fat was transpIanted to the raw surface and held in pIace by severa transrena1 sutures of catgut; this raw surface with its covering of fat was

NEW SEFUES VOL. LXV, .No. T. Gutierrez-Double Kidney American Journal of Surgery 263

then covered over with the renaI capsule, which was closed with mattress sutures. (Fig. 7c and D.) The rubber-shod cIamp on the pedicle was removed, and again there was no bleeding, hemostasis being compIete. Nephro- pexy of the remaining organ was then carried out by simple fixation with chromic catgut sutures between the IeveIs of the eIeventh and tweIfth ribs, suspending the organ in its norma position. This procedure puts the ureter in a perfectly straight Iine and secures good drain- age. The kidney was further anchored by placing another suture in the capsule of th$ lower poIe, fixing it to the quadratus Iumbaris muscIe to compIete the nephropexy. Gerota’s fatty capsule was cIosed from below, right up to the quadratus Iumbaris muscIe and over the kidney up to the costovertebra1 angle, as a further reinforcement of the nephropexy. A cigaret drain was pIaced in the upper angIe of the wound: the wound was cIosed in Iayers by chromic catgut sutures, first the muscles, then the fascia, and finally the skin with silk- worm gut sutures.

Postoperatively the diagnosis was doubIe kidneys with double ureters on the right side. The two ureters were doubIy crossed, and there was definite stricture at the point where they united, interfering with norma drainage, with evidence of dilatation of both ureters, acute pyeIitis and pyelonephritis. The specimen consisted of the upper poIe of the resected doubIe kidney with its diIated peIvis and ureter. (Fig. 8~ and B.)

The patient had an uneventfu1 convaIescence and Ieft the hospital twenty-five days after the operation with the wound compIeteIy heaIed and free from symptoms.

Three weeks after operation, in order to check up the resuIts, I carried out compIete studies, incIuding cystoscopy, catheterization of both ureters, differential functiona tests and biIatera1 retrograde pyeIo-ureterograms. The resuIts of these various tests proved that the remaining portion of the right doubIe kidney, which had been heminephrectomized, was functionalIy and UrographicaIIy perfectIy normal. (Figs. g, IO and I I.) In fact the func- tion of this kidney was better than that of the Ieft kidney with reference to phenolsuIphone- phthaIein and urea excretion, thus indicating that the remaining haIf of the double right kidney wiI1 be sufficient to sustain Iife.

COMMENT

I am reporting this case because it iIIus- trates so beautifuIIy the rbIe that the

FIG. 9. PIain roentgenogram of the same patient taken three weeks after heminephrectomy of the right doubIe kidney. Note the correct position of the two ureteral catheters and especialIy the one in the right ureter, which before operation LouId not be catheterized.

anomaIous doubIe kidney can play in the causation of surgica1 disorder in the upper urinary tract. It serves aIso to show how easiIy the genera1 surgeon can overlook the true cause of symptoms that masquer- ade as acute conditions of the abdomen, when in reaIity they originate in the uri- nary system.

Here was a girl who had suffered from birth with intermittent attacks of indefi- nite abdomina1 pain, often hovering about McBurney’s point, so that the case was easiIy mistaken for appendicitis and an un- necessary appendectomy performed with- out relief of symptoms. When the true cause was discovered in a double kidney

-with doubIe ureter, with congenita1 dys- function Ieading to chronic urinary stasis,

264 American Journal of Surgery Gutierrez-DoubIe Kidney Aucusr, 1944

it was obvious that treatment must be ing pyeIectasis, caIyectasis and diIatation addressed to the surgical correction of the of the ureters. Urinary stasis resuIts from maIformation. As soon as this was done, this interference with the dynamism of the

FIG. IO. Right retrograde pyeIo-ureterogram taken three weeks after right heminephro- ureterectomy in a double kidney followed bv nephropexy. Note that there is now only one renal peIvis, which is the lower Dole of the resected doubIe kidnev. The major and minor calyces are we11 deI;neated and appear normal. The ureterogram dis- closes a perfect right ureter with good drainage. The kidney has been restored to its normal position and function.

reIief of symptoms promptIy foIIowed, with compIete restoration of norma function and disappearance of symptoms.

