Use of subcutaneous venous access ports to treat refractory ascites.

To assess the feasibility of peritoneal ports for management of patients with cirrhotic refractory ascites, 10 ports were placed in nine patients for frequent outpatient paracentesis. Retrospective review and telephone interviews were used to assess port performance. Kaplan-Meier analysis revealed a median duration of port patency of 255 days. In 1,557 port days, four access problems prompted further interventional evaluation. Three cases of bacterial peritonitis and one catheter obstruction developed. The use of subcutaneous venous access ports to allow control of ascites by nursing personnel is a promising alternative for management of patients with refractory ascites. Additional studies are needed to determine long-term effectiveness and safety.

Contemporary "urologic" intervention in the pancreaticobiliary tree.

OBJECTIVES: To evaluate the role of minimally invasive "urologic" interventional techniques for the treatment of pancreaticobiliary calculi in contemporary practice. METHODS: Fourteen patients with retained cystic duct (n = 2), hepatic duct (n = 5), common duct (n = 2), pancreatic duct (n = 4), or gallbladder (n = 1) calculi were treated with 19 procedures, including shock wave lithotripsy (n = 9) and percutaneous flexible endoscopy with electrohydraulic or holmium laser lithotripsy (n = 10). Previous attempts using standard gastroenterologic or radiologic interventions before the urologic referral had failed in all 14 patients. RESULTS: A successful result, defined by the resolution of stones and symptoms, was achieved in 12 patients (86%); 2 patients (14%) had residual calculi that ultimately required an open operative procedure. The hospital stay for each intervention was 0 to 2 nights, and no patients had any significant complications. CONCLUSIONS: Even in this age of advanced gastroenterologic technology, including laparoscopic cholecystectomy, endoscopic retrograde cholangiopancreatoscopy, and percutaneous transhepatic cholangiography, the urologist can play a significant role in the minimally invasive treatment of patients with complicated biliary disease such that the need for open operative "salvage" procedures will be further minimized.

Endopyelotomy outcome as a function of high versus dependent ureteral insertion.

OBJECTIVES: To determine whether a high versus a dependent ureteral insertion significantly affects the outcome of endopyelotomy for management of ureteropelvic junction (UPJ) obstruction. METHODS: Sixty patients with UPJ obstruction were treated with an endopyelotomy by way of either an antegrade percutaneous approach (n = 36) or a retrograde hot-wire balloon incision (n = 24). In these 60 patients, the ureteral insertion was high on the renal pelvis in 19 (32%), dependent in 25 (42%), and indeterminate in 16 (26%). Intravenous urography was performed 4 to 6 weeks after stent removal (8 to 12 weeks after endopyelotomy) and then at 6 to 12-month intervals. Success of the procedure was defined as resolution of symptoms and decrease in hydronephrosis compared with pre-endopyelotomy studies. RESULTS: With a follow-up range of 2 to 41 months (mean 10.3), the overall success rate was 80%. This rate was independent of whether the procedure was performed in an antegrade or retrograde fashion. A successful result was achieved in 15 (78.9%) of those with a high insertion, 19 (76%) of those with a dependent insertion, and 14 (87.5%) of those with an equivocal insertion; these differences were not statistically significant (P = 0.72). CONCLUSIONS: The type of ureteral insertion (ie, high versus dependent) had no significant impact on the outcome of endopyelotomy by way of either a percutaneous or retrograde approach. As such, these anatomic variations need not play a role in a decision-making algorithm for contemporary management of UPJ obstruction.

13-year experience with percutaneous management of upper tract transitional cell carcinoma.

