Ethanolamine sclerotherapy of a renal cyst

Comparison of polidocanol sclerotherapy with laparoscopic deroofing in the management of pediatric symptomatic simple renal cysts: A long-term study

OBJECTIVE

To compare the efficacy and safety of percutaneous polidocanol sclerotherapy and laparoscopic deroofing in the management of pediatric symptomatic simple renal cysts.

METHODS

Forty-six patients with symptomatic simple renal cysts (cyst size ≥ 4 cm) were treated either with polidocanol sclerotherapy (group A) or by laparoscopic deroofing (group B) between December 2009 and October 2019. The patients were re-evaluated at 1, 6, and 12 months and annually thereafter.

RESULTS

Twenty-one patients were treated with polidocanol sclerotherapy (group A) and 25 patients with laparoscopic deroofing (group B). The mean follow-up period was 58.7 months (14-107) in group A and 57.2 months (12-118) in group B. Complete regression was seen in 19 (90.5%) and 24 (96%) patients in groups A and B, respectively (p<0.05). Partial regression was documented in one patient each in group A (4.8%) and B (4%). In one group A patient, a laparoscopic deroofing was performed due to sclerotherapy failure after 27 months. The operation time, postoperative hospital stay, and cost were significantly less in group A than in group B (36.3±8.4 vs. 96.9±19.1, 19.7±2.4 vs. 56.0±8.6, and ¥8173±1343 vs. ¥14119±2021, respectively; p < 0.05).

CONCLUSION

Polidocanol sclerotherapy and laparoscopic deroofing were found to be equally effective interventions associated with minimal complications for pediatric symptomatic simple renal cysts. We recommend polidocanol sclerotherapy as the first option for children with symptomatic simple renal cysts and laparoscopic deroofing in cases of failed polidocanol sclerotherapy.

A Complication of Percutaneous Sclerotherapy for Congenital Pulmonary Airway Malformation: Intravascular Injection and Cardiac Necrosis

INTRODUCTION

A congenital pulmonary airway malformation (CPAM) type III may become large enough to cause hydrops fetalis. In such circumstances, the fetus can be treated with open fetal resection, maternal betamethasone administration, or percutaneous sclerotherapy.

CASE REPORT

A 24 week gestation fetus with a CPAM type III was treated by percutaneous sclerotherapy using ethanolamine oleate (EO). The EO inadvertently entered the left atrium and ventricle with subsequent fetal bradycardia and demise. Autopsy revealed myocardial necrosis.

CONCLUSION

Percutaneous sclerotherapy has been previously described in the literature for the treatment of microcystic CPAMs with secondary hydrops. This is the first reported case of an adverse event after fetal sclerotherapy.

The efficacy of retroperitoneal laparoscopic deroofing of simple renal cyst with perirenal fat tissue wadding technique: A retrospective study

Treatment options for simple renal cyst (SRC) include open surgery, laparoscopy with decortication, or percutaneous aspiration with or without sclerotherapy. Though laparoscopic unroofing achieves better results than percutaneous sclerotherapy, the reported recurrence rate is still up to 19%. Thus, it is necessary to find methods to reduce the recurrence rate.To investigate whether the perirenal pedicled fat tissue wadding technique during retroperitoneal laproscopic deroofing (RLD) of SRC affects the incidence of recurrence.A retrospective analysis was carried out on clinical data of 254 patients with SRC treated by RLD in our hospital from 2008 to 2016. Among these patients,119 had a simple retroperitoneal deroofing (SRD) and 135 received a retroperitoneoscopic deroofing with wadding of the cyst using perirenal fat tissue (RDCW). The recurrence rate and variables, as well as perioperative complications, were compared. To further explore the potential variables influencing cyst recurrence rate, univariate and multivariate regression analyses were applied.A total of 251 patients were included in the analysis. The operation was successfully completed laparoscopically in all cases with no conversion to open surgery. No mortality or significant complication occurred in both groups. After a median follow-up of 38.67 months, we noted 41 recurrences. According to the univariate and multivariate regression analyses, patients managed with the wadding technique had superior recurrence-free survival (RFS), compared with patients in SRD group (log-rank P = .03 and P = .04, respectively). Moreover, patients with single renal cyst had a lower recurrence rate, compared with patients with multiple renal cysts (log-rank P < .01). Regarding the operation time, blood loss, and hospital stay, no statistically significant difference was found between 2 groups (P values .13, .30, and .75, respectively). However, less postoperative drainage and shorter postoperative interval until tube removal (P = .04) were observed in RDCW group.The perirenal pedicled fat tissue wadding technique can decrease the cyst recurrence rate and RCDW represents an effective and safe treatment option in the management of renal cysts.

Comparison of acetic acid and ethanol sclerotherapy for simple renal cysts: clinical experience with 86 patients

Background

To compare the efficacy and treatment session numbers of acetic acid to that of ethanol sclerotherapy for the treatment of simple renal cysts. Between February 2004 and June 2013, 86 patients with simple renal cysts underwent percutaneous aspiration and injection of 50 %-acetic-acid (42 cysts) and 95 %-ethanol (44 cysts). The patient demographics, volume reduction rate, number of treatment sessions, and complications were then analyzed.

