Intermittent Fluoroscopy Research Articles

The Combination of Laparoscopy and Nephroscopy for Treatment of Stones in Pelvic Ectopic Kidneys

Introduction: Minimally invasive treatment modalities for patients with large stone burden within pelvic kidneys present a special challenge. Interposing bowel loops between the kidney and the anterior abdominal wall, abnormalities in the vascular supply, and mal-rotation of the caliceal system are reasons of difficulties in percutaneous nephrolithotomy (PNL). Minimally invasive treatment modalities of large stones in ectopic pelvic kidneys have included pure laparoscopic pyelolithotomy,1–3 laparoscopy-assisted PNL,4–7 and ultrasound-guided PNL.8 These are attractive treatment options because they have the advantages of reduced analgesic requirement, shorter hospital stay, early convalescence, and better cosmoses in addition to high safety and efficacy profiles. The combination of laparoscopic and percutaneous approaches allows the establishment of the percutaneous tract into the kidney under direct vision, thus avoiding the risk of injury to abdominal viscera and blood vessels. This video presents the technique of the combination of laparoscopy and nephroscopy for treatment of stones in pelvic ectopic kidneys. Patients and Methods: The study included seven men and four women (mean age, 43 ± 9 years). Laparoscopy-assisted PNL was performed for caliceal stones in five patients after failure of shockwave lithotripsy. Laparoscopic pyelolithotomy was performed for six patients with large or branched renal pelvic stones. The patient was placed in the Trendelenburg position with slight lateral elevation of the side to be operated. In laparoscopy-assisted PNL the primary surgeon stands on the same side of the affected kidney and the assistant on the opposite side, whereas in laparoscopic pyelolithotomy the surgeon stands on the opposite side of the affected kidney. Three or four transperitoneal ports were placed in a fan-shaped distribution. The stone or the renal pelvis was identified using intraoperative fluoroscopy. Intermittent fluoroscopy was used to identify the point of entry to the desired calix during dilatation and during fixation of the nephrostomy tube. Results: The average preoperative stone length was 3 ± 1 cm (range, 1.1–4.2). There were some adhesions between the intestinal loops and the peritoneum on the anterior surface of the kidney in three patients (27%). There were neither intraoperative nor postoperative complications, and conversion to open surgery was not required. The mean hospital stay was 3.5 ± 0.7 days (range, 2–4). The stone-free rate was 91% as all stones were removed completely in 10 patients, whereas 1 patient had residual caliceal fragment that was treated with shockwave lithotripsy. After a mean follow-up of 27 ± 6 months, two out of the five patients who underwent laparoscopy-assisted PNL showed stone recurrence and were treated with extracorporeal shockwave lithotripsy. Conclusion: The combination of laparoscopy and nephroscopy for treatment of stones in pelvic kidneys is feasible, safe, and effective. The authors has nothing to disclose. Runtime of video: 8 min 24 sec

Accuracy of Live Fluoroscopy to Detect Intravascular Injection During Lumbar Transforaminal Epidural Injections

BackgroundComplications following lumbar transforaminal epidural injection are frequently related to inadvertent vascular injection of corticosteroids. Several methods have been proposed to reduce the risk of vascular injection. The generally accepted technique during epidural steroid injection is intermittent fluoroscopy. In fact, this technique may miss vascular uptake due to rapid washout. Because of the fleeting appearance of vascular contrast patterns, live fluoroscopy is recommended during contrast injection. However, when vascular contrast patterns are overlapped by expected epidural patterns, it is hard to distinguish them even on live fluoroscopy.MethodsDuring 87 lumbar transforaminal epidural injections, dynamic contrast flows were observed under live fluoroscopy with using digital subtraction enhancement. Two dynamic fluoroscopy fluoroscopic images were saved from each injection. These injections were performed by five physicians with experience independently. Accuracy of live fluoroscopy was determined by comparing the interpretation of the digital subtraction fluoroscopic images.ResultsUsing digital subtraction guidance with contrast confirmation, the twenty cases of intravascular injection were found (the rate of incidence was 23%). There was no significant difference in incidence of intravascular injections based either on gender or diagnosis. Only five cases of intravascular injections were predicted with either flash or aspiration of blood (sensitivity = 25%). Under live fluoroscopic guidance with contrast confirmation to predict intravascular injection, twelve cases were predicted (sensitivity = 60%).ConclusionsThis finding demonstrate that digital subtraction fluoroscopic imaging is superior to blood aspiration or live fluoroscopy in detecting intravascular injections with lumbar transforaminal epidural injection.

