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Chiba needle in renal puncture guided by real-time ultrasound
ClinicalRadiology (1981) 32, 421-424
0009-9260/81/01100421502.00
© 1981 Royal Collegeof Radiologists
Chiba Needle in Renal Puncture Guided by Real-time Ultrasound A. C. LAMONT and E. W. L. FLETCHER
Department of Radiology, University o f Oxford, John Radcliffe Hospital, Headington, Oxford A technique for renal cyst and renal pelvic puncture is presented using the Chiba needle guided by real-time ultrasound. Our experience in 10 cases is recorded. The advantages of real-time ultrasound guidance are described, and the value of the technique is illustrated. There were no complications in this small series. Renal cyst puncture is useful in showing the character of renal cavities. When intravenous urography (IVU) is combined with ultrasound and cyst puncture, the benign nature of a cyst may be established with 95% certainty (Sherwood et al., 1980). Antegrade pyelography shows the renal pelvis and ureters above an obstruction and is particularly useful in children when cystoscopy and retrograde pyelography is difficult or impossible (Goodwin et al., 1955; Lalli, 1968, 1969; Fletcher and Gough, 1973). Thus renal cyst and renal pelvic punctures are essential procedures. Our aim is to show a modified technique using the Chiba needle guided by real-time ultrasound. TECHNIQUE Most patients proceed directly from IVU to ultrasound and then to renal puncture, but renal cyst puncture or antegrade pyelography can be performed as elective procedures without the necessity of an intravenous injection of contrast medium. The patient is usually placed prone on the table, though the prone-oblique position has been used in some cases. The depth of the cyst or renal pelvis is observed on real-time ultrasound using the linear array transducer. The degree of angulation of the needle is estimated by observing the angle of the transducer to the skin. The site for puncture by the Chiba needle is marked on the skin over the cyst using pressure from the hub of a hypodermic needle which leaves a circular pressure mark long enough to allow cleansing of the skin. Local anaesthetic is administered to the skin and subcutaneous tissue, though the small size of the Chiba needle means that a local anaesthetic may not be necessary. While the patient suspends respiration, the needle is advanced to the depth measured on ultrasound and into the region of interest. We have found in common with other authors that the needle may need to be advanced 1 - 2 c m beyond the depth
measured. This is presumably due to compression of subcutaneous tissue and fat by the transducer and once reeognised offers no fur.ther problem (Stables and Johnson, 1979).
'Cyst' Puncture As the needle enters a cyst a slight 'give' may be felt. The stylet is removed and fluid aspirated. Up to 100ml of fluid is removed and an equal amount of contrast medium is injected to outline the cyst or renal pelvis and ureter. Coned-down radiographs are taken in prone, oblique and lateral positions as necessary. Bloody or cloudy fluid is an indication for double-contrast study using air and horizontal beam techniques. The contents of the cyst are aspirated before allowing a patient to leave the department. The aspirate is sent for cytology and estimation of lactate dehydrogenase and fat content (Leopold et al., 1973). If a tumour is entered, thick bloody material may be aspirated or a 'dry-tap' may be obtained. The position of the needle tip is confirmed by ultrasound. Sufficient cellular material may be obtained by aspirating hard after rotating the needle several times. The needle is then carefully washed with saline when it is removed.
Antegrade Pyelography When antegrade pyelography is performed the technique is similar to that used for renal cyst puncture except that the collecting system is punctured. It is opacified and the erect position used to outline the ureter and lower pole calyces by gravity, when necessary. A nephrostomy tube can be inserted if this is required and the renal pelvis is allowed to drain before returning the patient to the ward.
RESULTS Five renal cyst punctures arid five antegrade pyelograms were performed on patients varying between
422
CLINICAL RADIOLOGY
Table 1 - Analysis of patients Name
Age
Sex
Clinical diagnoses
Indication for puncture
Results
Renal cyst puncture P.W. 89
M
SOL on IVU
Benign cyst
B.D. J.E.
74 76
M M
SOL on IVU SOL on IVU
Benign cyst Benign cyst
M.W. D.M.
