454
ureterosigmoidostomy, permanent nephrostomy, ileal or colonic conduit, cutaneous ureterostomy, ring ureterostomy or ureterostomy-en-Y. Ureterostomy was first suggested in 1856 by Gignon, but it was not until 43 years later that LeDentu performed the first deliberate cutaneous ureterostomy. Our patient had a dilated but functioning left kidney associated with multiple tumours within its pelvicaliceal system. If these could be destroyed and recurrent tumours controlled by endoscopic means, preservation of the solitary kidney and its function might be achieved. If renal access were provided by some form of urinary diversion, one might avoid or postpone permanent dialysis or renal transplantation. The “ideal” diversion would be one which could be easily performed, could offer direct access to the renal pelvis with rigid endoscopes and could provide good urine drainage. Possible contenders included ureteroileal or ureterocolonic conduit diversion, permanent nephrostomy, pyelocutaneous ileal or colonic conduit, or autotransplantation of the kidney to the iliac fossa with anterior pyelostomy. Lloyd et al. (1962) described the technique of high lateral cutaneous ureterostomy (midway between the twelfth rib and iliac crest over the anterior axillary line) and had good results with over 20 patients. Young and Aleida (1966) had satisfactory results with flank ureterostomy for unilateral diversion in 11 patients. We favoured anterior upper quadrant ureterostomy in the presence of multiple intrarenal tumours and a dilated ureter for its advantage of simplicity, direct easy access to the renal pelvis by rigid instruments and avoidance of the risk of track seedings associated with nephrostomy. There is also less risk of stoma1 stricture in the presence of the dilated ureter, shorter ureteric length with reduced risk of ischaemia. Having to wear braces instead of a belt for his trousers is probably a small price to pay.
BRITISH JOURNAL OF UROLOGY
Endoscopic Removal of Non -deflating Foley Balloon Catheter K. SUBRAHMANYAM, P. SRIDAR, K. VENUGOPAL and B. SURYAPRAKASH, Department of Urology, NizamS Institute of Medical Sciences, Hvderabad, India
Removal of a Foley cathety can sometimes be difficult because of a blocke8 balloon channel. Techniques used to overcome this problem include injection of ether into the balloon and transrectal or transabdominal puncture of the balloon. We describe a new endoscopic technique for puncturing the balloon. The catheter is cut about 2.5cm beyond the external urethral meatus and a long thick silk stay suture is inserted into the end of the catheter. Under local analgesia the catheter is pushed into the bladder followed by a 19F cystoscope. Once the entire catheter is in the bladder a ureteric catheter stylet is passed through the cystoscope and the balloon is punctured. The catheter can then be removed by applying traction to the silk stay suture. This technique has been used successfully in 2 patients. Requests for reprints to: K. Subrahmanyam, Department of Urology, Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad 500 482, A.P. India.
Simple Technique for Everting a Spout I leostomy D. J. THOMAS and G. F. ABERCROMBIE, Department of Urology, St Mary‘s Hospital, Portsmouth
A simple technique is described to evert small bowel when fashioning a spout ileostomy as used for urinary diversion. References When forming an ileostomy it is important that a spout is created in order to protect the skin from Bunce,C. J., DevSarrnah, B. andconsidine, J. (1991).Cystoscopic suction diathermy for the treatment of superficial bladder irritation. Everting the small bowel to form the tumours. Br. J . Urol., 68, 157-161. spout can be awkward and grasping the mucosa Lloyd, F. A., Cottrell, T L., Cross, R. R. e l al. (1962). High with instruments such as Babcock forceps may cutaneous ureterostomy. J . Urol.,88,740-745. result in unnecessary tearing and bleeding. Young, J. D. and Aleida, F. T. (1966). Further observations on We recommend the use of a conventional adult flank ureterostomy and cutaneous transureteroureterostomy. Langenbeck retractor. If the small bowel is rolled J . Urol.., 95, 327-333. over the upturned blade of a Langenbeck retractor (Fig.) eversion can be achieved with minimal trauma to the small bowel. Traction may be applied Requests for reprints to: S . Liu, Department of Urology, St to the small bowel with stay sutures. The blade of Bartholomew’s Hospital, West Smithfield, London ECI A 7BE.
