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Renal cystoscopy
RENAL CYSTOSCOPY* JAMES
A. ROBERTS,
M.D.
From the Section of Urology and Delta Regional Primate Research Center, Tulane Medical Center, New Orleans and Covington, Louisiana
ABSTRACT -Percutaneous endoscopy of renal cysts is described. presence of tumor within a cyst.
In 1975, 14,900 cases of renal carcinoma were reported in the United States.’ If the incidence of renal cysts is twenty times that of tumors, as suggested in a review by Plaine and Hinman2 almost 300,000 renal cysts could be found each year. Of the several techniques that have been developed to help differentiate between cyst and tumor, none is completely satisfactory. Nephrotomography, the first of these techniques, can detect the difference between if cyst and tumor; 3 but how do we determine show that the cyst is benign. 2 Two studies tumors occur in 0.2 to 2.9 per cent of renal cysts. 4,5 Using the lower figure, a tumor within a cyst could be found in 600 patients each year. ultrasound, is useful in Another technique, revealing the difference between solid and cystic masses. Its accuracy is still unknown, however, and it also does not rule out tumors within cysts. Many urologists prefer to study all renal masses with angiography in addition to, or instead of, nephrotomography. But, since it has been shown that 5 per cent of renal carcinomas will be avascular (by angiography),6 tumors might be missed in another 750 patients if only angiography were relied on. Such statistics have been used as an argument for exploring all renal masses surgically. Instead of surgery percutaneous needle puncture of *Supported by United States Public Health Service Grant 5ROl-AM-14681-06 and RR00164-14. Reported at nleeting of the Southeastern Section, Alnerican Urological Association, April, 1974.
UROLOGY
/
DECEMBER
1976
/
VOLUSIE
VIII,
NUMBER
Its purpose is to rule out the
avascular renal masses has been advanced to confirm the diagnosis of cyst and rule out tumor within.’ The criteria for diagnosis of benign renal cyst are fulfilled if the cyst fluid is clear, cytologic findings negative, and the renal cystogram is smooth walled and fills the area of the mass seen on nephrotomography or angiography. This report suggests another technique that will rule out tumor in those patients with bloody cyst fluid or an irregular wall. I refer to renal cystoscopy (Fig. 1). Methods We have used renal cystoscopy to evaulate 27 patients after cystic masses were found on nephrotomography and, in most cases, confirmed by angiography.
EXCRETORY
UROGRAM
NEPHROTOMOGRAM
CYST
PUNCTURE 1
FLUID
BLOODY
CYSTOGRAM
(30%
of
NOT SAME
RENAL
i
6
1.
ANGIOiRAM
these wtll be malignant) SIZE
AS MASS
CYSTOSCOPY
Scheme for when presumed diagnosis FIGURE
ULTRASOUND
evaluation of renal mass is renal cyst at each step.
537
can then be done; and if the cyst is normal, the procedure is terminated. If the cystogram is not normal or the fluid is bloody, the trocar is inserted into the cyst, removed, and replaced in the sleeve by the telescope. I inspected the interior of the cysts in all my patients by a combination of foreoblique and lateral telescopes to rule out tumor. Results
lrragulor
Smooth WOII cyst
wall cyst Endosco~
stop FIGURE
Of the 27 patients whose cysts could be punctured, tumor was not found. Most cysts showed a trabeculated wall (Fig. 3A), but some were smooth (Fig. 3B). The irregular wall was shown to be a multilocular cyst (Fig. 3C) or, in several cases, a blood clot (Fig. 3D). Without endoscopy these patients might well have required surgery to rule out tumors. One patient was operated on when papillary tissue was seen at the base. Biopsy showed only degenerated renal tubules. Three patients could not be punctured because of the anterior position of their cysts. At surgical exploration, the cyst in 1 patient was found to contain a tumor; the cysts in the other 2 were benign. The only complication involving these 27 cases occurred when 1 patient required a transfusion.
2.
