Brozinski, M.

Kallistratos, G.

Knothe, W.

Noddack, W.

Noddack-Tacke, I.

Sengbusch, R.

Sücker, I.

Timmermann, A.

MPG.PuRe

214 Pron "Ilax-Plaiick-Institut für KulturpflansexiKüchtung'* Hamburg (Directors Professor DroH«,v»Senßbu©ch) Technical and Clinical Aspects of the Dissolution of Renal Calculi in the Humsui Body. by MoDroziuski^ GcKallistratos g y^ICnotue^ I^and WoNoddack^ itoV^Sencbusch ^  I a Slicker ^  Ac»Tinraernanno ^Lecture held by Dr^AoTinirnernann at tha Sixth lleetin^ of the :Hordrhein-\;est f Ulische Gtesellschaft far Urologie on April 2 2 ^ 1961 at Bad Oeynhausen) First infomations concernine application of the conpound EDTA (ethyl diamine tetra acetic acid) as a solvent for renal calculi In the human body were published in June I9600 The basic principle of renal calculus dissolution is the trans-foxTiation of its water-insoluble chelste complexo A solution of 2^5*;^ of the bi-sodium salt of the a^mc acid buffered by 3^4 tri« othanol anixie on a pll of 8 0 6 effects entire dissolution of all formations of calculi containing; calcium oxalate 0 Particles of uric acid compounds in mixed concrenerès also become soluble by transformation into tri-ethanol ammonium urateo Ihysioloßical toleration of tlie solution of this salt was tested in thousands of rinsing hours in both the animal and human body^ /e have already reported on chemolytical^ clinical treatment (literature)c Accordine to Sarre's statistics on che :iical formation of human renal calculi 951^ of them can be dissolved b/ this solvent (literature)o ]!Ieam;hile new and more effective solvents on the basis of Lithium compounds of EDTA have been prDposed by Professors loand '/oNoddack-s. Tliese solvouts with their laboratory descriptions Po2o and Vo3o are at present under cliiical testo Being especially veil tolerated they reivdex^ bettex* resuLtSc. (Po2o = 3/0 Lithium salt of B D T A 9 molar propoabt, 3 2 I Iritis O o 5 / ^ tri-«ethanoi amine0 p:I 8 o 5 I 'o3o 0 Lithiitm salt of ISDTA^ plus V}o trl-ethanol amine ^  pH S o 5 ) After their composition our treatment !ias been entirely changed to the application of the solvents P e 2 3 and P«3oo Lately Sucker hae tested a c^^oup of co ipounds effecting an especially good dissolution of phospho?:© concrements of caloulio Xt is a sodium solvent of the SDTA wit 1 the molar propo sodiums3EDTA 3:l9 corresponding to a tri-sodlum sal^.. A conpound of 5 % of the salt buffered with 1 of tri^^etha lol amine i^ in th© scope pH above 8 being favcj^xable for the Toriiiation of Ca-complexa8o 'Vhts comjiotrnd with its laboratory desc-^iption F^ho is well tolerated and has an extended possibility of application on oxalate tmd phosphate concrementso ^) ^) later added information o o o / 2 c - 2 -The dissolution of the renal calculus in the human kidney ±s carried through with the a.id of a double •channel catheter effecting continuous rinsing of the calculus^ surfaceo Two sizes of catheters are being used: 9 and 12 Charrlére o Generally the 9 Charrlére catheter will be sufficient for treatmento Severe infection of the kidney and nurierous calculi « however ^  may necessitate an Increase of rinsing capacity which^ after tissues have become adapted to rinsings, may be gained by exchanging the 12 Charrlére catheter through the stretched urethra^ Catheters are being well tolerated by the ureter and may remain there for weeks o Insertion of the 9 Chari^iere catheter Is to be carried out with the aid of the nortaal sisse cystoscoj^e^ the 1 2 Charrlére with adequate calibre « requiring only anaesthesia of the urethrals mucous membrane (Pantocaln 092^) after the patient had received a general sedative (Dolantine^ Cliradoa etc*) by injection» The Insertion of the rinsing catheter aecessitates an extreme lordosis in order to attain maximum witness of the urethra* As the rinsing catheter %#hich is made of plastics at a temperature of 37^ Co Is rather rigid and inflexible It will^ therefore » have to be heated In a water bath up to 80-90^ C* prior to insert ion Per some minutes It will lose its rigidity and will follow the curves of the urethrao Insertion thus becomes easy to handle and practically no discoirifort x/ill be caused to the pat lento After some minutes the catheter will regain its former i^igldlky eliminating alteration of position despite the peristalsis of th3 urethra. After Insertion of the rinsing catheter^s jet into the calclforra system its location will have to be checked upon by X-ray