Percutaneous kidney stone removal

Percutaneous nephrostomy has proved to be a reliable method to establish access to the collecting system of the kidney. Without adding any significant morbidity, this access can be used for the removal of kidney stones by simple extraction, chemolysis or ultrasound lithotripsy. A nephrostomy channel of the required size is rapidly and atraumatically established with a telescope dilation set. A set of instruments especially developed for intrarenal instrumentation is necessary to guarantee a low residual stone rate. With the use of intrarenal ultrasound disintegration the technique is successful regardless of stone composition and size.

[Localization of islet cell tumors using sonography, computed tomography, arteriography and selective transhepatic venous sampling for hormone assay (author's transl)]

Of 29 patients examined operation revealed a malignant tumor in 9 and a benign insulinoma in 18, 2 insulinomas were not found. The problems of preoperative tumor localization were limited to small insulinomas (size 7-35 mm). Ultrasound detected all of 3 insulinomas as low echogenic structures (size 7, 8, 17 mm). Computed tomography demonstrated 4 of 5 insulinomas (size 7, 8, 15, 17 mm) due to contrast enhancement following bolus injection. Arteriography localized 12 of 18 insulinomas preoperatively and 14 of 18 retrospectively. Selective transhepatic venous sampling for insulin assay identified 7 of 8 tumors. Real-time ultrasound and dynamic CT are promising in the diagnostics of insulinomas over 7 mm and should precede arteriography. Selective transhepatic venous sampling as the last diagnostic step is a major procedure and most specific, but not always without problems in interpretation.

Alterations of haemostasis after exposure to sauna

Blood coagulation and fibrinolysis were examined in young healthy male volunteers before and after sauna baths. No consistent or periodical changes could be found. However on several days the increases of haemoglobin, platelet counts and factor VIII associated antigen and to a lesser degree of haematocrit, factor VIII, IX and XII reached statistical significance after sauna. The results suggest a tendency to an increased activity of the blood coagulation system.

[Balloon occlusion test before carotid ligature (author's transl)]

The risk of ligating one carotid artery was tested by balloon occlusion of that vessel for a period of 30 to 60 minutes, during which time contralateral carotid angiography was carried out as well as an EEG and xenon-133 blood flow measurements. The procedure was carried out on seven patients, two showed a reduction in cerebral blood flow without EEG changes. In one patient the contralateral circulation could not be demonstrated by angiography. Carotid ligation was carried out in 5 of 7 patients. Neurological complications were not observed.

Sources of human plasma cyclic AMP. Examinations before and after beta 2 adrenergic stimulation

Plasma cyclic AMP was measured in different vessels in seventeen volunteers before and after stimulation with terbutaline. Differences between arterial blood and blood from the hepatic vein, right ventricle, inferior vena cava and a cubital vein could not be demonstrated. Only in the renal vein was the concentration of cyclic AMP decreased. Our results indicate that cyclic AMP is not generated from any specific isolated organ and that changes in cyclic AMP after subcutaneous injection of terbutaline reflect a general influence of this drug.

[B-scan sonography of the carotid artery. Technique, results and indications (author's transl)]

Three hundred and forty-six carotid arteries were examined with a two-dimensional 3.5 MHz real time scanner in 173 patients with evidence of cerebral ischaemia; 62 carotid arteries were investigated by selective trans-femoral angiography in 36 of these patients at the same time. Sonography and angiography agreed in 20 (91%) of 22 angiographically normal cases, in all cases (10) with haemodynamically insignificant plaques, in eight (66%) of 12 stenosis of less than 50%, in nine (90%) of ten stenosis of more than 50% and in four (44%) of nine total occlusions. Sensitivity of carotid sonography varied with the severity of the lesion from 44 to 100%. Its specificity was 91%. B-scan sonography of the carotid artery, in the presence of cerebro-vascular lesions (transitory ischaemia, cerebral infarcts) and in the presence of non-specific symptoms and of asymptomatic vascular murmurs, may provide indications for the use of angiography. Its values as a screening procedure remains to be assessed.

[B-scan sonography for tumour localisation in hyperparathyroidism (author's transl)]

Thirty-four patients with known primary, secondary or tertiary hyperparathyroidism were examined sonographically in order to localise the enlarged glands. Of 40 tumours found at operation, 27 (67%) could be demonstrated sonographically as oval or round structures with low echoes. The smallest tumour diagnosed pre-operatively was 10 x 5 x 4 mm. Sonography is useless for adenomas in the mediastinum. Sonographic localisation is desirable before primary operations for hyperparathyroidism, although it is not indispensable for the experienced surgeon. Sonography is essential before surgery for recurrences and should be performed before CT, arteriography or selective parathormone sampling.