Extracorporeal Shockwave Lithotripsy: Initial Experience at Bahawalpur

Place of Study: American Kidney Stone Centre (AKSC), Bahawalpur, a private setup.Duration of Study: January 2005 to June 2007.Design of Study: Prospective, Observational.Material & Methods: A total of 250 patients were evaluated for ESWL results. The one session comprised of 1500-2500shocks with intermittent fluoroscopy with X-Ray focusing. A period of 7 – 10 days was given between two sessions. Theprocedure was repeated till the clearance of stone no matter what was the number of sessions. The complications like pain,colic, hematuria were addressed adequately and immediately. The development of steinstrasse was initially observed and fewrequired manipulation. The stone size is the only matter of concern in few patients especially lower pole stones.Results: The stone clearance was achieved in 89% of patients. Auxillary procedures were required in 10.8% before ESWLand 9.6% of patients after ESWL. Which include Endoscopic stenting and manipulation with uretero-renoscopy andintracorporeal lithotripsy. Prophylactic insertion of DJ stenting reduced complication rate and incidence of steinstrasse.Conclusion: ESWL can be safely recommended for patients of urolithiasis irrespective of age and stone size with promisingresults of stone clearance and patient acceptance.Key Words: ESWL-Extracorporeal shock wave lithotripsy, URS-Ureterorenoscopy. ICL-Intracorporeal lithotripsy.

Accuracy of Intermittent Fluoroscopy to Detect Intravascular Injection During Transforaminal Epidural Injections

Prospective validity study. To determine how accurately intermittent fluoroscopy detects inadvertent intravascular injection during transforaminal epidurals. Serious morbidity caused by transforaminal epidural injections is frequently related to inadvertent vascular injection of corticosteroids. Several methods have been proposed to reduce the risk of vascular injection, but none have demonstrated efficacy. Because of the fleeting appearance of vascular contrast patterns, live fluoroscopy is recommended during contrast injection. Despite this, many practitioners continue to use intermittent fluoroscopy. During 50 epidural injections dynamic contrast flow was observed under live fluoroscopy, and the "dynamic true" image was determined. Two intermittent fluoroscopy images were saved from each injection, the first just before completing the contrast injection ("static C" image), and another 1 second after the contrast injection ceased ("static PC" image). Five physicians with experience performing these injections independently interpreted the 100 randomly ordered static images. Accuracy of intermittent fluoroscopy was determined by comparing the interpretation of the 100 static images with the dynamic true patterns observed under live fluoroscopy. Overall, interpretation of the static images missed 57% of the vascular injections. Timing of the static images influenced accuracy with the static C images missing 50% of vascular injections, and the static PC images missing 68% of vascular injections (P = 0.075). Accuracy was significantly worse when vascular injections occurred simultaneous to the expected epidural injection (P = 0.041), and in lumbar images (P = 0.012). Based on these findings, we recommend use of live fluoroscopy to observe dynamic contrast flow during transforaminal epidural steroid injections.

Intravascular Injection in Lumbar Medial Branch Block: A Prospective Evaluation of 1433 Injections

