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Radiology Handbook

Genitourinary System


Genitourinary System Quick Links Abdominal Plain Film Intravenous Urogram/Excretory Urogram Retrograde Pyelography Antegrade Pyelography Cystogram & Cystourethrogram Videourodynamics Retrograde Urethrogram Loopogram or Pouchogram Hystero-
salpingography Selective Salpingography & Fallopian Tube Recanalization Renal Cyst Aspiration & Ablation Percutaneous Nephrostomy Nephrostogram Percutaneous Ureteral Stenting Percutaneous Dilation Renal & Perinephric Abscess Drainage Pelvin Lymphocfile Drainage Transcatheter Urinary Tract Biopsy Extracorporeal Shock Wave Lithotripsy

 

ABDOMINAL PLAIN FILM (KUB)

 

Description:

KUB is an abbreviation for kidneys, ureters, and bladder. A supine film of the abdomen is exposed without administering oral or intravenous contrast material. For suspected urinary tract calculi, additional films (an oblique projection or a film centered over the kidneys) may be made.

Indications:

  1. Suspected renal, ureteral, or bladder calculi.

  2. To follow the progress of a known calculus or stone fragment following lithotripsy procedures.

  3. To determine the position of a urinary tract catheter or stent.

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INTRAVENOUS UROGRAM/EXCRETORY UROGRAM (IVU; IVP, EU)

 

Description:

The IVU (formerly known as an IVP) is a non-invasive method of visualizing the kidneys, ureters and bladder and is the basic diagnostic radiological study of the urinary tract.

Images of the entire abdomen and of the kidneys are exposed. The patient is then injected intravenously with iodinated contrast media, which is excreted by the kidneys. As the contrast passes through the kidneys, ureters and bladder, radiographs are exposed to display the morphology of the urinary tract. A post-micturition image of the bladder is usually obtained to assess bladder emptying.

Indications:

  1. Symptoms which suggest underlying urologic disease, i.e. hematuria, pyuria, dysuria, flank pain.

  2. Undiagnosed abdominal pain to exclude urinary tract obstruction as the cause of pain.

  3. Select patients with urinary tract infections (recurrent or persistent).

  4. Follow-up after urologic surgery such as stone removal, urinary diversion, etc.

  5. Patients presenting with acute flank or abdominal pain and suspected to have renal colic are best evaluated with a non-contrast CT scan. IVU is no longer performed for evaluating patients with acute flank pain in a search for obstructing stones.

Contraindications:

  1. Renal insufficiency, particularly diabetic nephropathy.

  2. Multiple myeloma (relative contraindication).

  3. Severe dehydration or fluid and electrolyte imbalance (relative contraindication).

  4. Multiple consecutive contrast studies.

Note: Previous contrast reactions may necessitate a steroid/antihistamine "prep" prior to repeat contrast administration. Such situations should be discussed with a GU Radiologist on a case-by-case basis.

Preparation:

  1. Clear liquids only for one day prior to the examination.

  2. Cathartics on the evening before the examination: Magnesium citrate, 10 oz. bottle at 5 p.m. (chilled) and Ducolax tablets, 4 tablets, p.o. at 10 p.m. with at least one full glass of water.

  3. Nothing by mouth after midnight of the day before the examination. If the examination is scheduled in the afternoon, clear liquids may be taken in the morning.

Complications:

Most complications associated with an IVU are related to the administration of contrast. Minor contrast reactions (nausea, vomiting, pruritis, urticaria, etc.) are less common with the nonionic contrast agents that are currently used. Major adverse reactions (hypotension, shock, death) are rare (occur in <1:40,000 to 1:60,000 patients who receive contrast).

If there is extravasation of contrast of contrast at the venipuncture site, management is determined by the volume of extravasated dcontrast and the site of extravasation.

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RETROGRADE PYELOGRAPHY

 

Description:

To investigate lesions of the ureter and renal collecting system that cannot be adequately defined by intravenous urography or CT urography. The patient is cystoscoped in the O.R. (Cystoscopy Suite) by members of the Division of Urology and a catheter is positioned intraoperatively in the appropriate ureter. The patient is then brought to the Radiology Department where contrast material is injected through the catheter to opacify the ureter and pyelocalyceal system. Multiple fluoroscopically guided images are obtained.

