Percutaneous nephrostomy--the method and technical problems

Ultrasound guided percutaneous nephrostomy (PNS) was performed on 72 patients (80 kidneys) including pretreatment for percutaneous nephro-uretero lithotomy (PNL). PNS was performed for post-renal anuria or hydronephrosis in 23 cases (28 kidneys), for urinary leakage in 4 cases (5 kidneys), for vesical bleeding in 1 case (2 kidneys) and as pretreatment of PNL in 44 cases (45 kidneys). Ultrasound guided renal puncture was done percutaneously and a 0.038 inch J-tipped wire guide was inserted into the suitable calyx. Then the nephrostomy tract was dilated with fascia dilators of Malecot nephrostomy set. A 14 Fr or 16 Fr Malecot catheter was used for hydronephrosis or urinary leakage cases. 18 Fr, 24 Fr Malecot catheter or Bardex balloon catheter 18-22 Fr was inserted for PNL cases. In the PNL group, Ht decreased slightly but there was no need of blood transfusion. In the other groups, Ht did not change. Defect of 99m-Tc-DMSA renal uptake in several cases suggested renal injury at nephrostomied cortex. In about 70% of the cases, a fever of more than 37 degrees C was observed, and in 4 cases, more than 39 degrees C was observed. There were no major complications observed. In conclusion, percutaneous nephrostomy using Malecot nephrostomy set is a safe and effective method.     

Subcutaneous pyelovesical bypass as replacement for standard percutaneous nephrostomy for palliative urinary diversion: prospective evaluation of patient's quality of life

PURPOSE: To improve the quality of life of patients with palliative definitive percutaneous nephrostomy, we prospectively evaluated a subcutaneous ureteral bypass using a newly designed ureteral prosthesis. PATIENTS AND METHODS: A series of 19 patients receiving 27 subcutaneous tubes in replacement for percutaneous nephrostomy were evaluated. The ureteral prosthesis (Detour), a silicone tube glued inside a polyester tube, is inserted percutaneously into the renal pelvis to replace an established nephrostomy, tunneled subcutaneously, and introduced into the bladder through a small incision. All patients were followed every 3 months for 18 months or until death from tumor. Quality of life was assessed using the EORTC QLC-30 questionnaire; ultrasonography, intravenous urography, or both were used to assess the position and patency of the tubes. RESULTS: There was no failure of insertion and no operative or immediate complication. The mean follow-up was 7.8 months, 6.6 months for the 15 patients who died from their tumors and 1 year for the 4 patients still alive at the end of the study. Suprapubic parietal infection occurred in three patients with altered bladders (radiation cystitis or tumor progression). There was an improvement of the function scale as a result of the elimination of the external percutaneous tube and a parallel worsening of the symptom scale secondary to the progression of disease. Patient ratings of the global quality of life and satisfaction with the urinary diversion were improved because of the absence of the percutaneous tube. CONCLUSION: The subcutaneous pyelovesical bypass provides a better quality of life than a standard percutaneous nephrostomy tube in terminally ill patients by making them external-tube free.     

Percutaneous nephrolithotomy in children: lessons learned in 5 years at a single institution

PURPOSE: We retrospectively compared morbidity and success rates in children who underwent percutaneous nephrolithotomy with 3 different sizes of instruments. MATERIALS AND METHODS: Percutaneous nephrolithotomy was performed using adult instruments via a 26Fr tract in 23 patients, using pediatric instruments via a 20Fr tract in 13 and using minimal access (14Fr) in 10. Percutaneous nephrolithotomy was performed using general anesthesia with parenteral antibiotic prophylaxis. Cystoscopy and retrograde pyelography were performed, and 5Fr to 6Fr soft ureteral catheters were placed during each procedure initially. Percutaneous access was established via fluoroscopic guidance with the patient in the prone position. Pneumatic, ultrasonic and holmium laser lithotriptors were used for in situ lithotripsy. A 14Fr nephrostomy catheter was placed at the end of the procedure in the 26Fr and 20Fr groups, and in the minimal access group the ureteral stent was left indwelling in cases of atraumatic procedure with no residual fragments. RESULTS: Mean patient age was 13.2, 5.9 and 6.3 years, respectively, in the 26Fr, 20Fr and minimal access groups (p=0.000). Sex distribution, previous surgery, stone size, surgery and fluoroscopy times, mean hemoglobin decrease and hospitalization time did not differ between the groups. However, blood transfusion rate was higher in groups 1 and 2. Stone-free rates were 69.5%, 80% and 90%, respectively, in groups 1 to 3. Overall, adjuvant shock wave lithotripsy treatment was needed in 3 children. CONCLUSIONS: Smaller instrument size to 20Fr did not significantly increase the operative time, and resulted in the same success rates as the adult sized devices. However, low blood transfusion rates were only reached in the minimal access percutaneous nephrolithotomy group.     

