Image Intensification Fluoroscopy

Vol. 116, September

THE JOURNAL OF UROLOGY

Copyright © 1976 by The Williams & Wilkins Co.

Printed in U.S.A.

IMAGE INTENSIFICATION FLUOROSCOPY LLOYD H. HARRISON

AND

WILLIAM H. BOYCE

From the Section of Urology, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina

Urologic fluoroscopy in relation to recent innovations in urologic instrumentation and methodology (optics-fiberoptics) evokes the term archaic. 1 This may be a well deserved connotation in view of the lack of progress in improvement and subsequent use of this technique by the operating room personnel and surgeons during the years following its initial introduction. This lack of interest was compounded by 1) poor radiographic equipment, 2) excessive radiation exposure to patients and personnel, 3) outmoded or cumbersome fluoro., scopic equipment, mobile units with small field of visualizati,on and 4) poor quality films as the end result. Within the last 15 to 20 years radiological equipment has improved radically but intensification fluoroscopy has been used with increasing efficacy only within the last several years. 2 Permanently installed units have proved capable of providing superior fluoroscopic films of good quality and versatility and, when required, the conventional films also. The installation of this unit in the operating room cystoscopic suites has brought about many improvements in on-the-spot filming of procedures, thereby improving the many surgical Accepted for publication February 6, 1976.

Fm. 1. View of table permanently installed in operating room

techniques described herein. Image intensification fluoroscopy is now being used extensively in our own cystoscopic suites with the resulting films equal to or superior to the studies obtained in the radiological unit (figs. 1 and 2). SURGICAL PROCEDURES

Stone manipulation. Observation of the actual motion of manipulation of a ureteral stone basket is invaluable to the urologic surgeon. The movement of the stone is easily discernible, allowing the surgeon to determine if the calculus is actually lodged within the basket or merely sliding in the ureter. Difficulties or complications are immediately observed with prompt reparation of the situation if necessary. This visualization conceivably decreases the length of surgical time involved and benefits the patient not only in terms of anesthesia time and trauma but also operating room expense. Ureterocelectomy. Cystoscopic scissors are used in this 'procedure in which unroofing of ureteroceles is done easily with the aid of image intensification. We have used electrodes with good results but the scissors are better suited for our personal needs. Relief of the obstruction can be seen and evacuation of

Fm. 2. Image intensification unit demonstrates mobility of table 348

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IMAGE INTENSIFICATION FLUOROSCOPY

the contrast material can be determined after completion of the operation. Lithotaµaxy. In our opinion, the Bigelow lithotrite is the instrument of choice for this procedure and is mechanically superior to various other instruments of this nature. The lithotrite is visualized in the bladder and opened in the depressed base of the bladder, creating a funnel and causing the stone to roll between its blades for crushing. With use of the image intensification unit the stone is quickly engaged, the instrument is rotated anteriorly and the stone is crushed. Suprapubic cystotomy. Image intensification fluoroscopy has relegated the insertion of a suprapubic trocar almost to the ranks of routine. The instruments required are minimal. The bladder may be filled with contrast material either by renal excretion of an intravenously administered agent or by retrograde insertion. The entire procedure is done under local anesthesia. Proper positioning of the dome of the bladder is ascertained easily, followed by insertion of the suprapubic tube with trocar. PHYSIOLOGICAL STUDIES

Fluoroscopy has been used extensively in the radiological unit for evaluation of vesicoureteral reflux and urinary incontinence. With the advent of image intensification the urologist was able to perform a voiding cystourethrogram under sterile conditions and conclude his planned diagnostic or surgical procedure. Needless to say, retrograde pyeloureterograms and excretory urography have been enhanced through visualization of ureteral peristalsis for atony or obstruction.

DIAGNOSTIC PROCEDURES

The diagnostic procedures performed routinely in conjunction with image intensification include studies for vesicoureteral reflux, urethral diverticula, prostatic biopsy, renal biopsies, renal pelvic brush biopsy, renal cyst aspiration, placement of ureteral catheters and perirenal carbon dioxide insufflation. Daily use of this technique ensures that the aforementioned ·procedures will continue to grow. COMPLICATIONS

To date we have not encountered any complications with the use of image intensification. However, if complications, such as ureteral or renal injury, develop during fluoroscopy it becomes obvious and immediate surgical correction can be done. RADIATION EXPOSURE

Careful evaluation of the actual radiation exposure of the patient, the surgeon and the operating room personnel has been carried out by the Health Physics and Radiologic Research Section of this institution. Intermittent checks of the equipment by this department guarantees continued safety and optimal efficiency of the image intensification unit. Documented study has revealed that 1 minute of fluoroscopy is equal to 1 conventional film. REFERENCES

1. Crowell, A. J. and Thompson, S. R.: Diagnosis of ureteral calculi and technic of removal without operation. J.A.M.A., 71: 440,

1918. 2. Berci, G. and Steckel, R.: Modern radiology in the operating room. Arch. Surg., 107: 577, 1973.