|Big rocks don't scare me|
If I had to pick a favorite it would be percutaneous nephrostolithotony. Some patients develop large staghorn stones that fill up the entire renal pelvis of the kidney. (The hollow middle of the kidney where urine collects before heading south through the ureter to the bladder.) The goal is to take this hard branched rock measuring 4 to 6 cm out through a straw that is one centimeter in diameter. For many years other urologists have referred theses tough cases to me, and I really love the challenge. Many urologists don't like these cases as they can be fraught with pitfalls. The most common of which is bleeding. To see what you are doing, you irrigate saline through the rigid 8 inch stainless steel nephroscope into the kidney. If the bleeding is faster than your irrigation, you only see red. The trick is to work fast and if you glimpse the stone attack quickly and without mercy. Which brings us to the arsenal. To remove a big stone through a small hole you must crush it. I have used pliers, spark plugs, pneumatic hammers, ultrasonic energy and various lasers. The new weapon of choice is the CYBERWAND. Yes, I have now advanced to wizard level, and like Harry Potter can wave my cyberwand, muttering the incantationn, "Calculo Evapero!!" and the stone will magically disappear. Actually, it is called a cyberwand and is the ingenious combination of two technologies; a jack hammer and an ultrasonic lithotriptor with a hollow core to suck out the debris, (a sonicare hammer vacuum.) Today I took care of a very sweet and very ill elderly woman. Her condition keeps her confined to a bed, and she developed major stones in her left kidney severely damaging the function of that kidney. Worst of all she had a large 3 cm stone down her ureter. Those are very hard to treat. Solid metal rod don't make 90 degree turns very well and ureters are notoriously narrow. As we say in New England, "You just can't get there from here." I knew it would be tough as she might not do well with anesthesia lying prone for two hours.Then, as we began placing tubes in the bladder and kidney, urine did not emerge, but rather a thick foul-smelling white stuff. We gave an extra dose of antibiotics.
Then everything changed. On entering the kidney, there was minimal bleeding and a clear view. Dr Jacobsen, the chief resident, kept inching the scope downward and was soon far down the ureter and at the stone. Fortuitously our access gave us a shallow angle into an uncommonly wide ureter. The years of obstruction had at least one benefit. The magic words were spoken, the cyberwand sprang into action and that stone was dust sucked into a bucket in less than 15 minutes. Dr Lytton at Yale would always remark in a situation like this, "Sometimes a blind squirrel finds a nut." Soon the mid pole and lower pole kidney stones were gone and I the pulled a few tricks from my bag to sneak up into the upper pole and annihilate the invader hiding up there. She was now stone free. It was quite satisfying. All this through an incision in her back measuring a 3/8 of an inch.
I marvel sometimes that I still get to do this. Two and a half years ago today I got a new heart and a new lease on life. I just renewed that lease for another eight years. I hope to honor it.
There are still many more mountains to climb and stones to conquer.