Antegrade pyelography before pyeloplasty via dorsal lumbar incision.

PURPOSE: The need for contrast imaging of the ureter before routine pediatric pyeloplasty is controversial. We evaluated the use of antegrade pyelography for upper tract imaging before pyeloplasty via dorsal lumbar incision. MATERIALS AND METHODS: The records of all patients who underwent pyeloplasty from April 1994 through April 1998 at our institution were reviewed. The findings and outcome of patients with presumed ureteropelvic junction obstruction in whom antegrade pyelography was performed under the same anesthetic were assessed, and those in whom this procedure changed the planned operative approach were identified. RESULTS: Antegrade pyelography was performed without complication in 72 patients before planned pyeloplasty and 2 attempts were unsuccessful. In 10 cases (14%) plans for dorsal lumbar incision were abandoned based on findings of renal malrotation in 3, ureteral stricture in 2, ureterovesical junction obstruction in 2, unusually low or high position of the ureteropelvic junction in 1 each, and concurrent ureteropelvic and ureterovesical junction obstruction in 1. The study was misinterpreted in 1 case of renal malrotation and 1 case of horseshoe kidney, and the dorsal approach was used. In 1 of these cases conversion to an anterior approach was required. A nonobstructing ureterovesical junction was seen in 2 other patients who had ureteropelvic junction obstruction with mild ureteral dilatation on ultrasound. CONCLUSIONS: The dorsal lumbar incision may provide inadequate exposure in certain patients with upper tract obstruction. Antegrade pyelography is a simple, safe and useful technique to visualize the collecting system before planned pyeloplasty via dorsal lumbar incision, allowing the surgeon to choose a more suitable operative approach or procedure when warranted.

Chopart's fracture dislocation: a case report and review of the literature.

The prompt identification of peri-talar dislocation with immediate reduction and early range of motion will generally result in a good outcome. Higher energy injury with greater soft tissue compromise and associated fractures worsen the prognosis. Salvage procedure for post-traumatic degenerative changes require arthrodesis for relief of pain. The deformity is usually apparent on physical examination, but occasionally is masked by marked early swelling. A high index of suspicion should be maintained with high or low energy injury to the foot and ankle with normal ankle radiographs. This particular case is unusual in that the patient was able to function as a farmer even with the fracture dislocation. This again is probably explained by his mild peripheral neuropathy. This case, however, does demonstrate the difficulty in making the diagnosis.

High-dose-rate intraluminal brachytherapy in the treatment of endobronchial malignancy. Work in progress.

Remote afterloading high-dose-rate brachytherapy (RAHDRB) was used endobronchially for the management of malignant airway obstruction in 82 patients, 72 of whom had primary disease in the lung. Treatment was palliative (n = 58) or definitive (n = 24). The extent of airway compromise was determined at bronchoscopy and with symptoms of hemoptysis, dyspnea, or cough or with radiographic evidence of atelectasis. RAHDRB doses were 1,000-4,700 cGy in one to five fractions. External beam radiation was used in previously unirradiated patients. A substantial reduction ,N airway disease and an improvement in symptoms were seen in 82% of patients. Obstruction scores showed an overall 74% improvement. Complications occurred in only 10 patients (two of whom died). Median survival was short (palliative group, 5 months; definitive group, 12 months); however, symptoms remained palliated in 62 patients (76%) until death or the last follow-up examination. RAHDRB is effective and can be applied with equal success in all patients with malignant airway obstruction, even those whose disease has recurred after external beam irradiation.