Use of balloon catheters for ureteral occlusion in urinary leakage

PURPOSE: Urinary fistula after treatment for cancer constitutes a therapeutic dilemma, especially in patients who have had various other treatments. We report on 7 patients with urinary leakage, treated conservatively with ureteric occlusion by way of percutaneous transrenal balloon catheters. MATERIALS AND METHODS: The indication for ureteral occlusion was persisting urinary leakage despite diversion by nephrostomy and drainage with atransurethral catheter. All patients had had previous treatment because of pelvic malignancy. Small Foley balloon catheters and angioplasty catheters were used. These devices were inserted percutaneously in an antegrade fashion. RESULTS: In all but 2 of the patients the leakage ceased with the aid of these devices. Insufficient ureteral occlusion necessitated unilateral uretero-cutaneostomy in 1 patient. In another patient a vesico vaginal fistula was closed surgically. The maximum duration of occlusion was 169 (mean 94, range 45-169) days, without any evidence of ureteric pressure necrosis. Despite good overall results many adjustments and replacements of catheters were necessary because of recurrent urinary leakage caused by inadequate obstruction and/or leakage of the occluding catheters. CONCLUSIONS: We conclude that long-term ureteral occlusion with percutaneous transrenal balloon catheters appears to be safe and does not result in pressure necrosis. Using this approach, urinary fistula can heal in some patients without the need for open surgery.     

Infundibular stenosis after percutaneous nephrolithotomy.

PURPOSE: Acquired infundibular stenosis can develop after percutaneous nephrolithotomy. We review our experience with infundibular stenosis after this procedure. MATERIALS AND METHODS: We evaluated the records of patients diagnosed with infundibular stenosis after percutaneous nephrolithotomy was performed at our institution between 1995 and 2000. Analysis included medical history, urinary stone type, stone removal procedure technique, length and number, postoperative course, stenosis time to development location, severity and treatment, and treatment outcome. RESULTS: Infundibular stenosis developed in 5 of 223 percutaneous nephrolithotomy cases (2%) performed during this period. Medical history in affected patients included previous ipsilateral open pyelolithotomy, diabetes and morbid obesity in 2 each. Percutaneous nephrolithotomy were done through a standard 30Fr nephrostomy tract and all cases were terminated before complete stone removal. Mean operative time was 258 minutes, which was significantly greater than the mean operative time of 207 minutes in all cases of unilateral percutaneous nephrolithotomy (p = 0.03). Postoperatively nephrostomy tube drainage was done for a mean of 33 days (range 16 to 51). All patients underwent at least 1 additional percutaneous stone removal procedure after primary percutaneous nephrolithotomy and before stenosis was detected. The mean time to stenosis detection was 9 months (range 2 to 24). Stenosis generally developed in areas corresponding to previous sites of percutaneous access and the degree of narrowing ranged from mild to severe. Mild and moderate stenosis was managed by observation and endoscopic dilation in 2 each. Severe stenosis in 1 patient was associated with significantly impaired ipsilateral renal function. CONCLUSIONS: Infundibular stenosis is a rare complication of percutaneous nephrolithotomy. In this series it was associated with prolonged operative time, a large stone burden requiring multiple removal procedures and extended postoperative nephrostomy tube drainage. In most cases stenosis developed at previous access sites within 1 year of initial percutaneous nephrolithotomy. Mild and moderate cases may be treated with observation and endoscopic dilation, respectively, while severe cases may result in renal impairment.     

Practical approach to terminate urinary extravasation: percutaneous fistula tract embolization with N-butyl cyanoacrylate in a case with partial nephrectomy

A 35-year-old woman who underwent partial nephrectomy had prolonged postsurgical urinary extravasation that led to a percutaneous fistula. A double-J catheter used as a ureteral stent during surgery was in place. A percutaneous pigtail nephrostomy was inserted on the 15th postoperative day but drainage continued. Antegrade pyelography demonstrated extravasation at the lower pole calyx. The double-J stent was removed on the 21st postoperative day, and a retrograde pyelogram showed no obstruction. Because drainage still was excessive on the 25th postoperative day, the fistula tract was embolized percutaneously with N-butyl cyanoacrylate, a tissue adhesive material. Drainage ceased immediately after the procedure, and control pyelography confirmed no extravasation. The patient was discharged on the 28th postoperative day. The patient had no additional complications at 36-month follow-up.     

