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Ethanolamine Sclerotherapy of a Renal Cyst
0022-5347/95/1532-0385$03.00/0
THEJOURNAL OF UROLOGY
VoI 153, 385XjH6.February 1995 Prrntrd i n U.S.A.
Copyright 0 1995 by AMERICAN UROLOGICAL ASSOCIATION, INC.
ETHANOLAMINE SCLEROTHERAPY OF A RENAL CYST BRUCE BROWN, ROOHOLLAH SHARIFI AND MARY LEE From the University of Illinois at Chicago, Colleges of Medicine and Pharmacy, Chicago, Illinois
ABSTRACT
We report the effective use of 5%ethanolamine oleate to sclerose a large simple renal cyst. The comparative advantages of ethanolamine versus other sclerosants are discussed in terms of adverse effects, availability and convenience. Guidelines to optimize sclerotherapy with ethanolamine are provided. KEYWORDS:kidney, cysts, sclerosing solutions, sclerotherapy, ethanolamines Large simple renal cysts that cause flank or back pain, hypertension, renal caliceal or pelvic obstruction, or deteriorating kidney function require intervention. Percutaneous puncture and aspiration or sclerotherapy are less invasive management options compared to open surgery. Although several sclerosing agents have been used, no single agent has been shown to be more effective or less toxic than others. Some previously recommended agents, for example phenol' and absolute alcohol,2 must be extemporaneously prepared and sterilized before instillation. Other agents, for example bismuth phosphate3 and io~ h e n d y l a t e are , ~ no longer commercially available in the United States. To our knowledge we report the first case in which ethanolamine, a p-amino alcohol, was used to treat a renal cyst safely and effectively.
On the following day blood urea nitrogen and serum creatinine were 13 mg./dl. and 1.2 mg./dl., respectively. Two weeks postoperatively the patient reported marked improvement in back pain. He required no analgesics during this time. Repeat CT delineated an 11 X 10 cm. right upper pole renal cyst, which was essentially unchanged from that seen before sclerotherapy. Three months later renal ultrasonography showed a right kidney of normal size and postoperative changes consistent with drainage and disappearance of the large upper pole renal cyst were also evident on CT (see figure). DISCUSSION
CASE REPORT
A. G., a 70-year-old black man, presented with complaints of intermittent painless gross hematuria and persistent right back pain. Excretory urography revealed a 10 x 7.5 cm. right upper pole mass. Renal ultrasonography confirmed the presence of a 12.7 x 8.3 cm. cyst in the right upper pole. In addition, several other echolucent areas were identified in the right renal sinus, which were consistent with smaller renal cysts. Computerized tomography (CT) confirmed a large upper pole renal cortical cyst. Renal scan showed a functioning right kidney with a flattened upper pole, which was replaced by the cyst. There was also prolonged excretion in the right kidney. Blood urea nitrogen was 10 mg./dl. (normal 7.0 to 30.0) and creatinine was 1.2 mg./dl. (normal 0.7 to 1.8).Urinalysis was significant for greater than 100 red blood cells per high power field. Cystoscopy revealed no significant abnormalities. Because the patient was symptomatic and had a documented large right renal cyst, interventional therapy was planned. One hour preoperatively 80 mg. gentamicin were administered. The patient was placed in the prone position. A 19 gauge spinal needle was inserted over the 12th rib space and directed under fluoroscopic guidance into the cyst. Aspiration yielded 360 ml. of fluid, which was negative for malignancy on cytology. Meglumine diatrizoate injected into the cyst revealed a smooth cavity with no obvious filling defects. The contrast material was then aspirated from the cyst using the same spinal needle. Following the recommendations of Tammela et a1 18 ml. of 5% ethanolamine oleate mixed with 2 ml. of 0.75%bupivacaine were injected into the cyst cavity' and the needle was removed. Postoperatively a chest radiograph revealed no evidence of pneumothorax. The patient did not complain of any pain and was discharged from the hospital that day. Accepted for publication May 27, 1994.
