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Two Aids for Removal of Renal Calculi
0022-5347 /78/1206-0666$02. 00/0 Vol. 120, December
THE JOURNAL OF UROWGY
Printed in U.S.A.
Copyright © 1978 by The Williams & Wilkins Co.
TWO AIDS FOR REMOVAL OF RENAL CALCULI ROBERT A. ROTH* From the Department of Urology, Lahey Clinic Foundation, Boston, Massachusetts
ABSTRACT
A calibrated x-ray grid for intraoperative localization of renal calculi and a long, flexible calix irrigator used with an oral hygiene irrigator are described. The major goal of surgical procedures to remove renal calculi is complete removal of all calculous material. Complete removal usually is not a problem for the single renal pelvic calculus but can be difficult for staghorn calculi and for multiple or mobile small calculi. The most helpful aid to localize elusive calculi or fragments is the intraoperative radiogram. Boyce recently reviewed the subject in great detail.' For th1.,last several years we have relied on intraoperative radiograms using the Kodalith cassette. Because a good deal of time is often wasted by trying to orient the exposed radiographic film to the exposed kidney we modified the Hanley grid. 2 A stone localizing gridt was constructed of a
ing grid. Calculi, thus, can be localized to the exterior of the kidney in the anteroposterior plane (fig. 2, B). If desired the cassette and the grid can be placed perpendicular to this plane to locate calculi in the anterior or posterior calices. Further exploration via the renal pelvis or nephrotomy can then be done with a reasonable degree of accuracy. A preliminary radiogram of the kidney with the grid in place often is helpful before the calculous material is removed so that retained fragments can be compared to post-lithotomy radiograms. This technique also can be used with in situ pyelography to locate accurately caliceal diverticulum or to localize an area for partial nephrectomy (fig. 3).
Fm. 1. Calibrated stone grid and x-ray cassette
sheet of radiolucent polytetrafluoroethylene slightly larger than the Kodalith cassette (fig. 1). The non-reactive polytetrafluoroethylene was photoengraved in 1 cm. square cross marks with gold. Thicker solid lines are used to mark the lateral and upper pole of the kidney. The grid was placed between the kidney and the x-ray cassette (fig. 2, A) and standard intraoperative radiograms were made. The x-ray cassette was removed and the grid was left in place. The exposed film can then be compared accurately to the kidney and to the localizAccepted for publication March 29, 1978. * Requests for reprints: Department of Urology, Lahey Clinic Foundation, 605 Commonwealth Ave., Boston, Massachusetts 02215. t Tuzik Surgical Instruments, 82 Chicatabut St., Boston, Massachusetts 02122. 666
The second aid is a dental oral irrigator used to clear small fragments of calculi by vigorous pulsating saline irrigation. 3 We have used the Water-Pik routinely to irrigate the collecting system after removal of staghorn calculi or multiple small calculi. However, we were unable to place the irrigator into small infundibula or to direct it into calices because of the size and shape of the tip of the irrigator. Therefore, we have modified the tip by making a long, 14 cm. malleable irrigator, t which fits the standard irrigator connection hose. It can be bent to any desired shape and it can reach into the calices (fig. 4). Iced saline solution rather than saline at room temperature is used in conjunction with hypothermia and ischemia. Routine irrigation by this method helps to remove loose material in the caliceal fornices that otherwise might not be cleared.
TWO AIDS FOR REMOVAL OF RENAL CALCULI
667
FIG. 2. A, grid is placed between kidney and x-ray cassette. Polar tip and lateral border are aligned with heavy grid lines. Grid is left in place after film is removed. B, intraoperative radiogram with grid marks. Residual calculus is located by counting over 2 cm. from pole and 2 cm. from lateral border.
FIG. 3. Large parenchymal stone accurately localized with grid (left). Nephrotomy made over stone for complete removal (right)
FIG. 4. Flexible calix irrigator (left). Standard commercial Water-Pik irrigator (right) REFERENCES
1. Boyce, W. H.: The localization of intrarenal calculi during
surgery. J. Urol., 118: 152, 1977.
2. Hanley, H. G.: Flexible renal grid-sling for localising stones during lithotomy. Lancet, 1: 661, 1967. 3. Gibbons, R. P., Correa, R. J., Jr., Cummings, K. B. and Mason, J. T.: Use ofwater-pik and nephroscope. Urology, 4: 605, 1974.