A prospective randomized trial comparing 2-octyl cyanoacrylate to conventional suturing in closure of laparoscopic cholecystectomy incisions

OBJECTIVE: To compare 2-octyl cyanoacrylate (Dermabond) with conventional suturing for closure of laparoscopic cholecystectomy (LC) wounds in a prospective randomized controlled trial. SUBJECTS: Twenty-five consecutive patients underwent LC at a teaching hospital in the United Kingdom. Patients were randomly allocated to have skin closed with 2-octyl cyanoacrylate or absorbable suture. METHODS: Fifty-one wounds underwent skin closure with absorbable subcuticular suture (3/0 polydiaxanone) and 48 wounds were closed with tissue adhesive. The time to close the wounds, including the placement of dressings, was recorded. At 6 to 8 weeks, the incisions were evaluated with the Hollander wound evaluation scale (HWES). Using a visual analogue scale (VAS), the wounds were also rated by a plastic surgeon who was blinded to the method of closure. RESULTS: The wounds were closed significantly faster in the Dermabond group (mean 165 seconds versus 356 seconds, P = 0.03). There were no differences in the percentage of wounds achieving optimal scores on the HWES (suture 64.7% versus tissue adhesive 60.4%, P = 0.42) nor on the mean VAS (suture 62 mm versus tissue adhesive 59 mm, P = 0.45). CONCLUSION: The tissue adhesive 2-octyl cyanoacrylate is a safe and fast method for closure of LC wounds, with cosmetic results comparable to suturing.     

Percutaneous dissolution of uric acid and cystine stones causing acute ureteral obstruction

Four cases with ureteral obstruction due to uric acid or cystine stones were treated successfully by percutaneous irrigation with sodium bicarbonate or tromethamine-E. These cases underwent percutaneous nephrostomy for the reason of prolonged complete obstruction (case 1), sustained pyelonephritis (case 2) or decreased renal function (case 3 and 4). Two catheters were placed through the nephrostomy tract before irrigation, 6 Fr. ureteral catheter just above the ureteral stone and 10 Fr. pigtail or 12 Fr. Malecot catheter in the renal pelvis. The ureteral stones were markedly reduced in size and passed spontaneously after 6-11 days' duration of irrigation in three cases. In case 2, the remaining stone was removed transurethrally after 14 days' duration of irrigation, and was found to be composed of organic matrix. Percutaneous dissolution is considered to be a safe and reliable method and may be an alternative way of treating uric acid or cystine stone causing acute ureteral obstruction.     

Percutaneous nephrolithotomy for caliceal diverticular calculi: a novel single stage approach

PURPOSE: Current percutaneous treatment of symptomatic caliceal diverticular calculi involves renal access, stone removal, dilation of the diverticular communication, fulguration of the cavity and placement of a nephrostomy tube. We reviewed the outcomes of patients undergoing a novel single stage percutaneous nephrolithotomy technique for radiopaque caliceal diverticular stones that eliminates ureteral catheterization and entry into the renal collecting system. MATERIALS AND METHODS: A total of 21 patients (8 male and 13 female including 1 bilateral) with a mean age of 42.4 years underwent percutaneous nephrolithotomy for caliceal diverticular stones from February 2001 to May 2003. Of the diverticula 12 were upper pole, 4 were interpolar and 6 were lower pole. Infracostal access was established by the urologist directly onto the radiopaque stones without the aid of a ureteral catheter. After balloon tract dilation a 30Fr Amplatz sheath was placed and following stone removal the diverticulum was fulgurated. The infundibulum was neither cannulated nor dilated. A 20Fr red rubber catheter or an 8.5Fr Cope loop was placed into the diverticulum. Stone-free status was assessed by noncontrast computerized tomography on postoperative day 1 (POD1). The drainage tube was removed if there was no urine drainage and the kidney was stone-free. Excretory urography was performed at 3 months to evaluate diverticular resolution. RESULTS: Of 21 patients 20 were discharged home tubeless on POD1 and 18 of 21 (85.7%) renal units were stone- free on POD1 noncontrast computerized tomography. Mean operative time was 58.5 minutes and mean stone burden was 138.9 mm. Mean stone diameter was 11.6 mm and mean diverticular diameter was 15.3 mm. Of 22 renal units 16 had followup excretory urography. All diverticula decreased in size and 14 (87.5%) had complete resolution. CONCLUSIONS: In patients with symptomatic radiopaque caliceal diverticular stones, a single stage procedure without the need for ureteral catheterization combined with direct infracostal diverticular puncture allows for a rapid procedure with little morbidity.     