[Percutaneous transhepatic gallstone extraction (author's transl)]

Gall stones 1-3 cm in size were removed in three out of four patients from the common bile duct using a Dormia basket via the percutaneous transhepatic route. This method is indicated in selected cases: inoperable patients or those with a high surgical risk, and calculous obstruction after hepatico-jejunostomy. The method is limited in stones over 1 cm by their hardness.

[Superselective embolisation in the urogenital tract with tissue adhesives (author's transl)]

The tissue adhesive butyl-2-cyanoacrylate mixed with lipiodol and tantulum powder is an excellent agent for superselective catheter embolisation of small vessels. The mixture is low viscous and can be injected through fine catheters. Occlusion is independent of blood clotting and is permanent. A coaxial catheter technique is recommended or, in cases of difficulty, a ballon catheter can be floated in. Super-selective embolisation was used in 15 patients, in seven for the kidney in eight for the pelvis. Indications were bleeding from the kidney, partial defunctioning of the kidney, tumours in single kidneys and bleeding from carcinomas in the bladder, prostate or cervix.

Percutaneous stone manipulation

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.

[Staging laparotomy for malignant lymphoma: interdisciplinary aspects and results (author's transl)]

Between 1963 and 1979 a total of 357 patients with malignant systemic lymphatic disease underwent splenectomy in the course of exploratory laparotomy. There were three groups: 1. Hodgkin's disease (215 patients), 2. non-Hodgkin's lymphoma (93), and 3. chronic lymphoid leukaemia (49). Comparing pre- and postoperative findings, primary exploratory laparotomy remained the most exact foundation for the differentiated treatment of Hodgkin's disease in stages I-III. Systematic staging laparotomy was of less importance for non-Hodgkin's lymphoma and chronic lymphoid leukaemia because of the much more frequent invasion of bone marrow, spleen and liver. However, it should be considered more often in the management of such cases.

[Intracranial Hemangiopericytoma in a newborn (author's transl)]

Report of a large, congenital hemangiopericytoma in a male neonate. The classification of these tumours is discussed. This is the first case, to date, of a tumour of this size, found intracranially.

Renal handling of L-histidine studied by continuous microperfusion and free flow micropuncture in the rat

Renal tubular reabsorption of L-histidine (His) was measured in vivo et situ by continuous microperfusion and free flow micropuncture of single proximal convoluted tubules of the rat kidney. The reabsorption is shown to be saturable. A permeability coefficient (P) of less than 29 microns 2 . s-1, a maximum reabsorption rate (J max) of 2.75 +/- 1.05 greater than J max greater than 1.97 +/- 0.86 (SEM) nmol . m-1 . s-1 and an affinity constant (Km) of 13.8 +/- 4.2 greater than Km greater than 10.9 +/- 4.0 (SEM) mol . 1-1 (lower values for P = 29 microns 2 . s-1, higher values for P = 0) were calculated from the microperfusion data. Using these constants and taking backflux of His and water reabsorption into account a good fit with the concentration profile of His along the proximal tubule--measured by free flow micropuncture--was obtained. Varying the buffered pH-values of the perfusion fluids (5.0 or 7.4) influenced neither the active reabsorption nor passive permeability of His. This indicates that the charge of the imidazol group of His does not play a significant role in His reabsorption. Further experiments showed that the addition of 20 mmol . 1-1 L-arginine--a strong inhibitor of the reabsorption system for dibasic amino acids--did not have a significant effect on the reabsorption of L-histidine. It is concluded, therefore, that His is reabsorbed by a system for neutral amino acids. Non ionic diffusion does not play an important role for His reabsorption.

[Preoperative percutaneous transhepatic drainage of the biliary system (PTCD) in malignant obstructive jaundice (author's transl)]

Percutaneous transhepatic intubation and drainage of the biliary system were performed in 23 patients, 19 cases preoperatively because of malignant obstructive jaundice. With 12 days the bilirubin serum level went to normal values, and the patients general condition and liver function showed marked improvement. By preoperative PTCD the mortality of palliative procedures in pancreatic carcinoma decreased. Complications occurred in five cases and were easy to manage. Clinical aspects such as indication, optimal period of drainage, and value of other techniques in bile drainage are discussed.

[Transrenal ureteric embolisation. Experimental and clinical results (author's transl)]

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.