Sclerosing agents are believed to produce local inflammation of the luminal surface of cysts, thereby resulting in adhesion of cyst walls. An ideal sclerosing agent should be effective in 1 dose, and produce minimal local and systemic adverse effects. Preferably, it should be commercially available in a ready to use dosage form. A mixture of 2.5% phenol and 25% glucose sterile solution has been extemporaneously prepared for use as sclerotherapy of renal cysts. In addition to being an effective sclerosant phenol has antiseptic properties that could reduce infection during its instillation. Escape of phenol into surrounding tissue has resulted in local tissue corrosion. Systemic absorption of large doses has produced severe central nervous system depression with respiratory and cardiovascular compromise.' Before instillation into renal cysts 95% or 96% ethanol must also be extemporaneously sterilized. Unlike other sclerosants that can be administered to outpatients, it is recommended that patients be hospitalized for 24 hours after sclerotherapy of renal cysts to ensure that no systemic complications occur. Leakage of alcohol outside of the cyst, particularly into the renal collecting system, can result in extensive tissue sloughing. Likewise, severe central nervous system depression can result from systemic absorption of ethanol. As a precaution Ozgiir et al recommend that ethanol be aspirated from the renal cyst approximately 20 minutes aRer instillation.6 Minocycline, a long acting tetracycline, has been used in doses of 100 to 200 mg. to sclerose 154 renal cysts7 Although results were good and no serious adverse effects were reported, fever and pain developed in 12.8% of patients. Parenteral minocycline is commercially available in the United States, although it is infrequently included on hospital formularies. The use of tetracycline: bismuth phosphate3 and iophendylate4 has also been reported but none is available in a parenteral formulation in the United States. A solution of 5% ethanolamine oleate is a commercially available, synthetic sclerosing agent that has been approved by the Food and Drug Administration for the management of
385
386
ETHANOLAMINE SCLEROTHERAPY OF RENAL CYST
A, ultrasound of right kidney before treatment. B, 3 months after treatment cyst has resolved. C, CT of right kidney before treatment. 0, CT of right hdney 3 months after treatment.
esophageal varices. Unlabeled uses include sclerosis of varicose veins, hydroceles and ~permatoceles.~ Based on its efficacy in the management of hydroceles, we decided to use it to sclerose the renal cyst in our case. The only local adverse effect reported with this agent is pain on instillation, which can be ameliorated by adding local anesthetic to the ethanolamine before injection. Systemic adverse reactions, which have been rarely reported, include allergic reactions and 2 cases of acute reversible renal fai1u1-e.~ We recommend consideration of 5% ethanolamine oleate as a convenient, safe, effective alternative sclerosing agent for the management of symptomatic renal cysts. We also offer guidelines to optimize results. Limit sclerotherapy to a single cyst at a time. Be sure that the cyst is in the periphery of the kidney and not near the renal pelvis. In the latter case leakage of sclerosant could result in severe local injury. Aspirate all fluid from the cyst to achieve clinical dryness, which will prevent dilution of the sclerosing agent. Inject a volume of sclerosing agent based on the volume of fluid aspirated such that the volume of ethanolamine used ranges from 2 to 30 ml. Repeat ultrasonography to determine the response to sclerotherapy no sooner than 3 months after instillation since there may be a delay in response. In conclusion, 5% ethanolamine oleate solution appears t o be a safe effective sclerosant for renal cysts. Our experience should encourage future controlled clinical trials to define further the role of ethanolamine oleate and compare its efficacy against that of other agents used to sclerose renal cysts.
REFERENCES
1. Pearman, R. 0.:Percutaneous needle puncture and aspiration of renal cysts: a diagnostic and therapeutic procedure. J . Urol., 9 6 139, 1966. 2. Bean, W. J.: Renal cysts: treatment with alcohol. Radiology, 138: 329, 1981. 3. Holmerg, G . and Hietala, S. 0.: Treatment of simple renal cysts by percutaneous puncture and instillation of bismuthphosphate. Scand. J . Urol. Nephrol., 2 3 207, 1989. 4. Camacho, M. F., Bondhus, M. J., Camon, H. M., Lockhart, J. L. and Politano, V. A,: Ureteropelvic junction obstruction resulting from percutaneous cyst puncture and intracystic isophendylate injection: an unusual complication. J . Urol., 124 713, 1979. 5. Tammela, T. L. J., Hellstrom, P. A,, Mattila, S. I., Ottelin, P. J., Malinen, L. J. and Markarainen, H. P.: Ethanolamine oleate sclerotherapy for hydroceles and spermatoceles: a survey of 158 patients with ultrasound followup. J. Urol., 147: 1551, 1992. 6. Ozgiir, S., Cetin, S. and Ilker, Y.: Percutaneous renal cyst aspiration and treatment with alcohol. Int. Urol. Nephrol., 2 0 481, 1988. 7. Ohkawa, M., Tokunaga, S., Onto, M., Shimamura, M., Hirano, S., Okasho, A. and Kosaka, S.: Percutaneous injection sclerotherapy with minocycline hydrochloride for simple renal cysts. Int. Urol. Nephrol., 25: 37, 1993. 8. Reiner, I., Donnell, S., Jones, M., Carty, H. L. and Rickwood, A. M.: Percutaneous sclerotherapy for simple renal cysts in children. Brit. J . Rad., 65: 281, 1992. 9. Maling, T. J. and Cretney, M. J.: Ethanolamine oleate and acute renal failure. New Zeal. Med. J., 82: 269, 1975.