66 78
F F
Hypertension temporal arteritis Hypertension Hypertension haematuria Hypertension diabetes Hypernephroma
SOL on IVU SOL on IVU
Benign cyst Benign cyst
Antegrade pyelogram J.A. 18
F
Spina bifida
A.W. J.L.
1 47
M F
Obstructive renal failure Diabetes SLE
Post-operative obstruction ureteric implant Obstructive renal failure Ureteric obstruction
P.E.
75
F
Mass left hypochondrium
Ureteric obstruction shown at site if implantation Lower ureteric obstruction ' High ureteric obstruction shown High ureteric obstruction
A.J.
8
F
Spina bifida
Non-functioning left kidney on IVU Non-functioning right kidney on IVU
Low ureteric obstruction
SOL = space-occupying lesion; IVU = intravenous urogram; SLE = systemic lupus erythematosis. the ages o f one and 89 years. Our fndings are shown in Table 1. One of our patients (P.W.) with flexion deformities of the hips was examined in the lateral position. The advantage o f the linear array transducer is that the exact site o f skin puncture and the angle o f the needle to the skin can be accurately determined. A second patient (A.W.), a child in a hip spica which covered the renal areas, needed oblique puncture. The direction and depth to which the needle should be advanced was rapidly ascertained in this case also (Fig. 1). No complications were encountered in this series.
DISCUSSION Development o f ultrasound techniques has simplified the differentiation o f renal masses found at IVU into solid or cystic. The criteria for diagnosis are well known. However, further confirmation is normally required before proceeding with surgery or 'masterly inactivity'. Similarly the dilated renal pelvis can be diagnosed with near certainty, but the ureter is inconsistently shown at IVU and antegrade opacification o f the renal tract may be necessary to demonstrate the site o f obstruction. Real-time ultrasound guidance has several advantages over b o t h static scanning and fluoroscopic guidance. Visualisation of the mass or hydronephrotic sac does not depend on the excretary function o f the kidney and can be performed despite non-visualisation on IVU. Exact Fig. 1 - Antegrade pyelogram in a child. The upper edge of the hip spica is indicated (arrows).
RENAL
PUNCTURE
tocalisation can be rapidly achieved, including the depth of the mass, and the area of interest can usually be punctured on the first pass of the needle (Weinstein and Skolnick, 1978). Use of the perforated 'B' scan transducer (KvistKristensen et al., 1972) has been discontinued in this department due to the rigidity with which the needle is held. Notched transducers are available, however, which allow removal of the transducer after the needle tip is in place. The phased-focused-lineararray transducer designed by Toshiba with inverted cone-shaped hole for passage of needle may overcome this difficulty (Ohto et al., 1980). This transducer allows prediction of the path of the needle and direct visualisation of the needle tip (Otto and Dehyle, 1980). The mobility of the real-time ultrasound machine has made it a useful adjunct in the fluoroscopy room and we combine fluoroscopy with ultrasound for renal puncture. The Chiba needle is highly flexible and although this has been cited as a disadvantage (Stables and Johnson, 1979) we have found that this is an advantage, particularly in those patients unable to cooperate fully, as in children or patients compromised by uraemia. With a rigid needle the risk of renal capsule laceration is small but real (Kvist-Kristensen et al., 1972). With the Chiba needle this risk becomes negligible and the patient is able to breathe freely throughout the procedure (Fig. 2).