Technique
Introduced
of renal cystoscopy.
For the first 14 patients, a sleeve and trocar, 2.2 mm. in diameter, was used.* The lens system gave a foreoblique view. It was possible to view the interior of the cyst because the cyst moved with the kidney during respiration while the lens was held fixed. Since then we have used the Fetascope, f a somewhat larger instrument (3.2 mm. diameter). This is a sleeve and trocar instrument designed for fetoscopy which will accept any 8 mm. pediatric cystocope telescope. I used both foreoblique and lateral telescopes which made possible an even better view of the cyst interior. With the patient prone, the mass is visualized by infusion pyelogram with fluoroscopy. Local infiltration anesthesia is used, and a stab wound is made in the skin with a 15 scalpel. The sleeve with cutting trocar is inserted into the cyst or to the border of the cyst, A 22-gauge 12-inch spinal needle may be inserted through the hollow trocar into the cyst (Fig. 2). Cystography *Needlescope, Dyonics, Inc., Woburn, Mass. t Fetascope, Richard Wolf Medical Instruments Rosemont, 111.
538
Corp.,
Comment Some texts state that all renal masses should be surgically explored. The argument for this is that a renal cyst is not normal and thus should be drained. But cases of renal damage from a renal cyst which does not obstruct the ureter or a calyx are rare. Hypertension or erythrocytosis caused by renal cyst adds further reason to operate on a renal cyst. These cases, however, should be documented by increased renal vein renin or increased erythropoietin levels. The possible presence of a tumor is still the principal reason for operating on a renal mass. However, if possible, the diagnosis should be proved before surgery to allow radical extirpation. Renal cystoscopy is proposed as a way to prove the presence of tumor within a cyst. This technique will more frequently show blood clot or multilocular cyst than tumor. Its morbidity in this series is similar to that of another study wherein renal cysts were punctured by a much smaller needle for renal cystography alone.* What are the complications when a renal tumor is punctured while investigating a renal
UROLOGY
/ DECEMBER
1976
/ VOLUME
VIII,
NUMBER
6
FIGURE 3. Endoscopic pictures of cyst interior: (A) trabeculated wall; (B) smooth wall; (C) multilocular cyst wall; and (D) blood clot within cyst.
mass? Lindholmg has punctured renal carcinomas for preoperative diagnosis without complication. Indeed, the von Schreeb et al. lo series of percutaneous biopsy of renal tumors showed no tumor implant in the puncture tract. They also did nephrectomies for tumors and found no difference in the five-year survival rate between patients who had preoperative percutaneous needle biopsy of tumors and those who were diagnosed by surgery alone. It has been suggested that the operative mortality of flank exploration is greater than per-
UROLOGY
/ DECEMBER
1976 / VOLUMEVIII,
NUMBER6
cutaneous renal cyst puncture. The mortality rate in this series of renal cystoscopy was zero and morbidity rate 3.6 per cent. Similarly, of zero and Zelch et al. s showed a mortality morbidity of 3.2 per cent from renal mass needle puncture. Their mortality for surgical exploration of renal masses was 11 per cent with a morbidity rate of 20 per cent. This is unusually high. Kropp et al. l1 studied surgery on renal cysts alone and had a much lower operative mortality of 1.6 per cent, but their morbidity rate remained high at 30 per cent. Review of the
539
other series of renal exploration by Plaine and Hinman2 and Scott and Selzman12 suggests that flank exploration alone is probably associated with an operative mortality of between 1 and 2 per cent. I do not wish to argue whether surgery should be done on all renal masses. The purpose of this report is to present another diagnostic tool for urologists to use in evaluating renal masses. It should extend to 100 per cent the accuracy rate of preoperative evaluation of a renal mass. Delta Regional Primate Research Center Three Rivers Road Covington, Louisiana 70433 References 1. SEIDMAN, H., SILVERBERG, E., and HOLLEB, A. I . . Cancer statistics, CA 26: 2 (1976). 2. PLAINE, L. I., and HJNMAN, F., JR.: Malignancy in asymptomatic renal masses, J. Urol. 94: 342 (1965). 3. EVANS, J. A.: Nephrotomography in the investigation of renal masses, Radiology 69: 684 (1957).
