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Stone basketry
EDITORIAL
STONE
Dr. Lamensdorf, Dr. Compere, and Dr. Begley are to be congratulated for their forceful approach to the annoying problem of ureteral calculi (“Forceful Endoscopic Extraction of Ureteral Calculi,” page 301). However, while I share their enthusiasm, our techniques and indications differ somewhat. One might permit the patient longer than a twenty-four-hour period of observation in the hope the calculus will be passed spontaneously. One reason for the delay, in addition to the fact that at least 95 per cent of stones less than 0.5 cm. will pass spontaneously if given time, is the possible occurrence of other more important pathologic disorders. We have just discharged from the hospital a thirty-two year-old man who was referred to us because of pain in the left flank radiating from the costovertebral angle to the left lower quadrant of the abdomen and in whom a small 2 by 4-mm. opacity had been demonstrated in a routine excretory urogram performed by the referring physician. There was little or no obstruction. The urine showed occasional red and white blood cells. The patient had a low-grade fever. His pain was out of proportion to the findings on the urograms. Although he had a low-grade fever and his blood spectrum was not remarkable, he appeared to be more anxious and toxic than reflected in the laboratory data. Because of the high level of pain in the costovertebral angle and during the course of routine studies, twenty-four hours after his
UROLOGY
/ APRIL
1973
/ VOLUME
I, NUMBER
4
BASKETRY
admission to the hospital, x-ray examination of the chest revealed bilateral atelectasis. This study suggested the possibility of pulmonary emboli, and, indeed, within thirty-six to fortyeight hours, a second shower of emboli occurred resulting in clipping of the vena cava by a vascular surgeon. In addition to a longer observation period, we find the use of a basket which has four rather than three wires gives us a higher success rate. With the four wires enclosed in the synthetic sheath, the basket can be adjusted to various sizes and is not fixed as is the Johnson basket, which we formerly used. The most important contribution made, as a suggestion by a colleague some twenty years ago, was the use of a 6-inch rather than the 2inch filiform tip. Our experience has been that the 2-inch tip may be withdrawn distal to the calculus and passage beyond the calculus at subsequent effort met with failure. In view of this we have routinely used the 6-inch filiform tip thereby permitting several passages of the basket without withdrawing the tip distal to the calculus. Also in cases of difficult extraction where the ureteral catheter is left, it is always possible to pass the catheter; whereas after extracting a stone a catheter often cannot be passed. It has been our policy not to leave indwelling ureteral catheters after successful extraction of the calculus, regardless of the difficulty in extraction. Peter L. Scardino,
M.D.
379
STONE
Dr. Lamensdorf, Dr. Compere, and Dr. Begley are to be congratulated for their forceful approach to the annoying problem of ureteral calculi (“Forceful Endoscopic Extraction of Ureteral Calculi,” page 301). However, while I share their enthusiasm, our techniques and indications differ somewhat. One might permit the patient longer than a twenty-four-hour period of observation in the hope the calculus will be passed spontaneously. One reason for the delay, in addition to the fact that at least 95 per cent of stones less than 0.5 cm. will pass spontaneously if given time, is the possible occurrence of other more important pathologic disorders. We have just discharged from the hospital a thirty-two year-old man who was referred to us because of pain in the left flank radiating from the costovertebral angle to the left lower quadrant of the abdomen and in whom a small 2 by 4-mm. opacity had been demonstrated in a routine excretory urogram performed by the referring physician. There was little or no obstruction. The urine showed occasional red and white blood cells. The patient had a low-grade fever. His pain was out of proportion to the findings on the urograms. Although he had a low-grade fever and his blood spectrum was not remarkable, he appeared to be more anxious and toxic than reflected in the laboratory data. Because of the high level of pain in the costovertebral angle and during the course of routine studies, twenty-four hours after his
UROLOGY
/ APRIL
1973
/ VOLUME
I, NUMBER
4
BASKETRY
admission to the hospital, x-ray examination of the chest revealed bilateral atelectasis. This study suggested the possibility of pulmonary emboli, and, indeed, within thirty-six to fortyeight hours, a second shower of emboli occurred resulting in clipping of the vena cava by a vascular surgeon. In addition to a longer observation period, we find the use of a basket which has four rather than three wires gives us a higher success rate. With the four wires enclosed in the synthetic sheath, the basket can be adjusted to various sizes and is not fixed as is the Johnson basket, which we formerly used. The most important contribution made, as a suggestion by a colleague some twenty years ago, was the use of a 6-inch rather than the 2inch filiform tip. Our experience has been that the 2-inch tip may be withdrawn distal to the calculus and passage beyond the calculus at subsequent effort met with failure. In view of this we have routinely used the 6-inch filiform tip thereby permitting several passages of the basket without withdrawing the tip distal to the calculus. Also in cases of difficult extraction where the ureteral catheter is left, it is always possible to pass the catheter; whereas after extracting a stone a catheter often cannot be passed. It has been our policy not to leave indwelling ureteral catheters after successful extraction of the calculus, regardless of the difficulty in extraction. Peter L. Scardino,
M.D.
379