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Percutaneous stone and stent removal in renal transplants
674
CLINICAL RADIOLOGY
Measurements of aortic diameter on the M R images were obtained of the mid-ascending aorta and of the descending aorta in the same transverse slice. The minimal diameter of the isthmus was also measured and the severity of the stenosis was expressed as a ratio of the isthmal diameter to the mean diameters of the ascending and descending aorta. Six patients had gradients at catheterisation varying between 10 and 55 mmHg, and seven others had significant gradients on Doppler echocardiography: in these 13, the isthmal/aortic diameter ratio varied between 0.18 and 0.15 (mean 0.38). Fifteen patients had no gradient on Doppler or at catheterisation, of whom two had an aneurysm at the isthmus. The other 13 had isthmal/aortic diameter ratios of between 0.48 and 0.95 (mean 0.70). Of the remaining seven patients with no gradient measurements, all had ratios above 0.5 (mean 0.65) and were regarded as having a successful result. Three patients were found to have an aneurysm at the site of the Dacron patch inserted 17 and 18 years previously. In morphology they were different, one being saccular, one fusiform, and one was a dissection. Two have been resected and the patient with the dissection has been treated conservatively as a second scan showed no change over a period of a year. These results show that M R tomographic spin-echo images in transverse and oblique planes provide a reliable method of demonstrating aortic anatomy non-invasively and can confirm or exclude the presence of an aneurysm. Re-stenosis at the site of the repair can be predicted when the isthmal/aortic diameter ratio is below 0.5. MAGNETIC RESONANCE IMAGING OF STRESSED ANTERIOR CRUCIATE LIGAMENTS A. M. R I J K E and T. H. G O I T Z
University of Virginia Medical Center, Charlottesville, Va. 22908 USA In t h e diagnostic analysis of anterior cruciate ligament (ACL) injury, magnetic resonance imaging can provide conclusive evidence in cases of a complete rupture and in most cases of intact cruciates, but partial tears cannot be diagnosed with confidence. Poor visualisation, a wavy appearance of the anterior margin, or an increased low signal intensity at its origin may raise the suspicion of an A C L tear, but correlation with functional status has proved elusive. We have used a stress apparatus made of wood and epoxy that can maintain a 15 kPa pressure, applied to the posterior-upper aspects of the lower leg, throughout the 16 min scanning time. T~-weighted sagittal F L A S H and FISP sequences, using 1.5 mm slice thickness, show an elevation of the A C L in all cases for which a partial tear was subsequently confirmed by surgery. This information was correlated with the results of the physical examination and has assisted our orthopedic surgeons in their decision between conservative treatment and intra- or extra-articular reconstruction.
THE URETERIC CALCULUS AN ALTERNATIVE APPROACH TO VISUALISATION WITH LITHOTRIPSY IN MIND B. ROSS -
Royal Hallamshire Hospital, Sheffield A major drawback to ultrasound lithotripsy is the poor access to the ureters from conventional ultrasound windows and hence the poor reputation of the piezo-electric ESWL in ureteric calculi. The author has explored alternative sites and positions for access and suggests that over 50% of calculi in the mid ureter can be both visualised by ultrasound and hence be accessible to ultrasounddirected lithotripsy. This access is a major advance as it avoids the necessity to use push-back or ureteroscopic techniques with the inevitable anaesthetic. Results in the visualisation using alternative sites are presented, as are various ancillary techniques which assist in the visualisation and eventual destruction. Results of the application of piezo-electric lithotripsy to ureteric calculi will be presented.
PERCUTANEOUS STONE AND STENT REMOVAL IN RENAL TRANSPLANTS W. M. W. G E D R O Y C , D. MacIVOR, M. L. J O Y C E and H. M. SAXTON
Guy's Hospital, London Techniques for the percutaneous removal of stones from normally sited kidneys are well described and accepted. A modified per-
cutaneous technique may be employed in calculus removal from renal transplants, and we describe four cases (two stones, one stent and one organised, infected blood clot) in which we have used this procedure effectively and safely in removing the above material from renal transplant collecting systems. We also describe the precise methods and their modifications which we have found useful for the successful application of radio-endourological procedures in renal transplant patients. ACQUIRED RENAL CYSTIC DISEASE: THE ROLE OF ULTRASOUND IN SCREENING R. A. MANNS, F. G. O. B U R R O W S , D. A D U and J. M. M I C H A E L
Queen Elizabeth Hospital, Birmingham Some patients with end-stage renal failure develop multiple cysts within their native kidneys. The importance of this so-called 'acquired cystic disease of the kidney' is because of several well described complications which may ensue. These include retroperitoneal haemorrhage, infection, calculi, painless haematuria and the development of solid tumours. Our study using ultrasonic examination was, initially, to document the incidence of acquired cystic disease in the renal unit at the Queen Elizabeth Hospital, Birmingham. Fifty-one patients were examined and twenty-four of these were found to have Cysts. As the period of renal replacement treatment (dialysis and renal transplantation) increased so there was a corresponding increase in acquired cystic disease. A n important group whose native kidneys could not be identified by ultrasound are also discussed. The second part of the study examined a particular subgroup of endstage renal failure patients who had been on dialysis (either haemo- or peritoneal dialysis) for over 3 years. From established literature and our own initial study, these patients should have a very high incidence of acquired cystic disease.