PURPOSE: We determined the immediate and long-term results of percutaneous management of upper trace transitional cell carcinoma in regard to rates of tumor recurrence and preservation of renal function. MATERIALS AND METHODS: Since July 1985, 12 men and 5 women 50 to 86 years old (mean age 72.2) years old underwent percutaneous management of upper tract transitional cell carcinoma. Of the patients 12 (71%) had a solitary kidney and 1 was treated bilaterally. In 16 of the 18 treated renal units (89%) definitive percutaneous resection of the tumor was followed by 6 weekly percutaneous installations of bacillus Calmette-Guerin. RESULTS: Complete resection was accomplished in 17 of the 18 renal units. Of the 18 renal units 15 (83.3%) had documented stage pTa lesions and 14 (77.8%) had grade 1/3 or 2/3 disease. Followup for all patients ranged from 1.7 to 75.5 months (mean 20.5). At the latest followup 11 patients (64.7%) are alive with no evidence of disease, and 6 (35.3%) died, 3 of whom (17.6%) had metastatic transitional cell carcinoma. Of the 13 patients undergoing treatment to solitary kidneys or bilaterally followup ranged from 1.7 to 75.5 months (mean 23.6). Serum creatinine ranged from 1.1 to 3.5 mg./dl. (mean 1.6) before percutaneous tumor resection and from 1.1 to 2.2 mg./dl. (mean 1.6) at the latest followup. Only 1 of these 13 patients (7.7%) with a solitary kidney has required dialysis. Ipsilateral local recurrence developed in 6 of the 18 renal units (33%), and in 4 of these 6 patients (67%) the tumor was grade 2/3 or 3/3 at initial resection. These recurrences were treated endoscopically in 4 patients, 3 of whom are currently without evidence of disease, and with nephroureterectomy in 2. Of the 17 patients only 1 (5.9%) with high grade (3/3), invasive (pT2) primary tumor at initial resection died of locally persistent or recurrent disease. CONCLUSIONS: Percutaneous management of upper tract transitional cell carcinoma is technically feasible and applicable in a significant number of patients in whom nephron sparing management is otherwise warranted. In carefully selected patients the results are at least comparable to other forms of "conservative" management in terms of tumor control and preservation of renal function.

Acute upper extremity deep venous thrombosis: safety and effectiveness of superior vena caval filters.

PURPOSE: To evaluate the safety and effectiveness of percutaneous filter placement in the superior vena cava for prevention of pulmonary embolism (PE) due to acute upper extremity deep venous thrombosis (DVT) in patients with contraindications to or unsuccessful anticoagulation. MATERIALS AND METHODS: Forty-one patients with acute upper extremity DVT and contraindications to or unsuccessful anticoagulation underwent percutaneous placement of a superior vena caval filter for prevention of PE. Four types of filters were used. Follow-up chest radiographs were used to detect filter migration, dislodgment, and fracture. Placements of central venous and Swan-Ganz catheters after filter insertion were recorded. Patients were followed up clinically for evidence of superior vena cava syndrome and PE. Kaplan-Meier survival rates were determined. Follow-up was 1 day to 221 weeks. RESULTS: No complications such as filter migration, dislodgment, or fracture occurred (median follow-up, 12 weeks). No patients developed clinical evidence of PE due to upper extremity thrombosis or superior vena cava syndrome (median follow-up, 15 weeks). Catheters were placed subsequent to filter placement in 23 patients (56%) without complication. CONCLUSION: Percutaneous filter placement in the superior vena cava is a safe and effective method for preventing symptomatic PE due to acute upper extremity DVT in patients in whom therapeutic anticoagulation has failed or is contraindicated.

Prevention and management of hemorrhage associated with cautery wire balloon incision of ureteropelvic junction obstruction.

The functional significance of crossing lower pole vessels in patients with ureteropelvic junction obstruction is controversial. However, there is clear evidence that the incidence of such vessels in patients with ureteropelvic junction obstruction is significantly higher than in the general population. We report on a patient with secondary ureteropelvic junction obstruction treated with retrograde cautery wire balloon incision in whom significant hemorrhage developed as a result of disruption of a lower pole accessory artery crossing the ureteropelvic junction. Angiographic intervention with selective arterial embolization resulted in immediate, complete resolution with salvage of the kidney. Because the incidence of crossing vessels is relatively high in this patient population, steps should be taken to identify and possibly exclude affected patients before the use of blind incisional procedures.

Fifty years of surgery for portal hypertension at the Cleveland Clinic Foundation. Lessons and prospects.

