John L. Weinerth

Percutaneous lithotripsy in morbid obesity

Percutaneous lithotripsy is an established, safe, effective method for the management of renal calculi. Obesity long has been associated with increased surgical morbidity and may eliminate a patient from shock wave treatment. We compared 44 obese patients to 226 nonobese patients undergoing percutaneous stone management. Stone number, location and total stone burden were comparable in the obese and nonobese groups. There was no significant difference between the groups in hospital time, operative time, fragment rate, access success rate or morbidity. Percutaneous procedures offer successful alternatives with low morbidity for patients with renal calculous disease.

Ejaculatory duct obstruction: the case for aggressive diagnosis and treatment.

Ejaculatory duct obstruction is considered a rare cause of infertility. Based on the results of treatment in our 5 patients and a review of 14 additional well documented cases we were able to classify these patients prognostically. Whereas congenital and acquired noninfectious obstructions are amenable to a transurethral operation in as many as 57 to 67 per cent of the cases, all obstructions secondary to genital infections failed treatment.

Role of linear tomography in evaluation of patients with nephrolithiasis

One hundred twenty-four consecutive patients with suspected or known nephrolithiasis were referred for evaluation by linear tomography. Renal calculi were detected in 98 patients (79%). Linear tomography revealed more renal calculi than did preliminary KUB films in 46 patients (37%), although in only 10 cases (8%) was the tomogram positive if the KUB was negative. Exact quantification of the numbers and locations of renal stones is important in patients to be managed metabolically, and in those being evaluated in advance of or following percutaneous or extracorporeal lithotripsy.

Lessons learned in patients with large steinstrasse.

Experience with 19 patients (25 ureters) who suffered the complication of a large steinstrasse (a third or more of the ureteral length) has led to lessons regarding the management of this complication as well as to insights into patient presentation, metabolic consequences, and the efficiency of diagnostic and therapeutic modalities. Few symptoms were present in a large percentage of patients despite urinary obstruction, decreased renal function, infection and in several cases impending sepsis. Large stone burdens, bilateral treatment, inability to debulk stone burden before extracorporeal shock wave lithotripsy and unexpected fragment movement were definite predisposing factors in the development of this complication. Double pigtail stents and percutaneous nephrostomy alone did not always prevent or resolve the problem. Combined use of percutaneous nephrostomy and ureteroscopic ultrasonic or laser lithotripsy appears to be the most effective treatment modality in patients who fail brief observation. This approach can be combined under appropriate circumstances with a secondary extracorporeal shock wave lithotripsy or percutaneous nephrolithotripsy treatment in the staged management of complex upper urinary tract calculous disease.

Factors Affecting the Success Rate of Percutaneous Nephrolithotripsy and the Incidence of Retained Fragments

The medical records of the first 210 patients treated with percutaneous nephrolithotripsy at our university medical center were reviewed. The data were analyzed in an attempt to define those factors that affect the success rate and incidence of retained fragments of these procedures. We found that stone location and extent, and to some degree stone size are the major factors affecting the success rate and incidence of retained stones. Chemical composition of the calculus, history of renal surgery and energy source used for stone removal have lesser roles.

Minimal mortality of renal surgery.

Eight hundred fourteen renal operative procedures were reviewed to determine overall mortality and to identify patients at risk. The over-all mortality was 1.35%, but as high as 30% in patients with uremia and spesis. Carcinomatosis contributed to higher mortality in other groups. In the absence of these three factors renal surgery was associated with very low or no postoperative (thirty day) mortality.

Comparison of the Costs and Morbidity of Percutaneous and Open Flank Procedures

A series of 47 percutaneous procedures for renal calculi was matched by description of calculi and previous flank exploration to 47 open flank procedures for comparison of relative morbidity and cost-efficiency. A retrospective analysis of paired data demonstrated that patients undergoing percutaneous procedures experienced significantly decreased duration of anesthesia, number of transfusions, postoperative disability, and duration and cost of hospitalization. These findings support the cost-effectiveness of the percutaneous approach to removal of renal calculi.

Bladder leiomyoma: Advantages of sonography over computed tomography

The complementary use of sonography in the evaluation of a bladder-base leiomyoma is reported. Sonography, as compared to computed tomography, was able to document the solid nature of the tumor, its submucosal location, and determined the site of origin and exact relationship to adjacent organs by virtue of the ability to image in multiple planes. The sonographic appearance of a submucosal, solid lobulated bladder-base mass is suggestive of a leiomyoma.

Percutaneous dissolution of renal calculi using ultrasonic litholapaxy.

The surgical treatment of renal calculi has been markedly changed by percutaneous manipulation and ultrasonic dissolution. The low morbidity and decreased cost of this procedure make it an obvious choice over classic surgical operations. We report our experience with percutaneous ultrasonic stone dissolution in 23 patients.

Neonatal female urethral diverticulum

Urethral diverticula are uncommon, and congenital origin has been disputed. A well-documented case in a six-hour-old baby girl is presented to reinforce the concept of congenital origin in some instances. Surgical diagnosis and management are discussed.