455
POINTS OF TECHNIQUE
phroscopy and nephroscopic surgery. Dilatation of the tract is often difficult in the presence of a tough thoraco-lumbar fascia or extensive perirenal fibrosis following previous renal surgery. A method is described which facilitates dilatation in situations where the procedure is difficult because of perirenal fibrosis. A
Technique Placement of a guide wire in the renal pelvis usually proceeds without difficulty, even in the presence of extensive perirenal fibrosis. However, dilatation from this point may be impossible using semi-rigid dilators (such as the Amplatz renal dilators) (Coleman, 1986). The dilator passes readily to the level of fibrosis and will pass no further, as the relatively flexible small dilator will buckle when it encounters the fibrous tissue (Fig. 1). This buckling effect may be overcome by dilating the tract down to the level of the fibrosis without attempting to pass the dilator through the area of high resistance, and then passing a smaller dilator (Fig. 2). The large dilator prevents buckling of the small dilator in the soft tissues overlying the fibrosis. This allows penetration of this tough tissue and, having initially being breached, further dilatation of the fibrotic area can usually be achieved with little difficulty.
Fig. Diagrammatic (A) and clinical (B) illustration of ileum everted over a Langenbeck retractor (L).
Comment Many methods are available for dilatation (Mazzeo
the retractor is 4 cm long and hence the spout will be the same length. This results in a stoma which is easy to manage and affords good skin protection. This simple technique not only assures the correct length of ileostomy spout but also reduces trauma during eversion and saves time.
et al., 1982; Ware, 1982) but we feel this technique
has certain advantages in situations where dense fibrosis is encountered in the perirenal tissue.
Requests for reprints to: D. J . Thomas, Department of Urology, St Mary's Hospital, Milton Road, Portsmouth PO3 6AD.
Percutaneous Dilatation of Difficult Nephrostomy Tracts W. LYNCH, B. DOUSTand D. GOLOVSKY, Departmentsof Urology and Radiology, St Vincent's Hospital, Sydney, Australia
\-
RESETANT TISSUE PLANE
Many techniques have been used to establish a percutaneous nephrostomy tract suitable for ne-
Fig. 1 Thin dilator bends when tough tissue is encountered, making further progress impossible.
ureterosigmoidostomy, permanent nephrostomy, ileal or colonic conduit, cutaneous ureterostomy, ring ureterostomy or ureterostomy-en-Y. Ureterostomy was first suggested in 1856 by Gignon, but it was not until 43 years later that LeDentu performed the first deliberate cutaneous ureterostomy. Our patient had a dilated but functioning left kidney associated with multiple tumours within its pelvicaliceal system. If these could be destroyed and recurrent tumours controlled by endoscopic means, preservation of the solitary kidney and its function might be achieved. If renal access were provided by some form of urinary diversion, one might avoid or postpone permanent dialysis or renal transplantation. The “ideal” diversion would be one which could be easily performed, could offer direct access to the renal pelvis with rigid endoscopes and could provide good urine drainage. Possible contenders included ureteroileal or ureterocolonic conduit diversion, permanent nephrostomy, pyelocutaneous ileal or colonic conduit, or autotransplantation of the kidney to the iliac fossa with anterior pyelostomy. Lloyd et al. (1962) described the technique of high lateral cutaneous ureterostomy (midway between the twelfth rib and iliac crest over the anterior axillary line) and had good results with over 20 patients. Young and Aleida (1966) had satisfactory results with flank ureterostomy for unilateral diversion in 11 patients. We favoured anterior upper quadrant ureterostomy in the presence of multiple intrarenal tumours and a dilated ureter for its advantage of simplicity, direct easy access to the renal pelvis by rigid instruments and avoidance of the risk of track seedings associated with nephrostomy. There is also less risk of stoma1 stricture in the presence of the dilated ureter, shorter ureteric length with reduced risk of ischaemia. Having to wear braces instead of a belt for his trousers is probably a small price to pay.
