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Intraoperative polaroid roentgenograms
INTRAOPERATIVE M. J. V SMITH,
M.D.,
POLAROID
ROENTGENOGRAMS
PH.D.
From the Medical College of Virginia, Richmond, Virginia
ABSTRACT-The introduction of a new Polaroid film (TPX) prompted an evaluation of all Polaroid films that are available, and a comparison with Kodak Xomat film was done both in the experimental mode and the clinical situation. Type TPX shows excellent definition but is still an experimental film. All the other Polaroid films (Types 52, 57, and TPX 10 x 8) produce images in twenty seconds. This is really the only advantage over the conventional Kodak X-Omat KS film processed as an x-ray film.
The ultimate goal of all surgery for renal stones is to leave the patient with a kidney free of calculi. This objective has been extraordinarily difficult to achieve. Sutherland’ and Singh, Marshall, and Blandy2 have shown that intraoperative roentgenograms are essential if one is to achieve this goal. Most surgeons have become disenchanted with the available techniques because they are time-consuming, and technical personnel often are not familiar with organ roentgenograms; also the machinery being used may vary. The end result is a frustrated surgeon with films that are sometimes uninterpretable. In 1980, Koshiba, Ishibashi, and Mashimo,3 from Japan, showed that it was possible to use a film pack of Polaroid Type 107 to produce excellent positive roentgenograms. Interestingly, about that same time Pahira and Pollack,4 in Philadelphia, were working with Polaroid Type 57 film. Several centers immediately incorporated this concept into their armamentarium. Roth and Griffith in 19805 pointed out that Polaroid Type 52 sheet film could be used as individual film (rather than 8 exposures in Type 107) and could be readily processed in a 545 Polaroid 4 x 5 Holder. In 1982, Koshiba and Yoshizawa6 modified their holder and used this cassette in a sterile container (surgical vinyl drape) to expose single films. Meanwhile, groups in Houston, Washington, Philadelphia, and Richmond were working with various sheet films and obtaining high quality studies.
UROLOGY
/ NOVEMBER 1987
/
In February, 1981, a new 8 x 10 Polaroid radiographic film known as TPX came to my attention. One year later the company furnished me with Type TPX that was 3l/2 x 4% and could be used much more easily in an operative situation. The purpose of this report is to evaluate our experimental and clinical experiences with the new Polaroid films and to compare them with currently available Kodak X-Omat KS film. Material and Methods Film types 1. Polaroid 4 x 5 Land Film Type 52/Pola Pan is a panchromatic fine-grain positive print film ASA 400 resolution 20-25 line pairs/mm. Processing time twenty seconds (21 “C) . * 2. Polaroid 4 x 5 Land Film Type 57/High Speed is a panchromatic medium-grain positive print film ASA 3000 resolution 18-22 lines/mm. Processing time fifteen seconds (21 “C). * This is essentially the same as Type 107. 3. Polacolor 2: 4 x 5 Land Film Type 58 ASA 75. Processing time sixty seconds (21 “C). * 4. Polaroid Transparent 4 x 5 sheet radiographic film (not available commercially) . Processing time sixty seconds (21 “C) * * *Films are processed in a Type 545 Polaroid Land Film Holder ($130.00 cost).
VOLUME XXX, NUMBER 5
509
FIGURE 1. With stones taped to its underside, a liter of saline is placed over half of the film, which is exposed to the x-rays and then developed in the Polaroid 545 Land Film Holder.
5. Polaroid Transparent Radiographic 8 x 10 Land Film Type TPX positive print from the negative processing in Polaroid Film processing Model 85-12. Sixty seconds (21 “C) ($1,000 cost). 6. Kodak X-Omat KS Film processed in a Kodak RP X-Omat at 35°C. Experimental
studies
Multiple calcium oxalate stones from less than 1 mm to 1 cm in size were taped to the back of a 1 L plastic bag of isotonic saline; this was then placed on the appropriate films: Polaroid Type 52, Type 57, Type 58, and Type TPX, and Kodak kidney film (Fig. 1). The optimal exposures and appropriate development times for each film were studied; then five pictures were taken with each film and submitted to five observers (4 urologists and 1 radiologist) who were asked to depict pictorially where they thought the stones might be. These studies were repeated in a cadaveric kidney in which the stones were placed in a random manner.
