Andrew J. LeRoy

Percutaneous Removal of Kidney Stones: Review of 1,000 Cases

We report the results of 1,000 consecutive patients who underwent percutaneous removal of renal and ureteral stones. Removal was successful for 98.3 per cent of the targeted renal stones and 88.2 per cent of the ureteral stones. Complications, evolution and technique are discussed. Percutaneous techniques are an effective way to handle the majority of renal calculi and these techniques will continue to be important as shock wave lithotripsy becomes more widespread in the United States.

Prospective Analysis of Computerized Tomography and Needle Biopsy With Permanent Sectioning to Determine the Nature of Solid Renal Masses in Adults

ABSTRACTPurpose: We prospectively determined the accuracy of computerized tomography (CT) and needle biopsy of solid renal masses.Materials and Methods: A total of 100 patients with a solid renal mass who were scheduled for operation were prospectively evaluated. CT was performed before radical or partial nephrectomy. Biopsy of the surgical specimens was done twice through the tumor using an 18 gauge biopsy gun. Specimens were sent for permanent section and review by 2 pathologists blinded to each other and to the whole tissue specimens. Images were reviewed by 2 radiologists blinded to each other and to the results of pathological analysis. Results of CT and permanent biopsy were compared with the results of whole tissue specimen analysis.Results: Specimens were obtained from 59 radical and 41 partial nephrectomies. Malignant neoplasms were present in 85 patients (85%). Overall accuracy was 77% and 72%, the nondiagnostic rate was 20% and 21%, sensitivity was 81% and 83%, and specificity was 60% and 33%. ...

Dissolution of Cholesterol Gallbladder Stones by Methyl Tert-Butyl Ether Administered by Percutaneous Transhepatic Catheter

We treated 75 patients with symptomatic cholesterol gallstones by dissolving the stones with methyl tert-butyl ether (MTBE) instilled into the gallbladder through a percutaneous transhepatic catheter. The MTBE was continuously infused and aspirated manually four to six times a minute, for an average of five hours per day for one to three days; the treatment was monitored by fluoroscopy. The placement of the catheter and the administration of MTBE caused few side effects or complications, and treatment did not have to be stopped in any patient for this reason. In 72 patients there was complete dissolution of stones or more than 95 percent dissolution. Among 21 patients who were completely free of stones after treatment, 4 had recurrence of stone formation 6 to 16 months later. The other 51 patients had residual debris, which spontaneously cleared completely in 15 patients within 6 to 35 months; only 7 with persisting debris have had symptoms. Five of the initial 6 patients treated, but only 1 of the next 69 patients, have required surgery during follow-up periods of 6 to 42 months. We conclude that the dissolution of gallstones by MTBE delivered through a percutaneous transhepatic catheter is a useful alternative to surgery in selected patients with symptomatic cholesterol stones. Further study will be necessary to establish the long-term effectiveness of this treatment and its appropriate role in the management of the various types of gallstones.

Renal Cell Carcinoma Metastatic to the Pancreas: Clinical and Radiological Features

OBJECTIVE To review the clinical features, computed tomographic (CT) appearance, and treatment outcomes in a case series of patients with renal cell carcinoma (RCC) metastatic to the pancreas. PATIENTS AND METHODS We retrospectively reviewed the records of 23 patients (15 men and 8 women) with RCC metastatic to the pancreas, detected by CT examination between 1986 and 1996. All patients had undergone a previous nephrectomy for RCC. RESULTS Isolated mild elevation in liver function test results (in 5 patients) or in serum amylase level (in 8 patients) was observed. New-onset diabetes was detected in 3 patients. The CT characteristics of the pancreatic metastases generally resembled those of primary RCC with well-defined margins and greater enhancement than normal pancreas with a central area of low attenuation. The mean interval between resection of the primary RCC and detection of the pancreatic metastases was 116 months (range, 1-295 months). In 18 patients (78%), the pancreatic metastases were diagnosed more than 5 years after nephrectomy. The pancreas was the initial metastatic site in 12 patients (52%). Survival was shortened with higher tumor grade (mean survival time of 41 months and 10 months in patients with grade 2 and 3, respectively). Surgical resection was carried out in 11 patients (7 distal and 3 total pancreatectomies and 1 distal pancreatectomy followed 4 years later by total pancreatectomy), with 8 patients alive at a mean follow-up of 4 years, 6 of whom remained free of recurrence. Overall, 12 patients (52%) were alive at a mean of 42 months after diagnosis of metastatic disease. CONCLUSIONS The appearance of metastatic RCC lesions in the pancreas closely resembles the appearance of primary RCC on CT images. Pancreatic metastases from RCC are frequently detected many years after nephrectomy. Patient survival correlates with tumor grade. Histologic analysis of pancreatic masses in patients with a history of resected primary RCC is important since the prognosis for RCC metastatic to the pancreas is much better than that for primary pancreatic adenocarcinoma.

