Correspondence journals from all continents that laser assisted angioplasty has not been subjected to assessment by controlled trials (Bonn, 1991; Fry, 1991; Sanborn, 1991). Readers of the BJR will know that such a trial was completed in 1989 and published in the BJR the following year (Jeans et al, 1990). A further controlled study was published in early 1991 (Spies et al, 1991). Perhaps when authors make claims for the uniqueness of their work or for the non-existence of the work of others they should at least provide editors with information of what literature searches were performed to substantiate their claims. Yours, etc., G. G. HARTNELL
New England Deaconess Hospital, 185 Pilgrim Road, Boston, Massachusetts 02215, USA (Received May 1991)
References BONN, J., 1991. Clinical utility of laser recannalization in occluded peripheral arteries. Radiology, 178, 323-325. DAWSON, P., 1991. Related articles? British Journal of Radiology, 64, 186. FRY, W. J., 1991. Presidential address: Who sets the standards? Journal of Vascular Surgery, 13, 6-9. HARTNELL, G. G., HENNESSY, O. F. & WILLIAMS, G., 1985. Percuta-
neous catheter drainage of obstructed transplant kidney in pregnancy. Urology, 25, 522-523. JEANS, W. D., MURPHY, K. P., HUGHES, A. O., HORROCKS, M. &
BAIRD, R. N., 1990. Randomized trial of laser assisted passage through occluded femoropopliteal arteries. British Journal of Radiology, 63, 19-21. SANBORN, T. A., 1991. Primary success, long term patency, reporting standards and indications for peripheral angioplasty devices. Circulation, 83, 350-352. SPIES, J. B., LE QUIRE, M. H., BRANTLEY, S. D., WILLIAMS, J. E.,
BECKETT, W. C. & MILLS, J. L., 1990. Comparison of balloon
angioplasty and laser thermal angioplasty in treatment of femoropopliteal atherosclerotic disease: Initial results of prospective randomized trial. Journal of Vascular and Interventional Radiology, 1, 39-42.
remained well with no further problems since. Yours, etc., F. H. RENNY
Wordsley Hospital, Stourbridge, West Midlands, DY8 5QX {Received May 1991) References LEWIS, G. J., CHATTERJEE, S. P. & ROWSE, A. D., 1985. Acute renal
failure in pregnancy secondary to idiopathic hydronephrosis. British Medical Journal, 290, 1250. TREWHELLA, M., REID, B., GILLESPIE, A. & JONES, D., 1991. Per-
cutaneous nephrostomy to relieve renal tract obstruction in pregnancy. British Journal of Radiology, 64, Al\-M2. THE EDITOR—SIR,
We were surprised to read that percutaneous nephrostomy in pregnancy had not been reported previously (Trewhella et al, 1991). We have records of three nephrostomies being performed in pregnancy in our department in the last 5 years. 1. An 18-year-old multigravida known to have congenital bilateral megacalycosis and megaureters developed right loin pain and fever at 35 weeks gestation. A nephrostomy catheter was inserted and together with intravenous antibiotics her symptoms settled. A nephrostogram performed 24 h post partum showed external compression of the right ureter at the pelvic brim. The nephrostomy catheter "fell out" 2 weeks later but the patient remained asymptomatic. 2. A 22-year-old multigravida developed right loin pain at 29 weeks gestation and was shown to have a right hydronephrosis on ultrasound. Her symptoms were relieved by a nephrostomy. A nephrostogram post partum showed no ureteric obstruction. The patient remained asymptomatic after the catheter was removed. 3. A 22-year-old primigravida developed right loin pain and fever at 13 weeks gestation. An ultrasound scan showed a right hydronephrosis and intra-renal acoustic shadowing consistent with calculi. A nephrostomy catheter was inserted and pus and urine drained. A limited nephrostomy confirmed renal calculi and a calculus in the upper ureter. The pregnancy is continuing.
TREWHELLA, M., REID, B., GILLESPIE, A. & JONES, D., 1991. Per-
cutaneous nephrostomy to relieve renal tract obstruction in pregnancy. British Journal of Radiology, 64, Al\-A12.