TECHNIQUE
423
The flexibility of the needle may cause the tip to be deflected from its course by the bevel as it is passed through the muscles of the back, but this is easily corrected by pressure on the skin Horton et al., 1980). This property can be used to advantage when trying to reach awkward upper pole cysts. We have found no difficulty in injecting contrast media through this t'me needle. The Chiba needle is probably too thin to aspirate thick pus (Weinstein and Skolnick, 1978), but it retains its value in making the diagnosis and allowing full distension and opacification of the collecting system with preliminary puncture before drainage through a thicker needle. Percutaneous nephrostomy is a useful holding procedure in patients with obstructive renal failure who are being prepared for surgery and on occasions may be offered as a useful palliative procedure when definitive treatment is not possible (Goodwin et aL, 1955). Preliminary opacification of the collecting system allows more accurate placement of the nephrostomy tube (Jonson et al., 1972). Antegrade pyelography using a fine needle is of particular value in demonstrating the site, length and possible nature of ureteric obstruction. Fluid may also be obtained from the renal pelvis yielding positive cystology for transitional cell neoplasm and establishing a bacteriological diagnosis in infection above the stone or stricture (Weinstein and Skolnick, 1978). Spread of malignant cells due to needling of a tumour is thought to occur by rupture of the natural barrier, with cells being carried into surrounding tissue by the needle. Cells could be further spread by injection of fluid into the tumour (von Schreeb, 1967). This is a rare complication seen when needling other neoplasms (Stables and Johnson, 1979) and is usually associated with large bore needles (Bush et al., 1977), however use of the f'me needle has been implicated in one case of renal tract neoplasm (Bush et aL, 1977). CONCLUSION We believe that the Chiba needle is a safe instrument and its use should be considered whenever puncture of a renal cyst or renal pelvis is planned. We have also found that the use of real-time ultrasound has simplified renal puncture and it is now used routinely in this department.
Fig. 2 - Renal cyst puncture showing marked flexion of the needlewith respiration.
Acknowledgements. We would like to thank the Trustees of the Oxford and District Hospitals Improvement and Development Fund for providing the Toshiba ultrasound equipment, the Medical Illustration Department of the John Radcliffe Hospital for providing the illustrations and Miss Yvonne Williams for typing the manuscript.
424
CLINICAL RADIOLOGY
REFERENCES Bush, W. H., Burnett, L. L. & Gibbons, R. P. (1977). Needle tract seeding of renal cell carcinoma. American Journal of Roentgenology, 129, 725-727. Fletcher, E. W. L. & Gough, M. M. (1973). Antegrade pyelography in children. British Journal o f Radiology, 46, 191-194. Goodwin, W. E., Casey, M. D. & Woolf, M. D. (1955). Percutaneous trocar nephrostomy in hydronephrosis. Journal of American Medical Association, 157, 891-894. Horton, J. A., Bank, W. O. & Kerber, C. W. (1980). Guiding the thin spinal needle. American Journal of Roentgenology, 134, 854-846. Jonson, M., Lindberg, B. & Risholm, L. (1972). Percutaneous nephro-pyelostomy in cases of ureteral obstruction. Scandinavian Journal of Urology and Nephrology, 6, 5 1 53. Kvist-Kristensen, J., Holm, H. N., Norby-Rasmussen, S. & Barlebo, H. (1972). Ultrasound guided percutaneous puncture of renal masses. Scandinavian Journal of Urology and Nephrology, Suppl. 15, 6, 49-56. Lalli, A. A. (1968). Percutaneous translumbar pyelography. Radiology, 90, 331-333.
Lalli, A. A. (1969). Translumbar pyelography in the child. Paediatrics, 44, 1016-1018. Leopold, G. R., Talner, L. B., Asher, W. M., Gosink, B. B. & Gittes, R. F. (1973). Renal ultrasonography: an updated approach to the diagnosis of renal cyst. Radiology, 109, 671-678. Ohto, M., Saotome, N., Saisho, H., Tsuchiya, Y., Ono, T., Okuda, K. & Karasawa, E. (1980). Real-time sonography of the pancreatic duct. American Journal o f Roentgeno. logy, 134, 647-652. Otto, M. D. & Dehyle, M. D. (1980). Guided puncture under real-time sonographic control. Radiology, 134, 784-785. Sherwood; T., Davidson, A. J. & Tainer, L. B. (1980). Uroradiology, Blackwell Scientific Publications. Sinner, W. N. & Zajicek, J. (1976). Implantation metastasis after percutaneous trans-thoracic needle aspiration biopsy. Acta Radiologica (Diagnostic, Stockholm), 17, 473-479. Stables, D. P. & Johnson, M. L. (1979). Genito-urinary Ultra. sound, ed, Rosenfield, A. T., Churchill Livingstone. yon Schreeb, T., Arner, O. & Skovsted, G. (1967). Renal adenocarcinoma. Scandinavian Journal of Urology and Nephrology, 1,270-276. Weinstein, B. J. & Skolnick, M. L. (1978). Ultrasound guided antegrade pyelography. JournaI o f Urology, 120, 323 - 327.
