Eugene L. St. Louis

Nonoperative urinary diversion for malignant ureteral obstruction.

The management of malignant ureteral obstruction (MUO) has undergone major changes due to the availability of percutaneous drainage techniques and new ureteral stents for endoscopic insertion. These procedures are less morbid than conventional surgical techniques so that the indications for urinary diversion due to untreated or relapsing malignancy have to be reconsidered. During the period of technological change from 1978 to 1984, 135 patients with unilateral (37) or bilateral (98) MUO were managed. Open nephrostomy is now almost never necessary. Initial retrograde ureteral stenting (RS) was successful under local anaesthesia in 41% of patients. Forty‐seven had percutaneous nephrostomy (PN), nine of whom underwent antegrade ureteral stenting (AS) and elimination of external appliances. Twenty‐nine patients underwent miscellaneous open procedures mostly in the earlier years, with a 57% morbidity rate compared to the minimal morbidity associated with the newer techniques. The overall mean survival post diversion was 9.9 months, which is significantly longer than that reported using open procedures. MUO can now be successfully relieved with little morbidity and frequently without the use of external urine collection devices. The relative ease of diversion can complicate decision making in patients with progressive renal failure due to bilateral MUO.

Potential for inter-observer and intra-observer variability in x-ray review to establish stone-free rates after lithotripsy.

The potential for variability among observers interpreting diagnostic tests is well known but has not been well established for radiological imaging of urolithiasis. We measured the inter-observer and intra-observer variability in the reporting of plain abdominal films and tomograms from patients who had undergone extracorporeal shock wave lithotripsy (ESWL). Unlabeled copies of the plain abdominal films and tomograms for 58 patients were individually submitted to 3 different radiologists. Selected films from 25 patients were resubmitted to the same radiologists. We found differences among radiologists reporting plain abdominal films alone 52% of the time and even by the same radiologist rereading the films 24% of the time. Tomograms alone decreased the uncertainty but differences still occurred among radiologists 24% of the time and with themselves 16% of the time. When plain abdominal films and tomograms were read together there were differences among radiologists 28% of the time and with themselves 7% of the time but these were usually minor. We concluded from this study that the plain abdominal film alone was frequently difficult to interpret, resulting in uncertainty about the presence or absence of residual stone fragments. Tomograms alone or a plain abdominal film plus tomograms is superior to a plain abdominal film alone. Finally, radiological assessment with all modalities probably overestimates stone-free rates after ESWL even without consideration of the potential for reporting variability among observers.

Percutaneous gastrostomy and gastro-jejunostomy

Percutaneous gastrostomy and gastro-jejunostomy are new techniques which may be used instead of surgical or endoscopic gastrostomy to feed patients with an intact small bowel. We have successfully performed 72 gastrostomies on 67 patients who had had unsuccessful procedures and required surgery. Two patients developed peritonitis when their catheter dislodged into the peritoneal space.

Computed tomographic diagnosis of pulmonary sequestration

Two cases of pulmonary sequestration demonstrated by CT scans of the chest are described. In one, CT demonstrated the anomalous artery. This finding may obviate the need for angiography when surgery is not contemplated.

The effect of femoral arteriography on the incidence of groin contamination and postoperative infections

A prospective study is presented on the effects of preoperative femoral arteriography on bacterial contamination and postoperative wound complications from groin incisions. Forty-four femoral reconstructive procedures (88 groin incisions) for aortoiliac disease were performed. Positive cultures occurred in 43.2% of patients and in 30.7% of the 88 incisions. There was no correlation found between the site of arteriography and positive cultures (Spearman correlation coefficient, p > .10). No correlation was found between the presence of hematoma due to arteriography and subsequent positive groin culture (Spearman correlation coefficient, p > .10). A higher incidence of positive cultures did occur for patients who had a difficult arteriographic procedure (Fishers exact test, p=.020) or whose reconstructive procedure was greater than four hours (Fischers exact test, p=.047). Seven patients had postoperative groin wound complications (15.9%), including three lymph leaks (6.8%) and four confirmed or suspected infections (9%). There were no graft infections. No correlation was found between the site of arteriography and the site of wound complication (Spearman correlation coefficient, p > .10). Neither positive culture results nor difficult arteriography nor presence of hematoma were accurate predictors of postoperative wound complications. We conclude that transfemoral arteriography does not increase the risk of complications of arterial reconstruction involving a femoral anastomosis.