THEJOURNAL OF UROLOGY
VoI 153, 385XjH6.February 1995 Prrntrd i n U.S.A.
Copyright 0 1995 by AMERICAN UROLOGICAL ASSOCIATION, INC.
ETHANOLAMINE SCLEROTHERAPY OF A RENAL CYST BRUCE BROWN, ROOHOLLAH SHARIFI AND MARY LEE From the University of Illinois at Chicago, Colleges of Medicine and Pharmacy, Chicago, Illinois
ABSTRACT
We report the effective use of 5%ethanolamine oleate to sclerose a large simple renal cyst. The comparative advantages of ethanolamine versus other sclerosants are discussed in terms of adverse effects, availability and convenience. Guidelines to optimize sclerotherapy with ethanolamine are provided. KEYWORDS:kidney, cysts, sclerosing solutions, sclerotherapy, ethanolamines Large simple renal cysts that cause flank or back pain, hypertension, renal caliceal or pelvic obstruction, or deteriorating kidney function require intervention. Percutaneous puncture and aspiration or sclerotherapy are less invasive management options compared to open surgery. Although several sclerosing agents have been used, no single agent has been shown to be more effective or less toxic than others. Some previously recommended agents, for example phenol' and absolute alcohol,2 must be extemporaneously prepared and sterilized before instillation. Other agents, for example bismuth phosphate3 and io~ h e n d y l a t e are , ~ no longer commercially available in the United States. To our knowledge we report the first case in which ethanolamine, a p-amino alcohol, was used to treat a renal cyst safely and effectively.
On the following day blood urea nitrogen and serum creatinine were 13 mg./dl. and 1.2 mg./dl., respectively. Two weeks postoperatively the patient reported marked improvement in back pain. He required no analgesics during this time. Repeat CT delineated an 11 X 10 cm. right upper pole renal cyst, which was essentially unchanged from that seen before sclerotherapy. Three months later renal ultrasonography showed a right kidney of normal size and postoperative changes consistent with drainage and disappearance of the large upper pole renal cyst were also evident on CT (see figure). DISCUSSION
CASE REPORT
A. G., a 70-year-old black man, presented with complaints of intermittent painless gross hematuria and persistent right back pain. Excretory urography revealed a 10 x 7.5 cm. right upper pole mass. Renal ultrasonography confirmed the presence of a 12.7 x 8.3 cm. cyst in the right upper pole. In addition, several other echolucent areas were identified in the right renal sinus, which were consistent with smaller renal cysts. Computerized tomography (CT) confirmed a large upper pole renal cortical cyst. Renal scan showed a functioning right kidney with a flattened upper pole, which was replaced by the cyst. There was also prolonged excretion in the right kidney. Blood urea nitrogen was 10 mg./dl. (normal 7.0 to 30.0) and creatinine was 1.2 mg./dl. (normal 0.7 to 1.8).Urinalysis was significant for greater than 100 red blood cells per high power field. Cystoscopy revealed no significant abnormalities. Because the patient was symptomatic and had a documented large right renal cyst, interventional therapy was planned. One hour preoperatively 80 mg. gentamicin were administered. The patient was placed in the prone position. A 19 gauge spinal needle was inserted over the 12th rib space and directed under fluoroscopic guidance into the cyst. Aspiration yielded 360 ml. of fluid, which was negative for malignancy on cytology. Meglumine diatrizoate injected into the cyst revealed a smooth cavity with no obvious filling defects. The contrast material was then aspirated from the cyst using the same spinal needle. Following the recommendations of Tammela et a1 18 ml. of 5% ethanolamine oleate mixed with 2 ml. of 0.75%bupivacaine were injected into the cyst cavity' and the needle was removed. Postoperatively a chest radiograph revealed no evidence of pneumothorax. The patient did not complain of any pain and was discharged from the hospital that day. Accepted for publication May 27, 1994.