The Etiology and Treatment of Delayed Bleeding Following Percutaneous Lithotripsy

In 1,032 percutaneous stone manipulations the incidence of significant, documented or presumed vascular injuries was 0.9 per cent. Seven cases of pseudoaneurysm, arteriovenous fistula or vascular lacerations were found, all of which were diagnosed angiographically. The patients were treated successfully with transcatheter embolization techniques. Two additional patients experienced delayed bleeding, presumably from vascular injuries, which resolved spontaneously with conservative therapy. Arteriography should be performed in these patients with serious postoperative bleeding. Embolization of the peripheral vessel is preferable to flank exploration.

CT findings of walled-off pancreatic necrosis (WOPN): differentiation from pseudocyst and prediction of outcome after endoscopic therapy

Computed tomography (CT) findings that may differentiate walled-off pancreatic necrosis (WOPN) from pancreatic pseudocyst were investigated. CT examinations performed before endoscopic therapy of pancreatic fluid collection (PFC) in 73 patients (45 WOPN, 28 pseudocysts) were evaluated retrospectively by two radiologists. PFC was evaluated for size, extension to paracolic space, characteristics of wall and internal structure. The pancreas was evaluated for deformity or discontinuity, and pancreatic duct dilation. CT findings that were associated with WOPN or pseudocyst were identified. CT score (number of CT findings associated with WOPN minus number of findings associated with pseudocyst) was calculated for each PFC. PFC was categorized as WOPN or pseudocyst using a CT score threshold. Larger size, extension to paracolic space, irregular wall definition, presence of fat attenuation debris in PFC, pancreatic deformity or discontinuity (P < 0.05–0.0001) were findings associated with WOPN. Presence of pancreatic duct dilation was associated with pseudocyst. Using a CT score of 2 or higher as a threshold, CT differentiated WOPN from pseudocyst with an accuracy of 79.5–83.6%. Thus, CT can differentiate WOPN from pseudocysts.

Percutaneous renal calculus removal in an extracorporeal shock wave lithotripsy practice.

The introduction of extracorporeal shock wave lithotripsy and transurethral ureteroscopy have altered markedly the incidence of standard surgical and percutaneous stone removal procedures. To help define the present role of percutaneous procedures in our practice we evaluated our indications, results and the clinical course of 143 patients who were treated primarily with percutaneous methods during 1 year in which extracorporeal shock wave lithotripsy also was available. The complexity of these residual percutaneous cases necessitated repeat endoscopic or fluoroscopic stone removal procedures in 20 per cent and ancillary extracorporeal shock wave lithotripsy in 22 per cent, and led to a slightly higher complication rate than in our previous percutaneous series. Despite the effectiveness of extracorporeal shock wave lithotripsy, percutaneous methods still are necessary for comprehensive therapy of upper tract urolithiasis.

Long-Term Outcomes of Percutaneous Nephrolithotomy Compared to Shock Wave Lithotripsy and Conservative Management