540
4. LEVINE, S. R., EMMETT, J. L., and WOOLNER, L. B.: Cyst and tumor occurring in the same kidney, J. Urol. 91: 8 (1964). 5. BRANNAN, W., MILLER, W., and CRISLER, M.: Coexistence of renal neoplasms and renal cysts, South. Med. J. 55: 749 (1962). 6. WATSON, R. C., FLEMING, R. J., and EVANS, J. . Arteriography in the diagnosis of renal car:norna Radiology 91: 888 (1968). 7. LALLI,‘A. F.: III. Argument for renal cyst aspiration, Urology 1: 523 (1973). 8. ZELCH, J., LALLI, A. F., STEWART, B. H., and DAUGHTRY,J. D.: Complications of renal cyst exploration versus renal mass aspiration, ibid. 7: 244 (1976). 9. LINDBLOM, K. : Diagnostic kidney puncture of cysts and tumors, Am. J. Roentgenol. 68: 209 (1952). 10. VON SCHREEB, T., ARNER, O., SKOVSTED, G., and WIKSTAD, N.: Renal adenocarcinoma. Is there a risk of spreading tumour cells in diagnostic puncture? Stand. J. Urol. Nephrol. 1: 270 (1967). 11. KROPP, K. A., GRAYHACK,J. T., MENDEL, R. M., and DAHL, D. S.: Morbidity and mortality of renal exploration for cyst, Surg. Gynecol. Obstet. 125: 803 (1967). 12. SCOTT, R. F., and SELZMAN, H. M.: Complication of nephrectomy; review of 456 patients and a description of a modification of the transperitoneal approach, J. Ural. 95: 307 (1966).
UROLOGY I DECEMBER 1976 / VOLUME VIII, NUMBER 6
A. ROBERTS,
M.D.
From the Section of Urology and Delta Regional Primate Research Center, Tulane Medical Center, New Orleans and Covington, Louisiana
ABSTRACT -Percutaneous endoscopy of renal cysts is described. presence of tumor within a cyst.
In 1975, 14,900 cases of renal carcinoma were reported in the United States.’ If the incidence of renal cysts is twenty times that of tumors, as suggested in a review by Plaine and Hinman2 almost 300,000 renal cysts could be found each year. Of the several techniques that have been developed to help differentiate between cyst and tumor, none is completely satisfactory. Nephrotomography, the first of these techniques, can detect the difference between if cyst and tumor; 3 but how do we determine show that the cyst is benign. 2 Two studies tumors occur in 0.2 to 2.9 per cent of renal cysts. 4,5 Using the lower figure, a tumor within a cyst could be found in 600 patients each year. ultrasound, is useful in Another technique, revealing the difference between solid and cystic masses. Its accuracy is still unknown, however, and it also does not rule out tumors within cysts. Many urologists prefer to study all renal masses with angiography in addition to, or instead of, nephrotomography. But, since it has been shown that 5 per cent of renal carcinomas will be avascular (by angiography),6 tumors might be missed in another 750 patients if only angiography were relied on. Such statistics have been used as an argument for exploring all renal masses surgically. Instead of surgery percutaneous needle puncture of *Supported by United States Public Health Service Grant 5ROl-AM-14681-06 and RR00164-14. Reported at nleeting of the Southeastern Section, Alnerican Urological Association, April, 1974.
