Introduction. Anatrophic nephrolithotomy is a procedure in which a parenchymal incision is made in an intersegmental plane, allowing removal of large renal. We offered the patient staged open anatrophic nephrolithotomy. Results. Operative time was minutes. Blood loss was cc. requiring one. The anatrophic nephrolithotomy described by Smith and Boyce is an excellent method of preserving a maximum number of functioning nephrons by minimizing .

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The main goals for urinary stone treatment are to preserve renal function, reduce or avoid complications related to calculi, and to render the patient free of calculi as soon as possible.

Anatrophic nephrolithotomy ANL is a valid and useful alternative for conventional staghorn calculi excision. Although excellent stone free rates can be achieved with ANL there are some drawbacks that may be of concern.

Morbidity related to intraoperative and postoperative complications is one of them. Another, great concern is the possibility of reduction on renal function related to the procedure itself. This may be related to nephron injury during nephrotomy and parenchymal closure or to ischemic injury. In this review we assess functional results after anatrophic nephrolithotomy. nephrolithitomy

Procedures with low morbidity and rapid recovery are also essential in current practice. Guidelines from American Urological Association and European Urology Association state that conventional excision of staghorn stones must be considered only in exceptional cases and that percutaneous nephrolithtomy PNL should be the preferred choice[ 12 ].

Computed Tomography based morphometric studies may help classify and predict outcomes for staghorn calculus treatment[ 34 ], nevertheless, it is implicit that the greater the stone more difficult it is to leave the patient without remaining calculi in the collecting system.

Several authors showed the relation between stone size and stone clearance. Undoubtedly, the main reason for conventional surgery rates decrease is the improvement of techniques such as extracorporeal shockwave lithotripsy SWL and endourological procedures ureteroscopy and PNL [ 6 – 9 ]. Yet, even with such technological developments, some special conditions are still best handled with conventional surgery, such as complex collecting system anatomy, extremely large stones, extremely poor function of the affected renal unit, or excessive morbid obesity.

Anatrophic nephrolithotomy ANL is one of the most used option for conventional staghorn calculus removal. Smith et al[ 10 ] described the anatrophic nephrotomy and plastic calyrhaphy a procedure in which stone removal and correction of collecting system anomalies was possible.

Morbidity related to intraoperative and postoperative complications is one of then. Smith et al[ 10 ] identified some factors that may contribute for perpetuating renal inflammatory process after stone surgery: In order to control those issues and to preserve the maximal number of functional nephrons they described the anatrophic nephrotomy and calyrhaphy. The main steps in this procedure are: Serum urea nitrogen obtained to assess renal function and serum creatinine has improved or remained stable in all but 2 patients.

Other authors also published their results regarding renal function. Thomas et al[ 12 ] used I hippuran scanning to assess renal function of thirteen patients operated on with classic ANL with a mean follow up of Thirteen percent decrease in renal function of the kidneys undergoing ANL surgery was reported.

Nonetheless, total renal function assessed by effective renal plasma flow level remained normal in the postoperative stage. Studies in patients with solitary kidney may help to understand changes in renal function without the compensatory effect of the contralateral kidney. With a mean follow-up of 6 years, patients with solitary kidneys operated on with classic ANL were evaluated by Stubbs et al[ 13 ] and associates.


No changes in pre- and post-operative serum creatinine was observed. Several modifications of the classical approach have been described usually without defining the intersegmental plane[ 14 – 19 ].

Kijvkai et al[ 18 ] compared standard ANL and modified ANL and concluded that the standard procedure preserved more renal function than the modified[ 18 ]. Table 1 describes results of modified ANL in regard to renal function assed by scintigraphy.

InKaouk et al[ 20 ] studied laparoscopic ANL for the management of staghorn renal stone in pigs[ 20 ].

After injecting polyurethane in the pyelocaliceal system to create a staghorn calculus model the animals were submitted laparoscopic nephrolithotomy. Glomerular filtration rate GFR was assessed before and four to five weeks later with diethylene triamine pentaacetic acid DTPA renal scans.

The mean total GFR rised from A case nephrolihhotomy was first reported by Simforoosh and associates in [ 21 ] with an update in [ 22 ]. Mean pre-operative serum creatinine level rised from 1. Tree patients were submitted to preoperative 99mTc-DTPA renography to asses renal function 3 mo after surgery. Nephrolithotpmy et al[ 23 ] tried to replicate the conventional technique with ice-slush hypothermia.

Follow-up at 1 mo demonstrated no change in renal function as estimated by creatinine clearance. King et al[ 24 ] evaluated seven consecutive patients submitted to RANL. Renal function was estimated by the Modification of Diet in Renal Disease study equation.

Anatrophic nephrolithotomy.

