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european urology xxx (2006) xxx–xxx

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

Case Study of the Month

Hemothorax after Percutaneous Cryoablation of the Kidney 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

Article info

Abstract

Article history: Accepted January 28, 2006 Published online ahead of print on March 29, 2006

Pleural effusions have not been reported after percutaneous cryoablation of the kidney. In our initial experience, we identified and treated two patients who had the complication of hemothorax after percutaneous cryoablation for renal malignancy. The occurrence of pleural effusions is frequently related to technical aspects of the procedure. The pathogenesis of this serious complication is discussed and preventive measures are highlighted. # 2006 Elsevier B.V. All rights reserved.

Keywords: Carcinoma Renal cell Complications Cryosurgery Hemothorax Pleural effusion Prevention and control

Please visit www.eu-acme.org to read and answer the EU-ACME questions on-line. The EU-ACME credits will then be attributed automatically. * 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.2006.03.014

EURURO-1295; No of Pages 3


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Case reports

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Patient 1

A 60-year-old woman with a past medical history of hypertension, transient ischemic attack, asthma, and Cushing syndrome was found to have bilateral renal masses. She was seen after laparoscopic cryoablation for a left renal tumor that was revealed to be a low-grade oncocytic neoplasm. Subsequently, she developed two adjacent right renal tumors (Fig. 1). The patient elected to proceed with percutaneous cryoablation of the two right renal tumors. A computed tomography (CT)-guided percutaneous cryoablation was performed with five 2.4mm probes. Two freeze-thaw cycles were performed. The CT scan demonstrated that the ice ball engulfed the lesions. Postprocedural CT scanning

Fig. 2 – Chest computed tomography scan demonstrates a moderate pleural effusion (arrow) on the right side.

showed no retroperitoneal bleeding. Several hours after the procedure, the patient developed significant nausea and vomiting. A repeat CT scan showed a right perirenal hematoma and a rightside pleural effusion, with no evidence of pneumothorax (Fig. 2). She was admitted to the surgical intensive care unit and received 2 U packed red blood cells due to a fall in the hematocrit to approximately 22. She developed shortness of breath, fatigue, and chest pain. A chest tube was placed, removing over 800 ml of a sanguineous fluid. Chest x-ray showed resolution of the pleural effusion and the tube was removed. 1.2.

Fig. 1 – Computed tomography scan of the abdomen shows two solid lesions with a diameter of 2 cm and 1.2 cm (arrows) in the lateral aspect of the midpole of the right kidney (A); close-up view of the right kidney (B).

Patient 2

An 87-year-old woman with a medical history of chronic obstructive pulmonary disease, hypertension, congestive heart failure, and atrial fibrillation was incidentally found to have a mass in her left kidney. Of note, she was taking anticoagulant therapy and was seen after a pacemaker implant and exploratory laparotomy for peritonitis. A CT scan showed a 1.7 cm  2.7 cm exophytic mass in the mid-portion of the left kidney. She elected to undergo an ablative procedure. Under CT fluoroscopic-guidance, a 22-gauge coaxial biopsy needle was used to obtain core tissue samples for pathologic examination before two 2.4-mm cryoablation probes were placed within the lesion (Fig. 3). Standard freeze-thaw cycles were used. The patient tolerated the procedure well. She was discharged home on postoperative day 1 after resuming anticoagulation therapy for chronic atrial fibrillation. Final pathologic examination revealed papillary renal cell carcinoma.


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tube placed, which drained >1 l of bloody fluid. Anticoagulation was halted and she received freshfrozen plasma and additional blood products. The chest tube was removed and the patient was discharged home. However, 20 d following surgery she was readmitted and died of a pulmonary embolism involving the right main pulmonary artery. EU-ACME Question Please visit www.eu-acme.org to answer the below EU-ACME question on-line (the EU-ACME credits will be attributed automatically). The answer will be given in next month’s Case Study of the Month: Part 2, which will be published in next month’s issue of European Urology. Question:

Fig. 3 – Intraoperative computed tomography scan shows a percutaneous probe (thick arrow) and a ‘‘frozen ice ball’’ (thin arrows) of adequate volume to include the entire renal lesion.

On postoperative day 3, the patient developed shortness of breath and left-sided chest pain. Chest CT revealed a large left-sided pleural effusion. No perinephric bleeding was noted. She had a chest

Which of the following mechanisms is most likely resposible 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.


Hemothorax after percutaneous cryoablation of the kidney: part 2