UROLOGY
/
DECEMBER
1976
/
VOLUSIE
VIII,
NUMBER
Its purpose is to rule out the
avascular renal masses has been advanced to confirm the diagnosis of cyst and rule out tumor within.’ The criteria for diagnosis of benign renal cyst are fulfilled if the cyst fluid is clear, cytologic findings negative, and the renal cystogram is smooth walled and fills the area of the mass seen on nephrotomography or angiography. This report suggests another technique that will rule out tumor in those patients with bloody cyst fluid or an irregular wall. I refer to renal cystoscopy (Fig. 1). Methods We have used renal cystoscopy to evaulate 27 patients after cystic masses were found on nephrotomography and, in most cases, confirmed by angiography.
EXCRETORY
UROGRAM
NEPHROTOMOGRAM
CYST
PUNCTURE 1
FLUID
BLOODY
CYSTOGRAM
(30%
of
NOT SAME
RENAL
i
6
1.
ANGIOiRAM
these wtll be malignant) SIZE
AS MASS
CYSTOSCOPY
Scheme for when presumed diagnosis FIGURE
ULTRASOUND
evaluation of renal mass is renal cyst at each step.
537
can then be done; and if the cyst is normal, the procedure is terminated. If the cystogram is not normal or the fluid is bloody, the trocar is inserted into the cyst, removed, and replaced in the sleeve by the telescope. I inspected the interior of the cysts in all my patients by a combination of foreoblique and lateral telescopes to rule out tumor. Results
lrragulor
Smooth WOII cyst
wall cyst Endosco~
stop FIGURE
Of the 27 patients whose cysts could be punctured, tumor was not found. Most cysts showed a trabeculated wall (Fig. 3A), but some were smooth (Fig. 3B). The irregular wall was shown to be a multilocular cyst (Fig. 3C) or, in several cases, a blood clot (Fig. 3D). Without endoscopy these patients might well have required surgery to rule out tumors. One patient was operated on when papillary tissue was seen at the base. Biopsy showed only degenerated renal tubules. Three patients could not be punctured because of the anterior position of their cysts. At surgical exploration, the cyst in 1 patient was found to contain a tumor; the cysts in the other 2 were benign. The only complication involving these 27 cases occurred when 1 patient required a transfusion.
2.
Technique
Introduced
of renal cystoscopy.
For the first 14 patients, a sleeve and trocar, 2.2 mm. in diameter, was used.* The lens system gave a foreoblique view. It was possible to view the interior of the cyst because the cyst moved with the kidney during respiration while the lens was held fixed. Since then we have used the Fetascope, f a somewhat larger instrument (3.2 mm. diameter). This is a sleeve and trocar instrument designed for fetoscopy which will accept any 8 mm. pediatric cystocope telescope. I used both foreoblique and lateral telescopes which made possible an even better view of the cyst interior. With the patient prone, the mass is visualized by infusion pyelogram with fluoroscopy. Local infiltration anesthesia is used, and a stab wound is made in the skin with a 15 scalpel. The sleeve with cutting trocar is inserted into the cyst or to the border of the cyst, A 22-gauge 12-inch spinal needle may be inserted through the hollow trocar into the cyst (Fig. 2). Cystography *Needlescope, Dyonics, Inc., Woburn, Mass. t Fetascope, Richard Wolf Medical Instruments Rosemont, 111.
538
Corp.,
Comment Some texts state that all renal masses should be surgically explored. The argument for this is that a renal cyst is not normal and thus should be drained. But cases of renal damage from a renal cyst which does not obstruct the ureter or a calyx are rare. Hypertension or erythrocytosis caused by renal cyst adds further reason to operate on a renal cyst. These cases, however, should be documented by increased renal vein renin or increased erythropoietin levels. The possible presence of a tumor is still the principal reason for operating on a renal mass. However, if possible, the diagnosis should be proved before surgery to allow radical extirpation. Renal cystoscopy is proposed as a way to prove the presence of tumor within a cyst. This technique will more frequently show blood clot or multilocular cyst than tumor. Its morbidity in this series is similar to that of another study wherein renal cysts were punctured by a much smaller needle for renal cystography alone.* What are the complications when a renal tumor is punctured while investigating a renal
UROLOGY
/ DECEMBER
1976
/ VOLUME
VIII,
NUMBER
6
FIGURE 3. Endoscopic pictures of cyst interior: (A) trabeculated wall; (B) smooth wall; (C) multilocular cyst wall; and (D) blood clot within cyst.
