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HORSESHOE KIDNEY, in combination with an abdominal aortic aneurysm, is a rare and challenging problem in management. In the following case, surgery was deferred 5 yr before our treatment owing to the complexities of these combined pathologies. This paper deals with the detailed care of a patient while reviewing the salient features of diagnosis and treatment for abdominal aortic aneurysm in conjunction with horseshoe kidney. In a careful review of the literature, we were able to find only two cases with the above pathology so reported. Report of a Case In 1957 a 48-yr-old male was admitted to another hospital complaining of chest pain radiating down the left arm. An electrocardiogram (EKG) revealed ischemic changes which subsequently reverted to normal. Physical examination revealed a pulsating mass in his abdomen. A translumbar aortogram demonstrated an abdominal aortic aneurysm. Surgery was contemplated but abandoned when intravenous pyelography revealed a horseshoe kidney overlying

Ask any urologist. Intravenous pyelography (IVP), like kissing your spouse good-bye in the morning or brushing your teeth before going to bed, goes hand in hand with transurethral prostatectomy (TURP). The most commonly performed urologic procedure in America, TURP until now has been almost invariably preceded by IVP for detection of any pathological condition in the upper urinary tract. But a new study conducted at the University of Kentucky Medical Center in Lexington by Department of Urology chairman J. William McRoberts, MD, and urology residents Daniel L. Bauer, MD, and Robert W. Garrison, MD, indicates that in most cases IVP before TURP is probably not necessary. "When we reviewed a specially selected group of 601 patients who had had routine IVP prior to transurethral resections," explained Bauer, "we found positive results so seldom that we believe the test is not indicated and certainly not cost-effective." However, Bauer was quick to

Diabetic patients with chronic renal failure are known to be at risk for exacerbation of renal failure if they undergo intravenous pyelography (IVP). The present report demonstrates that diabetic patients with normal serum creatinine levels can sustain irreversible renal failure following an IVP. The experiences with this case suggest that, if the creatinine clearance is decreased in an insulin-dependent patient irrespective of the serum creatinine value, one must be aware of the possible hazard of acute renal failure and irreversible renal damage following the IVP. This would appear to be especially true if the diabetic patient has proteinuria in combination with the decreased creatinine clearance.

To the Editor. —Computerized tomography (CT) is undoubtedly one of the transcendental inventions in medicine. Its popularity derives from its superb resolution, specificity, and noninvasiveness. Coupled with contrast intensification, it has proved unequaled in the diagnosis of cerebrovascular disease. The technique is painless, results are readily available, and its cost is most competitive with other techniques capable of yielding similar information (ie, selective arteriography). The iodinated radiographic material infused when contrast is desired is the same used for intravenous pyelography, but the dosage is often higher. Therefore, the same potential complications, including acute oliguric renal failure, seen with any iodinated contrast medium 1 should be expected. During the past year, we have seen two diabetic patients with mild to moderate renal insufficiency in whom acute renal failure developed after CT scanning of the brain and contrast medium infusion. Both patients had had relatively stable renal function before the procedure, were and

To the Editor.— A CLINICAL NOTE (239:2018, 1978) concerning renal failure following intravenous pyelography describes a patient with apparent diabetic amyotrophy. The workup is described as having been undertaken "to find out the cause of his proximal amyotrophy and weight loss." Very complete laboratory investigations were carried out (including the fatal intravenous pyelogram), but the single, most important investigation necessary in any neuromuscular involvement was not done. I refer to electrodiagnostic evaluation. If the patient indeed had diabetic amyotrophy, the electrodiagnositc findings might have been of diagnostic importance.1Certainly, there is no apparent justification to have labeled the disorder a "profound myopathy" when the involvement more probably was neuropathic in nature.

