William H. Bush

Kidney Stone Removal: Percutaneous Versus Surgical Lithotomy

Percutaneous removal of most urinary tract calculi may be performed as a 1-stage effort with techniques and skills developed recently in the specialties of urology and radiology. Ultrasonic fragmentation of most calculi was done to permit their extraction. Percutaneous ultrasonic lithotripsy was performed on 250 consecutive (a single exception) patients bearing stones that required removal. Targeted calculi were removed successfully from 97 per cent of these patients. One patient required surgical lithotomy. The previous 100 patients with stones underwent surgical lithotomy with 96 per cent success. Complications of percutaneous ultrasonic lithotripsy appeared equitable with those of surgical lithotomy. Of the patients who underwent percutaneous ultrasonic lithotripsy 6 (6 per cent) required extended hospital days or additional procedures for management of complications. None of these patients required a surgical incision. Anesthesia times were similar for both groups--average 159 plus or minus 4 (standard error) minutes for percutaneous ultrasonic lithotripsy and 193 plus or minus 8 minutes for surgical lithotomy. Hospital recovery days averaged 5.5 plus or minus 0.3 for percutaneous ultrasonic lithotripsy and 8.4 plus or minus 0.5 for surgical lithotomy (p less than 0.01). Associated costs averaged

Celiac Plexus Block: A Roentgenographic, Anatomic Study of Technique and Spread of Solution in Patients and Corpses

7,203 plus or minus 55 for lithotripsy and

Endopyelotomy: Review of Results and Complications

8,849 plus or minus 660 for lithotomy (p less than 0.01). The number of narcotic administrations per patient (days 1 to 5 postoperatively) averaged 9.88 plus or minus 0.70 for lithotripsy and 16.82 plus or minus 0.78 for lithotomy (p less than 0.01). The average patient who underwent percutaneous ultrasonic lithotripsy felt capable of full activity 2.0 plus or minus 0.2 weeks following stone removal, whereas no patient who underwent previous surgical lithotomy recalls a recovery period of less than 3 weeks (p less than 0.01). We believe that most upper urinary tract calculi may be removed cost-effectively with a percutaneous approach. Compared to surgical lithotomy, percutaneous ultrasonic lithotripsy may result in rapid convalescence with diminished pain.

Endopyelotomy for primary repair of ureteropelvic junction obstruction.

Techniques for blocking the celiac plexus were evaluated by conventional posteroanterior and lateral x-rays and computed tomography (CT) in 20 patients with intractable pain due to carcinoma of the pancreas and by determining spread of injected dye at the time of autopsy in three corpses. The results showed that (a) the site for insertion of the needles should not be more than 7.5 cm lateral to the spinous process of a lumbar vertebra, (b) needles should be placed bilaterally, (c) the depth to which needles are inserted is greater than previously recommended, and (d) at least 25 ml of solution should be injected through each needle.

Mammographic parenchymal patterns as a risk indicator for prevalent and incident cancer

Percutaneous endopyelotomy augmented by balloon dilation was performed on 27 of 40 patients for the treatment of symptomatic, primary ureteropelvic junction obstruction. Percutaneous ultrasonic lithotripsy was performed simultaneously on 12 of 27 patients (44%) for associated calculi. After endopyelotomy 24 of 27 patients became asymptomatic (clinical success rate 89%). Three clinically improved patients demonstrated only radiographic stability, while radiographic improvement was documented in 21 of 27 (radiographic success rate 78%). Adjuvant percutaneous ultrasonic lithotripsy was successful from the standpoint of stone removal in all patients and no increased morbidity could be identified. Of 27 patients 3 (11%) suffered major complications and are considered failures. Reasons for failure varied and are discussed. Included is a patient who at nephrostography and stent capping became septic and subsequently died. To decrease the risk of sepsis perioperative antibiotics to include at the time of nephrostomy tube capping are recommended. Angiography was performed in 19 of 40 patients to rule out an accessory crossing vessel at the ureteropelvic junction, and such a vessel was found in 6. From analysis of presenting excretory urograms (IVPs) we conclude that a crossing vessel cannot predictably be identified on an IVP.

