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Percutaneous nephrostomy and maintenance of nephrostomy drainage
PERCUTANEOUS NEPHROSTOMY AND MAINTENANCE OF NEPHROSTOMY DRAINAGE STEVEN
J. ROVEN,
M.D.
ROBERT
J. ROSEN,
M.D.
From the Department New York University
of Vascular and Interventional Radiology, Medical Center, New York, New York
ABSTRACT-A simple method for percutaneous insertion of nephrostomy tubes is described. In OUTseries of 47 patients there have been no jailed attempts at nephrostomy placement, and only one complication, transient septicemia, was noted. Catheter care is described, and use of the nephrostomy tract for various urologic problems is discussed.
Since Seldinger in 1953’ introduced a percutaneous technique for entering the femoral artery, arteriography rapidly became a widely used radiographic means for diagnosing a multitude of pathologic states in both the arterial and other organ systems. Over the years equipment became more sophisticated, and angiographers attained increasing skill in the manipulation of catheters over guide wires using fluoroscopic guidance. Catheters began to be used to deliver pharmacotherapeutic agents, and then to treat various disease entities mechanically, such as in balloon angioplasty and particulate embolization of bleeding vessels, far from the site of entry into the vascular system. The latest development has been the use of angiographic techniques in the diagnosis and treatment of disease outside the vascular system. Percutaneous biliary techniques, for example, enjoyed rapid popularization in the 1970s. Although a technique for percutaneous nephrostomy was first described in the urologic literature in 1955,2 it has not been until recent years that fluoroscopically guided urologic procedures have come into vogue. One of the primary factors in the recent advancement in the treatment of urologic diseases has been the ability of urologists and interventional radiologists to work together to find the most efficient and least invasive solution to a pathologic problem. Indications The percutaneous placement tube can represent a therapeutic
SPECIAL
ISSUE TO UROLOGY
i
of a nephrostomy measure in its en-
MAY 1984
/ VOLUME
tirety, or it can be a prelude to a more complicated therapeutic endeavor. By far the commonest indication for percutaneous nephrostomy is obstruction of the upper urinary tract, particularly in patients too ill to tolerate surgery or in whom there has been a failed attempt at endoscopic placement of a stent.3,4 Whether obstruction is caused by stone, stricture, or neoplasm, percutaneous decompression allows time for adequate diagnosis and the planning of an appropriate therapeutic approach. In the treatment of pyonephrosis, patients often demonstrate dramatic clinical improvement within twenty-four hours of urinary tract decompression. Less frequent indications for nephrostomy include diversion of urine from an inflamed, spastic, or tumor-filled bladder, the removal of foreign bodies, or the delivery of irrigants to dissolve renal pelvic calculi.3.5 Once entrance into the renal collecting system has been established, various interventional techniques can be applied to urinary tract disease such as the stenting of ureteral strictures or tears,6 or the dilatation of ureteral stenoses. Procedure Almost all proposed techniques for percutaneous placement of nephrostomy tubes fall into one of two categories: trocar or Seldinger.7.8 The trocar technique is an adaptation of a method used for suprapubic cystostomy in which a trocar surrounded by a thin-walled cannula is advanced into the intrarenal collecting system. The trocar is then removed, and the catheter is passed through the cannula into the
XXIII, NUMBER 5
25
Cope introducer system: (A) 21-gauge FIGURE 1. needle, (B) 0.018 monofilament guide wire, (C) straightening cannula for dilator, (0) 6.3-F dilator, and (E) 0.038 guide wire. collecting system. The more controlled Seldinger technique involves entry into the renal collecting system by a needle/sheath combination and a series of dilatations over a guide wire following which a catheter is placed. 8 lo We use a variation of the Seldinger technique in which the relatively atraumatic 21-gauge needle used initially to gain entrance into the renal pelvis is followed, through a series of guide wires of increasing caliber over which graded tract dilatations are performed, by an 8.3-F polyethylene nephrostomy tube (Fig. 1). Direct fluoroscopy generally provides adequate visualization of the renal outline. In cases in which the kidnev is not well seen, intravenous contrast material is given one to two hours prior to the procedure in an effort to opacify the pelvocalyceal system or enhance the renal outline. In actuality, many patients will have residual contrast media in their intrarenal collecting systems from intravenous or retrograde pyelography performed in the diagnosis of their conditions prior to request for nephrostomy. If the kidney is not well seen under direct fluoroscopy and if intravenous contrast material is contraindicated on the basis of poor or borderline renal function, ultrasound can provide excellent guidance
