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Renal Pelvic Explosion During Conservative Management of Upper Tract Urothelial Cancer
0022-5347/91/1462-0407$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1991 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 146, 407-408, August 1991 Printed in U.S.A.
RENAL PELVIC EXPLOSION DURING CONSERVATIVE MANAGEMENT OF UPPER TRACT UROTHELIAL CANCER PAULE. ANDREWS AND JOSEPH W. SEGURA* From the Department of Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT
Ureteroscopic fulguration of a renal pelvic papillary transitional cell carcinoma is a relatively new and limited procedure. We present a case of intrarenal explosion during ureteroscopic fulguration. KEY WORDS: kidney; carcinoma, transitional cell; kidney pelvis; endoscopy
Explosions during transurethral surgery of the bladder are familiar to all resectionists. They can be recognized by the occasional popping sounds they make. Intravesical explosions have been mentioned only briefly in the literature and to our knowledge no mention has been made of explosions during ureteroscopic fulguration.1 Ureteroscopy has been proved to be useful in the diagnosis and management of various urological diseases. Conservative management of upper tract urothelial tumors is a controversial issue. We present a case of intrarenal explosion during conservative treatment of an upper tract urothelial tumor.
months postoperatively. The patient currently is asymptomatic and without evidence of recurrence. DISCUSSION
Endoscopy of the ureter and renal pelvis has an increased role in the diagnosis and management of many upper tract urological problems.2 A previous report from this institution described ureteropyeloscopy in 43 patients with upper tract urothelial tumors.3 The rate of major complications in that
CASE REPORT
A 72-year-old woman presented with microscopic hematuria and positive urinary cytological results. Cystoscopy and bilat eral retrograde studies revealed a papillary bladder tumor, a right lower pole filling defect and a questionable irregularity of the left lower pole calix. Biopsy followed by fulguration of the bladder tumor revealed grade 2 superficial papillary cancer. Right ureteroscopy 2 weeks later revealed a papillary tumor in the lower pole calix. The 9.8F flexible ureteroscope was used with saline as irrigation fluid (fig. 1). In view of the contralateral lower pole irregularity, we elected to fulgurate the papillary tumor. Before fulguration the irrigation fluid was changed to water. Fulguration was performed with a standard 3F bipolar Bugbee electrode at a blend current set at 60 watts. At the end of the fulguration procedure a popping sound was heard and the field of view became bloody. Fluoroscopy showed extrava sation from the right renal pelvis (fig. 2, A). A 7F external ureteral catheter was placed in the right renal pelvis and tied to a Foley catheter. The patient was managed conservatively for 15 days with a ureteral stent until retrograde pyelography showed no evidence of extravasation (fig. 2, B). Results of excretory urography (IVP), cystoscopy and urinary cytological study were normal 2 months postoperatively. How ever, at followup 3 months later, urinary cytological study was positive and a recurrent filling defect of the right lower pole calix was detected (fig. 3). Attempted ureteroscopy was unsuc cessful because of a stricture in the proximal ureter. Left retrograde pyelography was normal. Through a right transcos tal incision right nephroureterectomy, including Gerota's fas cia, was performed. There was no gross evidence of peritoneal metastasis. Pathological examination revealed noninvasive grade 3 papillary transitional cell carcinoma in the lower pole calix, the area previously treated by fulguration (fig. 4). There was no evidence of tumor cells in the perirenal fat. Convales cence was uneventful and the patient was dismissed from the hospital on postoperative day 9. An IVP, cystoscopy, urinary cytology and routine blood tests were normal at 8 and 18 Accepted for publication January 24, 1991. *Requests for reprints: Department of Urology, Mayo Clinic, 200 First St., S. W., Rochester, Minnesota 55905. 407
FIG. 1. Flexible 9.8F ureteroscope in place
FIG. 2. A, extravasation secondary to intrarenal explosion. B, no evidence of extravasation on postoperative day 15.