Ureteral contusion with gunshot wounds

The entity of ureteral contusion with a gunshot wound has not been well described in the literature. The blast effect of the bullet, even one of low velocity, can cause contusion of the ureter manifested by hematuria, no extravasation on the IVP, and a normal appearing ureter or some bruising of the ureteral wall and periureteral tissues. The ureteral contusion may resolve or may progress to delayed necrosis of the ureteral wall with urine leakage. Twelve cases of ureteral contusion with gunshot wounds are reported. The ureter was found contused at exploration in two patients; one had excision of the contused area with end-to-end anastomosis and the other had a nephrostomy and ureteral splint. The ureter appeared normal in ten patients and no immediate treatment was performed to the ureter; eight had no postoperative evidence of urine leakage and two developed a urinary fistula.     

A prospective randomized comparison of type of nephrostomy drainage following percutaneous nephrostolithotomy: large bore versus small bore versus tubeless

PURPOSE: We compared postoperative outcomes among tubeless, conventional large bore nephrostomy drainage and small bore nephrostomy drainage following percutaneous nephrostolithotomy (PCNL) in a prospective randomized fashion. MATERIALS AND METHODS: Between January and June 2001, 30 patients undergoing PCNL were randomized to receive conventional large bore (20Fr) nephrostomy drainage (group 1, 10 patients), small bore (9Fr) nephrostomy drainage (group 2, 10 patients) or no nephrostomy drainage (group 3, 10 patients). Inclusion criteria included a single subcostal tract, uncomplicated procedure, normal preoperative renal function and complete stone clearance. Factors compared among the 3 groups were postoperative analgesia requirement, urinary extravasation, duration of hematuria, duration of urinary leak, decrease in hematocrit and hospital stay. RESULTS: The postoperative analgesic requirement was significantly higher in group 1 (217 mg) compared to groups 2 (140 mg, p <0.05) and 3 (87.5 mg, p <0.0001). Patients in group 3 had a significantly shorter duration (4.8 hours) of urinary leak through the percutaneous renal tract compared to patients in groups 1 (21.4 hours, p <0.05) and 2 (13.2 hours, p <0.05). Hospital stay was significantly shorter in group 3 (3.4 days) compared to groups 1 (4.4 days, p <0.05) and 2 (4.3 days, p <0.05). All 3 groups were similar in terms of operative time, duration of hematuria and decrease in hematocrit. Postoperative ultrasound did not reveal significant urinary extravasation in any case. CONCLUSIONS: Tubeless PCNL is associated with the least postoperative pain, urinary leakage and hospital stay. Small bore nephrostomy drainage may be a reasonable option in patients in whom the incidence of stent dysuria is likely to be higher.     

Foreign body reaction after usage of tissue adhesives for skin closure: a case report and review of the literature

Introduction  The usage of tissue adhesives such as 2-octyl cyanoacrylate is a standard tool for closure of superficial wounds of the body. The benefits using 2-octyl cyanoacrylate are well known and appreciated by surgeons world wide. Especially in superficial or small wounds in children where no surgical procedure is wanted this technique is commonly used. However, so far the risks and possible complications after using 2-octyl cyanoacrylate are not sufficiently published and discussed. Case report  We report a case of foreign body reaction after 3 weeks in a 39-year-old female patient after usage of 2-octyl cyanoacrylate treating a superficial wound of the right wrist. Conclusion  The use of 2-octyl cyanoacrylate for the closure of superficial and small wounds or lacerations is a simple, quick and comfortable method. However, there is clinical evidence that in some cases the use of this type of tissue adhesive may lead to foreign body reaction. We suggest that each patient who is treated by this type of wound closure technique should be mandatory informed on the potential risk of a foreign body reaction.     

Fluoroscopy guided retrograde ureteral stent insertion in patients with a ureteroileal urinary conduit: method and results

PURPOSE: We evaluated retrograde double pigtail stent placement in patients with ureteroileal anastomosis. MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.     