The successful outcome and validity of lumbar medial branch block (MBB) are largely dependent on technique accuracy. Intravascular uptake of injectate causes a false-negative response to block and is associated with various possible complications. In the current study, we prospectively evaluated the incidence of, and the factors associated with, intravascular injection during block. In addition, we assessed the efficiencies of generally accepted safety measures, such as preinjection aspiration and intermittent fluoroscopy to avoid intravascular injections. We prospectively examined 1433 lumbar MBBs in 456 patients performed by seven physicians. Aspiration test, spot radiography, and contrast injection under real-time fluoroscopic visualization were performed sequentially without repositioning the needle. Incidences of blood flashback and the presence of intravascular contrast spread on spot radiographic images and during real-time fluoroscopy were checked. The factors studied for intravascular injection included physician experience, patient age and sex, needle gauge, and block spinal level. No specific factors were found to affect the incidence of intravascular uptake during block. The overall incidence of intravascular uptake was 6.1% per nerve block (88/1433), and 30 of these were predicted by preinjection aspiration (sensitivity = 34.1%) and 52 by spot radiography (sensitivity = 59.1%). The aspiration test with or without spot radiography frequently missed the intravascular uptake of contrast during lumbar MBBs. We strongly advocate the use of real-time fluoroscopy during contrast injection to increase diagnostic and therapeutic value and to avoid possible complications.

Incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections

The incidence of vascular penetration during contrast confirmed fluoroscopically guided transforaminal lumbosacral epidural injections has been reported as 8.9% to 21.3% depending on the level of injection. Recently, intermittent fluoroscopy was shown to miss more than half of the vascular injections observed under live fluoroscopy. The number of misses increased when epidural and vascular contrast flow appeared simultaneously, even if the fluoroscopic image was taken during contrast injection. To date, no studies have documented the incidence of simultaneous epidural and vascular contrast injections. Also, most previous studies of vascular injections did not document use of live fluoroscopy during contrast injection, so the incidence of vascular injections may be higher than reported. To determine the incidence of simultaneous epidural and vascular contrast injection during lumbosacral transforaminal epidural injections. A prospective, observational, in vivo, study. Patients receiving lumbar transforaminal epidural injections at a university-based outpatient spine center. Incidence of epidural, vascular, and simultaneous epidural and vascular contrast patterns. One interventional spine physician and three fellows under his direct supervision recorded contrast patterns observed during 191 fluoroscopically guided lumbosacral transforaminal epidural steroid injections with injection of contrast observed under live fluoroscopy. The incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections was 8.9%. The incidence of a vascular injection alone was 4.2%, for a total vascular injection incidence of 13.1%. Subjects with a simultaneous epidural and vascular injection who returned for repeat injection had a statistically significant chance of a repeat simultaneous epidural and vascular injection when the injection was done at the same location. Fluoroscopy time was significantly increased, an average of 8.8 seconds, when a vascular injection was identified. There was no statistically significant correlation between the incidence of simultaneous epidural and vascular injection with subjects' age, sex, level of injection, side of injection, needle gauge, or diagnosis. Simultaneous epidural and vascular injection is twice as likely to occur as vascular injection alone. Use of intermittent fluoroscopy can miss the transient appearance of the vascular component of these injections, giving the false impression of successful contrast placement. In light of these results, live fluoroscopy is recommended during contrast injection for confirmation of lumbosacral transforaminal epidural injections.

PR_198: Accuracy of Intermittent Fluoroscopy to Detect Intravascular Injection During Transforaminal Epidural Injections

Objective: To determine how accurately intermittent fluoroscopy detects accidental intravascular injection during transforaminal epidurals. Design: Comparison of intermittent verses live fluoroscopy. Setting: University spine clinic. Participants: 5 physiatrist interventionists independently interpreted 100 images from cervical and lumbar transforaminal epidural injections. Intervention: For each epidural, a 0.5mL contrast was injected under live dynamic fluoroscopy, and 2 images were saved. The first image, or “contrast” image, was saved just before completing the 0.5mL injection. The second image, or postcontrast image, was taken 1 second after contrast injection. The “true” contrast pattern was determined under live fluoroscopy at the time of each injection and classified as: epidural only, vascular only, simultaneous epidural and vascular, or nonepidural. All saved images were randomly presented to 5 interventionists not present during the injections. They were told to assume 0.5mL of contrast injection and asked to identify each image with any or all of 3 potential contrast patterns: epidural, nonepidural, and/or vascular. Main Outcome Measures: Accuracy of intermittent fluoroscopy was determined by comparing patterns identified in the saved images with the “true” contrast patterns. Results: On average, vascular contrast patterns were correctly identified in 50% of contrast and 32% of postcontrast images. When epidural and vascular injection occurred simultaneously, the vascular component was identified in 46% of contrast and 26% of postcontrast images. Overall, interpretation of contrast and postcontrast images accurately described the true pattern observed under live dynamic fluoroscopy in 43% of the images. Conclusions: The reported incidence of vascular penetration during transforaminal epidural injections is between 8.1% and 21.3%. Intermittent fluoroscopy will miss from 50% to 74% of these accidental vascular injections, depending on when the image is obtained and if the vascular injection occurs simultaneous to epidural injection. Live dynamic fluoroscopy during contrast injection is recommended to avoid vascular injection.