Results

The volume reduction rate was 94.1 ± 7.6 % in the 50 %-acetic acid group and 94.7 ± 11.7 % in the 95 %-ethanol group, and without a statistical difference. The rates of complete remission, partial remission, and no response were 57.1, 42.9 and 0 %, respectively, for the acetic acid group, and 70.5, 25.0, and 4.5 %, respectively, for the ethanol group. No statistical difference was observed between the two groups. Compared to the acetic acid group, the ethanol group had a higher number of treatment sessions, i.e. 1.10 ± 0.30 in the acetic acid group and 1.80 ± 0.79 in the ethanol group. Mild flank pain was a minor complication that occurred in both groups.

Conclusions

Acetic acid seems to have equivalent sclerosing effects on simple renal cysts compared with those of ethanol despites of fewer treatment sessions.

Evaluation of ethanolamine oleate sclerotherapy on the submandibular glands of canines as a potential therapy for sialorrhea

BACKGROUND

Sialorrhea can have major negative effects on the physical and social well-being. Sclerotherapy may be useful in patients with sialorrhea by decreasing the amount of saliva production. The aim of this study was to test the effect of ethanolamine oleate (EO) in an experimental model as a preliminary step for its application in humans.

METHODS

Histopathological and morphometric analysis of submandibular glands from thirteen dogs was preformed. A total of 25 glands were injected with 1ml of 2.5% EO (n=5), 1ml of 5% EO (n=5), 5ml of 2.5% EO (n=5) and 5ml of 5% EO (n=5). Five glands were used as control.

RESULTS

EO significantly induced a dose dependent scaring of the gland ending in lobular transformation (salivary gland cirrhosis). Morphometric measurements showed that 1ml of 2.5% or 5% EO significantly induced fibrosis compared to normal glands (p=0.014 and 0.021, respectively). Fibrosis significantly increased and was more apparent when a dose of 5ml of 2.5% EO or 5% EO were injected [by semi-quantitative evaluation (p=0.016 and 0.002, respectively) and morphometric measurements (p=0.016 and 0.008, respectively)]. This scarring effect was significantly associated with reduction of area of acinar cells when a dose of 1ml-5%, 5ml-2.5% or 5ml-5% EO were applied (p=0.03. 0.012 and 0.004, respectively). Moreover, ductal injury was only significant when a dose of 5ml of 5% EO was used (p=0.034). This dose and concentration (i.e. 5ml-5% EO) had a significant synergetic effect [p=0.0119].

CONCLUSION

In this model, treatment with EO proved to permanently reduce the acinar area through induction of progressive, irreversible and dose dependant scarring (medical sialoadenectomy).

Treatment of congenital pulmonary airway malformation induced hydrops fetalis via percutaneous sclerotherapy

Large type II and III congenital pulmonary airway malformations (CPAMs) can cause pulmonary hypoplasia, non-immune hydrops fetalis and fetal demise. Fetal intervention is indicated if hydrops fetalis develops. In this report, we describe three cases of type II and III CPAMs complicated by hydrops and treated with percutaneous sclerotherapy by ethanolamine injection into the tumor. All 3 cases demonstrated reduction in size of the CPAM and resolution of the hydrops with subsequent delivery at term. We believe that fetal percutaneous sclerotherapy can be used as a minimally invasive palliative strategy to treat CPAM-induced hydrops fetalis. Further studies are needed to delineate the risks of this novel technique.

Treatment of venous malformations with ethanolamine oleate: a descriptive study of 83 cases

PURPOSE

To evaluate the outcome and complications of sclerotherapy with injection ethanolamine oleate for the treatment of venous malformations (VMs).

METHODS

Eighty-three patients' (39 males and 44 females) age ranging from 3 months to 21 years with 85 lesions were followed clinically for about 1 year following treatment with injection of ethanolamine oleate. The cases were enrolled between January 2006 and December 2009. The amount of ethanolamine oleate per treatment session ranged from 0.50 to 10 ml, and maximum dose was 0.40 ml per kg body weight. All patients were evaluated after 8 weeks of last injection session. All of the treatment sessions were performed on a day-case basis.

RESULTS

Eighty-five lesions have under gone 201 sclerotherapy sessions with 39 requiring one, 27 requiring two and 19 lesions requiring more than two sessions. Sclerotherapy with ethanolamine oleate provided complete resolution of symptoms in 79 lesions and significant improvement of 6 lesions. There is no recurrence of studied patients. All patients experienced pain and swelling to a variable degree for short duration. Skin sloughed out in four patients which were healed spontaneously. No other complications were observed in our study.

CONCLUSION

The treatment of VMs with injection ethanolamine oleate is safe and effective.

