Current trends in the management of urinary stones

The treatment of renal and ureteral stones has undergone rapid and major changes over the past ten years. Extracorporeal shockwave lithotripsy has become the most commonly used modality for the treatment of renal and upper ureteral stones. Lower ureteral stones are more commonly being approached by retrograde techniques. Percutaneous nephrolithotomy, medical therapy, and open surgical nephrolithotomy offer viable alternatives in given situations. Presented here is the current application of each of these techniques, both alone and in combination, for the treatment of urinary stones.

Percutaneous transhepatic biliary endoscopic procedures

Two cases are presented to demonstrate the acceptability of the percutaneous route for performing endoscopic procedures in the biliary tree. They involved debridement of an atypical villoglandular polyp and ultrasonic lithotripsy of intrahepatic stones. Both cases serve to introduce percutaneous biliary endoscopy as a viable alternative for diagnosis and therapy in selected cases.

Limited usefulness of carbon dioxide as a contrast agent for cholangiography

Carbon dioxide (CO2) was unsuccessfully used as a biliary contrast agent in 9 of 10 patients undergoing percutaneous transhepatic cholangiography prior to biliary drainage. The technique involved hand injection of 10-20 cc CO2 through the Chiba needle in an attempt to fill preferentially the anterior biliary radicals. Although CO2 remains a useful agent in many instances, particularly for percutaneous nephrostomy, its usefulness in the biliary tract is severely limited.

Balloon occlusion femoral angiography prior to in-situ saphenous vein bypass

The advent of the in situ saphenous vein bypass procedure for peripheral lower extremity ischemic disease has placed new demands on the angiographer. It is imperative that the small runoff arteries of the calf be seen beyond the level of the ankle to include evaluation of the patency of the plantar arch. Balloon occlusion femoral angiography (BOFA) has been used in 45 consecutive lower extremities in 40 patients referred for proposed in situ saphenous vein bypass; excellent visualization of the plantar arch on the first run was obtained in 40 of 45 extremities (88.9%). The patients included 35 (87.5%) insulin-dependent diabetics with severe proximal arterial disease. Initially, in situ candidates were studied using conventional "runoff" methods; it was rarely possible to visualize the upper trifurcation vessels let alone the plantar arch by this conventional method. The BOFA method was used to provide excellent visualization of the plantar arch and foot arteries. It permits use of smaller contrast medium volumes, provides all the arteriographic anatomy on one 51 inch long film, and is safe.

Percutaneously applied ureteral clips: treatment of vesicovaginal fistula

Percutaneous techniques to manage urinary fistulas have had limited success. To overcome this, self-closing metallic clips were developed to occlude the ureter. The clips are applied through a percutaneously placed 30-F Teflon sheath. A case is reported in which the clips and new technique were successfully used.

Improved vessel dilator for percutaneous catheterization

Three commercial vessel dilators and a dilator of an improved design were tested during percutaneous catheterization in 16 mongrel dogs to evaluate arterial damage produced with their use. The results indicate that, although all dilators often produce arterial damage, the improved design produced much less damage. In addition, lesions were less severe overall. The dilator has been safely and successfully used in patients for percutaneous vessel catheterization for the past 30 years at the authors' institution.

Safe splenoportography

The records of 37 patients who had undergone splenoportography, including one group of 12 who were studied before 1976 and a second group of 25 who were studied after 1977, were reviewed. The primary difference was that in the second group, the tract in the spleen was occluded with absorbable gelatin sponge (Gelfoam) plugs as the needle was withdrawn. In addition, there were minor changes in technique, such as changes in the needle puncture angle and entry site. When the new technique was used, there was a significant decrease in the complications traditionally associated with splenoportography. This procedure is safe and deserves to be considered the procedure of choice in patients in whom precise anatomic information is needed preoperatively that cannot be obtained with noninvasive procedures such as ultrasound or magnetic resonance imaging.

Misplacement of a vena cava filter in the retroperitoneum

An inferior vena cava filter was misplaced into the pericaval retroperitoneum. This was probably secondary to placement into and avulsion of the right spermatic vein. The filter delivery system was modified, and such misplacement should now be impossible.

Experience with the Amplatz retrievable vena caval filter. Work in progress

The Amplatz retrievable vena caval filter was designed in an attempt to decrease complications associated with the placement of Mobin-Uddin or Kimray-Greenfield filters. The design allows percutaneous retrieval, thus expanding application of the filter to situations requiring temporary prophylaxis against pulmonary embolism. Filters have been placed in 16 patients, nine (56%) for prophylactic purposes. All filters were easily inserted percutaneously. Complications occurred in three patients; these included complete thrombosis of the inferior vena cava below the filter, misplacement of one filter into the pericaval retroperitoneal tissue, and development of thrombus cranial to the filter. With the current introduction system, the possibility of filter misplacement has been essentially eliminated. No patient experienced symptoms suggestive of pulmonary embolism after filter insertion. One filter retrieval has been performed, with no complications.

New super-stiff guide wire

A super-stiff spring guide wire is described, which overcomes some of the drawbacks of the Lunderquist-Ring guide wire. The new wire couples maximum stiffness with a smooth, gradual transition to a floppy tip, thus decreasing the likelihood of breakage and organ perforation.

A new retention catheter

A new retention catheter made of a soft, biocompatible material is described. It has the advantages of the Cope- and Malecot-type systems without their inherent disadvantages. It is easily introduced into virtually any fluid collection and is optimal for smaller collections, such as a normal renal pelvis.

Movable core guide wire: evaluation of improved model

Six commercially available movable core guide wires were compared with each other and with a new design in glass models simulating tortuous vessels. The results demonstrate a wide variability in performance of the commercially available wires and the superiority of the new design.