In my early days as a consultant I saw a patient with left upper abdominal pain and a lump in the loin. Abdominal ultrasonography in the 38 year old widow revealed a grossly hydronephrotic left kidney and a right pelvic kidney. An intravenous urogram showed some functioning renal tissue in the region of the upper sacrum corresponding to the pelvic kidney. The left kidney was not visualised. An isotope renogram displayed tracer uptake in the region of the upper sacrum but no activity in the left renal area.
The pain from the dilated, non-functioning left kidney was interfering with her job as a tea plucker, and so she wanted it to be removed. I was reluctant to do the operation straight away as she had only a little renal tissue in her pelvic kidney and her serum creatinine concentration was already slightly raised. However, she was adamant—understandably, since her stay away from work was a serious financial loss.
On opening the patient, I found a very large hydronephrotic kidney extending to the pelvis. The decompressed kidney revealed paper-thin parenchyma except in the lower pole. For a moment, I wondered whether this could be the little functioning renal tissue that was shown in the isotope renogram as a pelvic kidney, and I considered whether to leave the hydronephrotic kidney behind.
Then I thought it would be amateurish to seem uncertain and abandon the nephrectomy in front of the junior doctors and the nurses. I did not want to be a cowardly surgeon who would have to tell the patient that I had left the diseased kidney because I was not sure. I therefore removed the kidney.
Postoperatively, the patient was anuric, and her serum creatinine continued to rise, necessitating haemodialysis. A few hours after the second session of haemodialysis, she developed a severe bout of haematemesis and melaena and died.
As a surgeon, one should never feel cowardly in abandoning a procedure when there is a doubt or an unexpected difficulty. This is true for any intervention. A living problem is always better than a dead certainty.