Acute renal failure (ARF) following infusion intravenous pyelography (IVP) has been reported in patients with chronic renal insufficiency, particularly diabetics. Renal function was evaluated before and after infusion IVP in 40 patients with chronic renal insufficiency. In 11 of 12 (92%) diabetics and 17 of 28 (61%) nondiabetics, a 25% or greater increase in serum creatinine values and/or decrease in creatinine clearance was noted after IVP despite adequate hydration in all patients. The maximum decrease in kidney function occurred within three days and usually returned to or near pre-IVP levels in seven to ten days. At least 70% of the patients had hypertension and/or evidence of vascular disease. The data suggest that preexisting vascular disease in the kidney, possibly associated with the known vasoconstricting effects of contrast media, may be an important factor in the ARF following infusion IVP.

To the Editor:— I am quite confident that the editorial "Gangrenous Extremities and Intra-Arterial Injection" ( 200 :788, 1967) implied that intra-arterial injections of opaque media used for intravenous pyelography could per se lead to gangrene of an extremity. Proper injections of the radiographic opaque media used in intravenous pyelography and vascular studies are no more likely to result in gangrenous change when injected intra-arterially than when injected intravenously, as radiologists are well able to document. Injuries to arteries associated with catheterization procedures or improper arterial puncture may result in vascular changes leading to disaster. I am confident that the cases referred to in the editorial were ones in which the injections were not intra-arterial but periarterial, leading, thereby, to the sequence of events described. It is highly important that this distinction be recognized. If this were not true, it would be impossible for us to do any arteriographic studies either

This handbook on the techniques, uses, and interpretation of urography (intravenous pyelography) is grounded in the experience of a major teaching center and constitutes a reliable guide for the uninitiated. Dr. Lalli demonstrates— and quite rightly stresses—the important point that the examination can be "tailored" to the requirements of the problem in hand; this includes the subsidiary point that uremia does not necessarily preclude informative urography. Dr. Lalli surveys the common lesions and others less common. The x-ray reproductions are numerous and distinct. However, Dr. Lalli's sound instruction would have been well served by textual revision. Conventional pedantic formality, digression, inaccurate English, and verbosity weaken a text that is academically scrupulous. In discussing the differential diagnosis of urographic findings, Dr. Lalli frustrates the reader with references to other radiologic modalities, which his title excludes from this book. Perhaps in a second edition he will survey all methods of radiologic study

Previous studies from this laboratory indicated that the sodium iodohippurate I 131 renogram was unsatisfactory as a "screening" test for the detection of surgically amenable renal hypertension due to a 29% incidence of false negatives. A new technique was, therefore, used in 11 normal controls and 26 hypertensive patients thoroughly studied during a one-year period. The patients were hydrated and underwent iodohippurate renograms and chlormerodrin Hg 197 renograms and renal scans. The isotope studies were compared with the results of intravenous pyelography, aortography, split renalfunction studies, and surgery. At least one radioisotope test was positive in all 13 patients with unilateral renal disease. The diagnostic accuracy of each test was 62% for the iodohippurate renogram, 92% for the chlormerodrin renogram, and 85% for the renal scan.

This book is a comprehensive review of the radiological approach to the spleen and pancreas. It is naturally divided into two sections. After a short introduction, each division has a short, concise chapter on embryology, anatomy, and physiology, which provides helpful orientation for the subsequent discussion. The following two chapters deal with the radiological methods applicable to each organ and the roentgen diagnosis of diseases of each organ. The chapter on radiological methods begins with a discussion of routine radiological procedures, including plain films, barium sulfate contrast studies, intravenous pyelography, and cholecystography. Gas insufflation studies of the gastrointestinal tract, peritoneal cavity, and retroperitoneum are fully discussed. These procedures are relatively simple and harmless. Hypotonic duodenography, a technique not used generally in this country, is well described and illustrated. This is a simple procedure, with low morbidity, which should become part of the radiographic evaluation of the duodenal loop. Operative techniques

In an investigation of the possibility of gonadal injury by x-rays, a preliminary study was made of the records of 200 consecutive patients who had undergone intravenous pyelography. The evidence, in retrospect, showed that about 75% of the pyelograms had been justified, and that close adherence to indications could have eliminated about one-fourth. Measurements were made to determine the amount of radiation received by testes or ovaries during intravenous pyelography. In adults, the dose received was generally less than one roentgen for the ovaries and more, up to several roentgens, for the testes. A critical study of the information gained from 4,000 intravenous pyelograms, with films exposed at 5, 10, and 15 minutes after injection of the opaque medium, showed that the first two exposures might well be limited to the renal area since not one instance was found in which they gave information vital to the diagnosis of lower ureteral disease. A piece of lead or lead rubber should be used to cover the testes in the male patient and to shield the lower half of the abdomen in the female patient against undesired radiation, and actual exposure should be reduced to the minimum by strictly observing the indications and relying on the 15-minute or subsequent films for information as to the ureters.

With the introduction of a satisfactory drug for intravenous pyelography, Swick and von Lichtenberg made a valuable addition to diagnostic methods. How useful this method will become, what its disadvantages and dangers may be, and to what extent it will replace some of the older methods will be determined only by a long experience with its use. The basis for this report is an analysis of the results obtained with iopax (introduced as "Uroselectan") in forty-five cases in which forty-seven injections were done. In all our cases a sterile, freshly prepared 40 per cent solution of iopax was injected directly and slowly into the vein. The usual dose for adults was 40 Gm., although in a few cases in which there was poor renal function or in which this amount had not given the desired results, larger doses were used. In children smaller doses were used, usually about 25 Gm.

The crucial problem in the treatment of Cushing's syndrome is the differentiation of tumor from nontumorous hyperfunction of the adrenal cortex. The usefulness of the roentgen examination in the detection of adrenocortical tumor has been noted on several occasions. Special emphasis has been laid on perirenal or presacral gas insufflation. However, most reports are concerned with the principles involved and do not include statistical documentation of the claims made. 1-7 This report is concerned with an evaluation of the efficacy of the roentgenogram in making a diagnosis of the presence or absence of tumor based on 57 instances of Cushing's syndrome observed personally by the authors at The Mount Sinai Hospital. The detailed clinical manifestations of these patients are being reported in separate publications. 8,9 Methods In the patients in this series, the roentgen examination in sequential order included a flat plate, intravenous pyelography, and presacral or perirenal gas insufflation

Based on renal arteriography, hypertensive patients were classified as (1) normal, (2) unilaterally significantly abnormal, and (3) borderline cases. Those who underwent surgery were classified as cured, improved, and unchanged. The results of renograms using iodohippurate sodium I 131 chlormerodrin Hg 197 renograms and renal scans were compared to rapid sequence intravenous pyelography (RSIVP). In group 1 (ten patients), there was one false-positive iodohippurate renogram and two false-positive RSIVPs. Chlormerodrin renograms and scans were normal. In group 2 (13 patients) all iodohippurate renograms and RSIVPs reflected the side of the arteriographic lesion. Of these, 12 were cured or improved surgically. Two false-negative chlormerodrin renograms and scans occurred. In group 3 (six patients), all iodohippurate renograms reflected the side of the lesion while two patients, one cured and one improved, had negative RSIVP. Chlormerodrin renogram and scan were each falsely negative once.

Radionuclide renal function tests and kidney scanning are not mainstays of a nuclear medicine laboratory, however busy it may be. I am not certain why this should be, since a number of the procedures are very sensitive detectors of disease and are ideal for screening. The renogram and isotopic renal angiography, for example, are superior to any method of performing intravenous pyelography for screening hypertensive patients for renovascular disease. This book is an excellent introduction to the subject, although the scope and treatment of the material make it of more value to the investigator and nuclear physician than to the clinician. The editors have assembled a group of experts to cover all phases of renal function and disease to which radionuclides have been applied. The results of their efforts are uniformly good. About one third of the book is devoted to measurements of glomerular filtration rate and renal blood flow