[Blood coagulation in hyperthermia]

Young healthy volunteers were treated with physical hyperthermia (baths) in order to investigate changes in blood coagulation. Such therapy is used in the treatment of rheumatic diseases. Single hot baths (mean body temperature 38,2-39,9 degrees C) resulted in a rise of fibrinogen, factors IX and XII, maximal amplitude of the thrombelastogram and hemoglobin and in a decrease of plasminogen. In a series of hypothermic baths no additional changes of coagulation or fibrinolysis could be found. The results suggest that hyperthermia causes a tendency to thrombosis.

[Internal ureteric drainage by antegrade ureteric splinting (author's transl)]

Internal urinary drainage by antegrade ureteric splinting was successfully performed in 24 patients and the catheter left indwelling in 19. The main indications were postoperative complications leading to ureteric obstruction and urinary extravasation; this could be treated successfully by conservative means in seven out of 15 patients. Temporary splinting in three patients with fibrotic ureteric stenosis, together with dilatation by means of a balloon catheter, did not result in normal urinary flow. In four patients with urinary obstruction due to a tumour, the method became the permanent treatment. Complications of the procedure were dislodgement, obstruction and incrustation of the catheter. The procedure is an alternative to retrograde splinting and percutaneous external urinary diversion.

[Trans-catheter embolisation of the spleen with butyl-2-cyanoacrylate. Experimental results and clinical application (author's transl)]

Partial and total trans-catheter embolisation of the spleen with butyl-2-cyanoacrylate-lipiodol in 23 dogs lead to partial necrosis and cicatrisation of the spleen after 3 to 5 weeks. The embolised vessels do not recanalise, but are by-passed by extra- and intra-splenic collaterals. In five animals there was a reduction in the number of erythrocytes; after embolisation there was increase in the number of leucocytes, whereas the thrombocytes were unchanged. The most common complication which occurred in five animals was a 1.5 to 2.5 cm. splenic abscess. The procedure was employed without success in one patient with bleeding oesophageal varices. The procedure was complicated by extensive necrosis of the gastric mucosa. Trans-catheter embolisation of the spleen has significant complications, despite strict asepsis and antibiotic cover. The main indication of the procedure is hypersplenism which cannot be treated surgically.

[A fine-needle puncture set for percutaneous bile duct drainage (author's transl)]

A new instrument for percutaneous bile duct drainage has been employed on 30 patients with obstructive jaundice. The instrument consists of a 28 cm. long needle of 0.7 mm. diameter placed inside a 15 cm. long Teflon sheath of 1.4 mm. external diameter. This permits fine-needle cholangiography and biliary duct drainage as a single procedure. It causes little trauma and speeds up and simplifies the examination. The instrument is also suitable for transhepatic portal vein puncture.

[Surgery of the adrenals: result of 154 operations (author's transl)]

Biochemical and radiological results, surgical technique and its results were critically analysed in a retrospective study of 154 operations on the adrenals in 127 patients, operated on between 1957 and 1980. There were no complications in 95 patients. In the remaining 32, both intra- and postoperative complication rate was greater after extraperitoneal than transabdominal approach to the adrenals. Postoperative mortality was 6%, but since 1967 only two patients have died in the postoperative period. Thromboembolic phenomena were the main cause of death, patients with Cushing's disease most commonly having this complication.

[Prostaglandins E2 and F2 alpha concentrations in the synovial fluid in rheumatoid and traumatic knee joint diseases]

Prostaglandin E2 (PGE2) and F2 alpha (PGF2 alpha) concentrations in synovial fluid samples from 15 patients with various knee joint disorders were measured by radioimmunoassay. High concentrations of PGE2 wee found in all the samples obtained from patients with knee effusions due to various inflammatory processes as compared to the very low PGE2 levels in patients with osteoarthritis or traumatic effusions. The highest PGE2 levels were measured in knee joint effusions from patients with severe forms of rheumatoid arthritis. Two patients suffering from rheumatoid arthritis commenced with indomethacin (150 mg/day) after the first synovial fluid sample collection only. Some weeks later in a new sample a partial reduction of PGE2 concentration was found. The results of our investigations ar discussed with regard to possible correlations between prostaglandins and inflammation on the one hand and bone resorption associated with various pathological disorders on the other hand.

[Endoscopic sclerotization of the oesophagus wall or transhepatic thrombosis of the coronary vein: Alternative or complementary therapy of bleeding oesophageal varices in portal hypertension (author's transl)]

Endoscopic sclerotization of esophageal wall has been performed in 48 patients with bleeding of esophageal varices. The mortality rate in the acute bleeding was 29,2%. There was no mortality, if sclerotherapy was done in the non hemorrhagic interval. Of the 48 patients 25 are still alive, 8 more than 2 years without bleeding. In 12 cases we performed transhepatic obliteration of the V. coronaria ventriculi. Only in 3 of them no further hemorrhage occurred within 6 months. Fibrosclerotization seems to be superior to the transhepatic obliteration, because the primary mortality and complications are lower and long term results better.

