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Sensitive method for intraoperative roentgenograms
SENSITIVE
METHOD
FOR INTRAOPERATIVE
ROENTGENOGRAMS R. A. FELDMAN, J. K. SHEARER, D. E. SHIELD, H. V. CHASE,
M.D. M.D. M.D.
M.D.
From the Departments of Urology and Radiology, Waterbury Hospital, Waterbury, and the Department of Urology, Yale University School of Medicine, New Haven, Connecticut
film has been developed. A portable x-ray - A new technique using mammography machine and mammographic jilm has been used to obtain excellent intraoperative radiographs of renal calculi. The kidney is exposed through a&nk incision. The jilm is cut to a size and shape that will permit an easy $t behind the kidney. Exposed film is developed in an automatic processor. This technique has facilitated location and removal of small calculi and faintly opaque calculi. Uric acid stones have been demonstrated in vitro. It is an inexpensive technique that requires no special equipment.
ABSTRACT
Complete removal of calculi or residual stone fragments during nephro- or pyelolithotomy is a constant and difficult problem for the urologist. l Retained fragments are the most common cause of recurrent calculi. Despite extended pyelolithotomy and nephroscopy, visualization of every portion of the kidney and collecting system is difficult and location of all stone fragments is sometimes impossible. Intraoperative, in situ x-ray photographs serve to localize the retained fragments, aid in their removal and finally determine when all the stones have been extracted.’ Conventional, cassette x-ray photographs and those especially designed for intraoperative use during stone surgery, have not been helpful in our hands, therefore, the following technique has been developed. Linke et a1.3 have reported a very similar technique. This article goes into further detail regarding the methods and demonstrates several sets of x-ray photographs (Figs. 1 to 3). Mammography film has been used. It is an easily applicable technique and provides high resolution with low radiation exposure. Mammography film is very sensitive and is designed
UROLOGY
I
JUNE 1977 / VOLUME
IX, NUMBER
6
to demonstrate differences in soft tissue density.4 The visualization of the stone is even clearer than conventional preoperative x-ray photographs. Uric acid calculi have been demonstrated in vitro with this technique. Uric acid stones were placed in a cadaver kidney and x-ray photographs were taken using the mammography film under conditions similar to those found in the operating room. Material and Methods Mammography film is contained in a thin, pliable envelope. It can be cut to an appropriate size and shape in the dark room prior to surgery. The cut edges of the envelope containing the film are folded and taped to prevent a light leak. The film is placed in a sterile plastic bag, thus obviating the need for prior sterilization. The kidney is extensively mobilized to insure adequate visualization, and its position is maintained with tape or sponge forceps. With the film applied to the posterior surface of the kidney, a portable x-ray machine can be used, and the exposed film developed in an automatic processor. Optimal exposures on the x-ray
695
FIGURE 1. Case 1. (A) Preoperative roentgenogram. (B) Sequential intraoperative mammograph views akmonstrating remaining calculi and their sequential removal; note surgical clips and needles used to help localize these fragments. Last film demonstrates stone-free kidney.
FIGURE 2. Case 2. (A) Preoperative roentgenogram demonstrating poorly opac$ed renal calculus. (B) Films showing remnant calculus and, finally, stone-free kidney.
UROLOGY
I JUNE1977
I VOLUMEIX,
NUMBER6
Case 3. (A) Preoperative roentgenogram. (B) Well-demonstrated FIGURE 3. ^ _* 1 _ culus; adjacent to this is stone-free kidney with surgical clips in place.
machine should be determined preoperatively. The best results were obtained at two seconds, 100 ma., 40 kv., and a tube to kidney distance of 12 to 18 inches. Case Abstracts Case 1
A forty-year-old female had hyperparathyroidism and large radiopaque stones bilaterally. Surgery was indicated because of the size of the stones and progressive obstruction. By using our technique, we were able to extract the multiple small calculi, rather than sacrifice functional renal parenchyma and perform a lower pole nephrectomy (Fig. 1). Case 2 A thirty-six-year-old female was seen with flank pain, fever, and sepsis. She had a known complex infectious stone. These are often of low, radiographic density as is evident from the roentgenogram (Fig. 2A). However, they are easily seen using the mammography film. The final film shows a stone-free kidney (Fig. 2B).
UROLOGY /
JUNE 1977 /
VOLUME IX, NUMBER 6
kidney with large staghorn cal-
Case 3
This fifty-five-year-old female had a known staghom calculus for many years and had suffered recurrent episodes of flank pain and fever. The mammography film clearly shows the ramifications of these calculi and document its complete removal (Fig. 3). Urological Associates of Waterbury 1211 West Main Street Waterbury, Connecticut 06708 (DR. FELDMAN) ACKNOWLEDGMENT. To Nancy Moschella, technical assistance.
R.T.,
for
References SINGH, M., TRESSIDER, M. D., and BLANDY, J.: The long term results of removal of staghorn calculi by extended pyelolithotomy without cooling or renal artery occlusion, Br. J. Urol. 43: 658 (1971). BECK, A. D.: Intraoperative radiography in conservative surgery for renal calculi, J. Urol. 110:494 (1973). LINKE, C. A., ROGOFF, S. M., LIND, B., and FFUDD, C. W. : Intraoperative roentgenograms of kidney, Urology 3: 28 (1974). PECK, D. R., and LOWMAN,R. M.: Mammography an appraisal, Conn. Med. 38: 103 (1974).
