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Renal cyst puncture and abscess formation
LETTERS TO THE EDITOR
RENAL CYST PUNCTURE ABSCESS FORMATION
AND
To the Editor: In the August issue (vol. 10, page 98) of UROLOGY, Dr. J. L. Lockhart et al. report on 2 cases of abscess formation occurring after puncture of a renal cyst, and they limit the value of the cyst puncture to a method which may provide accurate diagnosis in selected cases, particularly in patients who pose significant surgical risks or in whom other coexistent diseases take precedence. Their current diagnostic evaluation of renal masses seems to contain routine arteriography with excretory urography, nephrotomography, and ultrasonography. Apart from that, they insist on morbidity after puncture of a cyst, illustrated by their 2 cases of cyst abscess, and contrarily they state that the fear of a significant mortality rate as well as morbidity after surgical exploration for a cyst is groundless. They emphasize also that a renal cyst puncture with aspiration is not definitive therapy in most instances. The authors conclude that the decision for cyst puncture and aspiration is one to be made jointly by the radiologist to perform the procedure and the urologic surgeon. The authors’ ideas call for certain reflections on our part. First, it would seem to us that the real problem is not to confront puncture, arteriography, and intervention but to specify their respective places in the sequence of examinations, which are called for when considering a renal tumor. When the diagnosis of a cyst appears to be likely, it seems to us that a puncture should follow the intravenous urography and the ultrasonography and, if these tests are consistent with the criteria of a cyst, one could and should leave it at that for all patients and not just for certain patients, as the authors preconise. Indeed, when a puncture accumulates all the diagnostic criteria of a cyst, such as (1) clear liquid, (2) no chemical anomalies, (3) no atypical cells, and (4) a regular cavity superposable on the spaceoccupying lesion, we think it unlikely, if not impossible, that one should fail to recognize a cancer either in cyst form or one in the walls of a cyst. Such observations are not known to us. In case of need, though not routinely, arteriography should complete the other tests and if in spite of the utilization of all the processes of diagnosis incertitude persists because this or that sign is suspicious, surgical intervention is necessary. However, let us not forget that what is difficult to see before this exploratory surgical intervention is not necessarily better seen during it and is sometimes misleading. The lumbotomy “without risk’ that was
UROLOGY
/
MAY 1978
/
VOLUME
XI, NUMBER
5
intended to be exploratory becomes involuntarily destructive. To oppose on the one hand morbidity after a cyst puncture (which in the 2 cases brought the authors to surgical intervention) with mortality in the case of surgical intervention does not seem logical. I would say rather that the aim of a good technique of cyst puncture should be to avoid morbidity just as the progress in surgery should achieve an absence of mortality and equal the excellent results of the authors. However, this absence of mortality is no reason to limit an examination, which brings a sure answer. The puncture can be performed in the ambulatory patient with a minimum of cost and pain, whereas the intervention “without mortality” necessitates hospitalization, expense, and suffering. However, the real reasons for the tendency to surgical treatment of cysts seem to be doubts of making an error and to insecure feelings which we all have at the start - proper feelings for a surgeon who believes only in that which he sees when operating. With regard to the therapeutic value of cyst puncture with aspiration one can say that the evacuative puncture brings results in 50 per cent of cases and can be designated as curative in 25 per cent. The question seems to be, “Do cysts really necessitate treatment?’ As far as we are concerned the reply is negative. Except if it concerns cysts that are very voluminous and those with an intrasinusal development, which induces a pyelocalyceal stasis, the risks of possible evolutive complications jn a cyst do not weigh in favor of surgical treatment. Indeed, many are the cysts which do not reappear after a simple puncture and, contrary to numerous observations, take into account the development of other cysts in the same kidney in spite of the intervention. The frequency of cysts in the adult patient and the existence of cysts at the microscopic stage provide proof of this.* That the urologist should hold a central position during the diagnostic and surgical procedures seems to us also to be capital. We are partisan to the urologic surgeon proceeding to the puncture of cysts, after its indication and the proposed examinations have been discussed with the radiologist. This method must limit morbidity and render infections exceptional. Thus the central position in the strategy to be adopted remains in the hands of the urologist. Through the frequent practice of these techniques of cyst puncture, a certitude and a diagnostic tranquillity can be acquired and unfounded doubts *Baert L, and Steg A: On the pathogenesis of simple renal cysts in the adult: a microdissection study, Ural. Res. 5: 103 (1977).