Ofi
SPECIAL
with respect to the location and depth of the dilat renal pelvis. Once fine-needle access is gained ir the collecting system, however, fluoroscopy is us for the remainder of the procedure. Unless there is a reason for precipitious perfori ante of the procedure, we administer broa spectrum intravenous antibiotics prior to placeme of the nephrostomy. Antibiotics are continued for day or two after the procedure if the urine is steril and for longer if it is infected. The patient is placed in the prone position on t: fluoroscopic table with his arms resting on the p low at his head. After placing ECG-monitori] leads and obtaining a baseline blood pressure, an 1 is started, and parenteral analgesia is given. Sin the procedure is usually a relatively painless on analgesia is aimed at making the patient as relax1 and comfortable as possible. The patient should I able to comply with simple breathing instructio since respiratory motion during the passage of ne dles could result in a renal capsular tear. The flank then prepped with povidone-iodine (Betadine) ar the entire body draped with sterile towels, creatir a sterile field which is maintained throughout tl procedure. A spot in the posterior axillary line b neath the twelfth rib and lateral to the mid portic of the kidney is chosen for the entry site of the n phrostomy tube, and generous superficial and dec infiltration of lidocaine is administered to the are This posterior axillary approach allows for passal of the catheter lateral to the large paraspinous mu cle groups, through the lateral renal parenchym, and into the renal pelvis with the benefit of great catheter stability and increased patient comfort. A small nick is made in the skin at the ane thetized entry site, and the subcutaneous tissues a: bluntly dissected. The patient is asked to suspen respiration while a 21-gauge needle is passed, wit fluoroscopic guidance, into the area of the ren, pelvis. The needle is passed at a 30 to 45-degrt angle to the horizontal plane depending on the p; tient’s body habitus (Fig. 2A). The stylet is remove and the needle slowly withdrawn until urine we1 back into the hub. At this point a 0.018 monofil; ment wire with a floppy tip is advanced through tl needle until it is well situated in the renal pelvi The needle is removed, and a specially designed 6.: F Teflon dilator with a finely tapered tip and a larg sidehole is advanced over the wire. A stainless stec cannula fits inside the dilator facilitating its passag over the wire. As the dilator enters the renal pelvi: the cannula and guide wire are removed. At th point there will be free flow of urine from the dih tor. A sample is collected and sent for microbiologj analysis. A 0.038, 3-mm J guide wire is then passe through the dilator. Because of the dilator’s speci; angulation, the wire passes through the side ho1 into the renal pelvis (Fig. 2B). The 6.3-F dilator removed, and following dilatation of the tract wit 8-F and 9-F Teflon dilators, an 8.3-F polyethylen
ISSUE TO UROLOGY
!
MAY 1984
\‘OLUAfE XXIII.
NUMBER
FIGURE 2. (A) 21-gauge needle inserted at 45Degree angle to horizontal; (B) 0.038 guide wire fits through side hole of 6.3-F dilator; (C) 8.3-F zephrostomy tube in place.
nephrostomy tube is placed, the wire removed, and the renal pelvis emptied of its contents (Fig. 2C). A small amount of contrast material is injected through the tube to document its proper position and function. The tube is then sutured to the skin with 2-O silk and connected to a nephrostomy bag. To avoid the possibility of inducing septicemia by the injection of contrast material under pressure, the definitive diagnostic antegrade pyelogram is not performed until one or two days after placement of the nephrostomy tube when the renal collecting system is well decompressed. The patient is kept at bedrest, and vital signs are monitored closely for twenty-four hours. Almost invariably the initial flow of urine from the nephrostomy is grossly bloody. This clears spontaneously over a period of a few days and is generally of no clinical significance. Long-term maintenance of a percutaneously placed nephrostomy tube involves gentle irrigation with sterile saline solution twice weekly to inhibit formation of sediment in the tube. Tubes are replaced prophylactically every three months to prevent complete blockage by sediment, which will occur in most tubes despite irrigation if left in place for a prolonged period of time. Catheter replacement is done on an outpatient basis and is a quick, simple, and essentially painless procedure once the tract is well formed (l-2 months).