BRITISH JOURNAL OF UROLOGY
Endoscopic Removal of Non -deflating Foley Balloon Catheter K. SUBRAHMANYAM, P. SRIDAR, K. VENUGOPAL and B. SURYAPRAKASH, Department of Urology, NizamS Institute of Medical Sciences, Hvderabad, India
Removal of a Foley cathety can sometimes be difficult because of a blocke8 balloon channel. Techniques used to overcome this problem include injection of ether into the balloon and transrectal or transabdominal puncture of the balloon. We describe a new endoscopic technique for puncturing the balloon. The catheter is cut about 2.5cm beyond the external urethral meatus and a long thick silk stay suture is inserted into the end of the catheter. Under local analgesia the catheter is pushed into the bladder followed by a 19F cystoscope. Once the entire catheter is in the bladder a ureteric catheter stylet is passed through the cystoscope and the balloon is punctured. The catheter can then be removed by applying traction to the silk stay suture. This technique has been used successfully in 2 patients. Requests for reprints to: K. Subrahmanyam, Department of Urology, Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad 500 482, A.P. India.
Simple Technique for Everting a Spout I leostomy D. J. THOMAS and G. F. ABERCROMBIE, Department of Urology, St Mary‘s Hospital, Portsmouth
A simple technique is described to evert small bowel when fashioning a spout ileostomy as used for urinary diversion. References When forming an ileostomy it is important that a spout is created in order to protect the skin from Bunce,C. J., DevSarrnah, B. andconsidine, J. (1991).Cystoscopic suction diathermy for the treatment of superficial bladder irritation. Everting the small bowel to form the tumours. Br. J . Urol., 68, 157-161. spout can be awkward and grasping the mucosa Lloyd, F. A., Cottrell, T L., Cross, R. R. e l al. (1962). High with instruments such as Babcock forceps may cutaneous ureterostomy. J . Urol.,88,740-745. result in unnecessary tearing and bleeding. Young, J. D. and Aleida, F. T. (1966). Further observations on We recommend the use of a conventional adult flank ureterostomy and cutaneous transureteroureterostomy. Langenbeck retractor. If the small bowel is rolled J . Urol.., 95, 327-333. over the upturned blade of a Langenbeck retractor (Fig.) eversion can be achieved with minimal trauma to the small bowel. Traction may be applied Requests for reprints to: S . Liu, Department of Urology, St to the small bowel with stay sutures. The blade of Bartholomew’s Hospital, West Smithfield, London ECI A 7BE.
455
POINTS OF TECHNIQUE
phroscopy and nephroscopic surgery. Dilatation of the tract is often difficult in the presence of a tough thoraco-lumbar fascia or extensive perirenal fibrosis following previous renal surgery. A method is described which facilitates dilatation in situations where the procedure is difficult because of perirenal fibrosis. A
Technique Placement of a guide wire in the renal pelvis usually proceeds without difficulty, even in the presence of extensive perirenal fibrosis. However, dilatation from this point may be impossible using semi-rigid dilators (such as the Amplatz renal dilators) (Coleman, 1986). The dilator passes readily to the level of fibrosis and will pass no further, as the relatively flexible small dilator will buckle when it encounters the fibrous tissue (Fig. 1). This buckling effect may be overcome by dilating the tract down to the level of the fibrosis without attempting to pass the dilator through the area of high resistance, and then passing a smaller dilator (Fig. 2). The large dilator prevents buckling of the small dilator in the soft tissues overlying the fibrosis. This allows penetration of this tough tissue and, having initially being breached, further dilatation of the fibrotic area can usually be achieved with little difficulty.
Fig. Diagrammatic (A) and clinical (B) illustration of ileum everted over a Langenbeck retractor (L).
Comment Many methods are available for dilatation (Mazzeo
the retractor is 4 cm long and hence the spout will be the same length. This results in a stoma which is easy to manage and affords good skin protection. This simple technique not only assures the correct length of ileostomy spout but also reduces trauma during eversion and saves time.
et al., 1982; Ware, 1982) but we feel this technique
has certain advantages in situations where dense fibrosis is encountered in the perirenal tissue.
Requests for reprints to: D. J . Thomas, Department of Urology, St Mary's Hospital, Milton Road, Portsmouth PO3 6AD.
Percutaneous Dilatation of Difficult Nephrostomy Tracts W. LYNCH, B. DOUSTand D. GOLOVSKY, Departmentsof Urology and Radiology, St Vincent's Hospital, Sydney, Australia
\-
RESETANT TISSUE PLANE
Many techniques have been used to establish a percutaneous nephrostomy tract suitable for ne-
Fig. 1 Thin dilator bends when tough tissue is encountered, making further progress impossible.