It is important to understand what the mechanics of the emptying of a doubIe kidney is. Inasmuch as this anomaIous kidney is usuaIIy in a certain degree of nephroptosis, and the two ureters, crossing one another, are always anatomicaIIy adherent to the parieta1 peritoneum, which they continuaIIy traumatize, it is inevitabIe that each ureter will interfere with the drainage of the other by interrupting its normaI physioIogica1 peristaItic contrac- tions. This wiII naturaIly cause retention in both peIves of the doubIe organ, produc-

FIG. I I. BiIateraI retrograde pyeIo-uretero- gram in the same patient three weeks after operation. The right kidney pelvis, caIyces and ureter are within normal limits urographically and functionaIIy regarding urea excretion and phthaIein elimination. The Ieft pyeIo-ureterogram also reveals aIeft peIvis and ureter within norma Iimits. The patient is free from symptoms after right heminephro-ureter- ectomy for adynamic double kidney.

kidney, with the resuIt that a smaI1 hydro- nephrosis is formed, accompanied by crises of pain. The partia1 retention of urine in the peIvis of the kidney and in its two ureters not onIy produces chronic pyeIitis, pyeIonephritis and pyeIo-ureteritis but aIso acts as a constant insuIt to the parieta1 peritoneum, which is responsibIe for the attacks of abdomina1 pain with nausea and vomiting, simuIating those observed in appendicitis. The dynamics of the phys- ioIogic emptying of the renaI peIvis is interfered with and the emptying time retarded, due to the fauIty mechanics of the doubIe organ and its doubIe ureters. This interference Ieads in the course of

NEW SERIES VOL. LXV, No. 2 Gutierrez-DoubIe Kidney American Journal of Surgery 265

time to further disturbance, with a tend- ency to the compIete destruction of the renaI parenchyma if the maIformation is not surgicaIIy corrected.

The deIayed urograms taken one or more hours after intravenous injection of the opaque substance show cIearIy this deIay in emptying time of the organ, and discIose the actual condition present. The retardation indicates the impaired dynam- ism of the organ, which in my case was cIearIy reveaIed in the ninety-minute film, both renaI peIves and both ureters of the doubIe kidney being stiI1 distended with the opaque substance (Fig. I), whereas in the norma kidney the physioIogica1 emptying time is from five to fifteen minutes.

The conservative surgica1 treatment of doubIe kidney with a gross pathoIogic Iesion, visuaIized in the urograms, has been ampIy discussed in the Iiterature and need not be stressed at this time. Operations for heminephrectomy and partia1 resection of the kidney in cases of this type have been performed from the time of AIbarran,3 TuffIer,4 PaoIi,6 Czerny6 and other surgeons of the pre-urographic era. More recentIy this conservative operation for reIief of associated gross pathoIogic Iesions in the doubIe kidney has been carried out by Legueu,’ Papin,s Young,g Eisendrath,‘O Kretschmer,” GoIdstein and Abeshouse,12 Hess,13 CampbeII,14 Gutierrez15,16v17 and a host of others. In fact many cases have now been reported in the Iiterature in which heminephrectomy has been done in a doubIe kidney, but only when it has been associated with a gross Iesion urograph- icaIIy reveaIed.

These, however, are not the type of case with which I am concerned in this presenta- tion. AI1 these authors were deaIing with gross pathoIogic conditions, such as stone, cyst, Iarge hydronephrosis, pyonephrosis, tubercuIosis and even tumor in one-haIf of the doubIe organ, a11 of which frankly demanded surgica1 intervention. In the group of cases of doubIe kidney in which I am here interested, there is, on the con-

trary, no gross conditions visuaIized in the urogram. However, the deIayed in- travenous urograms wiI1 give a hint of what we are deaIing with, and the retro- grade pyelograms taken with the patient in the erect position wiI1 actuaIIy discIose the nature of the condition, which consists in the faulty dynamism of a double kidney, which is responsibIe for mechanica faiIure of the doubIe organ to empty properly and resuIts in the gastro-enterorena1 syndrome. This condition can definiteIy be reIieved and cured by a conservative heminephrec- tomy or hemi-ureterdnephrectomy, as in the case here reported.