543
disappear. Numerous wasteful interventions for an “illness,” which in the majority of cases does not require treatment, are thus avoided. Luc Baert, M.D. Loofstraat, 43 8500 Kortrijk, Belgium
USE OF LOWSLEY
TRACTORS
To the Editor: Those of us who still do perineal prostatectomies have encountered Lowsley prostatic tractors which have been used in the manner described by Dr. William J. Cromie and Dr. Michael H. Lake in their article, “The Lowsley Cystotomy,” in the January issue (vol. 11, page 78) of UROLOGY. We have found that these instruments have been damaged sometimes irreparably by their use as a not welcome grasping device. I would personally the widespread use of this instrument in this manner. Use of Lowsley tractors involves turning the screw device open and closed a certain number of turns. Grasping the Malecot catheter misaligns the sensitive opening-closing device of the instrument and facilitates injury by the wings (I prefer not to use the word jaws) of the tractor to the delicate urethra. “Evaluation of Closed Suprapubic The article, Cystotomy,” by William D. Flock, M.D., Austin S. Litvak, M.D., and J. William McRoberts, M.D., in the same issue (vol. 11, page 40) suggests a more rational use of the instrument if one does not have a Turner-Warwick staff or similar device. Gerald T. Keegan, M.D. Scott and White Clinic Temple, Texas 76501
UNEXPECTED
544
James A. Roberts, M.D. Tulane University Covington, Louisiana 70433
Reply from Dr. Shapiro To the Editor: I am grateful to Dr. James Roberts for pointing out a problem with our reference to his article, “The Unexpected Pheochromocytoma,” mentioned in our article on “Nonrenovascular Renal Hypertension in Children.” Our article states, “Goodman and Roberts reported a patient in whom the PRA was elevated and unilateral, chronic pyelonephritis was present. A pheochromocytoma was discovered only accidentally at surgery which nearly resulted in the death of the patient.” The last sentence should have read: “A pheochromocytoma, which was confirmed at surgery, could have resulted in the death of the patient had it not been diagnosed preoperatively. ” Stephen R. Shapiro,
M.D. University of California Sacramento, California 95817
PHEOCHROMOCYTOMA
the To the Editor: Although _ I ~enjoyed .__ reading review on “Nonrenovascular Renal Hypertension in Children” by Stephen R. Shapiro, M.D., R. D. Adelman, M.D., and H. Tesluk, M.D., in the December issue (vol. 10, page517)ofUROLOGY, I must comment on his reference to our* article, “The Unexpected PheoThey state on page 525 that, chromocytoma.” “Goodman and Roberts reported a patient in whom the PRA was elevated and unilateral chronic pyelonephritis was present.” They then state that, “A pheochromocytoma was discovered only accidentally at surgery, which nearly resulted in the death of the patient. ” This last sentence is grossly in error and is not stated in our article. *Goodman chromocytoma,
In our article we point out the danger of anesthesia and surgery in patients with pheochromocytoma. However, our patient, who we thought had hypertension from unilateral chronic pyelonephritis was evaluated completely for other causes of hypertension preoperatively and was found to have a pheochromocytoma on the same side as her chronic pyelonephritis. Her preoperative preparation with adrenergic blockade led to an uneventful operation. I do agree with Dr. Shapiro and his colleagues when they state in the last sentence of their article, “It is, therefore, necessary to screen all hypertensive children for pheochromocytoma prior to any major surgical procedure.” Our patient did not almost die because her pheochromocytoma was accidentally discovered, but found during careful preoperative evaluation.
JR, and Roberts JA: The Unexpected South. Med. J. 69: 374 (1976).