Percutaneous nephrostomy to relieve renal tract obstruction in pregnancy
Percutaneous nephrostomy can be performed using ultrasound guidance, so avoiding the risks of ionizing radiation to the foetus. We think that other departments must have similar experiences to our own and that percutaneous nephrostomy in pregnancy is not that uncommon. Yours, etc., D. HINWOOD A. R. MANHIRE
THE EDITOR—SIR,
With reference to the case report "Percutaneous nephrostomy to relieve renal tract obstruction in pregnancy" in the May issue by Trewhella et al (1991) the claim is made that percutaneous nephrostomy in pregnancy has not been reported previously. I performed bilateral percutaneous nephrostomy on a primigravid patient 27 weeks pregnant in 1984. This was subsequently reported by my clinical colleagues, Lewis et al,(1985). This case differs substantially in that the lady presented in acute renal failure with bilateral UP junction obstruction. After initial haemodialysis an unsuccessful attempt was made to pass retrograde catheters. Percutaneous nephrostomy was then successful and the blood urea dropped from 41.0 mmol/1 to normal within 48 h. A week later she delivered spontaneously and the baby after some initial problems progressed satisfactorily. At 12 days post partum a bilateral Anderson-Hynes operation was done and she has
976
City Hospital, Hucknall Road, Nottingham, NG5 1PB (Received June 1991)
References TREWHELLA, M., REID, B., GILLESPIE, A. & JONES, D., 1991. Per-
cutaneous Nephrostomy to relieve renal tract obstruction in pregnancy. British Journal of Radiology, 64, A1X-A12. (Authors' reply) THE EDITOR—SIR,
We are grateful for the comments on our case report. With regard to that from Drs Hinwood and Manhire, we read with interest of their experience of the technique.
The British Journal of Radiology, October 1991
Correspondence Whilst the reports cited by Dr Renny (Lewis et al, 1985) and Dr Hartnell (Hartnell et al, 1985) in both cases differ substantially from ours, they certainly are earlier reports of nephrostomy in pregnancy, so that our statement that the technique has not been reported previously is incorrect, and we thank them for drawing this to our attention. We would observe in passing that unfortunately the case reported by Hartnell et al (1985) is not "the true first report of this technique in pregnancy" either, which rather undermines the thrust of his letter. We are now aware of a number of earlier reports of percutaneous nephrostomy in pregnancy, the earliest that we know of being that of Kinn (1981). Perhaps what Dr Hartnell really experienced whilst reading the May issue of the BJR was in fact deja deja vu? However, we are grateful for his interesting comments regarding publications on laser assisted angioplasty. Yours, etc.,
London, WIN 8AA (Received May 1991)
Reference WALTER, MILLER & BOMFORD, K., 1979. A Short Textbook of Ra-
diotherapy. Fourth edn (Churchill Livingstone, Edinburgh).
M. TREWHELLA D. JONES
Department of Radiology, North Tees General Hospital, Hardwick, Cleveland, TS19 8PE {Received July 1991)
References HARTNELL, C. G., HENNESSY, O. F. & WILLIAMS, G., 1985. Percuta-
neous catheter drainage of obstructed transplant kidney in pregnancy. Urology, 25, 522-523. KINN, A. C , Complicated hydronephrosis of pregnancy. Acta Obstetrics & Gynaecology Scandinavica, 60 (1), 91-95. LEWIS, G. J., CHATTERJEE, S. P. & ROWSE, A. D., 1985. Acute renal
failure presenting in pregnancy secondary to idiopathic hydronephrosis. British Medical Journal, 290, 1250.
Mistaken hilar mass
Figure 1.
THE EDITOR—SIR,
A situation arose recently which helps to remind us that, despite the tempting logistical advantages, simulator radiographs should not be used for diagnostic evaluation (1). A 56-year-old man attended hospital for palliative radiotherapy to an uncomfortable chest wall secondary deposit from a prostatic primary malignancy. The field arrangement which best covered the lesion involved two opposing tangential beams, planned with the help of the simulator to estimate the volume of underlying lung. During this screening a hilar mass was observed and can be seen on the check film (Fig. 1). It was then documented in the case notes, with the background of known widespread bony disease, that the patient had hilar secondary involvement. However, a departmental radiograph (Fig.2) taken the following day demonstrated no such hilar disease. He had a history of oesophageal reflux. The disparity between the two radiographs is easily explained by oesophageal dilation, secondary to prolonged reflux, which was apparent when lying flat on the simulator couch but not when standing in the department. Oesophageal dilation as cause of hilar enlargement is well known. Fortunately, this error was corrected early, but by altering prognostic criteria it could have influenced strategic decisions. Furthermore, departmental radiographs are of superior quality and the patient's position is better appreciated by the radiologists who report them. Yours, etc., R. THOMAS
Meyerstein Institute of Clinical Oncology, The Middlesex Hospital, Mortimer Street,
Vol. 64, No. 766
Figure 2.