This type of operation is simpIe, since there is aIways a good Iine of demarcation between the two haIves of the double kidney, and each haIf has an independent bIood suppIy. (Fig. 6~.) The fear of bleed- ing during the resection of the kidney is groundIess, since proper Iigature of the bIood suppIy is easiIy made and the raw surface of the resected kidney can readiIy be covered with fat to prevent hemorrhage. (Fig. 7c.) In the case here reported there was no bIeeding whatsoever. As the two peIves of the doubIe organ are entirely independent of each other, there is no danger of urinary fistuIa. Even if a caIyx has to be resected, it can be sutured prop- erIy to prevent Ieakage. The operation shouId aIways be foIIowed by a nephropexy to secure good drainage from the remaining singIe ureter of the heminephrectomized kidney.

In the group of cases in which there is a history of a previous abdomina1 operation without reIief of symptoms, no other type of conservative operation seems so rationa as a heminephrectomy or hemi-uretero- nephrectomy, since it gives assurance of a permanent cure. Other conservative pro- cedures that have been envisaged for doubIe kidney and ureter, particuIarIy in cases of hydro-ureter and hydronephrosis, incIude peIvio-uretera anastomosis, anas- tomosis of the two ureters at any Ievel, transpIantation of ureters into the boweI or into another portion of the bladder,

266 American Journal of Surgery Gutierrez-DoubIe Kidney

simple nephropexy and even denervation or decapsulation of the kidney. But none of these conservative procedures seems to offer promising results. Some cases of ure- tera1 anastomosis have compIeteIy faiIed to correct the dynamic dysfunction and have come finaIIy to a secondary nephrectomy.

The technic of heminephrectomy and hemi-ureteronephrectomy is as simpIe as that of Iumbar nephrectomy and shouId be carried out, since it has the advantages not onIy of correcting the maIformation and overcoming the painful symptoms, but aIso of conserving renaI tissue and securing norma renaI function.

SUMMARY AND CONCLUSIONS ’

I. DoubIe kidney with doubIe ureter is the commonest of a11 congenita1 maI- formations of the upper urinary tract, and when accidentaIIy found demands a com- pIete uroIogic and urographic examination.

2. The doubIe kidney with bifurcation of ureters is a potentia1 source of dynamic dysfunction of the urinary system, resuIt- ing not 0nIy in painfu1 urinary symptoms but aIso in repeated crises of abdomina1 pain.

3. These recurring attacks of abdomi- na1 pain with gastrointestina1 symptoms are due to the constant insuIt inflicted upon the parieta1 peritoneum by the adynamic doubIe kidney and its crossed doubIe ureters.

4. The anomaIy of the double kidney per se, without association of visuaIized gross pathoIogic Iesions in the organ, is responsibIe for these painful symptoms.

5. Every patient suffering from re- peated attacks of indefinite abdomina1 pain shouId be submitted routineIy to uroIogic studies, especiaIIy when the pain is on the right side, in order to, ruIe out an anomaIous surgica1 condition of the kidney.

6. When the physioIogic emptying is retarded or incompIete in one or both peIves of the dupIex organ, there is aIways evidence of a surgica1 condition.

7. DeIayed urograms taken one or more hours after intravenous injection of the

opaque substance are of great vaIue in diagnosis, but an adynamic condition thus reveaIed shouId aIways be confirmed by retrograde pyeIographic studies.

8. Heminephrectomy or partia1 resec- tion of the doubIe kidney with the corre- sponding supernumerary ureter appears to be the operative procedure of choice, offering the best prospect of restoration of function and compIete disappearance of symptoms.

g. Heminephrectomy is as simpIe an operation to carry out as an ordinary Iumbar nephrectomy.

I I. This conservative surgica1 procedure shouId be foIIowed by nephropexy to straighten the ureter and secure good drainage from the remaining haIf of the doubIe organ.

IO. The technic of heminephrectomy for correction of a doubIe kidney is de- scribed in detai1 and graphicaIIy iIIustrated.