697
METHOD
FOR INTRAOPERATIVE
ROENTGENOGRAMS R. A. FELDMAN, J. K. SHEARER, D. E. SHIELD, H. V. CHASE,
M.D. M.D. M.D.
M.D.
From the Departments of Urology and Radiology, Waterbury Hospital, Waterbury, and the Department of Urology, Yale University School of Medicine, New Haven, Connecticut
film has been developed. A portable x-ray - A new technique using mammography machine and mammographic jilm has been used to obtain excellent intraoperative radiographs of renal calculi. The kidney is exposed through a&nk incision. The jilm is cut to a size and shape that will permit an easy $t behind the kidney. Exposed film is developed in an automatic processor. This technique has facilitated location and removal of small calculi and faintly opaque calculi. Uric acid stones have been demonstrated in vitro. It is an inexpensive technique that requires no special equipment.
ABSTRACT
Complete removal of calculi or residual stone fragments during nephro- or pyelolithotomy is a constant and difficult problem for the urologist. l Retained fragments are the most common cause of recurrent calculi. Despite extended pyelolithotomy and nephroscopy, visualization of every portion of the kidney and collecting system is difficult and location of all stone fragments is sometimes impossible. Intraoperative, in situ x-ray photographs serve to localize the retained fragments, aid in their removal and finally determine when all the stones have been extracted.’ Conventional, cassette x-ray photographs and those especially designed for intraoperative use during stone surgery, have not been helpful in our hands, therefore, the following technique has been developed. Linke et a1.3 have reported a very similar technique. This article goes into further detail regarding the methods and demonstrates several sets of x-ray photographs (Figs. 1 to 3). Mammography film has been used. It is an easily applicable technique and provides high resolution with low radiation exposure. Mammography film is very sensitive and is designed
UROLOGY
I
JUNE 1977 / VOLUME
IX, NUMBER
6
to demonstrate differences in soft tissue density.4 The visualization of the stone is even clearer than conventional preoperative x-ray photographs. Uric acid calculi have been demonstrated in vitro with this technique. Uric acid stones were placed in a cadaver kidney and x-ray photographs were taken using the mammography film under conditions similar to those found in the operating room. Material and Methods Mammography film is contained in a thin, pliable envelope. It can be cut to an appropriate size and shape in the dark room prior to surgery. The cut edges of the envelope containing the film are folded and taped to prevent a light leak. The film is placed in a sterile plastic bag, thus obviating the need for prior sterilization. The kidney is extensively mobilized to insure adequate visualization, and its position is maintained with tape or sponge forceps. With the film applied to the posterior surface of the kidney, a portable x-ray machine can be used, and the exposed film developed in an automatic processor. Optimal exposures on the x-ray
695
FIGURE 1. Case 1. (A) Preoperative roentgenogram. (B) Sequential intraoperative mammograph views akmonstrating remaining calculi and their sequential removal; note surgical clips and needles used to help localize these fragments. Last film demonstrates stone-free kidney.
FIGURE 2. Case 2. (A) Preoperative roentgenogram demonstrating poorly opac$ed renal calculus. (B) Films showing remnant calculus and, finally, stone-free kidney.
UROLOGY
I JUNE1977
I VOLUMEIX,
NUMBER6
Case 3. (A) Preoperative roentgenogram. (B) Well-demonstrated FIGURE 3. ^ _* 1 _ culus; adjacent to this is stone-free kidney with surgical clips in place.
machine should be determined preoperatively. The best results were obtained at two seconds, 100 ma., 40 kv., and a tube to kidney distance of 12 to 18 inches. Case Abstracts Case 1
A forty-year-old female had hyperparathyroidism and large radiopaque stones bilaterally. Surgery was indicated because of the size of the stones and progressive obstruction. By using our technique, we were able to extract the multiple small calculi, rather than sacrifice functional renal parenchyma and perform a lower pole nephrectomy (Fig. 1). Case 2 A thirty-six-year-old female was seen with flank pain, fever, and sepsis. She had a known complex infectious stone. These are often of low, radiographic density as is evident from the roentgenogram (Fig. 2A). However, they are easily seen using the mammography film. The final film shows a stone-free kidney (Fig. 2B).
UROLOGY /
JUNE 1977 /
VOLUME IX, NUMBER 6
kidney with large staghorn cal-
Case 3
This fifty-five-year-old female had a known staghom calculus for many years and had suffered recurrent episodes of flank pain and fever. The mammography film clearly shows the ramifications of these calculi and document its complete removal (Fig. 3). Urological Associates of Waterbury 1211 West Main Street Waterbury, Connecticut 06708 (DR. FELDMAN) ACKNOWLEDGMENT. To Nancy Moschella, technical assistance.
R.T.,
for
References SINGH, M., TRESSIDER, M. D., and BLANDY, J.: The long term results of removal of staghorn calculi by extended pyelolithotomy without cooling or renal artery occlusion, Br. J. Urol. 43: 658 (1971). BECK, A. D.: Intraoperative radiography in conservative surgery for renal calculi, J. Urol. 110:494 (1973). LINKE, C. A., ROGOFF, S. M., LIND, B., and FFUDD, C. W. : Intraoperative roentgenograms of kidney, Urology 3: 28 (1974). PECK, D. R., and LOWMAN,R. M.: Mammography an appraisal, Conn. Med. 38: 103 (1974).
697