Cervical Epidural Steroid Injection: Impact of Cervical Epidural Anatomy

Dr. Aldrete wonders how the fusiform anterior epidural mass got there. We postulate that shortly after the first epidural steroid injection, a granulomatous response occurred with thickening of the dura; after the second block, the patient was becoming more symptomatic because of the increasing size of the mass. Superiorly, the inflammation from the mass extended through the foramen magnum, accounting for the postural component of the headaches, so-called axial loading. Inferiorly, the anatomy became distorted from the swelling and mass effect, predisposing to the “lightning bolt” paraesthesia and dural puncture during the third block. The procedure was not aborted, allowing triamcinolone and its preservative to gain access into the subarachnoid space with resultant arachnoiditis. The dural tear did not leak substantial amounts of cerebrospinal fluid until the overall swelling and mass effect of the granuloma lessened many months later. This led to “secondary” intracranial hypotension, which accounted for the incapacitating postural headaches. We suspect that the mass was caused by the preservative in the triamcinolone acetonide (Kenalog; Bristol-Myers Squibb, Princeton, NJ) and not the steroid itself, but there is no way of knowing. The only way to know what the mass was composed of would be to obtain a biopsy, which would involve opening up the dura. This was not performed during surgery because of the risks involved. Injection of triamcinolone acetonide should have been aborted during the third cervical epidural steroid injection (CESI) block in our patient because of suspicion of wet tap due to the paresthesia with radicular irritation.As far as the technical aspects of CESI, there is no clear consensus as to the superiority of one approach over another (e.g. , prone vs. sitting, use of fluoroscopy, transforaminal vs. interlaminar). In academic practices, the most common position used for CESI was prone (46%), followed by sitting (35%) and lateral decubitus (10%).1Only 39% of academic institutions reported use of fluoroscopy for CESI.1At our institution, the transforaminal approach is preferred (Mohan Kareti, M.D., Assistant Professor, Director of Pain Management, Department of Anesthesia, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, verbal communication, May 2004). This approach can be used at nearly any level. The position for transforaminal injection is supine, with fluoroscopy on anterior-posterior and lateral views to confirm proper needle position. Aspiration is performed, and dye is injected to confirm epidural flow and to rule out intravascular (intraarterial), intrathecal, or soft tissue infiltration. For the interlaminar approach, injections are performed below C7, with the patient in the prone position.The current patient’s blocks were performed at an outside hospital, with the patient in the sitting position without head support, using a hanging drop method and intermittent fluoroscopy. Dr. Mchaourab reminds us that there is virtually no cervical posterior epidural space above C7.2,3Perhaps this unfortunate complication might have been avoided had the epidural been performed at a lower level. As mentioned by Dr. Aldrete, there is no solid evidence that depositing the steroid medication precisely at the level where pathologic findings have been reported produces better results than if injected one or two spaces away.Although the patient did have low-lying cerebellar tonsils 7 months after CESI as part of her constellation of symptoms and signs of intracranial hypotension, she did not have a Chiari I malformation as suggested by Dr. Aldrete at the time of the initial CESIs. “Sinking” or “sagging” of the brain is a common finding in patients with intracranial hypotension and may mimic type I Chiari malformation.4Fibrin glue, a mixture of fibrinogen, factor XIII, fibronectin, aprotinin, plasminogen, thrombin, and calcium, has a high tensile strength, tolerates moist environments, and forms a temporary biologic dural seal until healing occurs.5Fibrin glue is widely used in neurosurgery and otology to achieve watertight dural closure.6Regarding the long-term safety of fibrin glue, the patient is doing fine 17 months after surgery, the mass has regressed, the symptoms of intracranial hypotension have resolved, and the patient has returned to her former position as an attending anesthesiologist.* MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio. csmith@metrohealth.org

Management of difficult common bile duct stones.

