Biomedical subjects
Publications and source records attributed to M Marberger.
Disintegration of stones with ultrasound under endoscopic control has eliminated size as the major limitation to percutaneous and transureteral extraction of calculi from the upper urinary tract. With virtually no side effects to soft tissues, approximately 60 per cent of all renal calculi requiring intervention can be managed percutaneously instead of by open surgery.
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Experience with transcolonic Ureterosigmoidostomy (US) in 127 patients and colonic conduit (CC) in 152 patients is presented in detail. US proved to be highly satisfactory in children, in particular in bladder exstrophy (13% post-operative and 27% late complications, deterioration in 8% of all renal units), but gave poor results in adults. This was mainly due to the patient selection, as in this group preoperative damage to the upper urinary tract by pyelonephritis, obstruction, irradiation or previous surgery was frequent. Obviously these factors prohibit US. For the same reason US excludes adjunctive radiotherapy in cancer patients. Although employed in a higher renal risk group (signs of pyelonephritis in 34% and ureteral dilatation in 54% of the renal units in the preoperative IVP) CC with non-refluxing uretero-intestinal anastomoses reliably stabilized renal morphology (improvement of ureteral dilatation in 79%, over all deterioration 10% of all kidneys, mainly by progression of pyelonephritis established already before diversion). The low late complication rates of 21% in children and 31% in adults (with benign disease) compare favourably with the results reported in comparable series of ileal conduits.
Percutaneous stone manipulation by direct ultrasound disintegration, extraction or chemolysis was done on 34 patients. A total of 15 patients presented with an operatively established nephrostomy, while percutaneous nephrostomy and subsequent dilation of the nephrostomy channel were done in 19. The rate of complete stone clearance was 19 of 20 stones after percutaneous nephrostomy and 8 of 16 stones in the group with an operatively established nephrostomy. The primary goal, to remove obstructing pelvic stones, was achieved in all cases. There were no untoward side effects, such as back pressure damage owing to flushing of the collecting system during ultrasound disintegration, or persistent infection. Complications in 3 patients were managed conservatively.
Seventy-two patients with renal carcinoma (RC) in a solitary kidney or bilateral synchronous tumours underwent parenchyma-sparing excision of their neoplasms. This was performed in situ in 51 and extracorporeally in 21 kidneys, with a complication rate respectively of 17 and 43%. The 5-year survival rates were 78% for unilateral disease, 48% for bilateral synchronous and 38% for bilateral asynchronous disease. Survival correlated with P category, grade and diameter of the tumour. Vascular invasion and spindle cells indicated a poor prognosis; the position of the tumour, oncocytic elements, calcification, lymphocytic infiltration or the predominance of clear cell or granular cells did not influence survival.
Kidneys preserved with cold Collins' solution only function satisfactorily if there is no significant preceding period of warm ischaemia. This paper reports an attempt to provide protection to renal function during such a warm ischaemic episode using the nucleotide inosine. In these experiments inosine given intravenously to dogs followed by 15 min of warm renal ischaemia and by either 12 or 24 h of cold preservation with Collins' solution did not protect renal function against the warm ischaemic insult.
The reaction of periurethral tissue to retrograde urethrography with 30 or 60% contrast dye and/or iatrogenic infection following a sharp, penetrating injury of the urethra was investigated in rabbits. Urine was diverted continuously by tubeless cystostomy throughout the experiment. The local healing processes did not differ from the normal reaction after urethrography with 10 ml 30 or 60% sodium-meglumine-amidotrizoate or instillation of 1--2 . 10(6) E. coli in 10 ml saline. An increased inflammatory reaction was only observed when urethrography and the instillation of E. coli saline was combined, thus increasing the total fluid volume instilled and with it probably also the intraurethral pressure. The results suggest that retrograde urethrography as a diagnostic procedure immediately after an acute urethral trauma is free of adverse effects on the normal healing processes if performed under aseptic standards, with a small volume of contrast dye and as low as instillation pressure as possible.
Hypothermia reduces ischemic damage if prolonged occlusion of the renal artery is required during an in situ kidney operation. Hypothermia may be achieved by external cooling or by transarterial hypothermic perfusion. External cooling may lower intrarenal temperature heterogeneously. Perfusion techniques via intra-arterial catheters introduced percutaneously are associated with minimal technical difficulties. The 95 patients who underwent extensive hypothermic nephrolithotomy had differential 131iodine hippuran clearance studies preoperatively, and 2 weeks and 6 to 46 months postoperatively. Sixty-three kidneys were cooled by transarterial hypothermic perfusion and 39 were cooled with topical ice slush. In the perfused kidneys renal function had decreased to 80.6 plus or minus 3.7 per cent (mean plus or minus standard error) of the preoperative value 2 weeks postoperatively but recovered to 92.1 plus or minus 4.6 per cent of the pre-treatment value. In the slush-cooled (topically hypothermic) kidneys renal function decreased to 69.7 plus or minus 5.1 per cent of the pre-treatment value 2 weeks postoperatively but recovered to 70.8 plus or minus 4.4 per cent of pre-treatment values 6 months or more postoperatively. Percutaneous transarterial hypothermic renal perfusion seems to offer better preservation of renal function in the clinical situation than does topical ice slush hypothermia.