Indications:

  1. Unsatisfactory visualization of one or both collecting systems or ureters by intravenous urography or CT urography.

  2. To evaluate the renal collecting systems and ureters for a urothelial abnormality when intravenous contrast material cannot be given for intravenous urography.

  3. To evaluate a suspected filling defect in the renal collecting system or ureter (differentiate calculus from transitional cell carcinoma).

  4. Suspected calyceal abnormality such as tuberculosis or papillary necrosis.

Contraindications:

  1. Untreated urinary tract infection.

  2. Patients who cannot or should not be cystoscoped.

Preparation:

  1. Fluid status determined by the anesthesiologists if cystoscopy immediately precedes retrograde pyelography.

  2. Appropriate sedation and analgesia.

  3. Steroid/antihistamine prep if patient has a history of previous contrast reaction.

Complications:

  1. Infection.

  2. Contrast reaction (very rare).

  3. Perforation of ureter or bladder.

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ANTEGRADE PYELOGRAPHY

 

Description:

The renal pelvis is percutaneously punctured with a thin-walled needle from a posterior or posterolateral approach. Contrast material is then injected directly into the kidney and multiple fluoroscopic images are obtained in various projections. Either fluoroscopy or ultrasonography may be used to guide the placement of the needle.

Indications:

  1. Unsatisfactory visualization of one or both kidneys on intravenous urography when retrograde pyelography is not possible.

  2. To evaluate suspected ureteral obstruction in a renal transplant.

Contraindications:

  1. Should not be performed if a retrograde pyelogram can be performed.

  2. Uncorrected coagulopathy.

Preparations:

  1. NPO for at least 4 hours prior to the procedure

  2. Appropriate sedation and analgesia.

Complications:

  1. Urosepsis.

  2. Hemorrhage.

  3. Extravasation of contrast media.

  4. Inadvertent puncture of adjacent organs.

  5. Contrast reaction (very rare).

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CYSTOGRAM AND CYSTOURETHROGRAM (VCUG)

 

Description:

After aseptic catheterization, the urinary bladder is filled with contrast material to the patient's tolerance. When the patient feels a strong desire to void, the catheter is removed. Multiple fluoroscopic images of the bladder and urethra are obtained as the patient voids. Any evidence of vesico-ureteral reflux during bladder filling or voiding is noted. A post-void abdominal or pelvic radiograph is then obtained.

A cystogram is similar to a VCUG except that the voiding portion is deleted. The bladder is emptied through the catheter. Cystography is used primarily to rule out a perforated or ruptured bladder, to check the integrity of the bladder post-operatively, or to evaluate urinary incontinence.

Indications:

Some of the same information obtainable by cystography is also revealed by the cystourethrogram, so there is some overlap in the indications for the two procedures:

  1. To check for vesico-ureteral reflux in a patient with UTI/flank pain.


  2. To evaluate a suspected urethral abnormality such as a stricture urethral valves, urethral diverticula, urethal fistula.


  3. To check for and visualize the cause of urethral obstruction or other disease, i.e., valves, strictures, polyps, diverticula, etc.


  4. Miscellaneous voiding difficulties, i.e. detrusor-sphincter dyssynergia.


  5. Suspected ectopic insertion of ureter.


  6. Urinary incontinence.


  7. Suspected bladder perforation or rupture (post-procedural or post traumatic).


  8. Suspected bladder fistula.


  9. Evaluation of post-operative healing following open bladder, urethral, or prostatic surgery.


  10. Recurrent urinary tract infections.

Contraindications:

  1. Contraindications to passage of a urethral catheter may make attempts at cystography inadvisable.


  2. The procedure is not contraindicated in patients who have allergies to contrast media since very little if any of the contrast is absorbed during cystography.

Complications:

  1. Intravasation of contrast medium might precipitate allergic reactions in susceptible individuals--also very rare.


  2. Some hematuria and dysuria are not uncommon for a few hours after the procedure.


  3. Urinary tract infections (UTI) are very uncommon following this procedure, but may occur. Antibiotic coverage is not routinely employed. If there is an active UTI, the procedure should be postponed till the infection has been adequately treated.

