Hugh J. Williams

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.

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.

Analysis of failure after curative irradiation of extrahepatic bile duct carcinoma

Thirty-four patients with subtotally resected or unresectable carcinoma of the extrahepatic bile ducts received radiation therapy; a minimum of 45 Gy (external beam) to the tumor and regional lymph nodes ± 5-fluorouracil (5-FU). Seventeen patients received an external beam boost of 5 to 15 Gy to the tumor, and a specialized boost was used in the remaining 17 patients (iridium-192 transcatheter seeds in 10 and intraoperative radiation therapy [IORTJ with electrons in seven). The median time to death in all 34 patients was 12 months (range, 4 to 98 months). The only patients who survived longer than 18 months were those either with gross total or subtotal resection before external irradiation (2 of 6) or who received specialized boosts (192Ir, 3 of 10; IORT, 3 of 7). Local failure was documented in 9 of 17 patients who received external beam irradiation alone ± 5-FU, 3 of 10 patients who received an 192Ir boost, and 2 of 6 patients who received an IORT boost with curative intent.

Primary hyperoxaluria type III gene HOGA1 (Formerly DHDPSL) as a possible risk factor for idiopathic calcium oxalate urolithiasis

BACKGROUND AND OBJECTIVES Primary hyperoxaluria types I and II (PHI and PHII) are rare monogenic causes of hyperoxaluria and calcium oxalate urolithiasis. Recently, we described type III, due to mutations in HOGA1 (formerly DHDPSL), hypothesized to cause a gain of mitochondrial 4-hydroxy-2-oxoglutarate aldolase activity, resulting in excess oxalate. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS To further explore the pathophysiology of HOGA1, we screened additional non-PHI-PHII patients and performed reverse transcription PCR analysis. Postulating that HOGA1 may influence urine oxalate, we also screened 100 idiopathic calcium oxalate stone formers. RESULTS Of 28 unrelated hyperoxaluric patients with marked hyperoxaluria not due to PHI, PHII, or any identifiable secondary cause, we identified 10 (36%) with two HOGA1 mutations (four novel, including a nonsense variant). Reverse transcription PCR of the stop codon and two common mutations showed stable expression. From the new and our previously described PHIII cohort, 25 patients were identified for study. Urine oxalate was lower and urine calcium and uric acid were higher when compared with PHI and PHII. After 7.2 years median follow-up, mean eGFR was 116 ml/min per 1.73 m(2). HOGA1 heterozygosity was found in two patients with mild hyperoxaluria and in three of 100 idiopathic calcium oxalate stone formers. No HOGA1 variants were detected in 166 controls. CONCLUSIONS These findings, in the context of autosomal recessive inheritance for PHIII, support a loss-of-function mechanism for HOGA1, with potential for a dominant-negative effect. Detection of HOGA1 variants in idiopathic calcium oxalate urolithiasis also suggests HOGA1 may be a predisposing factor for this condition.

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.

Hemobilia Due to Hepatic Artery Pseudoaneurysm Thirteen Months After Laparoscopic Cholecystectomy

Although vascular complications following laparoscopic cholecystectomy are rare, hemobilia may occur within the first 4 weeks after surgery. We report a 57-year-old woman with hemobilia secondary to a pseudoaneurysm of the right hepatic artery presenting 13 months after laparoscopic cholecystectomy. To our knowledge, such late presentation has never before been reported.

Extracorporeal shock-wave lithotripsy and methyl tert-butyl ether for partially calcified gallstones

To explore the possibility that gallbladder stone fragments might be able to be safely dissolved using methyl tert-butyl ether immediately after extracorporeal shock-wave lithotripsy (ESWL), a feasibility study in 8 patients with one to four partially calcified gallbladder stones was performed. The gallstones averaged 2.2 cm in diameter (range 1.3-3 cm) and contained layered or diffuse calcium detectable by computed tomography scan only (7 patients) or plain film (1 patient). After a 5F (1.7 mm) pigtail catheter was placed percutaneously into the gallbladder, ESWL fragmentation was performed using a renal stone lithotriptor. The patients were under general anesthesia and in the prone position on a support gantry designed for gallbladder stone ESWL. Following ESWL, methyl tert-butyl ether was infused and aspirated via the gallbladder catheter until no further stone material was radiologically detectable or could be dissolved. After 8-26 h (mean = 13 h) of methyl tert-butyl ether therapy, no radiologically detectable gallstones remained in 6 of 8 patients. Shell fragments of three peripherally calcified stones in 1 patient and the densely calcified, predominantly pigment stone in a second patient were refractory to combined therapy. Both ESWL and treatment with methyl tert-butyl ether were well tolerated in all patients, although bile leakage after catheter removal occurred in 3 patients, one of whom was treated by cholecystectomy. Additional measures to prevent bile leakage may be advisable if these two modalities are to be used in tandem. We found no evidence, however, that predissolution stone fragmentation with ESWL predisposed the gallbladder to either mucosal damage by methyl tert-butyl ether or increased absorption of it.

Primary radiologic realignment of membranous urethral disruptions

A forty-two-year-old man with a traumatic, membranous urethral disruption underwent initial suprapubic catheter urinary diversion followed by a primary realignment twenty-one days after injury. Realignment was accomplished radiologically using an anterograde guide wire engaged by a retrograde stone basket and subsequent Foley catheter placement over the wire. The patient has remained totally continent, having partial erections, two years after injury, with no further intervention.

Fracture interpretation using electronic presentation: A comparison

The purposes of this study were to determine whether (1) fractures are interpreted differently after digitization and electronic presentation; (2) there are differences in accuracy between screen radiographs and electronic presentation; (3) differences in interpretation are a function of monitor resolution; and (4) differences in interpretation between radiographs and electronic images relate to radiological subspecialty. Forty cases with fractures of varying degrees of subtlety and 35 cases without fractures were interpreted. Radiographs were digitized with 2 different systems and displayed on 3 monitors of different spatial resolution. Four radiologists, with varying experience, were asked to decide whether fractures were present, absent, or they were uncertain. Accuracy of interpretation increased with improved electronic image presentation and monitor resolution. The sensitivity, specificity, and accuracy of fracture detection on System A were 63%, 98%, and 78%, respectively. The results were 72%, 98%, and 84% with System B. System C results were 81%, 97%, and 88% with Lumiscan 75, and 82%, 96%, and 88% with Lumiscan 150. Sensitivity, specificity, and accuracy results of the original radiograph interpretation were 89%, 95%, and 92%. Results were significantly different for System A. No significant differences were found for the other systems compared with film radiographs. System A did not have adequate monitors for interpretation of subtle fractures. Systems B and C were capable of displaying even subtle fractures. Our initial results indicate that interpretation with high-quality 1K×1K monitors is substantially similar to radiograph interpretation.

Dissolution of cholesterol gallstones using methyl tert-butyl ether

Symptomatic cholelithiasis affects a large segment of the population. Several nonoperative therapeutic alternatives for treatment of these gallstones have recently been developed. We present here the technical aspects and results of gallstone dissolution in 75 patients with the use of methyl tert-butyl ether (MTBE) administered via a small percutaneously placed cholecystostomy catheter. Successful stone dissolution was achieved in 69 patients. The average time required for stone dissolution was 12.4 h over an average of 2.4 days, with the success and rate of dissolution being very dependent on technique. Six patients have developed recurrent gallstones. Future efforts will focus on decreasing the labor intensity of the procedure, dealing with the noncholesterol components of gallstones, and preventing gallstone recurrence.