mass? Lindholmg has punctured renal carcinomas for preoperative diagnosis without complication. Indeed, the von Schreeb et al. lo series of percutaneous biopsy of renal tumors showed no tumor implant in the puncture tract. They also did nephrectomies for tumors and found no difference in the five-year survival rate between patients who had preoperative percutaneous needle biopsy of tumors and those who were diagnosed by surgery alone. It has been suggested that the operative mortality of flank exploration is greater than per-
UROLOGY
/ DECEMBER
1976 / VOLUMEVIII,
NUMBER6
cutaneous renal cyst puncture. The mortality rate in this series of renal cystoscopy was zero and morbidity rate 3.6 per cent. Similarly, of zero and Zelch et al. s showed a mortality morbidity of 3.2 per cent from renal mass needle puncture. Their mortality for surgical exploration of renal masses was 11 per cent with a morbidity rate of 20 per cent. This is unusually high. Kropp et al. l1 studied surgery on renal cysts alone and had a much lower operative mortality of 1.6 per cent, but their morbidity rate remained high at 30 per cent. Review of the
539
other series of renal exploration by Plaine and Hinman2 and Scott and Selzman12 suggests that flank exploration alone is probably associated with an operative mortality of between 1 and 2 per cent. I do not wish to argue whether surgery should be done on all renal masses. The purpose of this report is to present another diagnostic tool for urologists to use in evaluating renal masses. It should extend to 100 per cent the accuracy rate of preoperative evaluation of a renal mass. Delta Regional Primate Research Center Three Rivers Road Covington, Louisiana 70433 References 1. SEIDMAN, H., SILVERBERG, E., and HOLLEB, A. I . . Cancer statistics, CA 26: 2 (1976). 2. PLAINE, L. I., and HJNMAN, F., JR.: Malignancy in asymptomatic renal masses, J. Urol. 94: 342 (1965). 3. EVANS, J. A.: Nephrotomography in the investigation of renal masses, Radiology 69: 684 (1957).
540
4. LEVINE, S. R., EMMETT, J. L., and WOOLNER, L. B.: Cyst and tumor occurring in the same kidney, J. Urol. 91: 8 (1964). 5. BRANNAN, W., MILLER, W., and CRISLER, M.: Coexistence of renal neoplasms and renal cysts, South. Med. J. 55: 749 (1962). 6. WATSON, R. C., FLEMING, R. J., and EVANS, J. . Arteriography in the diagnosis of renal car:norna Radiology 91: 888 (1968). 7. LALLI,‘A. F.: III. Argument for renal cyst aspiration, Urology 1: 523 (1973). 8. ZELCH, J., LALLI, A. F., STEWART, B. H., and DAUGHTRY,J. D.: Complications of renal cyst exploration versus renal mass aspiration, ibid. 7: 244 (1976). 9. LINDBLOM, K. : Diagnostic kidney puncture of cysts and tumors, Am. J. Roentgenol. 68: 209 (1952). 10. VON SCHREEB, T., ARNER, O., SKOVSTED, G., and WIKSTAD, N.: Renal adenocarcinoma. Is there a risk of spreading tumour cells in diagnostic puncture? Stand. J. Urol. Nephrol. 1: 270 (1967). 11. KROPP, K. A., GRAYHACK,J. T., MENDEL, R. M., and DAHL, D. S.: Morbidity and mortality of renal exploration for cyst, Surg. Gynecol. Obstet. 125: 803 (1967). 12. SCOTT, R. F., and SELZMAN, H. M.: Complication of nephrectomy; review of 456 patients and a description of a modification of the transperitoneal approach, J. Ural. 95: 307 (1966).
UROLOGY I DECEMBER 1976 / VOLUME VIII, NUMBER 6