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VIDEOURODYNAMICS RETROGRADE URETHROGRAM

 

This study is performed jointly by the radiology and urology services. All patients have to be evaluated by the urologists prior to scheduling this procedure. It is performed in patients with voiding difficulties. In addition to radiographic evaluation of the bladder and urethra (as in a voiding cystourethrogram), pressure transducer catheters are also placed in the bladder and rectum, and the EMG activity of the pelvic floor muscles is assessed by placing EKG pads on the perineum.

Description:

A Foley catheter is placed within the urethral meatus and the balloon is inflated slightly. Contrast is injected to opacify the pendulous and bulbous portions of the male urethra and multiple images are obtained. Because of the resistance of the membranous urethra, retrograde injection does not result in a well-filled posterior urethra. Voiding cystourethrogram is the study of choice to evaluate the posterior urethra. A retrograde urethrogram is not used to study the female urethra – an MRI of the pelvis or a VCUA are better studied to evaluate the female urethra.

Indications:

  1. Suspected or known urethral stricture.


  2. Suspected or known diverticulum or fistula of the urethra.


  3. Pelvic trauma with suspected rupture of the urethra.

Contraindications:

Acute urinary tract infection.

Complications:

  1. Urinary tract infection.


  2. Contrast reaction (very rare since the contrast media is usually not absorbed from the urinary bladder).


  3. Hematuria.

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LOOPOGRAM OR POUCHOGRAM

 

Description:

A Foley catheter is inserted into the urinary conduit (usually fashioned from ileum) or urinary pouch (fashioned from ileum or large bowel) and under fluoroscopic guidance the conduit or reservoir is filled with contrast. Reflux into the ureters and renal collecting systems may be observed.

Indications

  1. To visualize the upper urinary tracts in patients with a refluxing ureteroenteral diversion.

  2. Suspected ureteral obstruction in patients with ureteroileostomy.

  3. Suspected anastomotic leak.

  4. Suspected conduit or reservoir disorders.

  5. Post operative evaluation as a baseline study 3-4 weeks after surgery.

Preparation:

Intravenous antibiotics are administered prior to the examination.

Complications:

  1. Infection

  2. Contrast reaction.

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HYSTEROSALPINGOGRAPHY

 

Description:

Following placement of a vaginal speculum, the cervix is cannulated by a gynecologist. Under fluoroscopic control, contrast material is injected into the uterus from where it flows into the fallopian tubes and peritoneal cavity. Multiple fluoroscopic images are obtained.

Indications:

  1. Patients with infertility to evaluate for:
    1. Suspected fallopian tube obstruction.
    2. Suspected submucous leiomyoma (fibroid).
    3. Suspected uterine anomaly or scarring.


  2. History of recurrent abortion.

  3. Pre and post tubal reanastomosis.

  4. History of in utero exposure to diethylstilbestrol (high risk for structural abnormality and consequent infertility or recurrent abortions).

Contraindications:

  1. Suspected pregnancy.

  2. Active pelvic infection.

  3. Immediate premenstrual phase.

  4. Patient still bleeding from last menstrual period.

  5. History of severe contrast reaction.

Complications:

  1. Pain.

  2. Pelvic infection particularly in patients with pre-existing chronic pelvic infection.

  3. Vasovagal reaction.

  4. Hemorrhage.

  5. Contrast reaction.

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SELECTIVE SALPINGOGRAPHY AND FALLOPIAN TUBE RECANALIZATION

 

Description:

This procedure is performed when a diagnostic hysterosalpingogram demonstrates proximal obstruction of the fallopian tubes at their origin from the uterus. A small catheter is introduced into the uterus via the cervix and directed at the tubal orifice. Contrast material is injected to better distend the fallopian tube and flush out any debris, which may be blocking the tube (selective salpingogram). If this procedure is not successful in restoring tubal patency, a small guide wire and catheter are passed through the blocked segment of the tube (tubal recanalization). This procedure can be performed on both tubes at the same sitting.