408
ANDREWS AND SEGURA
FIG. 4. Grade 3 papillary transitional cell carcinoma in lower pole calix (arrow).
generation of hydrogen and other gases during electrosurgery. These studies have shown that the hydrogen generated is from electrolysis of intracellular water and is not explosive without the presence of atmospheric air. The oxygen content of the gases liberated by electrolysis of intracellular water is insuffi cient to support combustion. The composition of the gases liberated during electrosurgery is not changed when distilled water, glycine or sorbitol is used as the irrigation fluid. 1• In addition, the composition of gas is unchanged irrespective of the tissue being fulgurated. Because hydrogen is not explosive without the presence of oxygen, it is important to prevent the introduction of air into the irrigating system. If air does enter the irrigating system, fulguration should cease to prevent ex plosion and the subsequent extravasation of malignant uro thelial cells. 6
FIG. 3. Recurrent right lower pole calix filling defect (arrow)
series was 7% and these complications did not seem to influence subsequent outcome unfavorably. A total of 21 patients in the series underwent conservative endourological management of upper tract tumors and none experienced a major urological complication. Our case details a major complication secondary to an explo sion that occurred during fulguration of a renal pelvic urothelial tumor. The explosion did not occur until the fulguration was completed, a fact that may have minimized the amount of retroperitoneal seeding of malignant cells. The significance of retroperitoneal spillage of malignant cells to local recurrence is worrisome. In a report from this institution intraoperative pyeloscopy was performed before nephroureterectomy in 18 patients. 4 Disease recurred locally in the region of the renal fossa in 2 patients (11%). In contrast, McCarron et al performed open pyelotomy in 33 patients with upper tract lesions and there was no evidence of local recurrence. 5 We report explo sion and extravasation during ureteroscopic management of an upper tract urothelial tumor. Previous reports have described
REFERENCES
1. Ning, T. C., Jr., Atkins, D. M. and Murphy, R. C.: Bladder explo sions during transurethral surgery. J. Urol., 114: 536, 1975.2. Blute, M. L., Segura, J. W. andPatterson, D. E.: Ureteroscopy. J. Urol., 139: 510, 1988. 3. Blute, M. L., Segura, J. W., Patterson, D. E., Benson, R. C., Jr. and Zincke, H.: Impact of endourology on diagnosis and man agement of upper urinary tract urothelial cancer. J. Urol., 141: 1298, 1989. 4. Tomera, K. M., Leary, F. J. and Zincke, H.:Pyeloscopy in urothelial tumors. J. Urol., 127: 1088, 1982. 5. McCarron, J.P., Mills, C. and Vaughan, E. D., Jr.: Tumors of the renal pelvis and ureter: current concepts and management. Sem. Urol., 1: 75, 1983. 6. Hansen, R. I. and Iversen, P.: Bladder explosion during uninter rupted transurethral resection of the prostate. A case report and an experimental model. Scand. J. Urol. Nephrol., 13: 211, 1979.
Vol. 146, 407-408, August 1991 Printed in U.S.A.
RENAL PELVIC EXPLOSION DURING CONSERVATIVE MANAGEMENT OF UPPER TRACT UROTHELIAL CANCER PAULE. ANDREWS AND JOSEPH W. SEGURA* From the Department of Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT
Ureteroscopic fulguration of a renal pelvic papillary transitional cell carcinoma is a relatively new and limited procedure. We present a case of intrarenal explosion during ureteroscopic fulguration. KEY WORDS: kidney; carcinoma, transitional cell; kidney pelvis; endoscopy
Explosions during transurethral surgery of the bladder are familiar to all resectionists. They can be recognized by the occasional popping sounds they make. Intravesical explosions have been mentioned only briefly in the literature and to our knowledge no mention has been made of explosions during ureteroscopic fulguration.1 Ureteroscopy has been proved to be useful in the diagnosis and management of various urological diseases. Conservative management of upper tract urothelial tumors is a controversial issue. We present a case of intrarenal explosion during conservative treatment of an upper tract urothelial tumor.
