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Complications associated with percutaneous nephrolithotripsy: supra- versus subcostal access: a retrospective study depression test bc order anafranil with visa. Single-center review of fluoroscopy-guided percutaneous nephrostomy performed by urologic surgeons mood disorder brochure order anafranil 50 mg with visa. Prediction of septicemia following endourological manipulation for stones in the upper urinary tract depression test dsm iv order anafranil once a day. Percutaneous nephrolithotomy in the prone and prone-flexed positions: anatomic considerations depression zoloft side effects order anafranil 10 mg online. Life-threatening biliary complications after percutaneous nephro-lithotomy: a case report. Hemorrhage following percutaneous renal surgery: characterization of angiographic findings. Measurement of needle-tip bioimpedance to facilitate percutaneous access of the urinary and biliary systems: first assessment of an experimental system. Collecting system percutaneous access using real-time tracking sensors: first pig model in vivo experience. Retrograde ureteral stents for extrinsic ureteral obstruction: 9 years of experience at the University of Michigan. Cone beam computed tomography for percutaneous nephrolithotomy: initial evaluation of a new technology. Nephrostomy tract dilation using a balloon dilator in percutaneous renal surgery: experience with 95 cases and comparison with the fascial dilator system. Management of lithiasis in pelvic kidney through laparoscopy-guided percutaneous transperitoneal nephrolithotripsy. Effectiveness of three-dimensional fluoroscopy in percutaneous nephrostomy: an animal model study. Endoscopy-guided percutaneous nephrostolithotomy: benefits of ureteroscopic access and therapy. Safe and effective obtainment of access for percutaneous nephrolithotomy by urologists: the Louisiana State University experience. The endovascular treatment of a renal arteriovenous fistula: placement of a covered stent. Percutaneous nephrolithotomy in ectopically located kidneys and in patients with musculoskeletal deformities. Estimated blood loss and transfusion rates associated with percutaneous nephrolithotomy. Robotic percutaneous access to the kidney: comparison with standard manual access. Percutaneous nephrolithotomy with and without retrograde pyelography: a randomized clinical trial. Mini-invasive management of a rare complication of percutaneous stone treatment: entrapped nephrostomy tube. Tubeless percutaneous nephrolithotomy in selected patients: a prospective randomized comparison. Impact of percutaneous renal access technique on outcomes of percutaneous nephrolithotomy. Laparoscopic-assisted "microperc" of a stone in a pelvic kidney of a 3-year-old girl. Planning percutaneous nephrolithotomy using multidetector computed tomography urography, multiplanar reconstruction and three-dimensional reformatting. Designing simulator-based training: an approach integrating cognitive task analysis and four-component instructional design. Factors affecting blood loss during percutaneous nephrolithotomy using balloon dilation in a large contemporary series. Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever. Extraperitoneal laparoscopy-assisted percutaneous nephrolithotomy in a left pelvic kidney. Effects of percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy on renal function and prostaglandin excretion. Endoscopic combined intrarenal surgery in Galdakao-modified supine Valdivia position: a new standard for percutaneous nephrolithotomy Nephrolithiasis clinical guidelines panel summary report on the management of staghorn calculi. Incidence, prevention, and management of complications following percutaneous nephrolitholapaxy. Catheter replacement of the needle in percutaneous arteriography: a new technique. Perioperative prophylaxis for percutaneous nephrolithotomy: randomized study concerning the drug and dosage. Splenic injury: rare complication of percutaneous nephrolithotomy: report of two cases with review of literature. A prospective, randomized trial evaluating the safety and efficacy of fibrin sealant in tubeless percutaneous nephrolithotomy. Safety and efficacy of supracostal access in tubeless percutaneous nephrolithotomy.