examination* Attention will have to be paid to the fact that all lateral openings of the jet are locate! within the cavity of the renal pelvisc The most eminent prerequisite of contl.auous rinsing of th© renal pelvis Is the unhampered return flow of the solvent « This demand is mot by the especially wide calibre 5f the catheter's out channel9 by the free position of the rinsing jet inside the renal pelvis and by a new-developed suction vacuum Ln the container receiving the out flowing solvents, Suction capacity for a continuous flow of the solvent will have to be kept at a pressure of O o l-o« 2 atUo Tlie removal of tiny blood clots and flakes of mucus may demand a temporary Increase up to O o 5 atUo Such an Increase of suction efficacy 4oes not Imply any danger to the kidneyo A vacuum of 0 , 1 - 0 0 2 atti effects a more intensive flow of 5co~6oo om-^  per hour as compared to a mere 15o om3 without the aid of a vacuumo In addition pressure can also be brought to bear through the Infusion burette and will thus add to the Increàise of flow*. Here also 0 , 1 - 0 « 2 atU will be sufficiento Both measures combined provide for a flow of 2c»ooo per houTo 0 0 0 / 3 3 • An increased speed of flo^ ^^  virtually inpllos an abbreviation of calculus dissolution as the factoz o f kidney urine thinning down the solvent is almost eliminated end alteration o f pll value la kept at a minimum^ The closer the contact between the lowest Jet opening and the calculus^ surface la the more effective the solvent will be« Therefore X-ray checking on the Jct^s location within the renal pelvis during insertion becomes essentíalo Provided attention has been paid to all prerequisites rinsing Itself will prove to be painlessPatients are made fai ; lliar with all facts and technical detail of the treatment and they soon will be able to take an active part regulating their own rinsing by adjusting pressure in case of minor disturbances^ Althou¿ih this will favourably distract them and will be of actual help frequent checking up by the nursing per sonreí caJinot be dispensed withe I n case the catheter gets clogged rinsing will have to be discontinued for at least some hours<> In many cases small blood clots 9 flakeSj of mucus or fragments of calculus will spontaneously be excreted o If® however, the catheter remains obstructed It will have to be exchanged; removal of it Is simple and painless o ZU hours should then elapse before re-insertion takes placeo Normally a 8«lo hours^ rinsing caja be carried through with patients treated In hospitalo Body temperature of the patients during treatment is generally normal ,3 In some cases sub«febrlle« Fever ^  however« indicates acute pyelitlc condition due to disturbances o f liquid circulation in the renal pelvis o In this case rinsing is to be entirely discontinued for some days o Now Increased Intravenous medication of antlbiotlca Is Indicated and the effect 4s to be augmented by a slow rinsing with physio^ logical NaCl-solutlon to which a concentration of antlbiotlca of l/oo has been added^ Nearly always the blood descent reaction is slightly Increased There will be values between 2 o - 4 c mm during the first hour and 4 o * 6 o mm during the seconde Numbers of leucocytes in the blood may rise whereas haemoglobin- and ery-valuos may fall in the course of a longer treatment^ These effects vary greatly and still ask for firm explanations as to their causesMinor blood transfusions are than to be perforaed in order to balance losses and to Improve general well«being» Treatment of year-long kidney infections in combination with a calculus filling all renal cavities or renal fistula v/ith calculi ask for frequent checking on blood values and general conditiono Examination of the calcium level of the blood prior to and after the daily rinsing does not show anjr great deviations from normal standards., Values vacillate be twee a 0^9 a^ d^ lo,l mg Up to now in all cases of chemolytioal treatnei>t ajitihlotloa were employed as a precautionary measure as to check lact^ria activityo Daily or every second day patients receive intravenous injeotions of 250 rag of a general antibiotlcum^ It will have to be ascertained whether such quantities are indispenealle or not 0 Occasionally observed anaemia roay possibly have beer caused by this measureo But so far no harm to the digestive system 1ms been notloedo During treatment patients receive vltarine compounds^ Bacteriological examination of urine j>ilor to