Indications:

  1. To evaluate the anatomy of the fallopian tubes in patients with proximal tubal obstruction.

  2. To restore tubal patency in patients who are infertile due to proximal obstruction of the fallopian tube.

Contraindications:

  1. Suspected pregnancy.

  2. Active pelvic infection.

  3. Immediate premenstrual or postmenstrual phase.

  4. History of severe contrast reaction.

Preparation:

  1. Nothing by mouth for at least 4 hours before the procedure.

  2. Oral antibiotics starting 2 days before the procedure and continuing for one day after.

  3. Appropriate analgesia and sedation.

Complications:

  1. Failure to open up tubes.

  2. Perforation of a tube. This is usually of no consequence.

  3. Pain.

  4. Pelvic infection, particularly in patients with pre-existing chronic pelvic infection.

  5. Hemorrhage.

  6. Contrast reaction.

  7. Ectopic pregnancy.

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RENAL CYST ASPIRATION AND ABLATION

 

Description:

Using ultrasonography or CT guidance, a needle is percutaneously inserted through the back into a renal cyst. A sample of cyst fluid is aspirated, and contrast material is injected into the cyst to ensure that the cyst does not communicate with the collection system. A sclerosing agent can be instilled into a cyst to prevent cyst-fluid reaccumulation.

Indications:

To obliterate a symptomatic benign simple renal cyst. Patient may have symptoms of severe pain or the cyst may be obstructing the collecting system.

Contraindications:

An uncorrectable bleeding disorder.

Preparation:

  1. NPO for at least 4 hours prior to the procedure.

  2. Appropriate sedation and analgesia.

Complications:

  1. Cyst infection.

  2. Bleeding.

  3. Pain.

  4. Extravasation of sclerosant into the tissues around the cyst or into the rectroperitoneum.

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PERCUTANEOUS NEPHROSTOMY (PCN)

 

Description:

Under ultrasonic or fluoroscopic guidance, a needle is percutaneously passed through the flank and renal parenchyma into the collecting system. A guide wire and, subsequently, a catheter are inserted into the renal pelvis. The catheter is secured to the skin and attached to an external gravity drainage bag.

Indications:

  1. To drain an obstructed kidney when a retrograde drainage catheter cannot be placed by the urologists due to bladder abnormality or large obstructing tumors in the bladder or pelvis.

  2. To remove large stones from the kidney or proximal ureter. Percutaneous stone removal is performed in conjunction with the urologists.

  3. To drain the kidney in patients with ureteral leak due to surgical complication or trauma.

  4. Rarely, bilateral nephrostomy may be performed in patients with bladder fistulae.

Contraindications:

Uncorrectable Bleeding Disorder. This is a relative contraindication as the coagulation parameters can be corrected in most patients to allow placement of a PCN.

Preparation:

  1. NPO for at least 4 hours prior to the procedure.

  2. Appropriate sedation and analgesia.

  3. Preprocedrual antibiotics.

Complications:

  1. Injury to renal vessel causing renal artery pseudoaneurysms or arterio-venous fistula. Such injuries require renal angiography and embolization of the affected vessel.

  2. Precipitating Urosepsis.

  3. Injury to adjacent organs or structures

  4. Contrast reaction

  5. Pain at catheter insertion site.

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NEPHROSTOGRAM

 

Description:

Contrast media is introduced through a nephrostomy tube, which has previously been placed in the kidney. Multiple fluoroscopic images are obtained.

Indications:

  1. To verify accurate placement and patency of the nephrostomy tube.

  2. To evaluate the location of opaque calculi within the renal collecting system.

  3. To evaluate stone burden in patients with non-opaque stones, both before and after therapy.

  4. To evaluate the site and cause of ureteral obstruction.

  5. To evaluate the site of ureteral injuries.

Contraindications:

Active renal infection

Preparation:

None

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PERCUTANEOUS URETERAL STENTING

 

Description:

Percutaneous ureteral stenting provides urinary diversion without the need for an external collection device when retrograde insertion of a ureteral stent is not possible or practical. Following percutaneous nephrostomy, a guide wire and catheter are manipulated through the abnormal (often stenotic) ureteral segment and into the urinary bladder or a bowel conduit or urinary reservoir. The catheter is replaced with a fenestrated ureteral stent. Kidney urine enters the stent through sideholes, travels through the catheter, and exits from its distal pigtail segment. Ureteral stent catheters must be periodically changed.