[Percutaneous drainage of the biliary tract by puncture with a fine needle]

Temporary pre-operative and post-operative as well as permanent palliative percutaneous biliary-tract drainage was performed in 12 patients with biliary tract obstruction; in three the drainage was internal and in nine external. Main indication of the method is permanent palliative decompression in cases of inoperable malignant tumour with obstructive jaundice. Pre-operatively, percutaneous biliary tract drainage serves as a temporary measure in order to perform an operation after decompression of the biliary tract and improving the patient's general condition. The only serious complication was biliary peritonitis after a drainage catheter had slipped out.

[Transvenous cholangiography and percutaneous transhepatic fine needle cholangiography (author's transl)]

The comparison of transvenous cholangiography (TVC) in 82 patients with percutaneous transhepatic fine needle cholangiography (PTFC) in 84 patients showed that TVC must be considered obsolete due to the complicated procedure with low success rate (56.9%). In one case it led to septicaemia followed by death. The total success rate was 84.5% in PTFC performed with an ultrathin needle (0.5 mm diameter); congested biliary ducts were successfully punctured in 87.9% and noncongested ducts in 72.2%. Severe complications consisted of one case of intraabdominal bleeding and one biliary extravasation. As shown in animal experiments, the superficial parenchymal lesion has not always the shape of a point. High accuracy also in noncongested biliary tracts and low mortality make PTFC superior to TVC and conventional percutaneous transhepatic cholangiography.

Prostaglandin F2 alpha levels in human cerebrospinal fluid in normal and pathological conditions

Prostaglandin F2 alpha concentrations in cerebrospinal fluid (CSF) from normal human subjects and patients with various pathological disorders of the central nervous system (CNS) were measured by radioimmunoassay. The mean PGF2 alpha level in 54 controls with no evidence of organic CNS disease was 67 pg/ml (range: 25-150 pg/ml). A significant increase of PGF2 alpha levels was demonstrated in most samples from patients with CNS diseases. Extremely high values were found in patients with stroke and subarachnoid hemorrhage when samples were collected shortly after the cerebral attack. With the regression of clinical symptoms and radiological findings a decrease of PGF2 alpha levels was demonstrated in this group of patients. In 32 patients with cerebral transient ischemic attacks a mean PGF2 alpha concentration of 170 pg/ml (range: 35-355 pg/ml) was found. Increased PGF2 alpha levels were found in patients with epilepsy when samples were collected within a few days after a convulsion. PGF2 alpha levels of four patients with slow progredient forms of multiple sclerosis without clinical symptoms at the time of sample collection were not different from normal controls while the mean PGF2 alpha level of all other patients with multiple sclerosis was 152 pg/ml (range: 55-325 pg/ml). Moreover, increased values could be demonstrated in patients with cerebral tumors and inflammatory processes.

[Progress in the localization of insulinomas]

Preoperative percutaneous transhepatic portal vein catheterization with selective blood sampling from the pancreatic veins and insulin radioimmunoassay is a very successful new procedure for localization of insulinomas. A careful peroperative inspection and bidigital palpation of the whole pancreas helps to avoid the problems of undetected insulinoma.

Circadian placebo and ACTH effects on urinary cortisol in arthritics

The effect of placebo and ACTH-1-17 (Synchrodyn, Hoechst) upon urinary free cortisol was examined at 5 different circadian stages on 10 men with Steinbrocker Stage II-III rheumatoid arthritis. A mean cosinor analysis of urinary cortisol data from the subjects prior to treatment with either ACTH or placebo revealed a statistically highly-significant rhythm. A circadian variation in a response of urinary free cortisol to a placebo was also seen. Moreover, the response of the midline-estimating statistic of rhythm (rhythm-adjusted circadian average) of urinary free cortisol to ACTH-1-17 by patients with rheumatoid arthritis is circadian rhythmic. This reactivity rhythm is out of phase with the spontaneous rhythm in urinary cortisol acrophases-in the tests limited thus far to midsummer. The further assessment of the circadian component in the context of broader interactions by rhythms with other frequencies in various conditions in health and disease is warranted by the demonstration of rhythms here presented for men with rheumatoid arthritis.

Inosine: alternative or adjunct to regional hypothermia in the prevention of post-ischemic renal failure?

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.

