Tuesday, October 28, 2014
Historical Contribution: 1955, Colston, Partial Nephrectomy on a Solitary Kidney
Colston JAC. Operation for Tumor of a Solitary Kidney. Southern Medical Journal. 1955. 48:12:1280-87.
In 1955, the gold standard treatment for renal neoplasms was radical nephrectomy. Partial nephrectomy had been described and performed for a number of benign conditions since the late 1800's, including calyceal obstruction due to nephrolithiasis (obstruction of a portion of the kidney with a kidney stone), removal of infectious abscess or granuloma in the case of tuberculosis, and removal of renal cysts. Partial nephrectomy for cancerous growths started to gain popularity in the 1930's. In 1950, Vermooten described and advocated for partial nephrectomy based on studies of renal cell carcinoma growth and anatomy. He especially advocated for partial nephrectomy in patients with a solitary kidney. If such patients were "inoperable" they were "otherwise condemned to die" – as either renal cell cancer would take its course or nephrectomy would leave the patient anephric at a time when renal replacement therapy (dialysis) was in its infancy.
At the time of this Historical Contribution by JAC Colston, three cases of partial nephrectomy for tumor were reported in the literature. In this manuscript, Colston added two more cases and successful surgeries.
The first patient had a right ureteral injury during hysterectomy and subsequent non-functioning kidney due to obstruction. She developed a filling defect in her remaining left kidney and underwent partial nephrectomy through a flank incision for, what ended up being, a papillary urothelial cancer. The patient was disease free four and half years later.
The second patient developed gross, painless hematuria and presented with a tumor of the right kidney and a non-functioning left kidney. Under spinal anesthetic, his non-functioning kidney was explored through a dorsal incision and found to have "no secretory renal tissue." As an aside, the incision of choice for nephrectomy during this time period was often a midline, transabdominal exposure so that the "uninvolved" kidney could be explored prior to nephrectomy to ensure adequate renal function postoperatively. A week after exploration confirming the non-functioning kidney on the left, the patient underwent a partial nephrectomy on the right. Pathology revealed a clear cell adenocarcinoma.
The discussion that follows this manuscript provides some additional commentary and criticism of partial nephrectomy during this time period. Dr. Edwin Alyea from Duke University comments, "Dr. Colston is to be congratulated for his success in this undertaking, and also for bringing this procedure before the profession… Dr. Colston, of course, does not suggest that this patient [in reference to the first patient above] is cured… it is quite probable that it will be true to form and reappear elsewhere in the urinary tract." This is followed by commentary by five other prominent urologists around the country in which they share cases of complex renal pathology or partial nephrectomy. Of interest, is that urothelial and parenchymal tumors were considered in the same spectrum of disease as they both presented with gross hematuria, deformities of the kidney and neither axial imaging nor ureteroscopy were available to distinguish between the two.
Today, nephron-sparing surgery is the gold-standard for all small renal masses to which the operation is technically feasible. This article provides a fascinating look at partial nephrectomy in the 1950's, where the modern indications and techniques were not yet established.
To read the entire manuscript: follow the link above, visit the Centennial Website or click here.
To read more about the history of partial nephrectomy, read the excellent article "A HISTORY OF PARTIAL NEPHRECTOMY FOR RENAL TUMORS" by Harry Herr in the March, 2005 edition of the Journal of Urology.
HISTORICAL CONTRIBUTIONS highlight the greatest academic manuscripts from the Brady Urological Institute over the past 100 years. As the Brady Urological Institute approaches its centennial, we will present a HISTORICAL CONTRIBUTION from each of the past 100 years. In the most recent experience, the most highly cited article from each year is selected; older manuscripts were selected based on their perceived impact on the field. We hope you enjoy!
 V. Vermooten. Indications for conservative surgery in certain renal tumors: a study based on the growth pattern of the clear cell carcinoma. J Urol, 64 (1950), p. 200