months postoperatively. The patient currently is asymptomatic and without evidence of recurrence. DISCUSSION
Endoscopy of the ureter and renal pelvis has an increased role in the diagnosis and management of many upper tract urological problems.2 A previous report from this institution described ureteropyeloscopy in 43 patients with upper tract urothelial tumors.3 The rate of major complications in that
CASE REPORT
A 72-year-old woman presented with microscopic hematuria and positive urinary cytological results. Cystoscopy and bilat eral retrograde studies revealed a papillary bladder tumor, a right lower pole filling defect and a questionable irregularity of the left lower pole calix. Biopsy followed by fulguration of the bladder tumor revealed grade 2 superficial papillary cancer. Right ureteroscopy 2 weeks later revealed a papillary tumor in the lower pole calix. The 9.8F flexible ureteroscope was used with saline as irrigation fluid (fig. 1). In view of the contralateral lower pole irregularity, we elected to fulgurate the papillary tumor. Before fulguration the irrigation fluid was changed to water. Fulguration was performed with a standard 3F bipolar Bugbee electrode at a blend current set at 60 watts. At the end of the fulguration procedure a popping sound was heard and the field of view became bloody. Fluoroscopy showed extrava sation from the right renal pelvis (fig. 2, A). A 7F external ureteral catheter was placed in the right renal pelvis and tied to a Foley catheter. The patient was managed conservatively for 15 days with a ureteral stent until retrograde pyelography showed no evidence of extravasation (fig. 2, B). Results of excretory urography (IVP), cystoscopy and urinary cytological study were normal 2 months postoperatively. How ever, at followup 3 months later, urinary cytological study was positive and a recurrent filling defect of the right lower pole calix was detected (fig. 3). Attempted ureteroscopy was unsuc cessful because of a stricture in the proximal ureter. Left retrograde pyelography was normal. Through a right transcos tal incision right nephroureterectomy, including Gerota's fas cia, was performed. There was no gross evidence of peritoneal metastasis. Pathological examination revealed noninvasive grade 3 papillary transitional cell carcinoma in the lower pole calix, the area previously treated by fulguration (fig. 4). There was no evidence of tumor cells in the perirenal fat. Convales cence was uneventful and the patient was dismissed from the hospital on postoperative day 9. An IVP, cystoscopy, urinary cytology and routine blood tests were normal at 8 and 18 Accepted for publication January 24, 1991. *Requests for reprints: Department of Urology, Mayo Clinic, 200 First St., S. W., Rochester, Minnesota 55905. 407
FIG. 1. Flexible 9.8F ureteroscope in place
FIG. 2. A, extravasation secondary to intrarenal explosion. B, no evidence of extravasation on postoperative day 15.
408
ANDREWS AND SEGURA
FIG. 4. Grade 3 papillary transitional cell carcinoma in lower pole calix (arrow).
generation of hydrogen and other gases during electrosurgery. These studies have shown that the hydrogen generated is from electrolysis of intracellular water and is not explosive without the presence of atmospheric air. The oxygen content of the gases liberated by electrolysis of intracellular water is insuffi cient to support combustion. The composition of the gases liberated during electrosurgery is not changed when distilled water, glycine or sorbitol is used as the irrigation fluid. 1• In addition, the composition of gas is unchanged irrespective of the tissue being fulgurated. Because hydrogen is not explosive without the presence of oxygen, it is important to prevent the introduction of air into the irrigating system. If air does enter the irrigating system, fulguration should cease to prevent ex plosion and the subsequent extravasation of malignant uro thelial cells. 6
FIG. 3. Recurrent right lower pole calix filling defect (arrow)
series was 7% and these complications did not seem to influence subsequent outcome unfavorably. A total of 21 patients in the series underwent conservative endourological management of upper tract tumors and none experienced a major urological complication. Our case details a major complication secondary to an explo sion that occurred during fulguration of a renal pelvic urothelial tumor. The explosion did not occur until the fulguration was completed, a fact that may have minimized the amount of retroperitoneal seeding of malignant cells. The significance of retroperitoneal spillage of malignant cells to local recurrence is worrisome. In a report from this institution intraoperative pyeloscopy was performed before nephroureterectomy in 18 patients. 4 Disease recurred locally in the region of the renal fossa in 2 patients (11%). In contrast, McCarron et al performed open pyelotomy in 33 patients with upper tract lesions and there was no evidence of local recurrence. 5 We report explo sion and extravasation during ureteroscopic management of an upper tract urothelial tumor. Previous reports have described
REFERENCES
1. Ning, T. C., Jr., Atkins, D. M. and Murphy, R. C.: Bladder explo sions during transurethral surgery. J. Urol., 114: 536, 1975.2. Blute, M. L., Segura, J. W. andPatterson, D. E.: Ureteroscopy. J. Urol., 139: 510, 1988. 3. Blute, M. L., Segura, J. W., Patterson, D. E., Benson, R. C., Jr. and Zincke, H.: Impact of endourology on diagnosis and man agement of upper urinary tract urothelial cancer. J. Urol., 141: 1298, 1989. 4. Tomera, K. M., Leary, F. J. and Zincke, H.:Pyeloscopy in urothelial tumors. J. Urol., 127: 1088, 1982. 5. McCarron, J.P., Mills, C. and Vaughan, E. D., Jr.: Tumors of the renal pelvis and ureter: current concepts and management. Sem. Urol., 1: 75, 1983. 6. Hansen, R. I. and Iversen, P.: Bladder explosion during uninter rupted transurethral resection of the prostate. A case report and an experimental model. Scand. J. Urol. Nephrol., 13: 211, 1979.