Clinical experience of single-session percutaneous aspiration and OK-432 sclerotherapy for treatment of simple renal cysts: 1-year follow-up

PURPOSE

To evaluate the efficacy and safety of single-session OK-432 sclerotherapy for the treatment of renal cysts.

MATERIALS AND METHODS

From October 2005 to November 2006, 48 patients (61 simple renal cysts) were included in the study. Indications were determined as flank discomfort (n = 37) or patient reassurance due to increasing size (n = 11). The simple renal cysts were aspirated under ultrasonography (US), at which point OK-432 was injected into the cyst. Follow-up was performed with US or computed tomography scan every 3 months until 1 year. Complete regression of the renal cyst or more than 70% reduction in size with no symptoms indicated a successful treatment.

RESULTS

Among 61 renal cysts of 48 patients, the overall success rate was 98.4%. Complete regression occurred in 46 cysts (75.4%), and more than 90% reduction in size occurred in 6 cysts (9.8%). A size reduction of 80% to 90% and 70% to 80% occurred in five (8.2%) and three cysts (4.9%), respectively. A size reduction less than 70% occurred in only one cyst (1.6%). The success of cyst regression was correlated with cyst volume. Clinical symptoms resolved in 100% of patients with symptomatic cysts, and there was no enlargement of the aspirated cysts at the 1-year follow-up. After the procedure, there were only some minor complications, such as mild fever, flank pain, and leukocytosis, which subsided with the conservative treatment.

CONCLUSIONS

Percutaneous OK-432 sclerotherapy is simple, safe, and effective, and it can be an alternative first-line therapy for simple renal cysts.

Percutaneous injection sclerotherapy with tetracycline hydrochloride in simple renal cysts

OBJECTIVES

Symptomatic simple renal cysts can be treated by combination of percutaneous aspiration and sclerotherapy. A number of sclerosing agents including glucose, phenol, iophendylate, polidocanol, minocycline and pantopaque have been used in the past to prevent reformation of cyst. In this study, tetracycline HCL solution is evaluated as a sclerosant for treatment of simple renal cysts.

METHODS

Our study treated 76 cysts in 70 patients with symptomatic renal cysts. Aspiration and sclerotherapy was performed on 56 cysts, and 20 cysts aspirated without sclerotherapy as a control group. Treatment was performed under local anesthesia and punctured under ultrasound guidances with an 18-gauge needle. Tetracycline HCL (20%) was injected into the cystic cavity according to cyst diameter. All patients were followed up with an ultrasound examination at 3 months, 6 months, and then at yearly intervals. The reduction rate was estimated by a comparison of the volume of the cyst before and after treatment. A cyst reduction of 50% or greater in diamater was considered as a successful treatment.

RESULTS

The average follow-up period was 9.8 months in the sclerotherapy group and 9.9 months in the control group. The success rate was 85.7% in the sclerotherapy group. There was a significant difference in the reduction rate of tetracycline HCL sclerotherapy group and control group. No major complications were encountered.

Comparison of ethanol and sodium tetradecyl sulfate in the sclerotherapy of renal cyst

BACKGROUND AND PURPOSE

Renal cysts are common in the adult population. Symptomatic cysts traditionally have been treated by percutaneous aspiration with injection of sclerosant agents. Our aim was to compare the efficacy and side effects of ethanol and sodium tetradecyl sulfate (STDS) as sclerosants for symptomatic simple renal cyst.

PATIENTS AND METHODS

Sixty-five patients with 68 symptomatic simple renal cysts were included in this study. An 8F pigtail catheter was inserted into the cyst under ultrasound guidance followed by aspiration of the cyst fluid. Either 95% ethanol (N = 34) or 3% STDS (N = 34), assigned randomly, was then instilled into the empty sac. Patients recorded any flank pain on a visual analog scale and were followed up by ultrasonography for 6 to 18 months.

RESULTS

There was complete ablation of 28 (82%) and 26 (76%) cysts, partial regression of 3 (9%) and 6 (18%) cysts, and failure of treatment in 3 (9%) and 2 (6%) cysts in the ethanol and STDS groups, respectively. There was no major complication in either group. The pain caused by the injection was significantly less for the group receiving STDS (pain score 2.1 +/- 1.1 v 3.8 +/- 1.2 for ethanol; P = 0.019).

CONCLUSIONS

Ethanol and STDS are simple, noninvasive, cost-effective, and well-tolerated sclerosants for the treatment of simple renal cysts. We prefer STDS as a first choice because it causes less pain.

Percutaneous treatment of renal cysts with OK-432 sclerosis

PURPOSE

The aim of this study was to demonstrate OK- 432 sclerotherapy efficacy for treatment of simple renal cysts.

MATERIALS AND METHODS

Twenty patients with 25 symptomatic or large simple cysts were treated by ultrasonography (US)-guided percutaneous aspiration and injection of OK-432 (8 men and 12 women, mean age 63.6 years, SD 9.5). Six patients presented with flank pain, 14 presented with renal mass; renal cyst location was right, left, or bilateral sided in 9, 8, and 8 kidneys, respectively. Patients were evaluated by clinical assessment, US, or CT scan 3 months following the procedure. Complete and partial success was defined as symptom resolution with either total cyst ablation or greater than 70% reduction, respectively. Failure was defined as 30% of cyst size recurrence and/or persistent symptoms.