SPECIAL ISSUE TO UROLOGY
I
MAY 1984
i
At the time of replacement, any one of several types of catheters can be inserted to suit the patient’s specific needs (pigtail, Cope loop, Foley). Skin care at the catheter entry site consists of the application of bacteriostatic ointment along with frequent dressing changes. As long as urine is flowing, clinically significant urinary tract infections are rare, however, most long-term nephrostomy patients are prescribed urinary antiseptic drugs to avoid a problem should the catheter become blocked. Complications Complications secondary to percutaneous placement of nephrostomy tubes are rare. In one series of 1,207 patients a 4-per cent incidence of significant complications, mostly attributed to infection or hemorrhage, was reported. A single fatal hemorrhage occurred.3 In our series of 47 cases performed from July 1, 1982, to December 31, 1983, with careful attention paid to the correction of bleeding diatheses, adequate antibiotic coverage, and the avoidance of overdistention of the pelvocalyceal system, we have had a single complication which consisted of the induction of a transient septicemia. We have had no failed attempts at placing a catheter. Most problems with nephrostomy tubes are mechanical: the tube becomes dislodged or drainage is blocked by the formation of sediment. If dislodgement occurs, the tract usually can be renegotiated using guide wire and catheter techniques with fluoroscopy if the patient is seen within twenty-four hours of the event. In patients who are prone to losing their catheters we generally use a self-retaining (Cope or Foley) type nephrostomy tube with a suture near the skin entry site. In patients whose tubes
VOLUME XXIII, NUMBER 5
27
UIUCK
XXUIlUary
10
eXCeSSlVe
SealInent
~OITTIatiOn,
we
suggest more frequent irrigation, use larger French (greater than or equal to 12) catheters, and change them more frequently. High fluid intake and urinary alkalinization may be helpful. Comment As a natural outgrowth of the technologic advances in the field of angiography and interventional radiology, fluoroscopically guided percutaneous urologic procedures have proved to be an important asset in the diagnosis and treatment of many urologic problems. In obstruction of the upper urinary tract a percutaneously placed nephrostomy tube may be the solution to a particular patient’s problem or it may decompress an infected system reducing the risk of septicemia and preserving renal function while time is gained for optimal planning of a definitive surgical approach. In ureteral obstruction not amenable to surgical intervention, the technology and skill necessary to stent lesions or dilate strictures are available at many centers. The most exciting new wrinkle in interventional urology has been the development of a profusion of techniques for the percutaneous extraction of renal pelvis or high ureteral stones. At our institution this is a two-step procedure. The first step is performed by the radiologist and involves placement of a nephrostomy tube into the portion of the intrarenal collecting system which provides the most direct access to the calculus. A few days later the second step is performed. Under general anesthesia using a system of coaxial dilators the radiologist dilates the tract up to 26 F leaving a Teflon cannula of that size in place. The urologist then inserts an endoscope through the cannula, and after removing any clotted material or debris that might be in the renal pelvis, he removes the calculus
28
SPECIAL
with a forceps under direct visualization. Stones th are too large to be removed through the tract can broken down to size with the use of electrohydrau: lithotripsy. Stones that are in hard to reach plac may be removed by a Dormia basket. These developments are exciting not only in th they present a nonoperative alternative to ren calculous disease, but they mark the beginning of cooperative era between the radiologist and tl urologist in which techniques are combined on tl basis of effectiveness and noninvasiveness to provic an optimum in patient care. 560 First Avem New York, New York 100; (DR. ROVE? References 1. Seldinger SI: The Seldinger technique-catheter replac ment of the needle in percutaneous arteriography, AJR 142: 5(1984). 2. Goodwin WE, Casey WC, and Woolf W: Percutaneous tr’ car (needle) nephrostomy in hydronephrosis, JAMA 157: 8! (1955). 3. Stables DP: Percutaneous nephrostomy: techniques, indic tions, and results, Ural Clin North Am vol 9, February, 1982. 4. Mitty HA, and Cribetz ME: The status of intervention uroradiology, review article, J Urol 127: 2-9 (1982). 5. Newhouse JH, and Pfister RC: Therapy for renal calculi v percutaneous nephrostomy: dissolution and extraction, Ural R; diol 2: 165-170 (1981). 6. Goldin AR: Percutaneous ureteral splinting. Urology 11 165 (1977). 7. Newhouse JH, and Pfister RC: Percutaneous catheterizatio of the kidney and perirenal space: trocar technique. Urol Radii 2: 157-164 (1981). 8. Bigongiari LR: The Seldinger approach to percutaneot nephrostomy and ureteral stent placement ibid 2: 141-145 (1981 9. Perinetti E, et al: Percutaneous nephrostomy: indication complications, and clinical usefulness, J Ural 120: 156-15 (1978). 10. Saxton HM: Percutaneous nephrostomy-technique. Urc Radio1 2: 131-140 (1981).