The Malecot catheter is also available with an extension that is directed down the ureter depression symptoms partner anafranil 25 mg fast delivery. This modification is called a "re-entry" catheter depression symptoms in seniors buy anafranil with paypal, because it simplifies placing a guidewire through the Malecot catheter and down the ureter into the bladder depression and symptoms purchase anafranil with a mastercard. The extension is long enough (18 cm) so that in most patients the Malecot tube can be withdrawn until the wings are externalized and a guidewire can be placed into the ureter depression prevalence buy anafranil canada. Malecot catheters for renal use are large-bore catheters, ranging from 16 to 30 Fr, although Malecot catheters as small as 8 Fr are available. Malecot Catheter the wings of the Malecot catheter expand when the catheter is at rest, providing a modest but atraumatic and nonobstructive Cope Catheter Cope nephrostomy tubes provide a more secure retention mechanism. A string exits the catheter a few centimeters from the distal tip and then re-enters the catheter near the tip. Pulling on the string forms a secure coil that is not easily dislodged from the renal pelvis. The string is fixed at the external end of the tube with a locking mechanism or by wrapping it around the tube and fixing it in place with a rubber cuff. The active reinforcement of the coil strength by the string is thought to provide more secure retention than the passive coil of a pigtail, although one comparative study did not confirm this (Chuang et al, 2011), and as such Cope catheters have replaced pigtail catheters for most percutaneous uses. Cope nephrostomy tubes, ranging from 6 to 14 Fr in diameter, can be used for simple upper urinary tract drainage and instillation procedures, as well as after percutaneous surgery. Nephroureteral Stent the Cope retention mechanism is also used in nephroureteral stents. A nephroureteral stent has a renal coil like that of a Cope nephrostomy tube, but the tube continues on to a ureteral extension that travels down the ureter to end in a passive pigtail that rests in the bladder. The ureteral portion can be the same diameter as the nephrostomy portion, or it can be narrower. A nephroureteral stent is passed percutaneously over a wire that ends in the bladder. After the end is coiled generously in the bladder, careful inspection of the fluoroscopy image shows the location of the side holes in the renal coil. By moving the catheter in and out while pulling on the string and rotating the external portion of the tube clockwise, the Cope retention coil is formed in the renal pelvis. General Considerations the advantages of a postoperative nephrostomy tube include good drainage and control of the upper urinary tract, and maintenance of percutaneous access for additional procedures. It was initially thought that a postoperative nephrostomy served to tamponade the nephrostomy tract and reduce hemorrhage, but subsequent studies have suggested that this is not the case. When hemorrhage does occur, however, the larger caliber of a nephrostomy tube provides better drainage of the upper urinary tract collecting system than does an internal ureteral stent. In addition, if a large perforation has occurred during the procedure, the additional diversion of urine away from the site might be advantageous. When a nephrostomy tube is left in place following percutaneous renal surgery, it is usually in the dilated access site. At least one group has attempted to reduce the discomfort associated with supracostal percutaneous renal surgery by placing a smallcaliber postoperative nephrostomy tube in a new subcostal site and leaving the dilated supracostal access site without a nephrostomy tube (although there was no control cohort for comparison) (Kim et al, 2006). Along with the nephrostomy, including a tube that goes down the ureter provides the greatest control and assurance of drainage. Because entry of a tube into the bladder is associated with additional symptoms, however, such a tube should only be used when needed. Considerations include the size of the patient (which determines to a large extent the risk of tube dislodgement), the importance of maintaining drainage, and the desire for ureteral intubation. Aside from the choice of retention mechanism, the main remaining consideration is the diameter of the nephrostomy tube. A number of studies have compared the impact of nephrostomy tube diameter after percutaneous renal surgery, including two nonrandomized prospective trials (Maheshwari et al, 2000; De Sio et al, 2011) and four randomized controlled trials comparing Circle Catheter A final type of nephrostomy tube is the circle nephrostomy tube. The circle nephrostomy tube requires two percutaneous access sites to the kidney, and this tube is most useful when maintenance of two tracts is desired, such as for irrigation of the renal pelvis or if more than one access is necessary for second-look nephroscopy (Kim et al, 2005). After obtaining access at two distant calyces, a flexible nephroscope or flexible ureteroscope passed over one wire is used to grasp the wire coming from the other site. When the endoscope is withdrawn, the wire is now in position to guide placement of the circle nephrostomy tube. Chapter8 PercutaneousApproachestotheUpperUrinaryTractCollectingSystem 173 Radiopaque markers Y connector Figure8-35. Among the six studies, comprising a total of 215 patients with nephrostomy tubes, five showed less pain and two reported less urinary leakage in the patients with smaller tubes. Bleeding did not increase in any of the studies for the groups with smaller tubes. Although tube diameter is not related to bleeding overall, the removal of larger tubes occasionally can be followed by immediate hemorrhage; this is rare with smaller tubes. As such, large-caliber nephrostomy tubes should be removed in a radiology suite where there is the opportunity for immediate replacement of the tube. Small-caliber tubes can be removed safely at the bedside after a period of clamping to assess clinically for distal ureteral obstruction. This practice never met with widespread acceptance, especially after Winfield and colleagues (1986) reported disastrous outcomes with this technique. The concept was revived in 1997 by Bellman and colleagues (1997), with the addition of an internal ureteral stent left in place for a week or two. Since then, many studies have evaluated the practice of omitting the nephrostomy tube after percutaneous renal surgery.