PURPOSE Percutaneous nephrolithotomy is successful at achieving stone-free status but long-term safety data are lacking. We report our long-term experience with percutaneous nephrolithotomy and compare these results with other treatment modalities. MATERIALS AND METHODS We identified 87 patients treated with percutaneous nephrolithotomy from 1983 to 1984 who continue to receive care at our institution. Retrospective chart review was performed. Long-term results were compared to those of a group of 288 patients with stones treated nonsurgically (controls) and a group of 288 patients treated with shock wave lithotripsy followed for 19 years. RESULTS Average followup was 19.2 years (range 12.7 to 23.0). After percutaneous nephrolithotomy new onset renal insufficiency was noted in 9 patients (10.6%), hypertension in 29 (34.1%), diabetes mellitus in 20 (23.5%) and ureteropelvic junction obstruction in 3 (3.5%). Stone recurrence occurred in 32 patients (36.8%). Recurrent stone events were associated with residual fragments after percutaneous nephrolithotomy (p = 0.049). Compared to shock wave lithotripsy there were no significant differences in the development of renal insufficiency, hypertension or diabetes mellitus. Stone recurrence was more common following shock wave lithotripsy (53.5%) compared to percutaneous nephrolithotomy (p = 0.033). Compared to controls there were no significant differences in the development of renal insufficiency or hypertension. On univariate analysis percutaneous nephrolithotomy was associated with the development of diabetes mellitus (p <0.001) but this association did not persist in multivariate analysis. CONCLUSIONS At 19 years of followup stone recurrences were less frequent following percutaneous nephrolithotomy compared to shock wave lithotripsy. Recurrent stone events were associated with residual fragments after percutaneous nephrolithotomy. Percutaneous nephrolithotomy was not associated with the development of adverse medical conditions compared to shock wave lithotripsy or conservatively managed stone cases.

Long-term followup in patients with cystine urinary calculi treated by percutaneous ultrasonic lithotripsy

From February 1983 through 1986, 15 patients (17 renal units) with cystine urinary lithiasis were treated by percutaneous ultrasonic lithotripsy. Three patients were lost to followup. Of the 13 renal units in the remaining 12 patients 7 (54 per cent) had retained stone fragments and 6 (46 per cent) were free of stones. While on medical management 7 of the 13 renal units (54 per cent) had new stones, 5 (38 per cent) remained unchanged and in 1 (8 per cent) the retained stones dissolved. The rate for reoperations was 43 per cent for the group with retained stones (3 of 7) and 17 per cent for the group that was free of calculi after percutaneous ultrasonic lithotripsy (1 of 6). Our study suggests that the optimal treatment with percutaneous ultrasonic lithotripsy should result in a patient who is free of stones.

Percutaneous Nephrolithotomy Success in the Transplant Kidney

PURPOSE Treatment for symptomatic calculi in the transplanted kidney can be problematic. Percutaneous nephrolithotomy has routinely been used but concerns exist about potential injury to adjacent organs using a percutaneous access technique. We report our experience with percutaneous nephrolithotomy in the transplant kidney. MATERIALS AND METHODS A retrospective chart review from 1988 to the present was performed of all cases of a renal transplant and subsequent renal calculi treated with percutaneous nephrolithotomy. RESULTS We identified 13 patients with a renal transplant who underwent percutaneous nephrolithotomy. Presenting symptoms included renal failure in 46.1% of cases, hematuria in 23.1%, urinary tract infection/pyelonephritis in 23.1%, pain in 15.4%, fever in 7.7% and hydronephrosis in 7.7%. Average calculus size was 1.36 cm (range 0.2 to partial staghorn). A single access tract was used in 12 cases and 2 access tracts were used in 1. Ultrasonic lithotripsy was performed in 10 cases, basket extraction was performed in 3 and the 2 techniques were performed in 1. No intraoperative complications occurred. Nephrostogram 24 hours after the procedure demonstrated no residual fragments in 10 patients (76.9%). Repeat endoscopy was required in 3 patients to achieve subsequent stone-free status. Postoperative complications developed in 3 patients, including sepsis, gastrointestinal bleeding and herpes esophagitis, respectively. Mean followup was 5.3 years (range 0.6 to 9). The single stone recurrence was treated with shock wave lithotripsy. Mean creatinine was stable at 2.0 mg/dl (range 0.9 to 3.9) preoperatively to 1.7 mg/dl (range 0.9 to 2.6) at the last visit (p = 0.311). CONCLUSIONS Percutaneous nephrolithotomy is safe and effective in the transplanted kidney. Minimal postoperative complications were noted and stone-free status was achieved in all cases. At long-term followup there were few stone recurrences with stable graft function after the procedure.