Effect of cryptands on cardiac Purkinje fibres

Cryptands are possibly useful synthetical models for passive ion carriers in biomembranes. Five mainly Na+ and K+ complex forming cryptands were studied in cardiac Purkinje fibres by means of standard microelectrode technique. Even at high concentrations the cryptands 22, 221 and 222 showed no effect. Possibly they are not lipophilic enough to accumulate within the membrane. The more lipophilic cryptands 222B and 222D caused a decrease of overshoot and maximal rate of rise (Vmax), a pronounced loss of plateau and a shortening of the action potential, while the resting potential was only slightly depolarized. 222B made some fibres inexcitable at normal resting potentials; only by increase in stimulation voltage a regular response was obtained. After about 20 min both cryptands (5 x 10(-5) mol/l) depolarized the fibres leading to irreversible inexcitability. The availability of the fast sodium current ("h infinity"-curve) was measured using Weidmann's (1955) technique. With 222B the h infinity-curve-showed a shift in the hyperpolarizing direction, and the maximal Vmax was diminished.

Maleic acid induced aminoaciduria, studied by free flow micropuncture and continuous microperfusion

The injection of 200 mg/kg BW maleic acid was found to be a suitable dose for exploring the experimental Fanconi syndrome by micropuncture techniques in rats. In clearance experiments, the fractional excretion of glycine, L-alanine, L-aspartate and taurine was measured. After intraperitoneal administration of maleic acid the excretion of these amino acids was increased in the range between the 20-fold and the 230-fold. Free flow micropuncture experiments showed that the reabsorption of these amino acids is reduced drastically along the whole proximal tubule. Continuous microperfusion experiments lead to the result that, in maleic acid pretreated rats, the reabsorption of 14C-glycine from the proximal convolution was strongly inhibited. It was found, furthermore, that after blocking the saturable glycine transport by L-phenylalanine, the remaining reabsorption of glycine (corresponding to passive diffusion) was exactly the same with and without maleic acid. Microinfusion experiments with 8 mumol.1(-1) L-3H-alanine into the early distal tubule showed a fractional recovery of 103 +/- 4.2% (S.D.) in the control and of 101 +/- 6.5% in presence of maleic acid. It is concluded that maleic acid inhibits the saturable reabsorption mechanism of amino acids along the proximal tubule. Passive permeability of the tubular membrane does not seem to be altered by maleic acid.

[Labor and delivery, fetal and maternal risk following cerclage. A comparative study (author's transl)]

In a comparative study of the course of pregnancy and delivery of 357 patients who delivered live infants between 1966-1976 following cerclage operation were compared to a control group of 380 without cerclage who were matched in age, parity and delivery time to the group under study. The high prematurity rate in the pregnancies preceeding the cerclage of 28.4% decreased following the cerclage to 16.8% (p less than 0.001). The perinatal mortality was reduced from 21.5% to 5.6% (p less than 0.001). This effect was especially achieved by the lower incidence of deliveries of infants with a birth weight of less than 1500 grams (p less than 0.05). The difference to the controls regarding prematurity (8.2%) and perinatal mortality (1.6%) remained significant (p less than 0.001). An increased rate of malformations in the cerclage children was not noticed. The maternal risk is low and consists mainly of a increase of cervical lacerations (4.9%) and problems of wound healing (2.2%). The duration of labor and type of delivery, the type of third stage of labor, and the post-partum course were not different from the control group.

Efficacy and safety of piroxicam and indomethacin in the treatment of musculoskeletal disorders. A double blind comparative study

A total of 17 patients suffering from musculoskeletal disease were included in a double blind study to compare the efficacy and safety of piroxicam and indomethacin. Seven patients received a single dose of 30 mg piroxicam daily for two weeks, an eight patient stopped treatment after two days because of thrombocytopenia of unknown origin. Nine patients received 50 mg indomethacin tid for two weeks although treatment was interrupted for 2 days in one patient when a pulmonary embolus (unrelated to trial treatment) developed. Both treatment groups showed significant reductions in pain scores assessed by the patient from day 2 in the indomethacin group and day 6 in the piroxicam group. There were significant differences between the groups in favour of indomethacin at days 5, 8, 11, 12 and 13, although the groups were not well matched at baseline. Other efficacy measurements including the patient's and physician's overall assessments showed an improvement in some patients in each group, but there were no significant differences between the two groups. Side effects recorded as due to trial treatment occurred in one piroxicam and four indomethacin treated patients. Minor abnormalities in laboratory test results without clinical significance occurred in both groups. One piroxicam treated patient had a low platelet count prior to treatment and a subsequent reduction on day 3 requiring treatment to be stopped.

Transrenal ureteral embolization

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.