977
New England Deaconess Hospital, 185 Pilgrim Road, Boston, Massachusetts 02215, USA (Received May 1991)
References BONN, J., 1991. Clinical utility of laser recannalization in occluded peripheral arteries. Radiology, 178, 323-325. DAWSON, P., 1991. Related articles? British Journal of Radiology, 64, 186. FRY, W. J., 1991. Presidential address: Who sets the standards? Journal of Vascular Surgery, 13, 6-9. HARTNELL, G. G., HENNESSY, O. F. & WILLIAMS, G., 1985. Percuta-
neous catheter drainage of obstructed transplant kidney in pregnancy. Urology, 25, 522-523. JEANS, W. D., MURPHY, K. P., HUGHES, A. O., HORROCKS, M. &
BAIRD, R. N., 1990. Randomized trial of laser assisted passage through occluded femoropopliteal arteries. British Journal of Radiology, 63, 19-21. SANBORN, T. A., 1991. Primary success, long term patency, reporting standards and indications for peripheral angioplasty devices. Circulation, 83, 350-352. SPIES, J. B., LE QUIRE, M. H., BRANTLEY, S. D., WILLIAMS, J. E.,
BECKETT, W. C. & MILLS, J. L., 1990. Comparison of balloon
angioplasty and laser thermal angioplasty in treatment of femoropopliteal atherosclerotic disease: Initial results of prospective randomized trial. Journal of Vascular and Interventional Radiology, 1, 39-42.
remained well with no further problems since. Yours, etc., F. H. RENNY
Wordsley Hospital, Stourbridge, West Midlands, DY8 5QX {Received May 1991) References LEWIS, G. J., CHATTERJEE, S. P. & ROWSE, A. D., 1985. Acute renal
failure in pregnancy secondary to idiopathic hydronephrosis. British Medical Journal, 290, 1250. TREWHELLA, M., REID, B., GILLESPIE, A. & JONES, D., 1991. Per-
cutaneous nephrostomy to relieve renal tract obstruction in pregnancy. British Journal of Radiology, 64, Al\-M2. THE EDITOR—SIR,
We were surprised to read that percutaneous nephrostomy in pregnancy had not been reported previously (Trewhella et al, 1991). We have records of three nephrostomies being performed in pregnancy in our department in the last 5 years. 1. An 18-year-old multigravida known to have congenital bilateral megacalycosis and megaureters developed right loin pain and fever at 35 weeks gestation. A nephrostomy catheter was inserted and together with intravenous antibiotics her symptoms settled. A nephrostogram performed 24 h post partum showed external compression of the right ureter at the pelvic brim. The nephrostomy catheter "fell out" 2 weeks later but the patient remained asymptomatic. 2. A 22-year-old multigravida developed right loin pain at 29 weeks gestation and was shown to have a right hydronephrosis on ultrasound. Her symptoms were relieved by a nephrostomy. A nephrostogram post partum showed no ureteric obstruction. The patient remained asymptomatic after the catheter was removed. 3. A 22-year-old primigravida developed right loin pain and fever at 13 weeks gestation. An ultrasound scan showed a right hydronephrosis and intra-renal acoustic shadowing consistent with calculi. A nephrostomy catheter was inserted and pus and urine drained. A limited nephrostomy confirmed renal calculi and a calculus in the upper ureter. The pregnancy is continuing.
TREWHELLA, M., REID, B., GILLESPIE, A. & JONES, D., 1991. Per-
cutaneous nephrostomy to relieve renal tract obstruction in pregnancy. British Journal of Radiology, 64, Al\-A12.
