Shortly after we treated this patient, we had another whose kidney was obstructed by a ureteroileal stone. Once again, a nephrostomy was performed and a catheter advanced down the ureter to the ileal loop and retrieved cystoscopically. A stone basket was attached to the tip of this catheter, and the stone was captured under fluoroscopic control [5] (Fig. 7.2).

In the days before ureteroscopy, blind stone basketing was the only technique available for endoscopic stone removal. If this extraction failed, or if there was more than one stone, it frequently was difficult to salvage the situation because the ureter resisted second and third passages of a stone basket. The problem was solved by advancing a catheter antegrade down the ureter and attaching a basket that could then be pulled up as often as necessary [6] (Fig. 7.3).

Patients who had repeated resections of bladder tumors sometimes developed ureteral meatal stenosis. Cystoscopic viewing of the ureteral orifice was not possible. If one advanced a catheter down the ureter from a percutaneous nephrostomy to the site of the stricture, one could resect over this site under fluoroscopic control and then stent the ureter if appropriate [7] (Fig. 7.4). In addition, it was possible to perform a meatotomy by attaching an adapted ureteral catheter with an exposed section of stylet to dilate and cut the orifice. A further application of the antegrade catheter was used in patients who developed ureteral strictures after ileal conduit surgery. The stricture could be bypassed, dilated and stented.

In the 1960s and early 1970s, ileal conduit diversion was commonly performed for the management of neurogenic bladder in paraplegic and quadriplegic patients. These patients frequently developed kidney stones, which had to be removed surgically. In quadriplegic patients with stone recurrence, a nephrostomy tube frequently was left in place and attempts were made to dissolve the stones with citric acid, magnesium carbonate and glucono-delta-lactone (Renacidin) [8]. This technique was later extended to patients with recurrent struvite stones without initial removal of the bulk of the stone (Fig. 7.5).

Let it be said that the technique worked, but it took more than a month to dissolve a stone. At that time, this was acceptable at the Veterans Administration hospital (as it was then called), but not in the real world. Moreover, Renacidin had many side effects, such as marked mucosal edema and hypermagnesemia. Fortunately, a urology surgery resident, Curtis Sheldon, was standing at the bedside and knew exactly what to do to revive the patient. The technique proved more successful and less dangerous for chemolysis of cystine and uric acid stones [9].

Several patients who had nephrostomy drainage tubes did not want to undergo chemolysis, and they therefore needed frequent changes of their drainage tubes (usually a Foley catheter). Moreover, we routinely injected only 3 mL of liquid into the balloon of the foley catheter , which meant they often fell out. If the catheter had been out of the nephrostomy tract for less than 1 day, it was usually possible to reestablish the tract by inserting a 5Fr catheter at the skin site and instilling a small amount of contrast medium. The tract become partially visible and a guidewire and more contrast medium could be injected to guide catheter insertion. The complete tract could then be dilated and new nephrostomy tube inserted.

It proved difficult to maintain a Foley catheter in the kidney, as the balloon would obstruct one or several calices. The best drainage device available at the time was a circle nephrostomy tube. [10] This tube entered through an upper calix and exited from a lower calix, allowing drainage without obstruction of any part of the kidney. In addition, the tube could be changed easily by attaching a new catheter to the old one and railroading it into position. To convert a nephrostomy tube already in place to a circle tube, the tube was removed and a stone basket inserted into the renal pelvis. A second puncture was then performed, usually into an upper calix and the guidewire it contained was directed toward the open stone basket. When it entered the basket, the basket was closed and the wire was pulled out through the original nephrostomy site. A catheter was then advanced over this captured guidewire, the tract was dilated and a circle tube was inserted. This technique was also used in patients who developed meatal stenosis after cutaneous ureterostomy.

All of the techniques were developed with the assistance of Robert Miller, an interventional radiologist at the Veterans Administration (now Veterans Affairs) Hospital in Minneapolis. Subsequently, I moved to the University of Minnesota campus and began working with Kurt Amplatz and Wilfrido Castaneda-Zuniga. They had a very capable technician who could manufacture any desired device overnight.