COMPUTED TOMOGRAPHY OF ACQUIRED CYSTIC KIDNEY DISEASE IN LONG TERM HAEMODIALYSIS PATIENTS G. T H O M A S and C. E V A N S
Cardiff Royal Infirmary, University Hospital of Wales, Cardiff End-stage kidneys in patients undergoing long term haemodialysis are known to undergo cystic change. There is also an increased incidence of adenocarcinoma, these complications being first described in the U K in pathological studies. The kidneys of dialysis patients are not routinely examined in this country unless there are clinical symptoms, whereas in the U S A routine screening by sonography or CT has been recommended and is being carried out in many centres. Regression of cystic disease has been demonstrated after successful transplantation. There have been no published clinical series in this country. We are in the process of carrying out renal CT in two patient groups. 1 Twenty-three patients who have been in haemodialysis for at least 5 years. 2 Twenty-one patients who were on haemodialysis for at least 5 years, but have subsequently had a successful renal transplantation for at least 5 years. The aim of the study is to demonstrate the prevalence of tumours and cysts, and to try and determine whether routine screening or long term dialysis patients is necessary.
ASSESSMENT OF ILEAL CONDUIT DIVERSIONS: IS INTRAVENOUS UROGRAPHY NECESSARY? K. K H A W and C. W. H E R O N
St George's Hospital, London Complications of ileal conduit diversions which may be detected radiologically include anastamotic leakage, stone formation, and recurrent tumour. These are rare and the most frequent long-term complication is hydronephrosis which is usually of obscure aetiology rather than obstructive. Intravenous urography (IVU) has been the primary investigation used to follow these patients. To date we have reviewed the IVUs of 30 patients with ileal conduits. In 25 patients surgery was performed for bladder carcinoma and the mean duration of follow-up was 34 months (range 6-84). Dilatation of the upper tracts was the only abnormality detected, occurring in three patients, none of whom had undergone an
CLINICAL RADIOLOGY
Measurements of aortic diameter on the M R images were obtained of the mid-ascending aorta and of the descending aorta in the same transverse slice. The minimal diameter of the isthmus was also measured and the severity of the stenosis was expressed as a ratio of the isthmal diameter to the mean diameters of the ascending and descending aorta. Six patients had gradients at catheterisation varying between 10 and 55 mmHg, and seven others had significant gradients on Doppler echocardiography: in these 13, the isthmal/aortic diameter ratio varied between 0.18 and 0.15 (mean 0.38). Fifteen patients had no gradient on Doppler or at catheterisation, of whom two had an aneurysm at the isthmus. The other 13 had isthmal/aortic diameter ratios of between 0.48 and 0.95 (mean 0.70). Of the remaining seven patients with no gradient measurements, all had ratios above 0.5 (mean 0.65) and were regarded as having a successful result. Three patients were found to have an aneurysm at the site of the Dacron patch inserted 17 and 18 years previously. In morphology they were different, one being saccular, one fusiform, and one was a dissection. Two have been resected and the patient with the dissection has been treated conservatively as a second scan showed no change over a period of a year. These results show that M R tomographic spin-echo images in transverse and oblique planes provide a reliable method of demonstrating aortic anatomy non-invasively and can confirm or exclude the presence of an aneurysm. Re-stenosis at the site of the repair can be predicted when the isthmal/aortic diameter ratio is below 0.5. MAGNETIC RESONANCE IMAGING OF STRESSED ANTERIOR CRUCIATE LIGAMENTS A. M. R I J K E and T. H. G O I T Z
University of Virginia Medical Center, Charlottesville, Va. 22908 USA In t h e diagnostic analysis of anterior cruciate ligament (ACL) injury, magnetic resonance imaging can provide conclusive evidence in cases of a complete rupture and in most cases of intact cruciates, but partial tears cannot be diagnosed with confidence. Poor visualisation, a wavy appearance of the anterior margin, or an increased low signal intensity at its origin may raise the suspicion of an A C L tear, but correlation with functional status has proved elusive. We have used a stress apparatus made of wood and epoxy that can maintain a 15 kPa pressure, applied to the posterior-upper aspects of the lower leg, throughout the 16 min scanning time. T~-weighted sagittal F L A S H and FISP sequences, using 1.5 mm slice thickness, show an elevation of the A C L in all cases for which a partial tear was subsequently confirmed by surgery. This information was correlated with the results of the physical examination and has assisted our orthopedic surgeons in their decision between conservative treatment and intra- or extra-articular reconstruction.