More than 80% of all CBD stones can be effectively treated by endoscopic sphincterotomy and stone extraction using baskets or balloon catheters. For stones up to 2.5 cm in diameter, mechanical lithotripsy is the method of choice as a next step. Very large, impacted, or very hard concretions, however, often make mechanical lithotripsy cumbersome or even impossible. For these stones laser lithotripsy, EHL, and ESWL are nonoperative options, especially for elderly patients and patients with an elevated surgical risk. Because these methods are often only available at endoscopic centers, stenting is a treatment modality for immediate stone therapy, but as a definitive treatment it should be restricted to selected cases. ESWL, EHL, and laser lithotripsy yield similar success rates of 80% to 95% and may be used complementarily in endoscopic centers. ESWL is the preferred therapy in intrahepatic lithiasis. Laser lithotripsy shows the best results in CBD stones. Electrohydraulic lithotripsy is rarely used because of its high potential for tissue damage and bleeding. Laser lithotripsy using smart laser systems such as the rhodamine 6G dye laser and the FREDDY laser system can simplify the treatment of these difficult bile duct stones. The rhodamine 6G-dye laser allows blind fragmentation of these stones by exclusive insertion of a 7-F metal marked standard catheter into the bile duct by standard duodenoscopes using intermittent fluoroscopy. An oSTDS safely cuts off the laser pulse if contact with the stone is lost, thus preserving the bile duct from potential damage. Unfortunately the system is no longer produced. The new FREDDY laser lithotriptor with a piezoacoustic stone/tissue discrimination system offers an alternative to the rhodamine 6G dye laser system at less than half the financial investment. Effective stone fragmentation is accompanied by only low tissue alteration. The holmium:YAG laser is an effective multidisciplinary lithotriptor, but it can be used only under cholangioscopic control, limiting its use to gastroenterologic centers.

Role of Digital Subtraction Fluoroscopic Imaging in Detecting Intravascular Injections

Complications of unintended intravascular penetration and subsequent injection of local anesthetics and/or other drugs occasionally are devastating. Multiple reports have related to unrecognized intravascular placement of the needle. The generally accepted technique during interventional techniques is intermittent fluoroscopy. In fact, this may miss vascular uptake due to rapid washout. Thus, digital subtraction, the commonly accepted standard for documenting angiography and venography, may be a useful tool for documentation of and/or avoidance of intravascular placement of the needle and subsequent injections with interventional techniques. This case report involves description of digital subtraction to enhance visualization of contrast distribution during injection. Three series of images are included from atlanto-occipital joint, caudal epidural catheterization, and a cervical transforaminal injection. The case reports demonstrate that digital subtraction fluoroscopic imaging is superior to intermittent or live fluoroscopy in detecting intravascular injections with interventional techniques.

One Thousand Small-bowel Biopsies in Children A Single-Port versus a Double-Port Capsule

Background: Small-bowel biopsy is a well-established technique in the evaluation of children with intestinal malabsorption, e.g. coeliac disease. The biopsy is performed endoscopically or with a peroral capsule instrument. The aim of the present retrospective study was to compare the single-port Watson capsule with the double-port Storz capsule with regard to procedure and fluoroscopy time, complications and failure rate. Methods: All 1,078 peroral small-bowel biopsies performed at our department during 1989-99 were studied. In 387 of these, the Watson capsule was used and in the remaining 691 the Storz capsule. Median age of the children was 2.5 years. About one-third of the children were premedicated with the prokinetic drug cisapride and as sedatives alimemazine or diazepam orally. Two-thirds of the children were given metoclopramide along with midazolam intravenously. The biopsies were performed under intermittent fluoroscopy. Results: The median biopsy procedure time was significantly shorter with the Storz capsule (7 min) compared to the Watson capsule (10 min) ( P < 0.05). The median fluoroscopy time was 5 sec with the Storz capsule and 8 sec with the Watson capsule ( P < 0.01). The failure rate did not differ significantly between the two capsule types: 10.3% (Watson) and 7.7% (Storz). One potential but no serious complication occurred. Conclusions: Providing that effective sedation is available, smallbowel biopsy with a peroral capsule, and the Storz double-port multibiopsy capsule in particular, is a safe and fast method exposing the child to a minimal radiation dose.