OBJECTIVE: The 50-year experience with surgery for the treatment of portal hypertension and bleeding varices at the Cleveland Clinic is reviewed. SUMMARY BACKGROUND DATA: A variety of procedures have been used to treat bleeding varices during the past 50 years. These include transesophageal ligation of varices or devascularization of the esophagus and stomach with splenectomy; portal-systemic (total) shunts; distal splenorenal (selective) shunts; endoscopic sclerotherapy; transjugular intrahepatic portal-systemic shunts; and liver transplantation. METHODS: Our experience with these procedures is reviewed in four time periods: 1946 to 1964, 1965 to 1980, 1980 to 1990, and 1990 to 1994. RESULTS: Our use of these procedures has changed as experience and new techniques for managing portal hypertension have evolved. Most ligation--devascularization--splenectomy procedures were performed before 1980; they provide excellent results in patients with normal livers and extrahepatic portal venous obstruction, but a major complication (40-50%) is rebleeding. Total shunts were performed most frequently before 1980; with patient selection, operative mortality was reduced to 8%, control of bleeding was achieved in more than 90%, but the incidence of encephalopathy was high (30%). Selective shunts provide almost equal protection from rebleeding with less post-shunt encephalopathy. We currently use selective shunts for patients with good liver function. Liver transplantation has been used since the mid 1980s for patients with poor liver function and provides good results for this difficult group of patients. CONCLUSIONS: The selection of patients for these procedures is the key to the successful management of portal hypertension.

Clinical outcome and cost comparison of percutaneous embolization and surgical ligation of varicocele.

We reviewed the records of 81 consecutive subfertile men with oligospermia and/or asthenospermia, treated for varicocele with either percutaneous embolization or surgical ligation between 1987 and 1991, and compared the outcomes and costs of the two procedures. All men had presented with infertility of at least 6 months duration, and in most cases female factors had been previously evaluated and treated. Patients were offered a choice of embolization or ligation of the internal spermatic vein. Forty-five men (56%) underwent ligation, and 36 men (44%) opted for embolization. The mean age, serum follicle-stimulating hormone, pretreatment sperm density, motility, and concentration of motile sperm were similar for the two groups. Seminal quality improved in 65% of all patients after varicocele ablation (46 of 71). Improvements were seen in postoperative sperm density (P < 0.01), motility (P < 0.002), and concentration of motile sperm (P < 0.001). Thirty-nine percent of the assessable patients established pregnancies during the study interval (26 of 66). The two treatment groups did not differ significantly with regard to the likelihood of postoperative improvement in sperm density (P = 0.64), motility (P = 0.33), concentration of motile sperm (P = 0.11), or pregnancy rate (P = 0.83). Percutaneous embolization and surgical ligation of varicocele are equally effective in improving male infertility and cost about the same. Embolization offers the potential advantage of shorter recovery to full activity as compared to surgical ligation. Where experienced interventional radiologists are available, percutaneous embolization should be offered as an alternative to open ligation.

Thoracic aortic disease: evaluation using a single MRA volume series.

OBJECTIVE: Use of MRA for thoracic aortic disease (TAD) evaluation has been limited. This report describes an initial experience with TAD evaluation using a single MRA volume series. MATERIALS AND METHODS: A single volume series, based on sequential 2D TOF MRA, was acquired in 30 cases (28 with suspected TAD and 2 normals). Each series was processed using multiplanar reconstruction (MPR) and maximum intensity projection (MIP); resulting tomographic (one base and two MPR) and MIP sets were blindly interpreted by four reviewers to detect TAD and, if present, to diagnose its specific form. For cases incorrectly interpreted, the standard MR images were subsequently interpreted. RESULTS: The TAD categories included aneurysm (n = 13), dissection (n = 9), and arch anomalies (n = 5). Sensitivities were high for TAD overall (89-100%) and TAD in ascending and descending portions; sensitivities were lower for TAD of the arch (two of four reviewers > or = 90% for TAD overall and descending TAD). Specificities for TAD overall had a wider range (67-100%), but were high for ascending, arch, and descending portions (three to four of four reviewers > or = 90% for each). Sensitivities for aneurysms (69-92%) and dissections overall (67-100%) were comparable, as they were in ascending and arch portions; descending dissection was better detected than descending aneurysm (two of four reviewers > or = 90% for ascending or arch aneurysm and for descending dissection); overall specificities (88-100 vs. 81-95%) and specificities in ascending, arch, and descending portions were also comparable (three to four of four reviewers > or = 90% for both in each portion; two of four reviewers > or = 90% for dissection overall). Each reviewer achieved > or = 70% diagnostic accuracy for TAD (one of four reviewers = 85%); accuracies for each category were comparable. Interpretation of standard MR images corrected all detection and most diagnostic (> or = 63%) errors. CONCLUSION: This initial experience with conventional TOF MRA for TAD evaluation is encouraging, but it indicates the potential for advancements in data acquisition and/or postprocessing.

