Biomedical subjects
Publications and source records attributed to Carson Wong.
We present a 35-year-old woman with symptomatic urolithiasis in an intrathoracic kidney. Percutaneous nephrolithotomy was successfully performed after ureteroscopy failed because of the unusual length of the ureter associated with the kidney position. We report the first case of percutaneous nephrolithotomy of an intrathoracic kidney.
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Various hand-assisted and purely laparoscopic nephroureterectomy techniques have been described in the urologic literature. We describe a technique of hand-assisted laparoscopic nephroureterectomy with cystoscopic en bloc excision of the distal ureter and bladder cuff that duplicates open surgical excision of these structures and obviates bladder trocar placement and midprocedural patient repositioning. The patient is placed in a modified dorsal lithotomy position with the tumor side elevated 30 degrees. Allen stirrups are utilized to allow simultaneous access to the urethra. A transperitoneal hand-assisted laparoscopic nephrectomy is performed. The technique is modified in that the ureter is clipped prior to the kidney dissection to avoid distal migration of tumor cells during kidney manipulation. After the kidney is isolated, the intact ureter is liberated distal to the intramural hiatus. The remaining dissection is completed intravesically under cystoscopic guidance. While the surgeon's intra-abdominal hand places the ureter on tension, the cystoscopist transurethrally excises the bladder cuff and intramural ureter with a Collings knife. The complete surgical specimen is removed en bloc through the hand port. The bladder is not closed. A urethral catheter connected to straight drainage remains until the seventh postoperative day, when a cystogram is performed; if it is normal, the catheter is removed.
BACKGROUND AND PURPOSE: Percutaneous nephrolithotomy for staghorn calculi is reported to have a residual stone rate of 28%, while shockwave lithotripsy alone results in residual stones in approximately 50% of cases. Combination therapy, sandwich therapy, and multiple percutaneous accesses have also been advocated for staghorn stones. We believe these stones can often be removed with a staged procedure via a single upper-pole percutaneous access using flexible nephroscopy and the holmium:YAG laser. Our experience is reviewed. PATIENTS AND METHODS: The hospital records of patients having a cumulative stone burden > or =5 cm who underwent percutaneous nephrolithotripsy (PCNL) for a single complex staghorn calculus were reviewed. There were 15 male and 34 female patients having 45 complete and 7 partial staghorn calculi constituting a mean stone burden of 6.7 cm (range 5.0-10.0 cm). A calix was punctured that would provide access to the majority of the involved calices. Thirty-five renal units were approached through a single upper-pole percutaneous access, and four and six renal units were accessed through single middle or lower-pole calices, respectively. The remaining seven renal units were treated with multiple percutaneous accesses. RESULTS: In the renal units having only a single access, a mean of 1.6 (range 1-3) procedures were required to achieve stone-free status. The mean operating room time was 2.9 hours (range 2.0-3.5 hours). For the second PCNL, the mean operating room time was 63 minutes (range 30-90 minutes). Two patients (two renal units) had residual stones <1 cm in diameter. One refused additional surgery, and the other is awaiting further treatment. The mean estimated blood loss was 238 mL (range 50-800 mL), with only one procedure (2.2%) necessitating a blood transfusion. One (2.8%) hydrothorax developed among the 35 upper-pole puncture cases. Six patients had transient oral temperature readings >101 degrees F with negative blood cultures. Other early complications included single cases of leg cellulitis, atrial fibrillation, and noncardiac chest pain. There were no delayed surgical complications. Patients were discharged from the hospital a mean 2 days (range 1-10 days) after the first PCNL. CONCLUSION: Use of flexible nephroscopy with holmium:YAG laser lithotripsy and Nitinol basket stone extraction has allowed us to render staghorn-containing renal units stone free in a mean of 1.6 procedures. Of the 45 renal units treated through a single percutaneous access, 43 (95%) were rendered stone free. The holmium:YAG laser appears to be a safe lithotrite for the kidney, as no complications occurred from its use.
We describe a renal arteriovenous malformation in a patient with a 1-month history of flank pain. Imaging studies were interpreted as being consistent with renal-cell carcinoma. However, Doppler ultrasonography demonstrated turbulent blood flow, and selective renal angiography confirmed the diagnosis of an arteriovenous malformation. Embolization relieved the pain. This case calls attention to the need to consider arteriovenous malformations in the differential diagnosis of central homogenously enhancing renal lesions.