THE URETERIC CALCULUS AN ALTERNATIVE APPROACH TO VISUALISATION WITH LITHOTRIPSY IN MIND B. ROSS -
Royal Hallamshire Hospital, Sheffield A major drawback to ultrasound lithotripsy is the poor access to the ureters from conventional ultrasound windows and hence the poor reputation of the piezo-electric ESWL in ureteric calculi. The author has explored alternative sites and positions for access and suggests that over 50% of calculi in the mid ureter can be both visualised by ultrasound and hence be accessible to ultrasounddirected lithotripsy. This access is a major advance as it avoids the necessity to use push-back or ureteroscopic techniques with the inevitable anaesthetic. Results in the visualisation using alternative sites are presented, as are various ancillary techniques which assist in the visualisation and eventual destruction. Results of the application of piezo-electric lithotripsy to ureteric calculi will be presented.
PERCUTANEOUS STONE AND STENT REMOVAL IN RENAL TRANSPLANTS W. M. W. G E D R O Y C , D. MacIVOR, M. L. J O Y C E and H. M. SAXTON
Guy's Hospital, London Techniques for the percutaneous removal of stones from normally sited kidneys are well described and accepted. A modified per-
cutaneous technique may be employed in calculus removal from renal transplants, and we describe four cases (two stones, one stent and one organised, infected blood clot) in which we have used this procedure effectively and safely in removing the above material from renal transplant collecting systems. We also describe the precise methods and their modifications which we have found useful for the successful application of radio-endourological procedures in renal transplant patients. ACQUIRED RENAL CYSTIC DISEASE: THE ROLE OF ULTRASOUND IN SCREENING R. A. MANNS, F. G. O. B U R R O W S , D. A D U and J. M. M I C H A E L
Queen Elizabeth Hospital, Birmingham Some patients with end-stage renal failure develop multiple cysts within their native kidneys. The importance of this so-called 'acquired cystic disease of the kidney' is because of several well described complications which may ensue. These include retroperitoneal haemorrhage, infection, calculi, painless haematuria and the development of solid tumours. Our study using ultrasonic examination was, initially, to document the incidence of acquired cystic disease in the renal unit at the Queen Elizabeth Hospital, Birmingham. Fifty-one patients were examined and twenty-four of these were found to have Cysts. As the period of renal replacement treatment (dialysis and renal transplantation) increased so there was a corresponding increase in acquired cystic disease. A n important group whose native kidneys could not be identified by ultrasound are also discussed. The second part of the study examined a particular subgroup of endstage renal failure patients who had been on dialysis (either haemo- or peritoneal dialysis) for over 3 years. From established literature and our own initial study, these patients should have a very high incidence of acquired cystic disease.
COMPUTED TOMOGRAPHY OF ACQUIRED CYSTIC KIDNEY DISEASE IN LONG TERM HAEMODIALYSIS PATIENTS G. T H O M A S and C. E V A N S
Cardiff Royal Infirmary, University Hospital of Wales, Cardiff End-stage kidneys in patients undergoing long term haemodialysis are known to undergo cystic change. There is also an increased incidence of adenocarcinoma, these complications being first described in the U K in pathological studies. The kidneys of dialysis patients are not routinely examined in this country unless there are clinical symptoms, whereas in the U S A routine screening by sonography or CT has been recommended and is being carried out in many centres. Regression of cystic disease has been demonstrated after successful transplantation. There have been no published clinical series in this country. We are in the process of carrying out renal CT in two patient groups. 1 Twenty-three patients who have been in haemodialysis for at least 5 years. 2 Twenty-one patients who were on haemodialysis for at least 5 years, but have subsequently had a successful renal transplantation for at least 5 years. The aim of the study is to demonstrate the prevalence of tumours and cysts, and to try and determine whether routine screening or long term dialysis patients is necessary.
ASSESSMENT OF ILEAL CONDUIT DIVERSIONS: IS INTRAVENOUS UROGRAPHY NECESSARY? K. K H A W and C. W. H E R O N
St George's Hospital, London Complications of ileal conduit diversions which may be detected radiologically include anastamotic leakage, stone formation, and recurrent tumour. These are rare and the most frequent long-term complication is hydronephrosis which is usually of obscure aetiology rather than obstructive. Intravenous urography (IVU) has been the primary investigation used to follow these patients. To date we have reviewed the IVUs of 30 patients with ileal conduits. In 25 patients surgery was performed for bladder carcinoma and the mean duration of follow-up was 34 months (range 6-84). Dilatation of the upper tracts was the only abnormality detected, occurring in three patients, none of whom had undergone an