Combination therapy for staghorn calculi in solitary kidneys: functional results with long-term followup.

A total of 10 patients with staghorn calculi in a solitary kidney was managed with endourological sandwich therapy consisting of primary percutaneous debulking followed by extracorporeal shock wave lithotripsy (ESWL*) of residual inaccessible stones. Secondary percutaneous procedures, ESWL and chemical dissolution were used as necessary in a vigorous attempt to render each patient stone-free. As such, these 10 renal units underwent 21 percutaneous procedures through 13 tracts, 17 ESWL treatments and 3 courses of hemiacidrin. No patient required open operative intervention or dialytic support. With 4 to 57 months (mean 31.6) of followup, renal function for the group as a whole improved as evidenced by a decrease in mean serum creatinine levels from 3.1 mg./dl. before treatment to 2.2 mg./dl. at latest followup. More importantly, renal function has remained stable or improved in 9 of the 10 patients individually. We conclude that an aggressive, combined endourological approach to the management of staghorn calculi provides long-term preservation of function in the affected kidney.

Diagnosis and localization of laceration of the thoracic duct: usefulness of lymphangiography and CT.

The usefulness of lymphangiography and CT in the diagnosis and localization of laceration of the thoracic duct was evaluated in 12 patients with chylothorax or chylous ascites after surgery. Bipedal lymphangiography was performed in all 12 patients. The last four patients studied also had CT after lymphangiography. Seven patients had abnormal findings on lymphangiograms; five with leaks from the thoracic duct, one with a lymphocele in a nephrectomy bed, and one with obstructed intestinal lymphatic vessels after thoracotomy. Five patients had no evidence of lymphatic leakage. CT in one patient with evidence of a leak on lymphangiography showed extravasation of contrast medium into the mediastinum and pleural space. CT in three patients with no abnormalities on lymphangiography also showed no abnormalities. Four of the five thoracic duct lacerations and the lymphocele were confirmed surgically. The diagnosis of obstructed intestinal lymphatic vessels was supported clinically. Four of the five patients with normal findings on lymphangiograms had resolution of their pleural effusions and no evidence of recurrence during a follow-up period of 1-27 months. One patient with normal findings on lymphangiography had an alternative diagnosis established at surgery. Laceration of the thoracic duct was accurately diagnosed and localized with lymphangiography, which allowed definitive surgical repair. CT was of little additional value in diagnosing these injuries.

Role of percutaneous nephrostomy in patients with upper urinary tract transitional cell carcinoma.

Percutaneous nephrostomy has become a well-established procedure for a wide variety of urologic disorders. However, its role in the management of patients with upper urinary tract transitional cell carcinoma has not been defined. We utilized percutaneous nephrostomy in 23 renal units for the evaluation or treatment of 21 patients in whom standard techniques were inconclusive or inadequate. The percutaneous nephrostomy provided adequate relief of obstruction in the face of significant azotemia or infection. Diagnostic abilities were improved through the use of antegrade pyelography, selective cytologic examination, and, at times, by providing direct access for endoscopic visualization and biopsy. In select cases, the percutaneous access provided a route for definitive or adjunctive treatment of the lesion. Complications were few and seeding of the tract or local tumor spread has not occurred at follow-up ranging from one to one hundred twenty-one (mean 27.8) months.