pheo-
CIRCLE
TUBE
URINARY
DIVERSION
To the Editor: In his article, “Loop Nephrostomy,” published in the December issue (vol. 10, page 582) of UROLOGY, Dr. Robert H. Hackler draws attention to the use of Silastic circle tubes for urinary diversion. We have previously described a similar procedure (nephronephrostomy) as a variant of the nephroureterostomy which can be used for either permanent or temporary urinary diversion. l-3 In addition to the conditions reported in these articles, I have been particularly pleased with its use when a temporary diversion was required in children while
UROLOGY
/
MAY 1978
/ VOLUME
XI, NUMBER
5
RENAL CYST PUNCTURE ABSCESS FORMATION
AND
To the Editor: In the August issue (vol. 10, page 98) of UROLOGY, Dr. J. L. Lockhart et al. report on 2 cases of abscess formation occurring after puncture of a renal cyst, and they limit the value of the cyst puncture to a method which may provide accurate diagnosis in selected cases, particularly in patients who pose significant surgical risks or in whom other coexistent diseases take precedence. Their current diagnostic evaluation of renal masses seems to contain routine arteriography with excretory urography, nephrotomography, and ultrasonography. Apart from that, they insist on morbidity after puncture of a cyst, illustrated by their 2 cases of cyst abscess, and contrarily they state that the fear of a significant mortality rate as well as morbidity after surgical exploration for a cyst is groundless. They emphasize also that a renal cyst puncture with aspiration is not definitive therapy in most instances. The authors conclude that the decision for cyst puncture and aspiration is one to be made jointly by the radiologist to perform the procedure and the urologic surgeon. The authors’ ideas call for certain reflections on our part. First, it would seem to us that the real problem is not to confront puncture, arteriography, and intervention but to specify their respective places in the sequence of examinations, which are called for when considering a renal tumor. When the diagnosis of a cyst appears to be likely, it seems to us that a puncture should follow the intravenous urography and the ultrasonography and, if these tests are consistent with the criteria of a cyst, one could and should leave it at that for all patients and not just for certain patients, as the authors preconise. Indeed, when a puncture accumulates all the diagnostic criteria of a cyst, such as (1) clear liquid, (2) no chemical anomalies, (3) no atypical cells, and (4) a regular cavity superposable on the spaceoccupying lesion, we think it unlikely, if not impossible, that one should fail to recognize a cancer either in cyst form or one in the walls of a cyst. Such observations are not known to us. In case of need, though not routinely, arteriography should complete the other tests and if in spite of the utilization of all the processes of diagnosis incertitude persists because this or that sign is suspicious, surgical intervention is necessary. However, let us not forget that what is difficult to see before this exploratory surgical intervention is not necessarily better seen during it and is sometimes misleading. The lumbotomy “without risk’ that was
UROLOGY
/
MAY 1978
/
VOLUME
XI, NUMBER
5
intended to be exploratory becomes involuntarily destructive. To oppose on the one hand morbidity after a cyst puncture (which in the 2 cases brought the authors to surgical intervention) with mortality in the case of surgical intervention does not seem logical. I would say rather that the aim of a good technique of cyst puncture should be to avoid morbidity just as the progress in surgery should achieve an absence of mortality and equal the excellent results of the authors. However, this absence of mortality is no reason to limit an examination, which brings a sure answer. The puncture can be performed in the ambulatory patient with a minimum of cost and pain, whereas the intervention “without mortality” necessitates hospitalization, expense, and suffering. However, the real reasons for the tendency to surgical treatment of cysts seem to be doubts of making an error and to insecure feelings which we all have at the start - proper feelings for a surgeon who believes only in that which he sees when operating. With regard to the therapeutic value of cyst puncture with aspiration one can say that the evacuative puncture brings results in 50 per cent of cases and can be designated as curative in 25 per cent. The question seems to be, “Do cysts really necessitate treatment?’ As far as we are concerned the reply is negative. Except if it concerns cysts that are very voluminous and those with an intrasinusal development, which induces a pyelocalyceal stasis, the risks of possible evolutive complications jn a cyst do not weigh in favor of surgical treatment. Indeed, many are the cysts which do not reappear after a simple puncture and, contrary to numerous observations, take into account the development of other cysts in the same kidney in spite of the intervention. The frequency of cysts in the adult patient and the existence of cysts at the microscopic stage provide proof of this.* That the urologist should hold a central position during the diagnostic and surgical procedures seems to us also to be capital. We are partisan to the urologic surgeon proceeding to the puncture of cysts, after its indication and the proposed examinations have been discussed with the radiologist. This method must limit morbidity and render infections exceptional. Thus the central position in the strategy to be adopted remains in the hands of the urologist. Through the frequent practice of these techniques of cyst puncture, a certitude and a diagnostic tranquillity can be acquired and unfounded doubts *Baert L, and Steg A: On the pathogenesis of simple renal cysts in the adult: a microdissection study, Ural. Res. 5: 103 (1977).