Renal parenchymal injury after standard and mini percutaneous nephrostolithotomy

PURPOSE: Mini percutaneous nephrostolithotomy was developed for use in children and in adults with a reduced renal reserve to minimize the morbidity and renal parenchymal damage presumed to occur with traditional percutaneous nephrostolithotomy. We compared the extent of renal injury incurred by different sized nephrostomy tracts in female farm pigs undergoing 11 or 30Fr percutaneous nephrostomy. MATERIALS AND METHODS: Bilateral percutaneous nephrostomy was attempted via a mid or lower pole calix under fluoroscopic guidance in 6 pigs. In 2 pigs the procedure was unsuccessful on 1 side, leaving 5 successfully established nephrostomy tracts on each side. In each pig the right percutaneous tract was dilated with a 28Fr dilating balloon and a 30Fr Amplatz working sheath (Cook Urological, Spencer, Indiana) was positioned in the collecting system. On the left side an 11Fr sheath (Cook Urological) was placed. The sheaths were removed after 1 hour and nephrostomy tubes (22Fr on the right and 8Fr on the left side) were left in place overnight and then removed. Six weeks later the pigs were sacrificed and the kidneys were harvested. The nephrostomy tracts were identified grossly and examined microscopically, and the fibrotic scar was measured using digital analysis. The volume of scar was estimated using the calculated volume of a cylinder. RESULTS: At kidney harvest all 10 kidneys appeared grossly normal. No intra-abdominal urine collection or perirenal hematoma was noted. Mean estimated scar volume of the 30 and 11Fr tracts was 0.29 and 0.40 cc, which translates into a mean fractional loss of parenchyma of 0.63% and 0.91%, respectively (p not significant). CONCLUSIONS: Renal parenchymal damage resulting from the creation of a nephrostomy tract is small compared to overall renal volume regardless of the size of the nephrostomy tract. Consequently there is no advantage to the use of a small access sheath based on renal scarring alone.     

经皮肾穿刺顺行球囊扩张治疗移植肾输尿管梗阻

目的探讨经皮肾穿刺顺行球囊扩张治疗移植肾输尿管梗阻的安全性和疗效。方法回顾性分析2007年至2011年华中科技大学附属协和医院6例接受经皮肾穿刺顺行球囊扩张治疗移植肾输尿管梗阻的患者资料。所有患者先行B超引导移植肾穿刺造瘘,顺行造影确定梗阻的具体位置,顺行球囊扩张输尿管狭窄段,术后留置双J管和肾造瘘管,无效则改开放手术。结果6例患者中1例输尿管狭窄段〉1cm,球囊扩张失败,1例合并尿瘘,尿囊肿,扩张治疗无效,此2例均经开放手术治愈;其余4例一次扩张治愈,随访16～38个月,肾功能正常,无梗阻复发。结论经皮肾穿刺顺行球囊扩张安全、损伤小,可作为治疗移植肾输尿管梗阻的首选方法,对于合并有其他外科并发症或扩张治疗失败的患者,需开放手术治疗。     

上尿路结石并发真菌感染的微创经皮肾镜治疗

目的：探讨输尿管镜和微创经皮肾镜探察取石术，以及术后局部灌注抗真菌药治疗上尿路结石并发真菌感染的有效性。方法：对49例上尿路结石并发真菌感染患者，采用输尿管镜探察和微创经皮肾镜取石术后经皮肾微造瘘管或输尿管外支架管灌洗抗真菌药治疗。结果：49例真菌感染均得到较好控制，尿液真菌培养阴性；45例结石取净，术后肾功能有不同程度的恢复，无一例出现大出血和真菌败血症。结论：输尿管镜探察和微创经皮肾镜取石术，以及术后局部灌注抗真菌药治疗上尿路结石并发真菌感染，是一种微创安全并能同时取石和控制感染的可靠方法。     

Intraluminal pneumatic lithotripsy for the removal of encrusted urinary catheters

