Biomedical subjects
Publications and source records attributed to J C Hulbert.
Renal calculi complicating transplanted kidneys are uncommon but they can be an important cause of deterioration in graft function. We report 2 complicated cases managed by percutaneous nephrostolithotomy.
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.
A new technique for the percutaneous extraction of ureteral calculi is described. A jet of CO2 is injected through a retrograde ureteral catheter to dislodge ureteral stones. This safe and simple technique has been successfully used in ten patients.
The authors achieved successful percutaneous extraction of urinary calculi via an intercostal approach in 24 patients. In one patient, a large hydrothorax developed and thoracentesis was required; 2 patients had moderate and 6 minimal pleural fluid collections which did not require treatment. No patient had pneumothorax. Intercostal puncture provides direct access to the upper and middle poles of the kidney when they lie above the twelfth rib and subcostal angulation is not feasible. Such an approach is advantageous for stones in the ureter, as well as renal stones which are inaccessible from the lower pole. Fluoroscopy should be performed when planning the puncture in order to avoid the lung, and a working sheath is recommended.
Twenty-five renal staghorn stones measuring at least 5 cm in diameter were removed percutaneously from 24 patients. Twelve patients required multiple access tracts for complete stone removal. Estimated blood loss more than 1000 ml occurred in 16 patients and temperature greater than 38.5 degrees C in 19 patients. All stones were successfully removed, with only two patients having definite residual fragments. Percutaneous nephrostolithotomy may be successfully applied to large staghorn stones. The relative roles of percutaneous therapy and extracorporeal lithotripsy remain to be determined.
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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.
Percutaneous removal of renal stones (percutaneous nephrolithotomy) 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, therefore, more difficult by the percutaneous route. We removed percutaneously 95 caliceal or otherwise poorly accessible renal stones from 53 patients with a variety of techniques, including percutaneous puncture above the 12th rib, double or Y percutaneous nephrostomy tracts, rigid and flexible endoscopy, and intrarenal cutting with diathermy. Intravenously assisted local anesthesia was used exclusively in 89 per cent of the patients. Status free of stones was achieved in all but 1 patient who retained 2 small fragments. The average number of sessions was 1.89 and the average hospital stay was 7.9 days. Complications were minor except for 1 patient who required tertiary renal artery embolization for bleeding. Illustrative cases are presented. Virtually all renal stones can be removed percutaneously.
Perineal liposarcoma is excessively rare. Its clinical and pathological behavior can only be predicted by comparison with the behavior of liposarcoma in other parts of the body. We describe the management of a man who presented with symptoms related to bladder outlet obstruction and was found to have a prostatic mass on digital examination of the rectum. A needle biopsy was performed and the tissue was histologically consistent with sarcoma of the prostate. Computerized tomography suggested that the mass extended through the urogenital diaphragm and was contiguous with the corpus spongiosum and corpora cavernosa of the penis. Complete surgical extirpation was achieved through a perineal approach, although local extension of the growth beneath the internal anal sphincter and the urogenital diaphragm necessitated reconstruction of these structures. The surgical margins were free of tumor. We advocate local surgical extirpation rather than pelvic exenteration in these cases.
On the basis of experience with over 350 percutaneous stone extractions, a logical approach assuring a high success rate and minimizing complications is described. The importance of the position of the kidney in the body, the caliceal anatomy, the renal arterial anatomy, and the instrumentation used on puncture site selection are discussed. Strategies for removal of caliceal, pelvic, ureteral, and staghorn calculi, rationale, and treatment of complications are also described.
The use of bleomycin as part of preoperative chemotherapy regimens for nonseminomatous germ cell tumors of the testis has gained increased acceptance. However, recent experience has suggested that patients so treated are at an increased risk of developing postoperative respiratory distress syndrome. The most clearly associated factor seems to be the fractional concentration of inspired oxygen intraoperatively and in the immediate postoperative period. Based on our experience and a review of the limited published reports, we recommend careful monitoring of fractional inspired oxygen and maintenance of the lowest tolerated oxygen concentration during this period.
Angiomyolipoma has been regarded as a benign renal neoplasm composed of adult fat cells, atypical blood vessels and smooth muscle. We report a case in which a renal angiomyolipoma showed clear evidence of involvement of the spleen and regional lymph nodes. The consensus in the literature suggests that this phenomenon is a manifestation of the multicentric nature of angiomyolipoma, rather than metastasis.
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Six patients have developed a lymphocoele after renal transplantation, an incidence of 4%. A lymphocoele should be suspected in a patient who develops a rising creatinine with a pelvic mass or pressure effects on the pelvic veins 1 or more months after operation. The diagnosis is confirmed by intravenous urography, venography and ultrasonography: the use of the latter as a diagnostic measure is recommended. Treatment is by marsupialisation into the peritoneum or external drainage with breakdown of all loculi. Aspiration is unsatisfactory.