C-arm Fluoroscopic Guidance Research Articles

Management of complete ureteral obstructions with a transluminal puncture technique

The traditional delayed treatment of iatrogenic complete ureteral obstruction is open surgery. An easy endourological technique, transluminal re-canalization of the ureter by guide-wire puncture under fluoro-endoscopic control, which has been performed on 4 patients, is described. With the guidance of C-arm fluoroscopy, by moving the C-arm to different planes, the tip of the ureteroscope is directed to the correct plane to meet the obliterated proximal end of the ureter and under direct vision, transluminal puncture is performed using the stiff end of a 0.035-inch guide wire. Once the stiff end of the guide-wire is in the lumen of the proximal ureter, an ureteral catheter is introduced over the guide wire, the guide wire is then removed and reinserted through the ureteral catheter with its soft end leading and a double J catheter is inserted. Ureteral stricture, if later encountered, is treated with balloon dilatation. Continuity of the ureter was restored in all 4 patients. The double J stents were removed 6 weeks later and a retrograde pyelography revealed resolution of the hydronephrosis without extravasation of urine. Although a very satisfactory result was achieved in our cases, more cases are needed to show if it can be an alternative to conventional surgical repair. However, we believe that this minimally invasive technique can be used for short obliterated ureteral segments and neither delays nor does it preclude further management using open surgery.

Clinical Efficacy of Ramus Communicans Nerve Block in Patient with Vertebral Compression Fracture

Background: Vertebral compression fractures can cause severe mechanical pain in spite of conservative treatments. Although vertebroplasty is an effective treatment for vertebral compression fractures, it is not strongly indicated in some patients. This study was performed to verify the usefulness of ramus communicans nerve block in patients suffering from back pain due to a vertebral compression fracture. Methods: A randomized clinical trial was carried out in 34 patients with a vertebral compression fracture after conservative therapy had failed. Nerve blocks on the ramus communicans corresponding to vertebral compression fracture were performed once a week for 2 consecutive weeks under C-arm fluoroscopic guidance. The pain scores were evaluated before and after each nerve block using a 100 mm VAS (visual analog scale), and the side effects were also checked. Results: All patients tolerated the procedures well. The VAS pain scores were significantly lower than that at the baseline (P

Fluoroscopy Guided Retrograde Ureteral Stent Insertion in Patients With a Ureteroileal Urinary Conduit: Method and Results

We evaluated retrograde double pigtail stent placement in patients with ureteroileal anastomosis. Procedures were performed under digital C-arm fluoroscopic guidance and the patient under sedation analgesia. Radiography of the conduit was done to delineate urinary diversion anatomy and identify ureteral reflux. A purpose designed, angled tip catheter was used to direct a straight glide wire across the ureteroileal anastomosis. The glide wire was exchanged for a stiff guide wire for stent placement. We retrospectively evaluated the clinical records of 7 men and 5 women with a mean age of 54.3 years in a 7-year period. In 11 patients a new stent was placed because of ureteroileal stricture in 5, anastomotic leakage in 3, ureterolithiasis in 2 and recurrent malignancy in 1. New stent placement was successful in 10 of the 11 patients (90.9%, 13 of 16 ureters or 81.3%). Stent placement was successful in the 8 ureters in which reflux was noted on radiography of the conduit and in 5 of the 9 (55.6%) in which no reflux was noted. Stent replacement was accomplished in all 22 ureters (6 patients) in which it was attempted. Mean radiological screening time for new stent placement was 13.3 minutes (range 4.7 to 19.7), while for exchange it was 6.4 minutes (range 0.8 to 15.1). There were no immediate complications. This technique represents a useful approach to the ureter and should be considered an alternative to percutaneous nephrostomy and surgical revision. The approach is also useful for other ureteral procedures, including stone or migrated stent retrieval.

Early endoscopic realignment as primary therapy for complete posterior urethral disruptions.

We assessed the outcome of early endoscopic realignment of posterior urethral disruptions. We evaluated six patients who underwent early or delayed endoscopic realignment for the disrupted posterior urethra over a 3-year period. C-Arm fluoroscopy guidance and orientation in two planes were used as necessary. Potency, restructure rates, and continence were assessed in addition to hospital length of stay, intraoperative blood loss, and uroflow. The collective results of ten publications were also reviewed. In the present study, all of the six patients were continent. One had diminished erectile capability, and four required subsequent internal urethrotomies. Evaluation of the cumulative data (including the present study) showed an overall 9% incontinence rate, 60% potency rate, and 54% restricture rate. Endoscopic realignment of the disrupted posterior urethra is a minimally invasive procedure with results comparable to those of open delayed urethroplasty. Early and delayed repairs have been applied with similar results, the former being advocated in patients who are medically and orthopedically stable. Hospital stay, loss of work, morbidity, and related complications are also markedly decreased with early endoscopic realignment.

Endoscopic Management of Traumatic Posterior Urethral Stricture: Early Results and Followup

We assessed the outcome of core through internal urethrotomy for traumatic posterior urethral stricture, and reviewed the followup results of these patients. During the last 4 years 13 patients with a stricture up to 2 cm. long underwent core through internal urethrotomy with C-arm fluoroscopy guidance and an orientation in 2 planes. Retrograde urethrotomy was performed and an 18F Foley catheter was left indwelling for 4 weeks, after which urethrotomy was repeated. All patients were advised to perform clean intermittent self-catheterization for urethral calibration and dilation. Outcome was defined as class 1-3 patients who required 2 or fewer urethrotomies with clean intermittent self-catheterization discontinued after the primary procedure, class 2-5 who required 2 or fewer urethrotomies with clean intermittent self-catheterization and class 3-5 who required 3 or more urethrotomies. Of the 13 patients 8 (61%) did well after a mean followup of 17.7 months. The 3 patients with a class 1 outcome did well, while 2 of 5 with a class 2 outcome required repeat urethrotomy during followup. Of the 5 patients (39%) with a class 3 outcome in whom core through internal urethrotomy failed 3 required open surgery and 2 were lost to followup. Recurrence rate was 69% at 3 months and 25% at 12 months after the initial procedure. No patient was incontinent at last followup. Two patients had significant hematuria postoperatively, which resolved with conservative treatment. Endoscopic treatment should be considered the first line procedure for all post-traumatic posterior urethral strictures. The morbidity of open surgery can be avoided in 61% of patients. Hospital stay, loss of work, morbidity and related complications are also markedly decreased with endoscopic therapy.

Emergency Percutaneous Nephrostomy: Results and Complications

Percutaneous nephrostomy is a well-established standardized procedure in the management of patients with various urologic problems. The goal of this study was to evaluate the effectiveness and safety of percutaneous nephrostomy in an emergency setting. Emergency percutaneous nephrostomy was performed in 160 patients with ages ranging from 2 to 89 years (mean, 52 years). Access to the kidney was planned and achieved with C-arm fluoroscopic guidance. The initial technical success rate was 98%. Overall complication rate was 34%; 6% were major and 28% were minor. Major procedure-related complications, including sepsis, occurred in 6% of patients. Hematuria requiring transfusion was noted in 2.4% of patients. Minor complications included catheter displacement or malposition (4.8%), pelvic perforation (4.3%), paralytic ileus (2.4%), pneumonia/atelectasis (1.8%), and pleural effusion (1.2%). High-risk patients included those with diabetes, hypertension, and obesity. No deaths or significant morbidity resulted from any complication. Emergency percutaneous nephrostomy under fluoroscopic guidance is a simple, safe, and effective procedure and should be offered in all suitably equipped radiology departments.