0009-9260/81/01100421502.00
© 1981 Royal Collegeof Radiologists
Chiba Needle in Renal Puncture Guided by Real-time Ultrasound A. C. LAMONT and E. W. L. FLETCHER
Department of Radiology, University o f Oxford, John Radcliffe Hospital, Headington, Oxford A technique for renal cyst and renal pelvic puncture is presented using the Chiba needle guided by real-time ultrasound. Our experience in 10 cases is recorded. The advantages of real-time ultrasound guidance are described, and the value of the technique is illustrated. There were no complications in this small series. Renal cyst puncture is useful in showing the character of renal cavities. When intravenous urography (IVU) is combined with ultrasound and cyst puncture, the benign nature of a cyst may be established with 95% certainty (Sherwood et al., 1980). Antegrade pyelography shows the renal pelvis and ureters above an obstruction and is particularly useful in children when cystoscopy and retrograde pyelography is difficult or impossible (Goodwin et al., 1955; Lalli, 1968, 1969; Fletcher and Gough, 1973). Thus renal cyst and renal pelvic punctures are essential procedures. Our aim is to show a modified technique using the Chiba needle guided by real-time ultrasound. TECHNIQUE Most patients proceed directly from IVU to ultrasound and then to renal puncture, but renal cyst puncture or antegrade pyelography can be performed as elective procedures without the necessity of an intravenous injection of contrast medium. The patient is usually placed prone on the table, though the prone-oblique position has been used in some cases. The depth of the cyst or renal pelvis is observed on real-time ultrasound using the linear array transducer. The degree of angulation of the needle is estimated by observing the angle of the transducer to the skin. The site for puncture by the Chiba needle is marked on the skin over the cyst using pressure from the hub of a hypodermic needle which leaves a circular pressure mark long enough to allow cleansing of the skin. Local anaesthetic is administered to the skin and subcutaneous tissue, though the small size of the Chiba needle means that a local anaesthetic may not be necessary. While the patient suspends respiration, the needle is advanced to the depth measured on ultrasound and into the region of interest. We have found in common with other authors that the needle may need to be advanced 1 - 2 c m beyond the depth
measured. This is presumably due to compression of subcutaneous tissue and fat by the transducer and once reeognised offers no fur.ther problem (Stables and Johnson, 1979).
'Cyst' Puncture As the needle enters a cyst a slight 'give' may be felt. The stylet is removed and fluid aspirated. Up to 100ml of fluid is removed and an equal amount of contrast medium is injected to outline the cyst or renal pelvis and ureter. Coned-down radiographs are taken in prone, oblique and lateral positions as necessary. Bloody or cloudy fluid is an indication for double-contrast study using air and horizontal beam techniques. The contents of the cyst are aspirated before allowing a patient to leave the department. The aspirate is sent for cytology and estimation of lactate dehydrogenase and fat content (Leopold et al., 1973). If a tumour is entered, thick bloody material may be aspirated or a 'dry-tap' may be obtained. The position of the needle tip is confirmed by ultrasound. Sufficient cellular material may be obtained by aspirating hard after rotating the needle several times. The needle is then carefully washed with saline when it is removed.
Antegrade Pyelography When antegrade pyelography is performed the technique is similar to that used for renal cyst puncture except that the collecting system is punctured. It is opacified and the erect position used to outline the ureter and lower pole calyces by gravity, when necessary. A nephrostomy tube can be inserted if this is required and the renal pelvis is allowed to drain before returning the patient to the ward.
RESULTS Five renal cyst punctures arid five antegrade pyelograms were performed on patients varying between
422
CLINICAL RADIOLOGY
Table 1 - Analysis of patients Name
Age
Sex
Clinical diagnoses
Indication for puncture
Results
Renal cyst puncture P.W. 89
M
SOL on IVU
Benign cyst
B.D. J.E.
74 76
M M
SOL on IVU SOL on IVU
Benign cyst Benign cyst
M.W. D.M.
66 78
F F
Hypertension temporal arteritis Hypertension Hypertension haematuria Hypertension diabetes Hypernephroma
SOL on IVU SOL on IVU
Benign cyst Benign cyst
Antegrade pyelogram J.A. 18
F
Spina bifida
A.W. J.L.