THE JOURNAL OF UROWGY
Printed in U.S.A.
Copyright © 1978 by The Williams & Wilkins Co.
TWO AIDS FOR REMOVAL OF RENAL CALCULI ROBERT A. ROTH* From the Department of Urology, Lahey Clinic Foundation, Boston, Massachusetts
ABSTRACT
A calibrated x-ray grid for intraoperative localization of renal calculi and a long, flexible calix irrigator used with an oral hygiene irrigator are described. The major goal of surgical procedures to remove renal calculi is complete removal of all calculous material. Complete removal usually is not a problem for the single renal pelvic calculus but can be difficult for staghorn calculi and for multiple or mobile small calculi. The most helpful aid to localize elusive calculi or fragments is the intraoperative radiogram. Boyce recently reviewed the subject in great detail.' For th1.,last several years we have relied on intraoperative radiograms using the Kodalith cassette. Because a good deal of time is often wasted by trying to orient the exposed radiographic film to the exposed kidney we modified the Hanley grid. 2 A stone localizing gridt was constructed of a
ing grid. Calculi, thus, can be localized to the exterior of the kidney in the anteroposterior plane (fig. 2, B). If desired the cassette and the grid can be placed perpendicular to this plane to locate calculi in the anterior or posterior calices. Further exploration via the renal pelvis or nephrotomy can then be done with a reasonable degree of accuracy. A preliminary radiogram of the kidney with the grid in place often is helpful before the calculous material is removed so that retained fragments can be compared to post-lithotomy radiograms. This technique also can be used with in situ pyelography to locate accurately caliceal diverticulum or to localize an area for partial nephrectomy (fig. 3).
Fm. 1. Calibrated stone grid and x-ray cassette
sheet of radiolucent polytetrafluoroethylene slightly larger than the Kodalith cassette (fig. 1). The non-reactive polytetrafluoroethylene was photoengraved in 1 cm. square cross marks with gold. Thicker solid lines are used to mark the lateral and upper pole of the kidney. The grid was placed between the kidney and the x-ray cassette (fig. 2, A) and standard intraoperative radiograms were made. The x-ray cassette was removed and the grid was left in place. The exposed film can then be compared accurately to the kidney and to the localizAccepted for publication March 29, 1978. * Requests for reprints: Department of Urology, Lahey Clinic Foundation, 605 Commonwealth Ave., Boston, Massachusetts 02215. t Tuzik Surgical Instruments, 82 Chicatabut St., Boston, Massachusetts 02122. 666
The second aid is a dental oral irrigator used to clear small fragments of calculi by vigorous pulsating saline irrigation. 3 We have used the Water-Pik routinely to irrigate the collecting system after removal of staghorn calculi or multiple small calculi. However, we were unable to place the irrigator into small infundibula or to direct it into calices because of the size and shape of the tip of the irrigator. Therefore, we have modified the tip by making a long, 14 cm. malleable irrigator, t which fits the standard irrigator connection hose. It can be bent to any desired shape and it can reach into the calices (fig. 4). Iced saline solution rather than saline at room temperature is used in conjunction with hypothermia and ischemia. Routine irrigation by this method helps to remove loose material in the caliceal fornices that otherwise might not be cleared.
TWO AIDS FOR REMOVAL OF RENAL CALCULI
667
FIG. 2. A, grid is placed between kidney and x-ray cassette. Polar tip and lateral border are aligned with heavy grid lines. Grid is left in place after film is removed. B, intraoperative radiogram with grid marks. Residual calculus is located by counting over 2 cm. from pole and 2 cm. from lateral border.
FIG. 3. Large parenchymal stone accurately localized with grid (left). Nephrotomy made over stone for complete removal (right)
FIG. 4. Flexible calix irrigator (left). Standard commercial Water-Pik irrigator (right) REFERENCES
1. Boyce, W. H.: The localization of intrarenal calculi during
surgery. J. Urol., 118: 152, 1977.
2. Hanley, H. G.: Flexible renal grid-sling for localising stones during lithotomy. Lancet, 1: 661, 1967. 3. Gibbons, R. P., Correa, R. J., Jr., Cummings, K. B. and Mason, J. T.: Use ofwater-pik and nephroscope. Urology, 4: 605, 1974.