Percutaneous nephrostomy to relieve renal tract obstruction in pregnancy
Percutaneous nephrostomy can be performed using ultrasound guidance, so avoiding the risks of ionizing radiation to the foetus. We think that other departments must have similar experiences to our own and that percutaneous nephrostomy in pregnancy is not that uncommon. Yours, etc., D. HINWOOD A. R. MANHIRE
THE EDITOR—SIR,
With reference to the case report "Percutaneous nephrostomy to relieve renal tract obstruction in pregnancy" in the May issue by Trewhella et al (1991) the claim is made that percutaneous nephrostomy in pregnancy has not been reported previously. I performed bilateral percutaneous nephrostomy on a primigravid patient 27 weeks pregnant in 1984. This was subsequently reported by my clinical colleagues, Lewis et al,(1985). This case differs substantially in that the lady presented in acute renal failure with bilateral UP junction obstruction. After initial haemodialysis an unsuccessful attempt was made to pass retrograde catheters. Percutaneous nephrostomy was then successful and the blood urea dropped from 41.0 mmol/1 to normal within 48 h. A week later she delivered spontaneously and the baby after some initial problems progressed satisfactorily. At 12 days post partum a bilateral Anderson-Hynes operation was done and she has
976
City Hospital, Hucknall Road, Nottingham, NG5 1PB (Received June 1991)
References TREWHELLA, M., REID, B., GILLESPIE, A. & JONES, D., 1991. Per-
cutaneous Nephrostomy to relieve renal tract obstruction in pregnancy. British Journal of Radiology, 64, A1X-A12. (Authors' reply) THE EDITOR—SIR,
We are grateful for the comments on our case report. With regard to that from Drs Hinwood and Manhire, we read with interest of their experience of the technique.
The British Journal of Radiology, October 1991
Correspondence Whilst the reports cited by Dr Renny (Lewis et al, 1985) and Dr Hartnell (Hartnell et al, 1985) in both cases differ substantially from ours, they certainly are earlier reports of nephrostomy in pregnancy, so that our statement that the technique has not been reported previously is incorrect, and we thank them for drawing this to our attention. We would observe in passing that unfortunately the case reported by Hartnell et al (1985) is not "the true first report of this technique in pregnancy" either, which rather undermines the thrust of his letter. We are now aware of a number of earlier reports of percutaneous nephrostomy in pregnancy, the earliest that we know of being that of Kinn (1981). Perhaps what Dr Hartnell really experienced whilst reading the May issue of the BJR was in fact deja deja vu? However, we are grateful for his interesting comments regarding publications on laser assisted angioplasty. Yours, etc.,
London, WIN 8AA (Received May 1991)
Reference WALTER, MILLER & BOMFORD, K., 1979. A Short Textbook of Ra-
diotherapy. Fourth edn (Churchill Livingstone, Edinburgh).
M. TREWHELLA D. JONES
Department of Radiology, North Tees General Hospital, Hardwick, Cleveland, TS19 8PE {Received July 1991)
References HARTNELL, C. G., HENNESSY, O. F. & WILLIAMS, G., 1985. Percuta-
neous catheter drainage of obstructed transplant kidney in pregnancy. Urology, 25, 522-523. KINN, A. C , Complicated hydronephrosis of pregnancy. Acta Obstetrics & Gynaecology Scandinavica, 60 (1), 91-95. LEWIS, G. J., CHATTERJEE, S. P. & ROWSE, A. D., 1985. Acute renal
failure presenting in pregnancy secondary to idiopathic hydronephrosis. British Medical Journal, 290, 1250.
Mistaken hilar mass
Figure 1.
THE EDITOR—SIR,
A situation arose recently which helps to remind us that, despite the tempting logistical advantages, simulator radiographs should not be used for diagnostic evaluation (1). A 56-year-old man attended hospital for palliative radiotherapy to an uncomfortable chest wall secondary deposit from a prostatic primary malignancy. The field arrangement which best covered the lesion involved two opposing tangential beams, planned with the help of the simulator to estimate the volume of underlying lung. During this screening a hilar mass was observed and can be seen on the check film (Fig. 1). It was then documented in the case notes, with the background of known widespread bony disease, that the patient had hilar secondary involvement. However, a departmental radiograph (Fig.2) taken the following day demonstrated no such hilar disease. He had a history of oesophageal reflux. The disparity between the two radiographs is easily explained by oesophageal dilation, secondary to prolonged reflux, which was apparent when lying flat on the simulator couch but not when standing in the department. Oesophageal dilation as cause of hilar enlargement is well known. Fortunately, this error was corrected early, but by altering prognostic criteria it could have influenced strategic decisions. Furthermore, departmental radiographs are of superior quality and the patient's position is better appreciated by the radiologists who report them. Yours, etc., R. THOMAS
Meyerstein Institute of Clinical Oncology, The Middlesex Hospital, Mortimer Street,
Vol. 64, No. 766
Figure 2.
977