510
Clinical
studies
The various films were placed inside a sterile intestinal bag; the face that must be toward the camera (x-ray machine) was kept as smooth as possible. A characteristic of Polaroid films is that they can be exposed only on one side and care must be exercised in this regard. This is not so with Kodak film. The 8 x 10 TPX film was first folded in half and then wrapped in a sterile plastic surgical drape. These packages were placed behind the kidney and the kidney and film suspended. The portable x-ray machine head was positioned thirty inches from the film and exposures were made. Results Some representative radiograms (renograms) are shown in Figure 2. The apparent Rorschach image is that produced of a kidney when, the film (8 x 10) is folded in half.
UROLOGY
/ NOVEMBER1987
/ VOLUMEXXX,NUMBER5
Experimental
studies
(Table
I. Comparison of films used in model and cadaver kidneys
I)
TABLE
It became apparent that most observations were made easier when the stone appeared as black rather than white. This subjective statement was checked by reversing the images photographically and repeating the observations; since the observer was no longer subjected to an unknown, the statement that black was better only held when the fragment was 1 mm and on TPX film and Type 52 film, but did not hold for the others. If the fragment was small (1 mm) 41 per cent were missed on Kodak film, 38-43 per cent on Types 52 and 58, and 27-49 per cent on Types 57 and TPX.
Comment
Film
-X-ray Correct
FilmIncorrect
False Positive
Model kidney
Type 52 57 58 TPX Kodak Cadaver kidney Type 52 57 58 TPX Kodak
11 15 12 20 11
10 5 11 3 9
4 5 2 2 5
11 16 8 19 12
9 6 14 4 8
5 3 3 2 5
These findings show that it is now possible to see “too much” on intraoperative renograms. The dust particles (1 mm) that are seen possibly are passed on. Singh and co-workers have shown that these small particles are not associated with later recurrence. This remains to be
(A) Experimental Polaroid image obtained on Type 52 film. (B) Intraoperative Polaroid TPX FIGURE 2. printed as it would appear in transparency. Stones are black; outline of kidney is gray; air bubbles and jut appear white. (C) TPX. Lower pole of kidney with radiopaque thread from 2 x 4 gauze sponge used as markers. (0) Polaroid TPX 8 x 10 folded in half; residual calculi following partial nephrectomy. Original magnijications (A) actual size, (B and C) x 2, and (D) reduced one-third.
UROLOGY
/ NOVEMBER
1987
I
VOLUME
XXX, NUMBER 5
511
seen. Certainly it raises the question as to whether or not every kidney that has had multiple stones or staghorn calculi removed from it should not be flushed by a postoperative forced diuresis or perhaps even irrigated routinely for forty-eight hours postoperatively before the patient is discharged. It is to be hoped that TPX film will be improved further. It has excellent definition and makes operative renograms an easy procedure because of the instant satisfaction of the sixtysecond development time. This is not available commercially at this time in the 4-5 inch size. However, Type 52 provides nearly the same definition but has the subjective defect that it must be viewed as a photograph and not as a transparency; a mode with which not all urologists are comfortable. The cost factor is a consideration since Kodak film is five times more expensive in our area than Type 52 or Type 57 film. Type 58 offers no advantages and is twice as expensive; also it is appreciably slower.
512
From the practical point of view all these films can be used with any x-ray unit as long as the surgeon is prepared to conduct preliminary tests as noted by Roth and Griffith5 and outlined herein. It is important to realize also that overexposure gives light radiograms and underexposure gives dark pictures, the reverse of conventional black and white photography. Richmond, Virginia 23298 References 1. Sutherland JW: Residual post-operative upper urinary tract stone, J Urol 126: 573 (1981). 2. Singh M, Marshall V, and Blandy J: The residual renal stone, Br J Urol 47: 125 (1975). 3. Koshiba K, Ishibashi A, and Mashimo S: Use of Polaroid film in intraoperative renal radiography: a new technique, J Urol 124: 586 (1980). 4. Pahira JJ, and Pollack HM: Use of Polaroid film in intraoperative renal radiography. Presented at Mid-Atlantic AUA annual meeting, White Sulphur Springs, West Virginia, November 4-8, 1981. 5. Roth D, and Griffith DP: Operative renal radiography, Urology 21: 60 (1983). 6. Koshiba K, and Yoshizawa K: A new device in intraoperative Polaroid radiography, J Urol 127: 1135 (1982).