ISSUE TO UROLOGY
/
MAY 1984
/
VOLUME
XXIII.
NUMBER
:
J. ROVEN,
M.D.
ROBERT
J. ROSEN,
M.D.
From the Department New York University
of Vascular and Interventional Radiology, Medical Center, New York, New York
ABSTRACT-A simple method for percutaneous insertion of nephrostomy tubes is described. In OUTseries of 47 patients there have been no jailed attempts at nephrostomy placement, and only one complication, transient septicemia, was noted. Catheter care is described, and use of the nephrostomy tract for various urologic problems is discussed.
Since Seldinger in 1953’ introduced a percutaneous technique for entering the femoral artery, arteriography rapidly became a widely used radiographic means for diagnosing a multitude of pathologic states in both the arterial and other organ systems. Over the years equipment became more sophisticated, and angiographers attained increasing skill in the manipulation of catheters over guide wires using fluoroscopic guidance. Catheters began to be used to deliver pharmacotherapeutic agents, and then to treat various disease entities mechanically, such as in balloon angioplasty and particulate embolization of bleeding vessels, far from the site of entry into the vascular system. The latest development has been the use of angiographic techniques in the diagnosis and treatment of disease outside the vascular system. Percutaneous biliary techniques, for example, enjoyed rapid popularization in the 1970s. Although a technique for percutaneous nephrostomy was first described in the urologic literature in 1955,2 it has not been until recent years that fluoroscopically guided urologic procedures have come into vogue. One of the primary factors in the recent advancement in the treatment of urologic diseases has been the ability of urologists and interventional radiologists to work together to find the most efficient and least invasive solution to a pathologic problem. Indications The percutaneous placement tube can represent a therapeutic
SPECIAL
ISSUE TO UROLOGY
i
of a nephrostomy measure in its en-
MAY 1984
/ VOLUME
tirety, or it can be a prelude to a more complicated therapeutic endeavor. By far the commonest indication for percutaneous nephrostomy is obstruction of the upper urinary tract, particularly in patients too ill to tolerate surgery or in whom there has been a failed attempt at endoscopic placement of a stent.3,4 Whether obstruction is caused by stone, stricture, or neoplasm, percutaneous decompression allows time for adequate diagnosis and the planning of an appropriate therapeutic approach. In the treatment of pyonephrosis, patients often demonstrate dramatic clinical improvement within twenty-four hours of urinary tract decompression. Less frequent indications for nephrostomy include diversion of urine from an inflamed, spastic, or tumor-filled bladder, the removal of foreign bodies, or the delivery of irrigants to dissolve renal pelvic calculi.3.5 Once entrance into the renal collecting system has been established, various interventional techniques can be applied to urinary tract disease such as the stenting of ureteral strictures or tears,6 or the dilatation of ureteral stenoses. Procedure Almost all proposed techniques for percutaneous placement of nephrostomy tubes fall into one of two categories: trocar or Seldinger.7.8 The trocar technique is an adaptation of a method used for suprapubic cystostomy in which a trocar surrounded by a thin-walled cannula is advanced into the intrarenal collecting system. The trocar is then removed, and the catheter is passed through the cannula into the
XXIII, NUMBER 5
25
Cope introducer system: (A) 21-gauge FIGURE 1. needle, (B) 0.018 monofilament guide wire, (C) straightening cannula for dilator, (0) 6.3-F dilator, and (E) 0.038 guide wire. collecting system. The more controlled Seldinger technique involves entry into the renal collecting system by a needle/sheath combination and a series of dilatations over a guide wire following which a catheter is placed. 8 lo We use a variation of the Seldinger technique in which the relatively atraumatic 21-gauge needle used initially to gain entrance into the renal pelvis is followed, through a series of guide wires of increasing caliber over which graded tract dilatations are performed, by an 8.3-F polyethylene nephrostomy tube (Fig. 1). Direct fluoroscopy generally provides adequate visualization of the renal outline. In cases in which the kidnev is not well seen, intravenous contrast material is given one to two hours prior to the procedure in an effort to opacify the pelvocalyceal system or enhance the renal outline. In actuality, many patients will have residual contrast media in their intrarenal collecting systems from intravenous or retrograde pyelography performed in the diagnosis of their conditions prior to request for nephrostomy. If the kidney is not well seen under direct fluoroscopy and if intravenous contrast material is contraindicated on the basis of poor or borderline renal function, ultrasound can provide excellent guidance