Sclerosing agents are believed to produce local inflammation of the luminal surface of cysts, thereby resulting in adhesion of cyst walls. An ideal sclerosing agent should be effective in 1 dose, and produce minimal local and systemic adverse effects. Preferably, it should be commercially available in a ready to use dosage form. A mixture of 2.5% phenol and 25% glucose sterile solution has been extemporaneously prepared for use as sclerotherapy of renal cysts. In addition to being an effective sclerosant phenol has antiseptic properties that could reduce infection during its instillation. Escape of phenol into surrounding tissue has resulted in local tissue corrosion. Systemic absorption of large doses has produced severe central nervous system depression with respiratory and cardiovascular compromise.' Before instillation into renal cysts 95% or 96% ethanol must also be extemporaneously sterilized. Unlike other sclerosants that can be administered to outpatients, it is recommended that patients be hospitalized for 24 hours after sclerotherapy of renal cysts to ensure that no systemic complications occur. Leakage of alcohol outside of the cyst, particularly into the renal collecting system, can result in extensive tissue sloughing. Likewise, severe central nervous system depression can result from systemic absorption of ethanol. As a precaution Ozgiir et al recommend that ethanol be aspirated from the renal cyst approximately 20 minutes aRer instillation.6 Minocycline, a long acting tetracycline, has been used in doses of 100 to 200 mg. to sclerose 154 renal cysts7 Although results were good and no serious adverse effects were reported, fever and pain developed in 12.8% of patients. Parenteral minocycline is commercially available in the United States, although it is infrequently included on hospital formularies. The use of tetracycline: bismuth phosphate3 and iophendylate4 has also been reported but none is available in a parenteral formulation in the United States. A solution of 5% ethanolamine oleate is a commercially available, synthetic sclerosing agent that has been approved by the Food and Drug Administration for the management of
385
386
ETHANOLAMINE SCLEROTHERAPY OF RENAL CYST
A, ultrasound of right kidney before treatment. B, 3 months after treatment cyst has resolved. C, CT of right kidney before treatment. 0, CT of right hdney 3 months after treatment.
esophageal varices. Unlabeled uses include sclerosis of varicose veins, hydroceles and ~permatoceles.~ Based on its efficacy in the management of hydroceles, we decided to use it to sclerose the renal cyst in our case. The only local adverse effect reported with this agent is pain on instillation, which can be ameliorated by adding local anesthetic to the ethanolamine before injection. Systemic adverse reactions, which have been rarely reported, include allergic reactions and 2 cases of acute reversible renal fai1u1-e.~ We recommend consideration of 5% ethanolamine oleate as a convenient, safe, effective alternative sclerosing agent for the management of symptomatic renal cysts. We also offer guidelines to optimize results. Limit sclerotherapy to a single cyst at a time. Be sure that the cyst is in the periphery of the kidney and not near the renal pelvis. In the latter case leakage of sclerosant could result in severe local injury. Aspirate all fluid from the cyst to achieve clinical dryness, which will prevent dilution of the sclerosing agent. Inject a volume of sclerosing agent based on the volume of fluid aspirated such that the volume of ethanolamine used ranges from 2 to 30 ml. Repeat ultrasonography to determine the response to sclerotherapy no sooner than 3 months after instillation since there may be a delay in response. In conclusion, 5% ethanolamine oleate solution appears t o be a safe effective sclerosant for renal cysts. Our experience should encourage future controlled clinical trials to define further the role of ethanolamine oleate and compare its efficacy against that of other agents used to sclerose renal cysts.
REFERENCES
1. Pearman, R. 0.:Percutaneous needle puncture and aspiration of renal cysts: a diagnostic and therapeutic procedure. J . Urol., 9 6 139, 1966. 2. Bean, W. J.: Renal cysts: treatment with alcohol. Radiology, 138: 329, 1981. 3. Holmerg, G . and Hietala, S. 0.: Treatment of simple renal cysts by percutaneous puncture and instillation of bismuthphosphate. Scand. J . Urol. Nephrol., 2 3 207, 1989. 4. Camacho, M. F., Bondhus, M. J., Camon, H. M., Lockhart, J. L. and Politano, V. A,: Ureteropelvic junction obstruction resulting from percutaneous cyst puncture and intracystic isophendylate injection: an unusual complication. J . Urol., 124 713, 1979. 5. Tammela, T. L. J., Hellstrom, P. A,, Mattila, S. I., Ottelin, P. J., Malinen, L. J. and Markarainen, H. P.: Ethanolamine oleate sclerotherapy for hydroceles and spermatoceles: a survey of 158 patients with ultrasound followup. J. Urol., 147: 1551, 1992. 6. Ozgiir, S., Cetin, S. and Ilker, Y.: Percutaneous renal cyst aspiration and treatment with alcohol. Int. Urol. Nephrol., 2 0 481, 1988. 7. Ohkawa, M., Tokunaga, S., Onto, M., Shimamura, M., Hirano, S., Okasho, A. and Kosaka, S.: Percutaneous injection sclerotherapy with minocycline hydrochloride for simple renal cysts. Int. Urol. Nephrol., 25: 37, 1993. 8. Reiner, I., Donnell, S., Jones, M., Carty, H. L. and Rickwood, A. M.: Percutaneous sclerotherapy for simple renal cysts in children. Brit. J . Rad., 65: 281, 1992. 9. Maling, T. J. and Cretney, M. J.: Ethanolamine oleate and acute renal failure. New Zeal. Med. J., 82: 269, 1975.