RESULTS

Average reduction was 93.0%. Complete and partial resolution occurred in 11 (44.0%) and 13 (52.0%) cysts, respectively. One case was defined as failure, with a 64.2% size reduction from 10.9cm to 3.9cm (volume reduction rate 95.4%). Renal pain improved in all patients, regardless of complete or partial resolution. Minor complications occurred in 3 patients, 2 developed leukocytosis and 1 had mild fever (< 38.5 degrees C) following aspiration and sclerotherapy. Successful treatment was achieved with conservative measures and NSAID therapy.

CONCLUSION

Percutaneous treatment of simple renal cysts with OK-432 sclerotherapy was found to be a safe, effective and minimally invasive procedure.

Povidone-iodine sclerotherapy is ineffective in the treatment of symptomatic renal cysts

PURPOSE

To evaluate the efficacy of povidone-iodine sclerotherapy after percutaneous drainage of simple renal cysts in the treatment of symptomatic patients.

PATIENTS AND METHODS

Sixteen patients with symptomatic renal cysts were treated by percutaneous drainage and injection of povidone-iodine solution. The cysts were drained by a nephrostomy tube catheter, and povidone- iodine injections were repeated every 24 hours for 3 days. All patients were followed up by ultrasound examination during a period ranging from 1 to 4 years (mean 1.8 years).

RESULTS

Thirteen patients experienced recurrence of cysts, while complete resolution was observed in only three patients. Of the cysts that recurred, only partial resolution in cyst diameter was observed (from 3-10.5 cm to 2.4-8.6 cm). During the follow-up period, 12 of the 16 patients (75%) continued to have pain that necessitated additional treatments.

CONCLUSION

Povidone-iodine sclerotherapy is followed by a high rate of recurrence and is therefore not indicated for the treatment of symptomatic simple renal cysts.

Long-term results of single-session percutaneous drainage and ethanol sclerotherapy in simple renal cysts

PURPOSE

To demonstrate the efficacy and long-term results of the single-session ethanol sclerotherapy in simple renal cysts.

MATERIALS AND METHODS

Ninety-eight cysts in 97 patients (range: 18-76 years; mean age, 54 years) were included in the study. Indications were determined as flank pain in 74, hydronephrosis in 12, hypertension in 8, patient reassurance due to increasing cyst size in three patients. Mean follow-up period was 24.4 months. Procedures were performed with the guidance of fluoroscopy and ultrasonography at all times using 5-7 Fr pigtail catheters. After the cystogram that was obtained in all cases, 95% ethanol with a volume of 30-40% of the cyst volume was used as a sclerosing agent on an outpatient basis. Maximum volume of the injected ethanol was 200 ml. Follow-up examinations were performed 1, 3, 6 and 12 months after the procedure and once every year thereafter.

RESULTS

Average cyst volume reduction was 93% at the end of the first year. The cysts disappeared completely in 17 (17.5%) patients. After the procedure, in 67 (90%) patients improvement in flank pain was noted. Sixty-one (82%) patients were free of pain and in 6 (8%) of them the pain decreased. Normotension was obtained in 7 (87.5%) of the 8 hypertensive patients and no hydronephrosis was detected in 10 (83.3%) of the 12 patients after the procedure. Second intervention was required in 2 (2%) patients due to recurrence of cysts and related symptoms. One (1%) patient had small retroperitoneal hematoma that resolved spontaneously and in another (1%) patient spontaneous hemorrhage was detected into the cyst 1 year after the procedure. No other complication was detected during the procedure and follow-up.

CONCLUSION

Percutaneous treatment of simple renal cysts with single-session sclerotherapy is a safe, effective and minimally invasive procedure and can be used as an alternative to multiple-session sclerotherapy with comparable results. High volume, up to 200 ml ethanol can be used without adverse effects for large renal cysts.

Treatment of Simple Renal Cysts with Single-Session Percutaneous Ethanol Sclerotherapy without Drainage of the Sclerosing Agent

PURPOSE

To evaluate percutaneous single-session sclerotherapy with ethanol without drainage of the sclerosing agent in symptomatic simple renal cysts that require treatment.

PATIENTS AND METHODS

A prospective series of 30 consecutive patients with symptomatic simple renal cysts with volume of 280.3 +/- 365.23 mL (range 28-1700 mL) estimated by ultrasonography were treated between July 1999 and July 2003. The cysts were punctured with an 18-gauge, 20-cm needle under ultrasound guidance and local anesthesia. A volume of ethanol equivalent to one third of the aspirated volume, up to a maximum of 100 mL, was injected into the cyst and left there. The patients were reassessed at 1, 3, and 6 months.