Percutaneous transluminal angioplasty without anticoagulation

This paper presents the results of a retrospective study of 110 percutaneous transluminal angioplasties done over a period of two years on 110 consecutive patients. Anticoagulation or antiplatelet drugs were not used during or after percutaneous transluminal angioplasty. Life-table analysis was used to calculate success rates at one and three months following the procedure. Success rates were determined using three criteria: clinical improvement, pre- and post-percutaneous transluminal angioplasty Doppler studies, and radiographic appearance. Claudication was present in 87 (79%) patients and severe ischemia in 23 (21%) patients. Sixty-eight (62%) PCTAs were done in the iliac arteries, 35 (32%) in the femoral arteries, and 7 (6%) in the popliteal artery. The majority of patients (61%) had 50%-75% arterial stenosis and only 18% had complete occlusion. Percutaneous transluminal angioplasty in the iliac arteries had the best results with cumulative success rates of 90% and 85% at one and three months, respectively. Success rates in the femoral arteries were 83% and 79% and in the popliteal artery 71% and 57% at one and three months, respectively. None of our patients required amputation. Ten patients (9.1%) suffered the following complications within 30 days of percutaneous transluminal angioplasty: death (2), thrombosis (2), perforation (3), minor hematoma (2), and false aneurysm (1). In conclusion, we have shown that percutaneous transluminal angioplasty can be performed safely and effectively without the use of anticoagulation and its associated risks.

Aneurysm of the dilatation balloon catheter: An unusual complication of percutaneous nephrolithotomy

We present herein a previously unreported complication of an aneurysm developing in a balloon dilatation catheter used to dilate a track prior to percutaneous nephrolithotomy. Direct needle puncture of the balloon was required for removal of the catheter.

Diuretic ultrasound: Technique for assessment of obstructed renal unit

We herein describe a new technique for the assessment of the clinically significant obstructed renal unit. The diuretic ultrasound utilizes the noninvasive, high resolution ultrasound unit in combination with diuresis induction with furosemide to assess renal collecting system obstruction.

Simplified technique of internal pudendal angiography in the investigation of impotence.

The authors describe a simplified method for evaluating the arterial status of the penis in patients with impotence. Internal pudendal angiography employing the “flour-bag” technique will likely become a routine procedure for angiographers.

Intravenous Digital Subtraction Arteriography in the Evaluation of Vascular Grafts

Between 1982 and 1986 intravenous digital subtraction arteriography was used to evaluate vascular grafts in 97 patients (54 males, 43 females). Indications included recurrent symptoms, absent or diminished pulses, a drop in Doppler pressure measurements, and clinical uncertainty with respect to graft patency. Problems identified included graft stenosis, stenosis of the anastomosis or its distal vessels, false aneurysm, arteriovenous fistula and emboli. Forty-eight operations were carried out following intravenous digital subtraction arteriography, and radiographic findings were verified surgically. Twice, intravenous digital subtraction arteriography did not show significant graft findings which were discovered at surgery. Thus intravenous digital subtraction arteriography showed a sensitivity of 95.8% and specificity of 100%. Complications following intravenous digital subtraction arteriography were: two patients developed urticaria, and one superficial thrombophlebitis. There were no cases of pulmonary edema or death. In conclusion intravenous digital subtraction arteriography is very useful in the diagnosis of graft-related problems if done on a selective basis looking at graft and anastomosis site only, intravenous digital subtraction arteriography is done on an outpatient basis, has high sensitivity and specificity, good patient acceptance, is safe, fast and is less expensive than conventional arteriography.