Transrenal ureteric embolisation with the tissue adhesive butyl 2-cyano-acrylate mixed with lipiodol and tantalum powder produces rapid and effective occlusion of the ureter. This can be combined with the use of a Gianturco spiral. In an experimental series of eight dogs observed for 54 days, the adhesive disappeared partly in three animals and totally in a further three. Fibrotic ureteric stenosis was observed in three animals. Clinical results were rather better because of the presence of external urinary drainage. Twenty-one ureters in eighteen patients were occluded either unilaterally or bilaterally, and sometimes combined with percutaneous contralateral renal embolisation. After one to four months, the ureter was still occluded in three out of six cases; after five to 17 months, three out of five cases were no longer totally occluded, but in two cases they were still blocked. The procedure is new and suitable for the treatment of otherwise untreatable conditions, such as extensive urinary fistulae, bladder tenesmus and haematuria due to extensive tumours of the minor pelvis.
This study describes the effect of the 4 most commonly used methods of intrarenal access on renal function and morphology in the dog at 48 h. The extended sinus approach was associated with no functional or parenchymal loss; the radial paravascular approach was followed by a 20% decrease in function and no significant parenchymal loss; the anatrophic intersegmental nephrotomy caused a 30% functional decrease with a significant parenchymal loss; the bivalve nephrotomy was associated with a 50% loss of function and considerable parenchymal loss and distortion.
Inosine administered into the renal artery improves renal ischemic tolerance. The study was designed to establish the limitations of this measure by comparing its effectiveness with that of regional hypothermia and to test the possibility of combining inosine and hypothermia in prolonged renal hypothermia. In uninephrectomized dogs, the remaining kidney was subjected to 2 h of ischemia under inosine protection; perfusion cooling, or no protection (experiment A), or to 90 min of warm ischemia plus inosine plus 90 min of cold ischemia; 90 min of warm plus 90 min of cold ischemia, or 180 min of cold ischemia (experiment B). Whereas perfusion cooling reliably prevented permanent loss of renal function even after 180 min of ischemia, inosine was clearly inadequate for protection against warm ischemia exceeding 90 min, but effective in shorter periods of ischemia with some unreliability in borderline cases. Inosine protection can be combined with hypothermia in a sequential manner if extended ischemia becomes necessary unexpectedly. For clinical use, however, it seems safer to commence with hypothermia after 60 min of inosine-protected warm ischemia. Simultaneous balloon occlusion of the renal artery and transcatheter perfusion cooling facilitates the clinical applicability of these results.
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Transrenal closure of the ureter with butyl-2-cyanoacrylate using adjuvant balloon catheter occlusion was successfully performed for the palliative management of inoperable vesicovaginal and vesicosacral fistulas in 3 patients. Unilateral percutaneous nephrostomy provided supravesical urinary diversion as well as access for permanent embolization of the ureter. The contralateral kidney was nonfunctional in 2 patients. In the third, in addition to unilateral ureteral occlusion, the contralateral kidney was defunctionalized by embolization of the renal artery ("radiological nephrectomy") to avoid the need for bilateral nephrostomy drainage.
At reexamination 67 patients with ureterosigmoidostomies showed no significant alteration of their acid-base and electrolyte metabolism as compared to the preoperative situation and 39 patients with a colonic conduit. If required these patients had received an oral alkali substitution therapy; this proved to be necessary as a permanent measure only in cases with functional and morphological defects of the upper urinary tract. Spells of hyperchloremic acidosis had occurred in 13 patients during the follow-up period and always coincided with attacks of acute pyelonephritis and renal deterioration, often accompanied by irregularities in the substitution. Obviously metabolic problems arise only with a deteriorating urinary tract and timely discovery and treatment of these patients is the main task of the supervising doctor. Although the metabolic imbalances usually respond promptly to an adaptation of the substitution therapy, patients with a predamaged upper urinary tract should not be subjected to ureterosigmoidostomy.
The technique and efficacy of therapeutic catheter embolization of the kidney with butyl-2-cyanoacrylate (Histoacryl) were studied in 80 rabbits (including control groups) and in 10 dogs. A mixture of butyl-2-cyanoacrylate, 50% glucose, and tantalum powder was used for the embolization. Complete and permanent vascular occlusion was found in nearly all cases. The main complication observed was a reflux of embolizing material into the lumbar arteries, which occurred in seven rabbits. Clinically therapeutic embolization was performed in six patients with hypernephroma. The indication for embolization in these patients, as well as in two others with iatrogenic lesions, was pronounced hematuria. Cessation of bleeding was achieved in all cases. For embolization the coaxial catheter technique is recommended; in special cases with extensive arteriovenous shunts, adjunctive balloon occlusion would be advisable.