RESULTS

The procedure was technically feasible in all patients. The aspirated volume was 259.8 +/- 265.2 mL (range 30-1900 mL). After 1, 3, and 6 months, the average volume was 52.7 +/- 71.4 mL, 22.7 +/- 43.2 mL, and 11.6 +/- 30.7 mL, respectively. After this period, 28 patients (93%) were asymptomatic, showing total remission of the cyst (17 cases) or at least a 90% decrease (10 cases) or a 50% decrease (1 case) in the initial volume. One patient (3%) had a 50% reduction of the cyst and persistent symptoms, and one patient (3%) had persisting symptoms despite the total remission of the cyst.

CONCLUSION

Single-session percutaneous sclerotherapy with ethanol is a good option for the treatment of symptomatic renal cysts, as it is highly effective and offers the benefits of a less-invasive procedure.

Percutaneous sclerotherapy of renal cysts with a beta-emitting radionuclide, holmium-166-chitosan complex

OBJECTIVE

To evaluate the usefulness of a beta-emitting radionuclide (holmium-166-chitosan complex) as a sclerosing agent for the treatment of renal cysts.

MATERIALS AND METHODS

Using 10-30 mCi of holmium-166-chitosan complex, 20 renal cysts in 17 patients (14 male and 3 female patients, ranging in age from 47 to 82 years) were treated by percutaneous sclerotherapy under ultrasonographic guidance. The volume of the cysts before and after the sclerotherapy and the percentage change in volume were calculated in order to evaluate the response to therapy, which was classified as either complete regression (invisible), nearly complete regression (< 15 volume% of initial volume), partial regression (15-50 volume%) or no regression (> 50 volume%).

RESULTS

The follow-up period ranged from 6 to 36 months (mean 28 months). Eighteen cysts (90%) regressed completely (n=11, 55%) or near-completely (n=7, 35%). Partial regression was obtained in one patient (5%) and there was no regression in one patient (5%). No significant complications were encountered.

CONCLUSION

The holmium-166-chitosan complex seems to be useful as a new painless sclerosing agent for the treatment of renal cysts with no significant complications.

Ablation of symptomatic cysts using absolute ethanol in 11 patients with autosomal-dominant polycystic kidney disease

Objective

To evaluate the effects of cyst ablation with absolute ethanol in autosomal-dominant polycystic kidney disease (ADPKD) patients with symptomatic cysts.

Materials and Methods

Using absolute ethanol, cyst ablation was performed in 11 patients with documented ADPKD who suffered cyst pain refractory to medical treatment. An ethanol solution was instilled into the largest symptomatic cysts through a catheter. We assessed the therapeutic efficacy of the procedure by tracking subjective pain relief during a 3 to 24-month follow-up period after ablation.

Results

At follow-up, we found that the duration of subjective pain relief was 12 to 24 months in seven patients, 4 to11 months in one, and less than 3 months in three.

Conclusion

Selective ablation of a symptomatic cyst may be a valid option in managing chronic pain caused by one or a few large cysts in ADPKD patients.

Renal cysts: can percutaneous ethanol injections be considered an alternative to surgery?

AIM

To evaluate the efficacy of a new sclerotization technique with pure ethanol in the treatment of symptomatic renal cysts.

PATIENTS AND METHODS

Fourteen patients having renal cysts with a meant diameter of 10 (range 5-15) cm were treated. Our technique includes: ultrasound-guided percutaneous puncture with an 18-gauge needle, positioning of a 5-Fr catheter, complete cyst fluid aspiration, injection of pure alcohol equal to 15% of the initial cyst volume, and alcohol aspiration after 90 min. The procedure was repeated eight times within 5 days. The patients were followed up by ultrasound and/or CT scan for 1 year.

RESULTS

All patients became symptom free. Follow-up showed a progressive reduction of the cyst diameter in all cases. Three cysts only (in 2 patients; cyst diameter <2 cm) persisted after 12 months. No significant complications were observed.

CONCLUSIONS

In our experience, injections of pure ethanol in renal cysts, repeated after some days, were effective in eliminating recurrences and related symptoms. The procedure was not associated with significant complications. Our findings suggest that it be considered the first-choice procedure in the treatment of renal cysts, due to the good results and the low cost of ethanol.

A comparison of aspiration and sclerotherapy with laparoscopic de-roofing in the management of symptomatic simple renal cysts

OBJECTIVES

To present the results of a minimally invasive treatment of symptomatic simple renal cysts, and to propose an algorithm for their management.

PATIENTS AND METHODS

Seventeen patients presenting with suspected symptomatic simple renal cysts were referred for trial aspiration; 16 presented with loin pain and one with a flank mass. If the cyst and symptoms recurred after a temporary response, they were managed by re-aspiration with sclerotherapy using 95% ethanol, or by laparoscopic de-roofing of the cyst.