An intraoperative consultation with a general surgeon should be obtained regardless of whether the urologist performs the repair; from a medicolegal and quality of care standpoint mood disorder icd 10 code discount anafranil 25mg with visa, involvement of the general surgeon at the time of the acute event facilitates subsequent care should further complications arise while ensuring the best possible repair of the injury at the time of the acute event depression va rating buy anafranil australia. When the injury to the bowel is a through-and-through injury mood disorder related to general medical condition generic 10mg anafranil otc, it can similarly be repaired with an open or laparoscopic approach depression fallout purchase 75mg anafranil mastercard. In either case, the abdomen should be irrigated with 4 to 5 L of saline containing an antibiotic solution, and the patient must be placed on broad-spectrum antibiotic coverage. Perforation of the stomach is distinctly rare; however, to best preclude this problem patients should refrain from oral intake for 12 hours before surgery. The management of this complication is the same as for injury to the bowel, with primary closure and general surgery consultation. In addition, when the stomach is noted to be distended, a nasogastric or orogastric tube should be placed to decompress the stomach and facilitate further trocar insertion. It is far more common in procedures related to the retroperitoneum, as opposed to pelvic laparoscopy. The inferior vena cava is less affected because of its lateral location in relation to the aorta; likewise, the common iliac vein is rarely involved given its posterior position in relation to the common iliac artery. Rarely, in a patient with adhesions or prior surgery, intestinal mesenteric vessels servicing a "fixed" loop of bowel may be injured. In addition, the epigastric vessels are at risk for injury during trocar placement. The first sign of a major vascular complication is the onset of sudden hypotension and associated tachycardia. If the trocar has not been moved, then, as the obturator is withdrawn, the diagnosis is made immediately based on whether there is a pulsatile (arterial) or nonpulsatile (venous) profuse bleeding from the trocar sheath. If the trocar has been displaced from the injured vessel, then, depending on the vessel injured, when the laparoscope is introduced the surgeon will see blood rapidly accumulating in the abdominal cavity, a mesenteric hematoma, blood dripping from the trocar entry site, or, rarely, blood that preferentially accumulates retroperitoneally, in which case the space within the peritoneal cavity will appear to be markedly reduced and actively decreasing because of the expanding retroperitoneal hematoma. If blood is coming through the trocar, then the trocar should be closed and left in place. An emergency laparotomy is performed, and the trocar is followed to its point of entry into the vessel. The injured vessel should be controlled proximal and distal to the site of trocar injury with vessel loops or bulldog clamps, or alternatively a Satinsky clamp can be placed to isolate the area of injury so that as the trocar is withdrawn the wound can be controlled and repaired quickly. Alternatively in this situation, the procedure can be converted to a hand-assist approach and the surgeon can then use the intra-abdominal hand to control the bleeding vessel. In this regard, knowledge of the exact location and possible anatomic variations of major intra-abdominal blood vessels is mandatory. Because of limited intraperitoneal space, special care must be given to trocar placement in children and very thin adults. It is important to note that several maneuvers can be used to help prevent vascular injury. These include ensuring that all the safety signs of passage of a Veress needle are present before proceeding with trocar passage, obtaining an adequate pneumoperitoneum before trocar passage (intra-abdominal pressure may be raised to 25 mm Hg temporarily for placement of the primary trocar), passing the initial trocar under direct endoscopic control. Furthermore, it is helpful to consider having a "hemorrhage" tray available in the operating room at all times (Box 10-3). This laparoscopic tray should contain a Satinsky clamp, a 10-mm suction tip for large clot evacuation, an Endo Stitch device with 4-0 Vicryl suture, a Lapra-Ty clip applier and a rack of Lapra-Ty clips (six clips per rack), two laparoscopic needle holders, and 4-0 vascular suture. With this tray available, some injuries to major venous structures can be successfully resolved laparoscopically. Urinary tract injuries during laparoscopy are most commonly associated with trocar passage, specifically injury to the bladder at the time of initial trocar placement. Chances of this problem occurring have been greatly reduced by the introduction of blunt trocars. The diagnosis can be confirmed by retrograde intravesical instillation of indigo carmine diluted with saline; this allows the surgeon to rapidly identify the cystotomy site. The injury can be repaired laparoscopically with laparoscopic suturing techniques; however, extensive defects may require open surgical repair (Ostrzenski and Ostrzenska, 1998). These injuries should always be closed and not left to heal on their own with prolonged Foley catheter drainage. Preoperative placement of a urethral catheter to drain the bladder is recommended for all major laparoscopic urologic cases. Not only does it largely preclude bladder injury, but it also provides the necessary means for monitoring urine output during major laparoscopic procedures. Blood dripping from the port entry site and onto the underlying abdominal viscera is the first sign of an injured abdominal wall vessel. The exact site of hemorrhage is determined by cantilevering the trocar into each of the four quadrants and noting which position of the trocar tamponades the bleeding. Chapter10 FundamentalsofLaparoscopicandRoboticUrologicSurgery 219 Definitive therapy for this problem can be undertaken in one of three ways. The simplest method, albeit the most costly, is the insertion of curved electrosurgical scissors or forceps through another port, which can then be articulated up into the port site to coagulate the bleeding. This can be accomplished by inserting a straight Keith needle with a 0-0 absorbable suture from the outside of the abdomen at one side of the affected quadrant and then grasping the needle with laparoscopic forceps and pushing it back out of the abdomen at the opposite side of the affected quadrant until it can be recovered on the surface of the abdomen. Alternatively, various port closure devices, in particular the Carter-Thomason device, may be used to similarly pass a suture to control the bleeding (Ortega, 1996). Ultimately, at the end of the procedure a device of this nature should be used to definitively close the port site and occlude the injured vessel no matter which of the aforementioned techniques is used.
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