Percutaneous abdominal and pelvic interventional procedures using CT fluoroscopy guidance.

The purpose of our study was to assess the use of low-milliamperage CT fluoroscopy guidance for percutaneous abdominopelvic biopsy and therapeutic procedures. We reviewed the clinical records and relevant imaging studies of 97 patients who underwent 119 percutaneous CT fluoroscopy-guided abdominal or pelvic procedures: fluid collection aspiration or drainage catheter insertion (n = 59), biopsy (n = 49), hepatocellular carcinoma ethanol ablation (n = 6), chemoneurolysis (n = 4), and brachytherapy catheter insertion (n = 1). These procedures were guided using a helical CT scanner providing real-time fluoroscopy reconstruction at six frames per second. A control panel and video monitor beside the gantry allowed direct operator control during all interventional procedures. One hundred twelve (94.1%) procedures were successfully performed using either a stand-off needle holder and continuous real-time CT fluoroscopy guidance or incremental manual insertion and intermittent CT fluoroscopy to confirm position. Image quality using low milliamperage was adequate for needle or drainage tube placement in all but two low-contrast liver lesions. Two hematomas were accessed but yielded no fluid on aspiration; one drainage procedure was abandoned after the patient developed endotoxic shock. Imaging of ethanol distribution during injection facilitated tumor ablation and neurolytic procedures. CT fluoroscopy allowed rapid assessment of needle, guidewire, dilator, and catheter placement, especially in nonaxial planes. Average CT fluoroscopy time for biopsy and therapeutic procedures was 133 sec (range, 35-336 sec) and 186 sec (range, 20-660 sec), respectively. CT fluoroscopy is a practical clinical tool that facilitates effective performance of percutaneous abdominal and pelvic interventional procedures.

Digital imaging: a valuable technique for the postoperative assessment of cochlear implantation.

Cochlear implantation with a multi-channel electrode array which provides stimulation via the auditory nerve has become a standard treatment for profound deafness. Postoperative radiography demonstrates electrode position and enables confirmation of satisfactory intra-cochlear electrode placement. The number of active electrodes which have been inserted can be determined and possible complications such as electrode kinking or slippage can be assessed. We evaluated digital radiography with confirmation of electrode position by intermittent fluoroscopy and assessed the relative radiation dose of the digital technique, conventional radiography and CT scanning. Radiation dose for this method usually ranges between 40 microGy and 440 microGy compared with a single exposure on the skull stand which produces a dose to the region of the cochlea of 470 microGy and a CT exposure of 950 microGy. The digital technique is comfortable for the patient, easily reproducible and provides images of high diagnostic quality enabling each electrode to be identified, which is especially valuable in association with postoperative electrode mapping. It also involves a lower radiation dose than conventional radiography. We now use digital radiography for all postoperative cochlear implant assessment.

Treatment of urethral stones by retrograde manipulation and extracorporeal shock wave lithotripsy.