RESULTS

Of the 17 patients referred, one failed to respond to aspiration and was excluded from further analysis. Three patients had sustained pain relief from simple aspiration alone, 13 required further treatment for symptom relapse, of whom six had aspiration and sclerotherapy, and seven had laparoscopic de-roofing. After a mean follow-up of 17 months, pain had recurred in all five patients originally presenting with pain and managed by sclerotherapy, and the patient who presented with a painless mass from a large cyst also developed pain after sclerotherapy. In contrast, the subsequent seven patients managed by laparoscopic treatment are pain-free at a mean follow-up of 17.7 months.

CONCLUSION

Evaluation including a diagnostic aspiration is essential to diagnose a symptomatic cyst. When treatment is indicated, laparoscopic de-roofing appears to be more effective than sclerotherapy.

Renal cyst ablation with n-butyl cyanoacrylate and iodized oil in symptomatic patients with autosomal dominant polycystic kidney disease: preliminary report

Fifty renal cysts in 14 patients with autosomal dominant polycystic kidney disease (ADPKD) were treated with percutaneous needle aspiration and intracystic injection of a mixture of n-butyl cyanoacrylate and iodized oil in a ratio of 1:2. At follow-up of 1-12 months, symptoms improved in 12 (86%) of 14 patients, and 25 (81%) of 31 cysts decreased more than 50% in diameter. This procedure appears to be feasible and may be an effective modality in ablation of renal cysts in patients with ADPKD.

Percutaneous sclerotherapy of a giant benign renal cyst with alcohol

We report a case of giant, benign renal cyst that was treated with percutaneous aspiration and sclerotherapy using 95% alcohol. A seven French catheter was inserted into the cyst under ultrasonographic and fluoroscopic guidance, and was then left in place to drain the cyst contents. Approximately 4 l of fluid was drained the first day. The following day, a gravity sinogram was obtained, which showed there were no connections between the cyst and the collecting system. The alcohol treatment involved repeated injections of decreasing amounts of alcohol, with volumes selected in accordance with follow-up sinograms. The patient's symptoms resolved and cyst drainage stopped after 3 successive days of therapy. Totally 600 ml alcohol has given. Follow-up ultrasound (US) and computed tomography (CT) studies showed no recurrent disease; with only a small remnant of the cyst wall. We encountered no major complications during follow-up.

Dacryocystosclerotherapy

PURPOSE

To introduce a less invasive therapeutic method in selected patients with primary nasolacrimal duct obstruction.

METHODS

Noncomparative interventional case series. Seven patients with primary acquired nasolacrimal duct obstruction who were poor candidates for dacryocystorhinostomy because of underlying medical conditions and two symptomatic patients with previous incomplete dacryocystectomy were included. Ethanolamine oleate 5% was slowly injected through the puncta into the patent portion of the lacrimal drainage apparatus.

RESULTS

After a mean follow-up period of 26 months, the lacrimal pathway was permanently obliterated in 6 cases (66.7%). In two cases, the procedure was repeated successfully and in one case, the patient refused to repeat the procedure after the initial failure.

CONCLUSIONS

In selected patients, ethanolamine oleate dacryocystosclerotherapy appears to offer a simple, low-cost, less invasive alternative to dacryocystectomy.

Percutaneous treatment of large symptomatic renal cysts

PURPOSE

To evaluate the efficacy of alcohol in combination with tetracycline for the treatment of symptomatic renal cysts.

PATIENTS AND METHODS

Twenty-four patients age 45 to 77 years (mean 66 years) with a large (5-13-cm; mean 7.5-cm) symptomatic renal cyst associated with flank pain were treated by aspiration under ultrasound guidance and injection of alcohol and tetracycline. Patients were followed with ultrasonography at 1, 6, and 12 months and once a year thereafter.

RESULTS

The aspirated volume ranged from 65 to 1500 mL (mean 360.5 mL). Two patients experienced mild pain during alcohol injection, but the procedure was completed successfully. One patient reported severe pain after tetracycline injection. The tetracycline was immediately aspirated, and the procedure was then aborted. The remaining patients were relieved of their symptoms after treatment, and they remained symptom free during a mean follow-up of 20 months (range 7-36 months).

CONCLUSIONS

The combination of alcohol and tetracycline is safe and effective and offers a very favorable minimally invasive therapeutic alternative for the treatment of symptomatic renal cysts.

Permanent implantation of 125I sources in the prostate: radical limits of simplicity

PURPOSE

To determine the effect of reducing the number of sources per implantation on the dose coverage of the prostate volume.

MATERIALS AND METHODS

Idealized source distributions were planned for four, eight, 16, 24, 32, and 48 sources. The peripheral loading technique was used to plan a uniform, conformal dose distribution to the target volume, which was the prostate volume as visualized at ultrasonography. Source-placement error was estimated by using measured error magnitudes and was expressed with systematic and random components. The relative sensitivities of the plans to the source-placement error were studied.

RESULTS

Idealized planned target coverage can be adequately achieved with comparable dose distributions with eight or more sources. The sensitivity to source-placement error is comparable for plans with 16 or more sources.

CONCLUSION

It is theoretically possible to radically simplify implantation without compromising target coverage or error tolerance.