Ofi
SPECIAL
with respect to the location and depth of the dilat renal pelvis. Once fine-needle access is gained ir the collecting system, however, fluoroscopy is us for the remainder of the procedure. Unless there is a reason for precipitious perfori ante of the procedure, we administer broa spectrum intravenous antibiotics prior to placeme of the nephrostomy. Antibiotics are continued for day or two after the procedure if the urine is steril and for longer if it is infected. The patient is placed in the prone position on t: fluoroscopic table with his arms resting on the p low at his head. After placing ECG-monitori] leads and obtaining a baseline blood pressure, an 1 is started, and parenteral analgesia is given. Sin the procedure is usually a relatively painless on analgesia is aimed at making the patient as relax1 and comfortable as possible. The patient should I able to comply with simple breathing instructio since respiratory motion during the passage of ne dles could result in a renal capsular tear. The flank then prepped with povidone-iodine (Betadine) ar the entire body draped with sterile towels, creatir a sterile field which is maintained throughout tl procedure. A spot in the posterior axillary line b neath the twelfth rib and lateral to the mid portic of the kidney is chosen for the entry site of the n phrostomy tube, and generous superficial and dec infiltration of lidocaine is administered to the are This posterior axillary approach allows for passal of the catheter lateral to the large paraspinous mu cle groups, through the lateral renal parenchym, and into the renal pelvis with the benefit of great catheter stability and increased patient comfort. A small nick is made in the skin at the ane thetized entry site, and the subcutaneous tissues a: bluntly dissected. The patient is asked to suspen respiration while a 21-gauge needle is passed, wit fluoroscopic guidance, into the area of the ren, pelvis. The needle is passed at a 30 to 45-degrt angle to the horizontal plane depending on the p; tient’s body habitus (Fig. 2A). The stylet is remove and the needle slowly withdrawn until urine we1 back into the hub. At this point a 0.018 monofil; ment wire with a floppy tip is advanced through tl needle until it is well situated in the renal pelvi The needle is removed, and a specially designed 6.: F Teflon dilator with a finely tapered tip and a larg sidehole is advanced over the wire. A stainless stec cannula fits inside the dilator facilitating its passag over the wire. As the dilator enters the renal pelvi: the cannula and guide wire are removed. At th point there will be free flow of urine from the dih tor. A sample is collected and sent for microbiologj analysis. A 0.038, 3-mm J guide wire is then passe through the dilator. Because of the dilator’s speci; angulation, the wire passes through the side ho1 into the renal pelvis (Fig. 2B). The 6.3-F dilator removed, and following dilatation of the tract wit 8-F and 9-F Teflon dilators, an 8.3-F polyethylen
ISSUE TO UROLOGY
!
MAY 1984
\‘OLUAfE XXIII.
NUMBER
FIGURE 2. (A) 21-gauge needle inserted at 45Degree angle to horizontal; (B) 0.038 guide wire fits through side hole of 6.3-F dilator; (C) 8.3-F zephrostomy tube in place.
nephrostomy tube is placed, the wire removed, and the renal pelvis emptied of its contents (Fig. 2C). A small amount of contrast material is injected through the tube to document its proper position and function. The tube is then sutured to the skin with 2-O silk and connected to a nephrostomy bag. To avoid the possibility of inducing septicemia by the injection of contrast material under pressure, the definitive diagnostic antegrade pyelogram is not performed until one or two days after placement of the nephrostomy tube when the renal collecting system is well decompressed. The patient is kept at bedrest, and vital signs are monitored closely for twenty-four hours. Almost invariably the initial flow of urine from the nephrostomy is grossly bloody. This clears spontaneously over a period of a few days and is generally of no clinical significance. Long-term maintenance of a percutaneously placed nephrostomy tube involves gentle irrigation with sterile saline solution twice weekly to inhibit formation of sediment in the tube. Tubes are replaced prophylactically every three months to prevent complete blockage by sediment, which will occur in most tubes despite irrigation if left in place for a prolonged period of time. Catheter replacement is done on an outpatient basis and is a quick, simple, and essentially painless procedure once the tract is well formed (l-2 months).