To assess the effect of retrograde manipulation and extracorporeal shock wave lithotripsy (ESWL) as a monotherapy for urethral stones that are not associated with urethral strictures. Between August 1993 and January 1995, 34 male patients (mean age 38.7 years, range 7-55) presented with urethral stones. No patient had a suggested or past history of urethral stricture. Lidocaine jelly (2%) was instilled and retained inside the urethra for 5 min. A 16 F urethral catheter was advanced gently to push the stone back to the urinary bladder. Twenty patients had ESWL of their stones in the bladder, using a Storz Modulith SL20, in the prone position. Tilting the patient about 15 degrees towards the side with the stone minimized movement of the stone during fragmentation. In-line co-axial echography (3.5 MHz) and intermittent pulsed fluoroscopy were used to monitor stone fragmentation. In situ fragmentation of posterior urethral stones was not possible because localization was difficult and the treatment was painful. Thirteen patients had cysto-urethroscopy and mechanical cystolitholapaxy under general anaesthesia. Stones impacted in the posterior urethra in 31 (91%) patients and in the anterior urethra in three (9%) patients. Stones ranged in size from 7 to 25 mm. One patient expelled an anterior urethral stone after the instillation of 2% lidocaine jelly. The urethral stones were pushed back to the bladder without complication in the remaining 33 patients. All 20 patients except one had their stones fragmented by ESWL in one session. The mean number of shock waves was 3600 +/- 1480 (range 1200-6000) and the generator voltage ranged between 5 kV (560 bar) to 8 kV (940 bar). No patient in the ESWL group required anaesthesia or analgesia. Thirteen patients had successful mechanical cystolitholapaxy with no complications. Both endoscopic lithotripsy and ESWL of urethral stones are safe and effective. However, transurethral lithotripsy requires general anaesthesia and carries a risk of bladder and urethral trauma. This study demonstrated that, in the absence of urethral stricture, urethral stones can be pushed back safely to the urinary bladder and fragmented effectively by ESWL. The success of the treatment depends on adequate anaesthesia of the urethra before inserting the urethral catheter. We propose that this new technique should be considered before resorting to endoscopic or surgical management of urethral stones, particularly in children.

Percutaneous Rotational Lithotripsy of Urinary Bladder Stones

Mechanical rotational lithotripsy of urinary bladder stones, up to 20 mm in diameter, was performed in 6 male patients with the Rotolith lithotriptor. The lithotriptor was introduced through a 10 F (OD 3.3 mm) suprapubically inserted sheath, and the procedure was performed under intermittent fluoroscopy and inspection through a transurethral cystoscope. In 3 patients, the bladder stones were fragmented to pieces small enough to be evacuated through the cystoscope. The instrument, which is designed for lithotripsy of gallbladder stones, was less efficient for fragmentation of urinary bladder calculi, primarily due to the large volume of the human urinary bladder, and possibly because of the higher gravity of bladder stones. There was no substantial damage to the mucosa of the urinary bladder.

Percutaneous Rotational Lithotripsy of Urinary Bladder Stones

Mechanical rotational lithotripsy of urinary bladder stones, up to 20 mm in diameter, was performed in 6 male patients with the Rotolith lithotriptor. the lithotriptor was introduced through a 10 F (OD 3.3 mm) suprapubically inserted sheath, and the procedure was performed under intermittent fluoroscopy and inspection through a transurethral cystoscope. In 3 patients, the bladder stones were fragmented to pieces small enough to be evacuated through the cystoscope. the instrument, which is designed for lithotripsy of gallbladder stones, was less efficient for fragmentation of urinary bladder calculi, primarily due to the large volume of the human urinary bladder, and possibly because of the higher gravity of bladder stones. There was no substantial damage to the mucosa of the urinary bladder.

THE VALUE OF DOUBLE-CONTRAST EXAMINATION OF THE STOMACH WITH PRESSURE "SPOTS" IN THE DIAGNOSIS OF INFANTILE HYPERTROPHIC PYLORIC STENOSIS.

The purpose of this paper is to review briefly the technic, findings, and limitations of the standard method of x-ray diagnosis of infantile hypertrophic pyloric stenosis and to describe a simple maneuver designed to increase the speed and accuracy of the examination. Standard Method of Examination (1–20) Technic: Fasting of four or more hours prior to the examination is usually recommended. Preliminary films of the abdomen are useful but not indispensable. Aspiration of all gastric content prior to the examination is generally advised. Barium is the most commonly used contrast material, and may be administered either by means of a nursing bottle or through a nasogastric tube. The examination is carried out with the patient in the prone position and the left side slightly raised. The stomach and duodenum are studied either by intermittent fluoroscopy and “spot” films, or by a short period of fluoroscopic observation followed by radiographs of the abdomen at regular intervals until the diagnosis is establi...