Indications:

  1. Long-term stenting (months to years) is performed to bypass a ureteral obstruction.

  2. Short-term stenting (weeks to months) facilitates healing of postoperative or traumatic pyeloureteral leaks or ureteral fistulae by diverting the urinary stream, prevents stricture formation as ureteral injuries heal, and maintains ureteral caliber following balloon dilation of benign ureteral strictures.

  3. Ureteral stent catheters facilitate intraoperative ureteral identification during difficult surgical dissections.

  4. Ureteral stents are often used in conjunction with percutaneous treatment of renal and ureteral calculi.

Contraindications:

  1. Active renal infection.

  2. Markedly diseased bladders or extreme bladder irritability.

  3. Bladder fistulae.

Preparation:

  1. NPO for at least 4 hours prior to the procedure.

  2. Appropriate sedation and analgesia.

  3. Preprocedural antibiotics.

Complications:

  1. Improperly positioned ureteral stents do not provide optimal urinary drainage.

  2. Irritative bladder symptoms and microscopic hematuria attributable to the intravesical coil of the stent may occur.

  3. Fractures, obstruction, and encrustation of ureteral stents may occur if stents are not periodically replaced (at least every 6 months and more often in patients who form stones).

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PERCUTANEOUS DILATION OF URETERAL AND URETHRAL STRICTURES

 

Description:

Many benign ureteral and urethral strictures are amenable to balloon catheter dilation, which, if successful, can spare patients the nuisance of chronic indwelling stents or catheters, or the risks of additional endoscopic or open surgery.

A catheter with an inflatable balloon capable of withstanding approximately 17 atmospheres of pressure is percutaneously or perurethrally advanced across a ureteral or urethral stricture. The balloon is fully inflated for several minutes. For ureteral strictures, the balloon is exchanged for a ureteral stent, which is kept in place for 6 weeks to maintain luminal patency while the ureteral musculature heals. Urethral strictures are stented with a large Foley catheter for 24 hours; the patient then catheterizes himself once or twice a day for the next month or so to maintain urethral patency.

Indications:

  1. Benign ureteral strictures.

  2. Postoperative strictures at the vesicourethral anastomosis following radical prostatectomy.

Contraindications:

  1. Ureteral strictures caused by malignant disease, either primary or recurrent.

  2. Inflammatory or traumatic urethral strictures are more amenable to surgical urethrotomy than to balloon dilation.

  3. Active urinary tract infection.

Preparation:

  1. NPO for at least 4 hours prior to the procedure.

  2. Appropriate sedation and analgesia.

  3. Preprocedural antibiotics.

Complications:

No known permanent sequelae have resulted from unsuccessful dilation therapy.

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RENAL AND PERINEPHRIC ABSCESS DRAINAGE PELVIN LYMPHOCFILE DRAINAGE

 

Description:

Under ultrasonic, computed tomographic or fluoroscopic guidance, a small needle is inserted through the flank, back, or anterior abdominal wall into an abscess or lymph collection. Aspirated material is sent for culture and antibiotic sensitivity determination. The needle is exchanged for a drainage catheter, which is secured to the skin and connected to an external drainage bag (either gravity or suction drainage).

Percutaneous abscess drainage and lymphocyte drainage with siterosis is almost always clinically efficacious and usually obviates the need for surgical drainage or lymphocele marsupialization. However, lymphocele drainage is usually followed by sclerotherapy to prevent reaccumulation.

Indications:

  1. Drainage of a renal or perinephric abscess, infected renal cyst, or infected renal pyelocalyceal diverticulum in a patient who fails to improve with broad-spectrum antibiotics. These infected fluid collections are usually a complication of acute pyelonephritis.

  2. Other retroperitoneal fluid collections (lymphoceles, urinomas, etc.), which require drainage, can be treated in similar percutaneous, non-operative fashion.