543
disappear. Numerous wasteful interventions for an “illness,” which in the majority of cases does not require treatment, are thus avoided. Luc Baert, M.D. Loofstraat, 43 8500 Kortrijk, Belgium
USE OF LOWSLEY
TRACTORS
To the Editor: Those of us who still do perineal prostatectomies have encountered Lowsley prostatic tractors which have been used in the manner described by Dr. William J. Cromie and Dr. Michael H. Lake in their article, “The Lowsley Cystotomy,” in the January issue (vol. 11, page 78) of UROLOGY. We have found that these instruments have been damaged sometimes irreparably by their use as a not welcome grasping device. I would personally the widespread use of this instrument in this manner. Use of Lowsley tractors involves turning the screw device open and closed a certain number of turns. Grasping the Malecot catheter misaligns the sensitive opening-closing device of the instrument and facilitates injury by the wings (I prefer not to use the word jaws) of the tractor to the delicate urethra. “Evaluation of Closed Suprapubic The article, Cystotomy,” by William D. Flock, M.D., Austin S. Litvak, M.D., and J. William McRoberts, M.D., in the same issue (vol. 11, page 40) suggests a more rational use of the instrument if one does not have a Turner-Warwick staff or similar device. Gerald T. Keegan, M.D. Scott and White Clinic Temple, Texas 76501
UNEXPECTED
544
James A. Roberts, M.D. Tulane University Covington, Louisiana 70433
Reply from Dr. Shapiro To the Editor: I am grateful to Dr. James Roberts for pointing out a problem with our reference to his article, “The Unexpected Pheochromocytoma,” mentioned in our article on “Nonrenovascular Renal Hypertension in Children.” Our article states, “Goodman and Roberts reported a patient in whom the PRA was elevated and unilateral, chronic pyelonephritis was present. A pheochromocytoma was discovered only accidentally at surgery which nearly resulted in the death of the patient.” The last sentence should have read: “A pheochromocytoma, which was confirmed at surgery, could have resulted in the death of the patient had it not been diagnosed preoperatively. ” Stephen R. Shapiro,
M.D. University of California Sacramento, California 95817
PHEOCHROMOCYTOMA
the To the Editor: Although _ I ~enjoyed .__ reading review on “Nonrenovascular Renal Hypertension in Children” by Stephen R. Shapiro, M.D., R. D. Adelman, M.D., and H. Tesluk, M.D., in the December issue (vol. 10, page517)ofUROLOGY, I must comment on his reference to our* article, “The Unexpected PheoThey state on page 525 that, chromocytoma.” “Goodman and Roberts reported a patient in whom the PRA was elevated and unilateral chronic pyelonephritis was present.” They then state that, “A pheochromocytoma was discovered only accidentally at surgery, which nearly resulted in the death of the patient. ” This last sentence is grossly in error and is not stated in our article. *Goodman chromocytoma,
In our article we point out the danger of anesthesia and surgery in patients with pheochromocytoma. However, our patient, who we thought had hypertension from unilateral chronic pyelonephritis was evaluated completely for other causes of hypertension preoperatively and was found to have a pheochromocytoma on the same side as her chronic pyelonephritis. Her preoperative preparation with adrenergic blockade led to an uneventful operation. I do agree with Dr. Shapiro and his colleagues when they state in the last sentence of their article, “It is, therefore, necessary to screen all hypertensive children for pheochromocytoma prior to any major surgical procedure.” Our patient did not almost die because her pheochromocytoma was accidentally discovered, but found during careful preoperative evaluation.
JR, and Roberts JA: The Unexpected South. Med. J. 69: 374 (1976).
pheo-
CIRCLE
TUBE
URINARY
DIVERSION
To the Editor: In his article, “Loop Nephrostomy,” published in the December issue (vol. 10, page 582) of UROLOGY, Dr. Robert H. Hackler draws attention to the use of Silastic circle tubes for urinary diversion. We have previously described a similar procedure (nephronephrostomy) as a variant of the nephroureterostomy which can be used for either permanent or temporary urinary diversion. l-3 In addition to the conditions reported in these articles, I have been particularly pleased with its use when a temporary diversion was required in children while
UROLOGY
/
MAY 1978
/ VOLUME
XI, NUMBER
5