PURPOSE: Urologists frequently treat patients requiring long-term urinary drainage with a percutaneous nephrostomy tube or ureteral stent. When such tubes are neglected and become encrusted, removal challenges even experienced urologists. We describe a new, minimally invasive technique for safely and rapidly removing encrusted, occluded tubes using the Swiss Lithoclast pneumatic lithotriptor. MATERIALS AND METHODS: Patients presenting with an encrusted urinary catheter were evaluated by excretory urography for renal function and obstruction. Gentle manual extraction of the tube was attempted, followed by traditional extracorporeal shock wave lithotripsy and/or ureteroscopy. When the tube was not extracted, patients were then treated with intraluminal insertion of a pneumatic lithotripsy probe. RESULTS: One patient presented with an encrusted, occluded nephrostomy tube and 2 had an encrusted, occluded, indwelling ureteral stent. None was removed by manual traction. Intraluminal encrustations prevented the pigtail portions of these tubes from uncoiling and removal. In each case a pneumatic lithotripsy probe was inserted into the lumen of the catheter and advanced in a jackhammer-like fashion. This technique resulted in disruption of the intraluminal encrustations and straightening of the tubes so that they were removed in an atraumatic manner. CONCLUSIONS: Intraluminal pneumatic lithotripsy is a safe, easy and rapid technique for removing encrusted urinary catheters. It is unique in that the pneumatic lithotripsy probe functions in an aqueous and nonaqueous environment, and dislodges intraluminal calcifications. We recommend its use as first line treatment for removing encrusted urinary catheters.     

Endoureterotomy by intraluminal invagination for nonmalignant ureterointestinal anastomotic strictures: description of a new surgical technique and long-term followup

PURPOSE: We describe a new surgical endoscopic technique for nonmalignant ureterointestinal anastomotic strictures. This procedure involving endoureterotomy by intraluminal invagination (the Lovaco technique) is performed by adopting a combined percutaneous antegrade and endoscopic retrograde approach. The results obtained by this technique are reviewed with long-term followup. MATERIALS AND METHODS: A total of 25 ureterointestinal anastomotic strictures were subjected to endoureterotomy by intraluminal invagination, including 12 left, 7 right and 3 bilateral cases. Surgical success was defined by radiological improvement and/or the ability to recover normal activity in the absence of flank pain, infection, or the need for ureteral stents or nephrostomy tubes. RESULTS: At a median followup of 51 months (range 2 to 145) the success rate for endoureterotomy by intraluminal invagination was 80% (20 of 25 ureterointestinal anastomotic strictures). No complications were recorded in the patients following endoureterotomy. CONCLUSIONS: This new endoureterotomy technique for ureterointestinal strictures following urinary diversion can be applied to any type of urinary diversion. It allows direct visualization of the stricture and stricture tissue biopsy. Intraluminal invagination makes it possible to increase the distance between the stricture, and the retroperitoneal vessels and bowels. The technique provides the control required to ensure full-thickness and full-length stricture incision. The success rate is high and it persists after long-term followup.     

肾移植中供肾输尿管异常的处理

目的：探讨肾移植术中供肾输尿管异常的手术处理方法。方法：回顾性分析18例供。肾输尿管异常的肾移植术中处理,包括损伤致输尿管过短8例,完全型双输尿管4例,不完全型双输尿管2例,输尿管结石2例,巨输尿管2例。根据具体情况采用输尿管膀胱吻合术、供受者输尿管端端吻合术和膀胱腰大肌悬吊术等方法再植输尿管。结果：术后恢复顺利,未发生移植肾功能延迟恢复和尿漏。随访3～8年,发生输尿管梗阻1例,行经皮。肾造口输尿管镜切开后治愈。发生尿路感染5例（其中2例为反复感染）。未见膀胱输尿管返流。结扎输尿管的原肾未出现胀痛和不适,B超检查未见肾积水。带输尿管结石移植肾未见结石复发。巨输尿管供肾移植后输尿管管径稳定,无明显增大。结论：供肾输尿管损伤和异常时采用不同的技术修复和再植输尿管,可减少并发症的发生。     

A case of superselective transcatheter embolization for injured renal segmental artery associated with percutaneous nephroureterolithotomy (PNL)

A case in which the renal segmental artery was injured due to percutaneous nephroureterolithotomy (PNL) and treated by superselective transcatheter embolization is reported. The patient was a 30-year-old man with left ureteral and bilateral renal calculi. The left renal and ureteral calculi were successfully removed by PNL and a 24Fr. nephrostomy catheter was placed for 8 days after PNL. A few minutes after removal of the nephrostomy catheter, arterial bleeding, which seemed to occur due to injury of renal segmental artery associated with PNL, began. The bleeding was stopped by replacement of a 24Fr. nephrostomy catheter and the patient received 5 units of packed red blood cells. Six days after hemorrhage, superselective transcatheter embolization was performed. No further bleeding occurred and the nephrostomy catheter was removed 2 days later without any incident. This interventional technique is safe and useful to control bleeding from renal segmental artery injured by PNL.