Robert P. Miller

Percutaneous Nephrolithotomy: Extraction of Renal and Ureteral Calculi from 100 Patients

A percutaneous nephrostomy tract was used as a conduit to the kidney and ureter for extraction of 149 calculi in 100 patients. A variety of grasping and fragmentation techniques under fluoroscopic and endoscopic control were used to extract calculi in 88 per cent of the patients. With experience, operator efficiency and rate of stone extraction increased from 76 per cent early in the series to 91 per cent in the most recent patients, and the incidence of complications decreased from 17 to 5 per cent. Percutaneous removal of upper tract urinary calculi appears to be an appropriate alternative to an open operation in most patients with symptomatic urolithiasis.

Percutaneous removal of renal and ureteral calculi: experience with 400 cases.

Percutaneous removal of renal and ureteral calculi was performed in 500 patients since 1979. Experience with our first 100 cases enabled us to accumulate a variety of techniques. We report our experience with the subsequent 400 cases. As judged by plain films of the kidneys, ureters and bladder, and renal tomograms without contrast medium we attained a status free of stones in 99 per cent of the patients with renal and 94.5 per cent with ureteral calculi. Intravenous-assisted local anesthesia was used in 94 per cent of the cases. There was no mortality and the incidence of complications was low. Most patients with renal and ureteral calculi can be managed successfully and safely by percutaneous methods with good patient tolerance and minimal convalescence.

Renal vascular complications associated with the percutaneous removal of renal calculi.

Significant immediate and delayed vascular complications occurred in 4 of 140 patients (3 per cent) undergoing percutaneous removal of renal and ureteral calculi. An understanding of renovascular anatomy, use of a safety guide wire and intraoperative availability of an angiographic balloon catheter may help to prevent and to treat bleeding problems.

Percutaneous Nephrostomy in the Management of Ureteral and Renal Calculi

A percutaneous nephrostomy tract can serve both to decompress the renal pelvis and as a route for dissolving renal stones and assisting in basket retrieval of ureteral stones. These techniques are especially valuable in patients who are poor operative risks.

Percutaneous removal of caliceal and other "inaccessible" stones: instruments and techniques.

Percutaneous removal of renal stones is becoming an established procedure, especially for stones lying free in the renal pelvis. However, some renal stones, particularly caliceal stones, are less accessible and require special techniques for removal. We discuss these techniques, which include 1) retrograde pyelography to facilitate a thorough understanding of caliceal anatomy and stone position in 3 dimensions, 2) approaches for accurate placement of a nephrostomy tract for straight-line access to the stone(s), 3) judicious use of percutaneous punctures above the 12th rib and secondary percutaneous tracts, and 4) skilled choice and use of a large variety of cutting, extracting and disintegrating instruments with endoscopic and/or fluoroscopic control. The flexible nephroscope is valuable especially to reach inaccessible areas, although its skilled use requires experience. Flexible endoscopy often is aided by pressure irrigation, an assistant and simultaneous fluoroscopic control.

Introduction of the Gibbons Ureteral Stent Facilitated by Antecedent Percutaneous Nephrostomy

Patients in whom retrograde catheterization of the ureters has failed can have the Gibbons catheter placed by a new technique that requires no regional or general anesthesia. This technique entails antecedent percutaneous nephrostomy and passage of an angiographic catheter down the ureter. The catheterizing apparatus is attached to the angiographic catheter and then pulled into position.

Pursuit of the renal mass: Is ultrasound enough?

The accuracy of ultrasonography in evaluating renal masses was assessed retrospectively in 260 renal lesions detected by intravenous urography in 242 patients. The ultrasonographic diagnosis was confirmed by cyst puncture, surgery, or autopsy. Of the lesions, 168 were benign cysts, and all were diagnosed correctly by ultrasonography. The remaining 92 lesions were renal carcinomas, and 90 were diagnosed correctly by ultrasonography. In retrospect, it was clear that the two missed cancers did not fulfill all the ultrasonographic criteria for a cyst. An algorithm is presented for the differential diagnosis of renal masses primarily by ultrasonography, and the arguments in favor of operative diagnosis of renal masses are rebutted. With the approach described, invasive studies such as cyst puncture and arteriography will be required for a definitive diagnosis in fewer than 10 percent of patients, and the morbidity and expense of the diagnostic approach will be minimized, with no decrease in accuracy.

Controlled ureteral meatotomy.

An endourologic technique for a safe and adequate ureteral meatotomy has been devised. The ureter is catheterized anterograde through a percutaneous nephrostomy and a controlled ureteral meatotomy is done with a modified ureteral catheter. A silicone splint is then placed. The technique is safer than other techniques because repeated, more proximal incisions can be made and because the splint and proximal urinary division will prevent extravasation.

Percutaneous U-Loop Nephrostomy

Single-tube nephrostomy drainage can be converted to U-loop drainage using percutaneous methods. Because only local anesthesia is required the technique can be used for patients who are poor operative risks.

Mycotic aneurysm of the renal artery: CT appearance

Mycotic aneurysms of the renal artery are rare with the diagnosis usually made by angiography (Clark et al, 1972; Kaufman & White, 1978). Computed tomographic diagnosis of abdominal mycotic aneurysms has been discussed (Pripstein et al, 1979), but to date the CT appearance of a renal artery mycotic aneurysm has not been reported. Mycotic aneurysms are uncommon and difficult to differentiate on CT from an aortic dissection with involvement of the renal artery. However, renal artery mycotic aneurysms should be considered, given the appropriate clinical circumstances. We report a case of a pathologically proven main renal artery mycotic aneurysm. A 66-year-old white man was admitted with right lower quadrant tenderness, fever, and leukocytosis. His urinalysis indicated three to five white blood cells per low power field and the rare occurrence of bacteria. He had a longstanding history of chronic urinary tract infections secondary to benign prostatic hypertrophy, and the urinalysis findings were considered h...