Several studies have assessed the impact of PNL on renal function[ 25 – 32 ]. Usually there is an immediate decrease on renal function after surgery with return to baseline on long term. Improvement or stabilization of renal function may occur because of better drainage, infection and inflammation resolution after surgery. On the contrary, renal function may decrease because of several injury mechanisms. Patient comorbidities, direct injury by kidney puncture and tract dilation, ischemia, inflammation and fibrosis are some of the possible mechanisms implicated on renal function deterioration.

Wilson et al[ 33 ] tried to quantify the level of parenchymal injury after stone treatment in an animal study. Moskovitz et al[ 26 ] evaluated renal units separately and identified a remarkable reduction in the functional volume of the pole that underwent PNL, nevertheless, regional uptake and total renal function remained unchanged[ 26 ].

In cases where the amount of calculi is remarkable multiple access tracts may be required during the PNL procedure. It could be expected that the number of access tracts and ancillary procedures used for complete stone clearance could negatively impact on renal function.

In regard to multiple tracts, there are few studies that support this hypothesis. El-Tabey et al[ 34 ] found that multiple punctures were an independent risk factor for renal function deterioration in a cohort of patients with solitary kidney. Hegarty et al[ 35 ] and Fayad et al[ 36 ] also noted that multiple tracts carries a risk of adversely affect renal function. Handa et al[ 37 ], on the other hand, showed that multiple access tracts does not lead to a more severe reduction in renal function[ 37 ].

Ancillary procedures such as extracorporeal shock wave lithotripsy ESWL and retrograde intrarenal surgery RIRS are frequently required for complete clearance of staghorn stones. The number of ancillary procedures to render the patient stone-free may range from 2. Zeng et al[ 43 ] reported that only 2. Nevertheless, the potential deleterious effect of ESWL on kidney structures is well established[ 4445 ] and the combination of PNL may have a greater impact on renal function.

In regard to RIRS parenchymal injury is not so evident, even so, more studies with longer follow-up are needed. Most of the studies shows that renal function is not greatly compromised after PNL Table 2. Eighty-eight renal units were assed, 43 submitted to PNL and 45 to conventional surgery.


Renal function was assessed with 99mTc-mercaptoacetyltriglycine MAG3 scans and no significant decline in the operated renal unit was observed, although, results were not segregated by technique. Shen et al[ 47 ] also compared PNL and open surgery in a prospective randomized study. Renal function was assessed with serum and urinary b2-microglobulin and they found no difference between groups.

As in Al-Kohlany et al[ 46 ] study, results were not segregated by technique. Renal function improvement may occur after stone treatment. Possible mechanisms related to increase in renal function are the relieve in obstruction, resolution of infection and inflammatory process, and compensatory hypertrophy of the remaining tissue[ 12 ].

Nevertheless, the stone-extraction procedure may itself negatively compromise the functional condition of the surgically treated kidney. Decreased renal function after percutaneous nephrolithotomy may occur because of parenchymal damage during needle puncture and tract dilation.

Ischemic injury may also arise if there is inadvertent injury to major vessels, although, it is not so common. In regard to anatrophic nephrolithotomy decrease in renal function may occur because of direct injury to parenchymal tissue, leading to a permanent scar at the site of nephrotomy. Another possible mechanism is the ischemia-reperfusion injury related to occlusion of renal artery and vein.

Protection measures as ice-slush hypothermia and mannitol have been used, as well as restriction of ischemia time to no longer than 30 min. However, the impact of those measures on renal function are not fully known. It seems that the type of methodology used to assess renal damage influences the postoperative results.

When functional markers are employed, kidney damage is temporary and usually mild. However when cellular damage and morphological assessment are considered, renal damage becomes more evident. In most surgeries postoperative renal function is preserved and even when renal dysfunction is observed, it is usually negligible. Nevertheless, information about long term follow-up is scarce, as well as the the cumulative impact of multiple procedures. As previously addressed PNL is the standard treatment for staghorn stones.

Nevertheless, there are some limitations with this approach. They found that patients with staghorn stones more frequently underwent multiple punctures When the number of less invasive procedures exceeds what is considered reasonable, we must consider the conventional surgery[ 12 ]. With the advances in laparoscopic and robotic assisted methods replication of the open technique is possible with less morbidity.

Although a definitive conclusion can not be drawn from the available literature in regard to which one is the best approach to treat complete staghorn stone, percutaneous nephrolithotomy still is the first option. Nevertheless, in carefully selected cases anatrophic nephrolithotomy may achieve optimal outcomes. Although parenchymal damage after anatrophic nephrolithotomy is of concern renal dysfunction is usually clinically insignificant. Comparative studies of the available modalities are scarce as well as long term follow-up and the impact of multiple procedures.

Citation of this article. Review on renal recovery after anatrophic nephrolithotomy: Are we really healing our patients? Corresponding Author of This Article.

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