1 47
M F
Obstructive renal failure Diabetes SLE
Post-operative obstruction ureteric implant Obstructive renal failure Ureteric obstruction
P.E.
75
F
Mass left hypochondrium
Ureteric obstruction shown at site if implantation Lower ureteric obstruction ' High ureteric obstruction shown High ureteric obstruction
A.J.
8
F
Spina bifida
Non-functioning left kidney on IVU Non-functioning right kidney on IVU
Low ureteric obstruction
SOL = space-occupying lesion; IVU = intravenous urogram; SLE = systemic lupus erythematosis. the ages o f one and 89 years. Our fndings are shown in Table 1. One of our patients (P.W.) with flexion deformities of the hips was examined in the lateral position. The advantage o f the linear array transducer is that the exact site o f skin puncture and the angle o f the needle to the skin can be accurately determined. A second patient (A.W.), a child in a hip spica which covered the renal areas, needed oblique puncture. The direction and depth to which the needle should be advanced was rapidly ascertained in this case also (Fig. 1). No complications were encountered in this series.
DISCUSSION Development o f ultrasound techniques has simplified the differentiation o f renal masses found at IVU into solid or cystic. The criteria for diagnosis are well known. However, further confirmation is normally required before proceeding with surgery or 'masterly inactivity'. Similarly the dilated renal pelvis can be diagnosed with near certainty, but the ureter is inconsistently shown at IVU and antegrade opacification o f the renal tract may be necessary to demonstrate the site o f obstruction. Real-time ultrasound guidance has several advantages over b o t h static scanning and fluoroscopic guidance. Visualisation of the mass or hydronephrotic sac does not depend on the excretary function o f the kidney and can be performed despite non-visualisation on IVU. Exact Fig. 1 - Antegrade pyelogram in a child. The upper edge of the hip spica is indicated (arrows).
RENAL
PUNCTURE
tocalisation can be rapidly achieved, including the depth of the mass, and the area of interest can usually be punctured on the first pass of the needle (Weinstein and Skolnick, 1978). Use of the perforated 'B' scan transducer (KvistKristensen et al., 1972) has been discontinued in this department due to the rigidity with which the needle is held. Notched transducers are available, however, which allow removal of the transducer after the needle tip is in place. The phased-focused-lineararray transducer designed by Toshiba with inverted cone-shaped hole for passage of needle may overcome this difficulty (Ohto et al., 1980). This transducer allows prediction of the path of the needle and direct visualisation of the needle tip (Otto and Dehyle, 1980). The mobility of the real-time ultrasound machine has made it a useful adjunct in the fluoroscopy room and we combine fluoroscopy with ultrasound for renal puncture. The Chiba needle is highly flexible and although this has been cited as a disadvantage (Stables and Johnson, 1979) we have found that this is an advantage, particularly in those patients unable to cooperate fully, as in children or patients compromised by uraemia. With a rigid needle the risk of renal capsule laceration is small but real (Kvist-Kristensen et al., 1972). With the Chiba needle this risk becomes negligible and the patient is able to breathe freely throughout the procedure (Fig. 2).
TECHNIQUE
423
The flexibility of the needle may cause the tip to be deflected from its course by the bevel as it is passed through the muscles of the back, but this is easily corrected by pressure on the skin Horton et al., 1980). This property can be used to advantage when trying to reach awkward upper pole cysts. We have found no difficulty in injecting contrast media through this t'me needle. The Chiba needle is probably too thin to aspirate thick pus (Weinstein and Skolnick, 1978), but it retains its value in making the diagnosis and allowing full distension and opacification of the collecting system with preliminary puncture before drainage through a thicker needle. Percutaneous nephrostomy is a useful holding procedure in patients with obstructive renal failure who are being prepared for surgery and on occasions may be offered as a useful palliative procedure when definitive treatment is not possible (Goodwin et aL, 1955). Preliminary opacification of the collecting system allows more accurate placement of the nephrostomy tube (Jonson et al., 1972). Antegrade pyelography using a fine needle is of particular value in demonstrating the site, length and possible nature of ureteric obstruction. Fluid may also be obtained from the renal pelvis yielding positive cystology for transitional cell neoplasm and establishing a bacteriological diagnosis in infection above the stone or stricture (Weinstein and Skolnick, 1978). Spread of malignant cells due to needling of a tumour is thought to occur by rupture of the natural barrier, with cells being carried into surrounding tissue by the needle. Cells could be further spread by injection of fluid into the tumour (von Schreeb, 1967). This is a rare complication seen when needling other neoplasms (Stables and Johnson, 1979) and is usually associated with large bore needles (Bush et al., 1977), however use of the f'me needle has been implicated in one case of renal tract neoplasm (Bush et aL, 1977). CONCLUSION We believe that the Chiba needle is a safe instrument and its use should be considered whenever puncture of a renal cyst or renal pelvis is planned. We have also found that the use of real-time ultrasound has simplified renal puncture and it is now used routinely in this department.