Contraindications:

  1. Untreated bleeding diathesis.

  2. Absence of a safe percutaneous drainage route.

  3. Multiseptated abscesses may be more easily and rapidly drained surgically than percutaneously, although not necessarily with less morbidity. Septated lymphoceles can usually be managed percutaneously. However, drainage alone does not suffice for treatment of a lymphocele and sclerotherapy is essential to prevent reaccumulation.

Preparation:

  1. NPO for at least 4 hours before the procedure.

  2. Appropriate intravenous antibiotics.

  3. Appropriate sedation and analgesia.

  4. Appropriate preprocedural antibiotics if patients is not already on antibiotics.

Complications:

  1. Transient bacteremia, febrile episodes, and even septic shock may occasionally follow percutaneous abscess drainage.

  2. Less than complete clinical response may result from only partial drainage of septated collections or premature catheter removal.

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TRANSCATHETER URINARY TRACT BIOPSY

 

Description:

Biopsies of renal and ureteral lesions can be obtained through catheters (transcatheter) inserted percutaneously or endoscopically into the urinary tract. A nylon brush mounted on a guide wire is passed through the catheter and the suspicious abnormality "brushed" under fluoroscopy. Exfoliated cells retrieved by the brush are subjected to cytological analysis. Other biopsy instruments, including forceps and snares, can be passed through larger catheters or sheaths percutaneously or perurethrally inserted into the upper urinary tract.

Needle aspiration biopsies of soft tissue, visceral, and nodal lesions related to the urinary tract are usually performed with either ultrasonic, computed tomographic or MRI guidance and are described under those Section's interventional procedures.

Indications:

  1. Primary diagnosis of upper urinary tract malignancy when imaging studies and cytology are not definitive.

  2. Evaluation of the cause of ureteral obstruction in patients with a known current or past malignancy.

Contraindications:

None

Preparation:

  1. NPO if prior cystoscopic or percutaneous insertion of a catheter is to precede the transcatheter biopsy.

  2. Fluids only on the day of the procedure if a catheter is already in place.

  3. Appropriate sedation and analgesia.

  4. A cytopathologist in the Uroradiology Suite to ascertain the adequacy of biopsy samples.

Complications:

  1. Patient discomfort and hematuria related to catheter manipulation and vigorous "brushing" of friable lesions.

  2. Collecting system or ureteral perforation with catheters or guide wires is innocuous if adequate urinary drainage is maintained for a day or so after the procedure, usually with a retrograde ureteral catheter.

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EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL)

 

Description:

This procedure provides a non-surgical alternative for the treatment of kidney and proximal ureteral stones. High-pressure shock waves are aimed at the stone to disintegrate it into fine sand-like particles, which then pass naturally through the urinary tract. The shock waves are generated outside the patient's body in a water bath in which the patient is immersed and the energy is delivered to the kidney stone. The procedure itself takes approximately one hour and may require an overnight hospital stay.

Indications:

Many individuals with kidney stone disease are potential candidates for ESWL. Selected stones in the ureter, usually the upper half of the ureter, are also suitable for treatment.

Contraindications:

  1. Patients who are pregnant.

  2. Extremely obese patients (usually > 300 lbs.) or very small patients (children less than 3 feet tall).

  3. Some very complicated stones, such as large staghorn calculi, may require multiple treatments or treatments by more than one modality (e.g., ESWL + percutaneous nephrolithotomy).

  4. Untreated bleeding diathesis.

  5. Patients at high risk for anesthesia complications.

  6. Urinary obstruction distal to the target stone.

  7. Untreated urinary tract infection or urosepsis.

  8. Nonfunctioning kidney.

Preparation:

Usual preoperative preparation for general or spinal anesthesia.

Complications:

  1. Varying degrees of shock wave induced renal parenchymal injury including renal contusion and hematoma within or around the kidney. These occur infrequently. Most small hematomas are not clinically significant. Larger ones require close observation and may have to be drained.

  2. All patients develop hematuria, which is usually transient and mild.

  3. Ureteral obstruction by a column of stone fragments (steinstrasse) which has failed to spontaneously pass into the bladder. This may require endoscopic or even percutaneous intervention.

  4. Urosepsis.

  5. Residual stone fragments in the treated kidney.

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Last Updated:12/19/06 ALK