Radiation Exposure to Patient and Urologist During Percutaneous Nephrostolithotomy

A total of 12 patients underwent primary repair of ureteropelvic junction obstruction between November 1, 1985 and December 31, 1986. Ten patients underwent percutaneous incision of the ureteropelvic junction (endopyelotomy) as the initial effort to correct the obstruction. Two patients with ureteropelvic junction obstruction associated with an aberrant lower pole renal artery underwent dismembered pyeloplasty (Anderson-Hynes) via a flank incision. Of the 10 patients who underwent endopyelotomy 8 (80 per cent) have shown radiographic improvement. Radiographic stability of the obstructed ureteropelvic junction was demonstrated in the remaining 2 patients. No patient exhibited evidence of increased obstruction or decreased renal function. No patient required prolonged or rehospitalization for complications, and none required additional endoscopic or surgical procedures. All patients have remained clinically well after the initial release from the hospital.

Long-Term Radiographic-Pathologic Follow-Up of Patients Treated with Visceral Transcatheter Occlusion Using Isobutyl 2-Cyanoacrylate (Bucrylate)

Different mammographic parenchymal patterns have been found to be associated with significantly different rates for the development of breast cancer in a screening program of self‐referred women. These differences are qualitatively similar but of lesser magnitude than those in previous reports by Wolfe which were based on symptomatic women who had had a previous negative mammogram. In addition, this report indicates a small difference in the rate of breast cancer at first mammographic examination, using the same parenchymal classifications. These findings, coupled with other risk factors, may permit the concentration of mammographic screening on a smaller segment of the population at risk, thus improving the benefit to risk ratio.

Radiation Dose to Patient and Personnel During Extracorporeal Shock Wave Lithotripsy

Radiation exposure to the patient and urologist was determined during 60 procedures for percutaneous removal of calculi from the upper collecting system. For male patients the average radiation dose at the surface of the testis was 160 mrem (1.6 mSv.). Surface dose to the female patient at the ovary level averaged 580 mrem (5.8 mSv.). Radiation doses to the small field or region of fluoroscopy on the skin surface anterior to the kidney averaged 25 rem (0.25 Sv.). Radiation exposure to the urologist at collar level averaged 10 mrem (0.1 mSv.) per case. Patient gonad doses from percutaneous nephrostolithotomy are similar to those from a 7-view excretory urogram. Patient surface exposures at the nephrostomy are comparable to skin doses from standard angiographic procedures. The exposure to the urologist is similar to that from other interventional fluoroscopic procedures and is within acceptable limits. Appropriate use of radiological technology and shielding can keep radiation exposures during percutaneous nephrostolithotomy within acceptable limits for patients and physicians.

Results of renal artery balloon angioplasty limit its indications

Visceral transcatheter occlusive therapy was performed with isobutyl 2-cyanoacrylate (Bucrylate) in 14 patients. Of 10 patients who subsequently died, postmortem examination in 6, performed 2--196 days post-embolization, showed only a mild histiocytic foreign body giant cell reaction to Bucrylate. The reaction was confined to the vessel lumina and did not involve the vessel walls or contiguous parenchymal tissues. Clinical and radiographic follow-up in the other 4 patients (range = 30--180 days) showed no evidence of untoward reaction to Bucrylate. No ischemic or inflammatory complications were observed in any of the peripheral organs.

Ultrasonic lithotripsy of a large staghorn calculus

Radiation dose to the patient and personnel was determined during extracorporeal shock wave lithotripsy treatment of 60 patients. Surface radiation dose to the patients back from the fluoroscopy unit on the side with the kidney stone averaged 10 rem (100 mSv.) per case, although the range was wide (1 to 30 rem). The surface dose from the opposing biplane x-ray unit was less, averaging 5.5 rem (55 mSv.) per case but again with a wide range (0.1 to 21 rem). Exit dose at the lower abdomen averaged 13 mrem. (0.13 mSv.) per case and estimated female gonad dose averaged 100 mrem. (1.2 mSv.). Radiation dose to personnel working in the extracorporeal shock wave lithotripsy suite averaged less than 2 mrem. (0.02 mSv.) per case, making it a procedure that is safe in regard to radiation exposure.