UROLOGY
i
NOVEMBER
1987
/ VOLUME XXX, NUMBER 5
M.D.,
POLAROID
ROENTGENOGRAMS
PH.D.
From the Medical College of Virginia, Richmond, Virginia
ABSTRACT-The introduction of a new Polaroid film (TPX) prompted an evaluation of all Polaroid films that are available, and a comparison with Kodak Xomat film was done both in the experimental mode and the clinical situation. Type TPX shows excellent definition but is still an experimental film. All the other Polaroid films (Types 52, 57, and TPX 10 x 8) produce images in twenty seconds. This is really the only advantage over the conventional Kodak X-Omat KS film processed as an x-ray film.
The ultimate goal of all surgery for renal stones is to leave the patient with a kidney free of calculi. This objective has been extraordinarily difficult to achieve. Sutherland’ and Singh, Marshall, and Blandy2 have shown that intraoperative roentgenograms are essential if one is to achieve this goal. Most surgeons have become disenchanted with the available techniques because they are time-consuming, and technical personnel often are not familiar with organ roentgenograms; also the machinery being used may vary. The end result is a frustrated surgeon with films that are sometimes uninterpretable. In 1980, Koshiba, Ishibashi, and Mashimo,3 from Japan, showed that it was possible to use a film pack of Polaroid Type 107 to produce excellent positive roentgenograms. Interestingly, about that same time Pahira and Pollack,4 in Philadelphia, were working with Polaroid Type 57 film. Several centers immediately incorporated this concept into their armamentarium. Roth and Griffith in 19805 pointed out that Polaroid Type 52 sheet film could be used as individual film (rather than 8 exposures in Type 107) and could be readily processed in a 545 Polaroid 4 x 5 Holder. In 1982, Koshiba and Yoshizawa6 modified their holder and used this cassette in a sterile container (surgical vinyl drape) to expose single films. Meanwhile, groups in Houston, Washington, Philadelphia, and Richmond were working with various sheet films and obtaining high quality studies.
UROLOGY
/ NOVEMBER 1987
/
In February, 1981, a new 8 x 10 Polaroid radiographic film known as TPX came to my attention. One year later the company furnished me with Type TPX that was 3l/2 x 4% and could be used much more easily in an operative situation. The purpose of this report is to evaluate our experimental and clinical experiences with the new Polaroid films and to compare them with currently available Kodak X-Omat KS film. Material and Methods Film types 1. Polaroid 4 x 5 Land Film Type 52/Pola Pan is a panchromatic fine-grain positive print film ASA 400 resolution 20-25 line pairs/mm. Processing time twenty seconds (21 “C) . * 2. Polaroid 4 x 5 Land Film Type 57/High Speed is a panchromatic medium-grain positive print film ASA 3000 resolution 18-22 lines/mm. Processing time fifteen seconds (21 “C). * This is essentially the same as Type 107. 3. Polacolor 2: 4 x 5 Land Film Type 58 ASA 75. Processing time sixty seconds (21 “C). * 4. Polaroid Transparent 4 x 5 sheet radiographic film (not available commercially) . Processing time sixty seconds (21 “C) * * *Films are processed in a Type 545 Polaroid Land Film Holder ($130.00 cost).
VOLUME XXX, NUMBER 5
509
FIGURE 1. With stones taped to its underside, a liter of saline is placed over half of the film, which is exposed to the x-rays and then developed in the Polaroid 545 Land Film Holder.
5. Polaroid Transparent Radiographic 8 x 10 Land Film Type TPX positive print from the negative processing in Polaroid Film processing Model 85-12. Sixty seconds (21 “C) ($1,000 cost). 6. Kodak X-Omat KS Film processed in a Kodak RP X-Omat at 35°C. Experimental
studies
Multiple calcium oxalate stones from less than 1 mm to 1 cm in size were taped to the back of a 1 L plastic bag of isotonic saline; this was then placed on the appropriate films: Polaroid Type 52, Type 57, Type 58, and Type TPX, and Kodak kidney film (Fig. 1). The optimal exposures and appropriate development times for each film were studied; then five pictures were taken with each film and submitted to five observers (4 urologists and 1 radiologist) who were asked to depict pictorially where they thought the stones might be. These studies were repeated in a cadaveric kidney in which the stones were placed in a random manner.