Preliminary results of percutaneous treatment of renal cysts with povidone-iodine sclerosis

Symptomatic renal cysts can be treated with percutaneous sclerosis using ordinary povidone-iodine solution. We describe our methods and outcomes in 5 patients so treated.

Laparoscopic renal cryotherapy in swine: comparison of puncture cryotherapy preceded by arterial embolization and contact cryotherapy

Variable results of open, percutaneous, and laparoscopic cryosurgery of the kidney have been reported. Minimally invasive approaches to lower-pole renal ablation were prospectively compared in swine: laparoscopic puncture cryoablation preceded by arterial embolization, laparoscopic contact cryosurgery, and arterial embolization alone. Eighteen kidneys in nine domestic pigs were randomized to one of three treatment groups of six organs each: (1) puncture cryotherapy preceded by selective lower-pole arterial embolization; (2) contact cryotherapy alone; and (3) arterial embolization alone. Under general anesthesia, appropriate animals underwent selective arterial embolization of the lower pole via femoral cutdown using Gelfoam pledgets. Animals randomized to cryotherapy underwent dissection of the lower pole of the kidney using a single 12-mm umbilical and two midclavicular-line ports in the lateral position. Under external ultrasound guidance, two 3-mm cryoprobes (Cryomedical Sciences, Rockville, MD) were positioned in the lower pole of the kidney, and double-freeze technique to -190 degrees C was performed using puncture or contact application. Ultrasonography was used to guide probe insertion during puncture cryotherapy only. Kidneys were harvested 11 to 14 days after the procedure. Both puncture and contact kidneys demonstrated cell death and subsequent necrosis by light microscopy and electron micrography. On average, puncture lesions were heavier than contact lesions, 19.3 g v 10.1 g (P = 0.02; unpaired t-test), whereas the kidneys were equivalent in weight: 74.1 g v 74.1 g. Puncture lesions represented 26.4% of total kidney weight v 13.5% in the contact group (P = 0.002; unpaired t-test). Only focal infarcts were identified in the embolization group. No evidence of adjacent visceral injury was identified in any of the groups, and no animal required conversion to open laparotomy. One kidney bled after contact cryotherapy, and hemostasis was achieved laparoscopically. Laparoscopic cryotherapy is reproducible and effective using either the puncture technique preceded by arterial embolization or the contact technique, without evidence of damage to adjacent structures. Contact lesions were less voluminous and more peripheral than puncture lesions. Embolization alone produces focal infarcts and focal zones of cell death.

Percutaneous sclerotherapy of hydronephrosis in a non-functioning kidney

A 27-year-old woman was admitted with an abdominal mass in the right hypochondrium. Ultrasound, intravenous urography and scintigraphy revealed a giant non-functioning hydronephrosis. Because she refused surgery, a percutaneous aspiration with instillation of doxycycline was performed. One year thereafter, the patient was still without recurrence of any symptoms or hydronephrosis.

The history of interstitial brachytherapy of prostatic cancer

The history of interstitial brachytherapy of the prostate began in 1917 when Barringer inserted radium needles transperineally into the prostate, guided by a finger in the rectum. In 1952, Flocks et al. injected radioactive gold solution in prostatic cancer during open operation. In 1972, Whitmore et al. described retropubic Iodine-125 seed implantation through an open operation with pelvic lymph node dissection. The basis for ultrasound (US)-guided seed implantation was established in the late 1960s by Kratochwil's description of the first puncture transducer for one-dimensional US-guidance and Watanabe's pioneer work in prostatic screening. Our group performed the first punctures guided by static two-dimensional ultrasonic scanning (1969) and by dynamic ultrasound scanning (1974). During the 1970s, US-guided biopsies of almost all abdominal organs were performed and, in 1981, we introduced US-guided seed implantation of abdominal tumors and developed a technique for precise needle placement in the prostate guided by transrectal ultrasound. This was followed in 1983 by a technique for seed implantation guided by transrectal (transverse) ultrasonic scanning. That same year, Fornage described prostatic biopsy guided by transrectal longitudinal scanning. In 1990, we developed the seed implantation technique further by combining transverse and longitudinal scannings. In the late 1980s, Ragde from Seattle transferred the technique to the U.S., and since then, Ragde, Blasko, and others have treated numerous patients, refined the technique, taught many courses, and published extensively. They have obtained very promising prostate-specific antigen (PSA)-based results which compare favorably with radical prostatectomy and external beam radiation in the treatment of prostatic cancer.