SPECIAL ISSUE TO UROLOGY
I
MAY 1984
i
At the time of replacement, any one of several types of catheters can be inserted to suit the patient’s specific needs (pigtail, Cope loop, Foley). Skin care at the catheter entry site consists of the application of bacteriostatic ointment along with frequent dressing changes. As long as urine is flowing, clinically significant urinary tract infections are rare, however, most long-term nephrostomy patients are prescribed urinary antiseptic drugs to avoid a problem should the catheter become blocked. Complications Complications secondary to percutaneous placement of nephrostomy tubes are rare. In one series of 1,207 patients a 4-per cent incidence of significant complications, mostly attributed to infection or hemorrhage, was reported. A single fatal hemorrhage occurred.3 In our series of 47 cases performed from July 1, 1982, to December 31, 1983, with careful attention paid to the correction of bleeding diatheses, adequate antibiotic coverage, and the avoidance of overdistention of the pelvocalyceal system, we have had a single complication which consisted of the induction of a transient septicemia. We have had no failed attempts at placing a catheter. Most problems with nephrostomy tubes are mechanical: the tube becomes dislodged or drainage is blocked by the formation of sediment. If dislodgement occurs, the tract usually can be renegotiated using guide wire and catheter techniques with fluoroscopy if the patient is seen within twenty-four hours of the event. In patients who are prone to losing their catheters we generally use a self-retaining (Cope or Foley) type nephrostomy tube with a suture near the skin entry site. In patients whose tubes
VOLUME XXIII, NUMBER 5
27
UIUCK
XXUIlUary
10
eXCeSSlVe
SealInent
~OITTIatiOn,
we
suggest more frequent irrigation, use larger French (greater than or equal to 12) catheters, and change them more frequently. High fluid intake and urinary alkalinization may be helpful. Comment As a natural outgrowth of the technologic advances in the field of angiography and interventional radiology, fluoroscopically guided percutaneous urologic procedures have proved to be an important asset in the diagnosis and treatment of many urologic problems. In obstruction of the upper urinary tract a percutaneously placed nephrostomy tube may be the solution to a particular patient’s problem or it may decompress an infected system reducing the risk of septicemia and preserving renal function while time is gained for optimal planning of a definitive surgical approach. In ureteral obstruction not amenable to surgical intervention, the technology and skill necessary to stent lesions or dilate strictures are available at many centers. The most exciting new wrinkle in interventional urology has been the development of a profusion of techniques for the percutaneous extraction of renal pelvis or high ureteral stones. At our institution this is a two-step procedure. The first step is performed by the radiologist and involves placement of a nephrostomy tube into the portion of the intrarenal collecting system which provides the most direct access to the calculus. A few days later the second step is performed. Under general anesthesia using a system of coaxial dilators the radiologist dilates the tract up to 26 F leaving a Teflon cannula of that size in place. The urologist then inserts an endoscope through the cannula, and after removing any clotted material or debris that might be in the renal pelvis, he removes the calculus
28
SPECIAL
with a forceps under direct visualization. Stones th are too large to be removed through the tract can broken down to size with the use of electrohydrau: lithotripsy. Stones that are in hard to reach plac may be removed by a Dormia basket. These developments are exciting not only in th they present a nonoperative alternative to ren calculous disease, but they mark the beginning of cooperative era between the radiologist and tl urologist in which techniques are combined on tl basis of effectiveness and noninvasiveness to provic an optimum in patient care. 560 First Avem New York, New York 100; (DR. ROVE? References 1. Seldinger SI: The Seldinger technique-catheter replac ment of the needle in percutaneous arteriography, AJR 142: 5(1984). 2. Goodwin WE, Casey WC, and Woolf W: Percutaneous tr’ car (needle) nephrostomy in hydronephrosis, JAMA 157: 8! (1955). 3. Stables DP: Percutaneous nephrostomy: techniques, indic tions, and results, Ural Clin North Am vol 9, February, 1982. 4. Mitty HA, and Cribetz ME: The status of intervention uroradiology, review article, J Urol 127: 2-9 (1982). 5. Newhouse JH, and Pfister RC: Therapy for renal calculi v percutaneous nephrostomy: dissolution and extraction, Ural R; diol 2: 165-170 (1981). 6. Goldin AR: Percutaneous ureteral splinting. Urology 11 165 (1977). 7. Newhouse JH, and Pfister RC: Percutaneous catheterizatio of the kidney and perirenal space: trocar technique. Urol Radii 2: 157-164 (1981). 8. Bigongiari LR: The Seldinger approach to percutaneot nephrostomy and ureteral stent placement ibid 2: 141-145 (1981 9. Perinetti E, et al: Percutaneous nephrostomy: indication complications, and clinical usefulness, J Ural 120: 156-15 (1978). 10. Saxton HM: Percutaneous nephrostomy-technique. Urc Radio1 2: 131-140 (1981).
ISSUE TO UROLOGY
/
MAY 1984
/
VOLUME
XXIII.
NUMBER
: