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european urology xxx (2006) xxx–xxx

available at www.sciencedirect.com journal homepage: www.europeanurology.com

Previous Month’s Discussion and Answer

Hemothorax after Percutaneous Cryoablation of the Kidney: Part 2 Frederico R. Romero a,*, Michael Muntener a, Aaron Sulman a, Fa´bio Augusto R. Brito a, Louis R. Kavoussi b a b

James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA Department of Urology, North Shore-LIJ Health System, Long Island, NY, USA

1.

Discussion

Cryoablation is a recently introduced minimally invasive nephron-sparing procedure for managing renal malignancy. This induces cell death through a rapid freeze-thaw process that results in ice crystal formation and ischemic necrosis [1]. Cryosurgery has the advantage of sparing nephrons while minimizing the need for renal dissection and the complications related to extirpative renal surgery. Indications include patients who are not surgical candidates and individuals with a solitary kidney or renal insufficiency where surgical excision would result in dialysis [2,3]. Although clinical experience has confirmed the safety and efficacy of cryosurgery for patients with renal malignancies [4], the technique is not without risk. Major complications are similar to other laparoscopic and percutaneous renal procedures [2,5–7]. Pulmonary complications are recognized sequelae of any abdominal procedure. Atelectasis and pneumonia have been reported following laparoscopic and percutaneous procedures. Moreover, exudative pleural effusions have been described [2]. Percutaneous cryoablation has been associated with reduced morbidity and mortality than with surgical ablation [2,3]. With the increasing enthu-

siasm for minimally invasive ablative techniques in the treatment of renal cancer, however, novel complications are being recognized. In this report, we describe data on two patients with hemothorax, a previously unpublished complication following percutaneous cryoablation of the kidney. The pathogenesis of pleural effusions (including hemothorax) can arise from several technical aspects of the procedure. Posteriorly, the diaphragm and parietal pleura frequently extend below the 12th rib to the level of the first lumbar vertebrae. Insertion of the probes during percutaneous surgery may result in injury to the phrenic or subcostal arteries that run along the lower border of the 12th rib behind the kidney [8], resulting in bleeding through the probe tract into the pleural space [9]. Pleural blood often does not clot and small amounts of blood can be readily removed by lymphatics. Larger effusions require tube drainage, as in the cases reported herein. Persistent bleeding requires surgical correction. Direct contact with the posterior surface of the diaphragm in laparoscopic or percutaneous ablation of the upper pole of the kidney can produce a local irritative process that may result in a reactive pleural effusion. In these cases, pleural effusions are usually nonbloody transudates and seem to be

DOI of original article: 10.1016/j.eururo.2006.03.014 * Corresponding author. Johns Hopkins Medical Institutions, James Buchanan Brady Urological Institute, 600 North Wolfe Street, Suite 161, Jefferson Street Bldg., Baltimore, MD 21287-8915, USA. Tel. +1 410 502 7710; Fax: +1 410 502 7711. E-mail address: frederico.romero@gmail.com (F.R. Romero). 0302-2838/$ – see back matter # 2006 Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2006.03.015

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directly proportional to the amount of tissue frozen. This complication has been reported in cryosurgery of hepatic lesions [10], but has not been described with renal ablation. Most cases are asymptomatic and usually resolve within approximately 14 d. Fewer than 10% of these patients require chest tube placement for drainage and symptomatic relief [10]. Bearing these technical aspects in mind may prevent intrathoracic complications. One should take care to insert the needle away from the lower border of the ribs when using an intercostal approach. For upper pole lesions, contact with the surface of the diaphragm may be avoided by injection of CO2 or saline to move the kidney inferiorly. The differential diagnosis of chest pain and acute respiratory distress following renal cryoablation should include cardiac causes as well as atelectasis, pulmonary embolism, or pneumothorax. In our series of 35 cases, we have seen two pleural effusions. The only other patient with chest pain was found to have atelectasis, which responded to vigorous pulmonary toilet. As such, hemothorax and pleural effusions must be considered in the differential diagnosis of pulmonary symptoms following renal cryoablation. A high level of suspicion postoperatively may allow prompt treatment and prevention of serious sequelae, even death.

2.

EU-ACME question and answer

Which of the following mechanisms is most likely responsible for hemothorax after percutaneous cryoablation of the kidney? A. Injury to the phrenic or subcostal arteries that run along the lower border of the 12th rib. B. A consequence of infectious or noninfectious pulmonary infiltrations such as pneumonia and atelectasis.

C. Direct contact of the ‘‘ice ball’’ with the posterior surface of the diaphragm. D. All of the above.

Correct answer: A Injury to the phrenic or subcostal arteries during percutaneous procedures may result in bleeding through the probe tract into the pleural space. Pleural effusions complicating pneumonia or atelectasis are commonly exsudates, whereas the direct contact of the ‘‘ice ball’’ with the surface of the diaphragm frequently results in transudates, which are usually nonbloody effusions.

References [1] Desai MM, Aron M, Gill IS. Laparoscopic partial nephrecomy versus laparoscopic cryoablation for the small renal tumor. Urology 2005;66:23–8. [2] Lane BR, Moinzadeh A, Kaouk JH. Acute obstructive renal failure after laparoscopic cryoablation of multiple renal tumors in a solitary kidney. Urology 2005;65:593. [3] Anderson CJ, Havranek EG. Minimally invasive ablative techniques in renal cancer. BJU Int 2004;93:707–9. [4] Gill IS, Remer EM, Hasan WA, et al. Renal cryoablation: outcome at 3 years. J Urol 2005;173:1903–7. [5] Johnson DB, Solomon SB, Su LM, et al. Defining the complications of cryoablation and radio frequency ablation of small renal tumors: a multi-institutional review. J Urol 2004;172:874–7. [6] Gill IS, Novick AC, Meraney AM, et al. Laparoscopic renal cryoablation in 32 patients. Urology 2000;56:748–53. [7] Silverman SG, Tuncali K, vanSonnenberg E, et al. Renal tumors: MR imaging-guided percutaneous cryotherapy– initial experience in 23 patients. Radiology 2005;236:716–24. [8] Anatomy of the human body [http://www.bartleby.com/ 107]. Accessed on 13 January 2006. [9] Bissler JJ, Warner BW, Welch TR. Hemothorax as a complication following percutaneous renal biopsy. Am J Kidney Dis 1991;18:122. [10] Sarantou T, Bilchik A, Ramming KP. Complications of hepatic cryosurgery. Semin Surg Oncol 1998;14:156–62.


Hemothorax after percutaneous cryoablation of the kidney