Interstitial implantation techniques in prostate cancer

Brachytherapy is a radiotherapeutic technique that allows the physician to implant radioactive isotopes into a body cavity or directly into tissue. Different radioisotopes have unique characteristics that the brachytherapist may utilize for a particular situation. The use of brachytherapy is part of standard radiation oncology practice in gynecological and head and neck cancer management. The prostate is approachable for interstitial implantation due to its close proximity to the perineum. Over 20 years ago, primitive methods of brachytherapy were utilized in the treatment of prostate cancer. However, poor results due to inconsistency in achieving adequate coverage of the entire prostate and poor patient selection caused this treatment modality to fall out of favor. Technological advances over the last decade have restored attention to brachytherapy for prostate cancer. Particularly important has been the development of transrectal ultrasound, new radioisotopes such as palladium-103, computer tomography, computerized dosimetry systems, and earlier diagnosis. Modern interstitial implantation utilizing transperineal template and transrectal ultrasound guidance has resulted in improved consistency in radiation dose delivery to the entire prostate. Early results are encouraging in terms of the relatively low morbidity of the procedure, improved local control rates, and biochemical progression free survival. This has resulted in an outpatient treatment that has high patient acceptance.

Radiotherapy for localized prostate carcinoma. The correlation of pretreatment prostate specific antigen and nadir prostate specific antigen with outcome as assessed by systematic biopsy and serum prostate specific antigen

BACKGROUND

The objective of this study was to correlate the failure pattern of localized prostate carcinoma after radiotherapy (RT) with pretreatment (preTx) PSA and post-RT nadir PSA, using systematic biopsies and serum PSA in the assessment of outcome.

METHODS

From January 1990 to February 1994, 207 patients treated with external beam RT were followed prospectively with systematic transrectal ultrasound-guided biopsies and measurements of serum PSA levels. Three hundred forty-three biopsies were performed, with 4-7 samples taken per session. The distribution of T classification was as follows: 19 patients had T1b, 15 had T1c, 34 had T2a, 79 had T2b/c, 53 had T3, and 7 had T4. Median follow-up was 36 months (range, 12-70 months). Failures were categorized as biochemical (chemF) (PSA > 2.0 ng/mL and > 1 ng/ mL over nadir), local (LF) (positive biopsy and PSA > 2), and distant (DF). The Cox proportional hazards model was used for multivariate analysis (MVA).

RESULTS

Overall, failures were seen in 68 of 207 patients: 20 LF, 24 DF, 7 LF + DF, and 17 chemF. In univariate analysis, failures correlated significantly with preTx PSA, post-RT nadir PSA, T classification, and Gleason's score (GS). The total failure rate was 12% for T1b, T1c, and T2a; 39% for T2b and T2c; and 60% for T3 and T4 (P < 0.0001). By evaluation with preTx PSA, at 36 months the total failure rate was 3% for preTx PSA < or = 5 ng/mL 16% for 5.1-10 ng/mL, 32% for 10.1-15 ng/mL, 42% for 15.1-20 ng/mL, 63% for 20.1-50 ng/mL, and 88% for > 50 ng/mL (P < 0.0001). By evaluation with post-RT nadir PSA, at 36 months the total failure rate was 4% for nadir PSA < or = 0.5 ng/ mL, 26% for 0.6-1 ng/mL, 33% for 1.1-2 ng/mL, and 92% for > 2 ng/mL (P < 0.0001). In MVA, nadir PSA (P < 0.0001) and T classification (P < 0.0005) were independent predictors for any failure. LF occurred in 13% of patients (27 of 207). For these 27 patients, the categorization of T classification was: T1b/T1c/T2a, 7%; T2b/T2c, 16%; and T3/T4, 15% (P = not significant). In MVA, only nadir PSA (P = 0.0004) predicted for LF. DF occurred in 15% of patients (31 of 207). In MVA, nadir PSA (P < 0.0001) and T classification (P < 0.0001) predicted for DF, with pretreatment PSA of borderline significance (P < 0.05). To assess preTx predictors of outcome, post-RT nadir PSA was removed from the model. PreTx PSA then became the dominant variable to predict any failure (P < 0.0001), LF (P = 0.05), chemF (P = 0.0001), and DF (P < 0.003), while T classification also predicted for any failure (P = 0.03), chemF (P = 0.05), and DF (P < 0.0001).

CONCLUSIONS

Systematic prostate biopsies, performed as part of the rigorous followup of prostate carcinoma after RT, define the patterns of failure and confirm the prognostic value of preTx PSA, post-RT nadir PSA, and T classification. Prior to treatment, preTx PSA is the overwhelming independent predictor of failure, but it is surpassed by post-RT nadir PSA when this is added to the model.

Role of laparoscopy in the diagnosis and treatment of prostate cancer

Laparoscopic surgical techniques were originally applied to the staging of prostate cancer in the form of laparoscopic pelvic lymph node dissection. The efficiency of laparoscopic pelvic lymph node dissection has proven to be comparable to open lymphadenectomy in tissue yield and also shows a considerable decrease in postoperative morbidity. Subsequently, laparoscopy has been used as an adjuvant to perineal prostatectomy for preliminary dissection of the seminal vesicles. Laparoscopic radical prostatectomy has been performed but the long-term efficacy of this treatment is unknown at this point. Future clinical applications of laparoscopic surgical techniques in the diagnosis and treatment of prostate cancer include harvesting of primary and metastatic prostatic tissue for adjuvant gene therapies for prostate cancer.