12. Conservation of tissue in renaI sur- gery is imperative whenever feasibIe.

13, Patients submitted to this ortho- pedic correction of the double kidney should have a compIete uroIogic anduro- graphic postoperative check-up to confirm the anatomic and functiona resuIts before Ieaving the hospita1.

14. When the doubIe kidney is uro- graphicaIIy discovered and is associated with painfu1 symptoms and dynamic dys- function, the condition shouId aIways be considered surgica1 even in a so-caIIed “norma doubIe kidney.”

15. An iIIustrative case is reported to demonstrate the practica1 appIicabiIity and the exceIIent resuIts of heminephrec- tomy in adynamic doubIe kidney.

REFERENCES

I. GUTIERREZ, R. Indications and technique of com- bined uretero-nephrectomy. Ann. Surg., 93: 5’1-5439 1931.

2. GUTIERREZ, R. AnomaIies of the Kidney. Hydro- neDhrosis. MovabIe Kidnev. Iniuries of the Kibney. In: Cabot’s Moderi Urology, 3rd ed., vol. 2, pp. 374-509. PhiIadeIphia, 1936. Lea & Febiger.

3. ALBARRAN, J. Resection orthopkdique du rein. Nkphrectomie partiek. H&ninCphrectomie.

NEW SERIES VOL. LXV, No. 2 Gktierrez-DoubIe Kidney American Journal or surgery 267

NCphrectomie partietle pour nkoplasmes. In MMecine Opkratoire des Voies Urinaires. pp. 23 I, 263, 264, 324. Paris, Igog. Masson et Cie.

4. TUFFIER, T. Etudes Experimentale sur la Chirurgie du rein. Thkse de Paris, 1889.

5. PAOLI, E. Etude Exptrimentale sur Ia Resection du rein. Verbandl. de X Internat. Med. Congress, 3: 248-250, 1890.

6. CZERNY, H. E. Cited by HerczeI, E.: Ueber Nierenexstirpation. Beitr. z. Klin. C&r., 6: 5 I I, I 8go.

7. LEGUEU, F. La Nkphrectomie Partielle. Clinique de Necker, Vols 2, pp. 237-253. Paris, 1922. Maloine et Fils.

8. PAPIN, E. Des N&phrectomies PartieIIes ou R&ec- tions duC rein. Des opCrations qui se pratiquent sur les reins anormaux. In: Chirurgie du Rein. Paris, 1928, Doin et Cie.

g. YOUNG, H. H. and DAVIS, E. G. DoubIe ureter and kidney with calculous pyonephrosis of one-haIf; cure by resection; the embryoIogy and surgery

of doubIe ureter and kidney. J. Urok, I: 17-32,

1917. IO. EISENDRATH, D. N. and PHIFER, F. M. BiIateraI

heminephrectomy in bilatera1 double kidney. J. .!hcd., 13: 525-535, 1925.

I I. KRETSCHMER, H. L. Resection of the kidney. Surg., Gynec. c~ Obst., 60: 984-995, 1935.

12. GOLDSTEIN. A. E. and ABESHOUSE. B. S. Partial resection’of the kidney. J. urol., i8: 15-42, 1937.

13. HESS, ELMER. Heminephrectomy. J. Ural., 38:

43-57, 1937. 14. CAMPBELL. M. F. Resection of the kidnev. J. A.-

M. A., ;17: 1223-1229, 194%. 15. GUTIERREZ, R. Operative technic for division of

renal isthmus in horseshoe kidney. Am. J. Surg., 55: 28-36, 1942.

16. Idem. Large solitary cysts of the kidney. Types, differential diagnosis and surgica1 treatment. Arch. Surg., 4.4: 279-318, 1942.

17. Idem. The CIinicaI Management of Horseshoe Kidney. New York, 1934. PauI B. Hoeber, Inc.

WHEN intranasal tubercuIosis extends to the nasa1 bone or nasa1 process

of the maxiHa, it causes necrosis, cold abscess, and fistuhzation of the

cutaneous structure. From “Tuberculosis of the Ear, Nose, and Throat,” by Mervin C.

Myerson (CharIes C. Thomas).