510
Clinical
studies
The various films were placed inside a sterile intestinal bag; the face that must be toward the camera (x-ray machine) was kept as smooth as possible. A characteristic of Polaroid films is that they can be exposed only on one side and care must be exercised in this regard. This is not so with Kodak film. The 8 x 10 TPX film was first folded in half and then wrapped in a sterile plastic surgical drape. These packages were placed behind the kidney and the kidney and film suspended. The portable x-ray machine head was positioned thirty inches from the film and exposures were made. Results Some representative radiograms (renograms) are shown in Figure 2. The apparent Rorschach image is that produced of a kidney when, the film (8 x 10) is folded in half.
UROLOGY
/ NOVEMBER1987
/ VOLUMEXXX,NUMBER5
Experimental
studies
(Table
I. Comparison of films used in model and cadaver kidneys
I)
TABLE
It became apparent that most observations were made easier when the stone appeared as black rather than white. This subjective statement was checked by reversing the images photographically and repeating the observations; since the observer was no longer subjected to an unknown, the statement that black was better only held when the fragment was 1 mm and on TPX film and Type 52 film, but did not hold for the others. If the fragment was small (1 mm) 41 per cent were missed on Kodak film, 38-43 per cent on Types 52 and 58, and 27-49 per cent on Types 57 and TPX.
Comment
Film
-X-ray Correct
FilmIncorrect
False Positive
Model kidney
Type 52 57 58 TPX Kodak Cadaver kidney Type 52 57 58 TPX Kodak
11 15 12 20 11
10 5 11 3 9
4 5 2 2 5
11 16 8 19 12
9 6 14 4 8
5 3 3 2 5
These findings show that it is now possible to see “too much” on intraoperative renograms. The dust particles (1 mm) that are seen possibly are passed on. Singh and co-workers have shown that these small particles are not associated with later recurrence. This remains to be
(A) Experimental Polaroid image obtained on Type 52 film. (B) Intraoperative Polaroid TPX FIGURE 2. printed as it would appear in transparency. Stones are black; outline of kidney is gray; air bubbles and jut appear white. (C) TPX. Lower pole of kidney with radiopaque thread from 2 x 4 gauze sponge used as markers. (0) Polaroid TPX 8 x 10 folded in half; residual calculi following partial nephrectomy. Original magnijications (A) actual size, (B and C) x 2, and (D) reduced one-third.
UROLOGY
/ NOVEMBER
1987
I
VOLUME
XXX, NUMBER 5
511
seen. Certainly it raises the question as to whether or not every kidney that has had multiple stones or staghorn calculi removed from it should not be flushed by a postoperative forced diuresis or perhaps even irrigated routinely for forty-eight hours postoperatively before the patient is discharged. It is to be hoped that TPX film will be improved further. It has excellent definition and makes operative renograms an easy procedure because of the instant satisfaction of the sixtysecond development time. This is not available commercially at this time in the 4-5 inch size. However, Type 52 provides nearly the same definition but has the subjective defect that it must be viewed as a photograph and not as a transparency; a mode with which not all urologists are comfortable. The cost factor is a consideration since Kodak film is five times more expensive in our area than Type 52 or Type 57 film. Type 58 offers no advantages and is twice as expensive; also it is appreciably slower.
512
From the practical point of view all these films can be used with any x-ray unit as long as the surgeon is prepared to conduct preliminary tests as noted by Roth and Griffith5 and outlined herein. It is important to realize also that overexposure gives light radiograms and underexposure gives dark pictures, the reverse of conventional black and white photography. Richmond, Virginia 23298 References 1. Sutherland JW: Residual post-operative upper urinary tract stone, J Urol 126: 573 (1981). 2. Singh M, Marshall V, and Blandy J: The residual renal stone, Br J Urol 47: 125 (1975). 3. Koshiba K, Ishibashi A, and Mashimo S: Use of Polaroid film in intraoperative renal radiography: a new technique, J Urol 124: 586 (1980). 4. Pahira JJ, and Pollack HM: Use of Polaroid film in intraoperative renal radiography. Presented at Mid-Atlantic AUA annual meeting, White Sulphur Springs, West Virginia, November 4-8, 1981. 5. Roth D, and Griffith DP: Operative renal radiography, Urology 21: 60 (1983). 6. Koshiba K, and Yoshizawa K: A new device in intraoperative Polaroid radiography, J Urol 127: 1135 (1982).
UROLOGY
i
NOVEMBER
1987
/ VOLUME XXX, NUMBER 5