Current management of varicoceles.

In spite of all that has been written about the varicocele, it is still not clear who will benefit from occlusion of the spermatic vein or why improvement in semen takes place in some patients but not in others. Because fertility is usually assessed in the framework of a couple who are trying to establish a pregnancy, it is important to evaluate both partners before making any recommendations regarding therapy. If the man is found to have a varicocele and semen analyses that indicate deficits in either the quantity or quality of the sperm, surgical ligation or transvenous occlusion should be considered as one appropriate form of therapy. Varicocele ligation and embolotherapy both can be performed as an outpatient procedure with minimal morbidity and equal effectiveness regarding pregnancy outcome. The cost, if the procedures are done in an outpatient facility, should be approximately equal. The obvious benefits of the percutaneous technique are a slightly lower recurrence rate and a more rapid return to full physical activity. The surgical procedure described by Marmar and associates appears to have a similar rate of recurrence and short postoperative period of recovery. Greater experience by more urologists using this technique needs to be gained to compare it adequately with the other methods described. Varicocele ligation by the inguinal or retroperitoneal routes is familiar to most urologists and does not require the operating microscope or other special instruments. With greater understanding of the venous anatomy and with careful dissection, the persistence and recurrence rate can be acceptably low and the postoperative recovery relatively rapid and smooth.

Radiologic methods of bile duct stone extraction.

Fluoroscopically guided extraction of retained common duct calculi through a T-tube tract has a high success rate, low complication rate, and negligible mortality rate. It is not unduly uncomfortable and can be performed on an outpatient basis. The only disadvantage is a wait of approximately 6 weeks after surgery to let the T-tube sinus tract mature. If no T tube is present, endoscopic sphincterotomy is usually the treatment of choice. In difficult cases, the radiologist may be able to assist the endoscopist by placing a wire across the sphincter through a percutaneous transhepatic route. If endoscopic sphincterotomy is not successful or feasible, an attempt at percutaneous stone removal can be made from a transhepatic approach. A variety of new devices and dissolution agents is becoming available for stone fragmentation or reduction.

Outpatient angiographic evaluation of living renal donors.

A total of 71 potential living kidney donors was evaluated on an outpatient basis with either a modification of standard catheter angiography (30 patients) or intra-arterial digital subtraction angiography (41 patients). Both procedures provided accurate assessment of the main renal vasculature as proved at the time of donor nephrectomy. Neither technique was associated with any significant morbidity. We conclude that complete angiographic evaluation of potential kidney donors can be performed accurately and safely on an outpatient basis.

Long-term efficacy of ureteral dilation for transplant ureteral stenosis.

Transluminal ureteral dilation was performed in 11 renal allograft recipients with transplant ureteral obstruction. Success was achieved in 5 patients (45 per cent) with a followup of 12 to 29 months (mean 19.6 months). All failures have been evident within 12 months of dilation. We conclude that ureteral dilation can provide long-term success in renal allograft recipients. However, continued close long-term monitoring of the anatomical and functional result is mandatory for patients treated in this manner.

Endourologic management of upper and mid ureteral calculi: percutaneous antegrade extraction vs transurethral ureteroscopy.

Fifty patients requiring intervention for upper or mid ureteral calculi were managed initially with a percutaneous antegrade approach (25 patients) or a transurethral ureteroscopic approach (25 patients). In both groups, a crossover to the other modality was at times utilized to accomplish stone removal. Success for either group was defined as complete stone removal without the need for open intervention.

Recurrent pulmonary embolism after Greenfield filter placement.

Three patients with documented recurrent pulmonary embolism with an inferior vena cava (IVC) Greenfield filter in place were examined with contrast-material-enhanced cavography. Mechanisms for recurrent pulmonary embolism were found to be propagation of thrombus through the filter struts, occlusion of the IVC at the level of the filter, and loss of contact of the filter hooks with a portion of the caval wall.