Fig. 2 - Renal cyst puncture showing marked flexion of the needlewith respiration.
Acknowledgements. We would like to thank the Trustees of the Oxford and District Hospitals Improvement and Development Fund for providing the Toshiba ultrasound equipment, the Medical Illustration Department of the John Radcliffe Hospital for providing the illustrations and Miss Yvonne Williams for typing the manuscript.
424
CLINICAL RADIOLOGY
REFERENCES Bush, W. H., Burnett, L. L. & Gibbons, R. P. (1977). Needle tract seeding of renal cell carcinoma. American Journal of Roentgenology, 129, 725-727. Fletcher, E. W. L. & Gough, M. M. (1973). Antegrade pyelography in children. British Journal o f Radiology, 46, 191-194. Goodwin, W. E., Casey, M. D. & Woolf, M. D. (1955). Percutaneous trocar nephrostomy in hydronephrosis. Journal of American Medical Association, 157, 891-894. Horton, J. A., Bank, W. O. & Kerber, C. W. (1980). Guiding the thin spinal needle. American Journal of Roentgenology, 134, 854-846. Jonson, M., Lindberg, B. & Risholm, L. (1972). Percutaneous nephro-pyelostomy in cases of ureteral obstruction. Scandinavian Journal of Urology and Nephrology, 6, 5 1 53. Kvist-Kristensen, J., Holm, H. N., Norby-Rasmussen, S. & Barlebo, H. (1972). Ultrasound guided percutaneous puncture of renal masses. Scandinavian Journal of Urology and Nephrology, Suppl. 15, 6, 49-56. Lalli, A. A. (1968). Percutaneous translumbar pyelography. Radiology, 90, 331-333.
Lalli, A. A. (1969). Translumbar pyelography in the child. Paediatrics, 44, 1016-1018. Leopold, G. R., Talner, L. B., Asher, W. M., Gosink, B. B. & Gittes, R. F. (1973). Renal ultrasonography: an updated approach to the diagnosis of renal cyst. Radiology, 109, 671-678. Ohto, M., Saotome, N., Saisho, H., Tsuchiya, Y., Ono, T., Okuda, K. & Karasawa, E. (1980). Real-time sonography of the pancreatic duct. American Journal o f Roentgeno. logy, 134, 647-652. Otto, M. D. & Dehyle, M. D. (1980). Guided puncture under real-time sonographic control. Radiology, 134, 784-785. Sherwood; T., Davidson, A. J. & Tainer, L. B. (1980). Uroradiology, Blackwell Scientific Publications. Sinner, W. N. & Zajicek, J. (1976). Implantation metastasis after percutaneous trans-thoracic needle aspiration biopsy. Acta Radiologica (Diagnostic, Stockholm), 17, 473-479. Stables, D. P. & Johnson, M. L. (1979). Genito-urinary Ultra. sound, ed, Rosenfield, A. T., Churchill Livingstone. yon Schreeb, T., Arner, O. & Skovsted, G. (1967). Renal adenocarcinoma. Scandinavian Journal of Urology and Nephrology, 1,270-276. Weinstein, B. J. & Skolnick, M. L. (1978). Ultrasound guided antegrade pyelography. JournaI o f Urology, 120, 323 - 327.