rinsing ti^eatment shows mixed infections originating froii different bacteria^ Also during treatment bacteria are presents Examinatidns of i)atients who had undergone rinsing treatment lol/2 years ago showed that their urine was sterile^ After conclusion of clinical treatment patients receive diet perscrlptIons and medicaments in order to prevent liamiful acidity of the urine ^  Vith male patients s p ^ a l attention will have to be paid^ to the prostata^ Frequently an inflamed implication of the male annexes coincides with an infection of the ureter^ The increased sensitivity of these organs then uakos insertion ucro coiiplicated a^d in addition causes dysury durin/i treatment c Daily massage of the prostata^ hot sitting baths and oocasicnal Injections of Depot Oyren (15 mg or more) render reliefo Vrtth female patients a longer rinsing catheter of 13o cm ought to be employed so that the Joinings of in- and out tubes can easily be connected ^ distant enough from the thighsc Chenolysis \t'ithout any complication will soon become oppressively tedious to the patient said readings racio^ television along with a va.rying diet will gain special bearlrg^ Also light massage of extremities will be of advantage as the repose of the long rinsing hours caqsas growing uneasinesso ^ Uith regard to treatments hitherto carried through we can now . safely say that the dissolution of one ore more calculi in the renal pelvis which lie open to the sol-vent is technically simpleo Calculi iii the calciform system can also be treated successfully If the opening of the renal pelvis is \iide enoughs Duration of rinsing Is^ however^ still difficult tc predicto The question whether continuous rinsing empliiis damage to th© function of the renal parenchyma cannot be definitely answered as yeto Intravenous pyelograms made lur. edlately or some days after conclusion of treatment showed prompt« syiiimetrical secretion of the contrast substanceo On the treated side the contours of the renal callx appeared , coarsened^ typical for pyelltldeso Control examination some months later shw^ed nonrial funotlono Pathological nitrogen»»value remnants could not be made out In the blood serumo • eo/5 - 5 -Tfith a 3o year old patient whose sii.gle kidney had been operated i^ pon one year ago 2 hean-sized recic ivous calculi were dissolved by P«2o In 9o hourso Reianants of nli rogen values stayed nonrial during treatment also in this case. Blood descent reaction and leucocyte values showed a slight« temporary increajsee Examination of concentration capacity resulted u top concentration of l«o2o« Inasmtuch continuous rinsing is to b^ blamed for the decrease of function cannot be argued in the case of this anamnesiso The question of the formation of rec idivous calculi in already treated kidneys can only be cons idea ed with wltli restraint as time for observation and statist lea.' material are Inadequate o But up to now tliore have not occurec any recldivous formations where total dissolutions or partial dissolutions leaving small fragments had taken places On the a ntrairy ^ smaller fragments tend to decay and in due course are being spontaneously excretedo In only two cases treatment had to 1 e interrupted - due to the patients' lack of time leaving ral her large calculi in the callXc After one year both' sho^^d considarivble growtho • Of the 3o patients who hitherto had undergone chemolytioal treatment radiographs will be demons tratedo (Demonst ratio] v) Conclusion We have endeavoured to compile a sua vey on clinical application of results gained In laboratory research aiming at Intra-renal dissolution of renal calculi In the human body» Ue are of opinion that on the basis of facts already attained further development of this method i ill be answerabloo Future only tirlll be able to allot the proper place to chemolytioal treatment of renal calculi as compai^ed to surgical therapy« Latest tests proved solvents Po2o and Po3o to be besto Their compositions are as follows« P« 8 « 2o5/^ Dl-sodlum salt of EDTA < 3/^  tri-ethanol amine Po2o « 3 '}o trl-llthlua " " < 0.5'/^ Po3o » 5 ^ It ft ^ i r/o Po4o a 5 trl-sodluia " " 4 ifo " *) n It If ft V *) later added Information 

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Technical and Clinical Aspects of the Dissolution of Renal Calculi in the Human Body

Technical and Clinical Aspects of the Dissolution of Renal Calculi in the Human Body

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