RENAL SYSTEM
INTERVENTIONA
L RADIOLOGY
COMMON DAILY PRACTICE
PROCEDURES
1. PERCUTANEOUS RENAL BIOPSY
2. PERCUTANEOUS NEPHROSTOMY
3. PLACEMENT OF DOUBLE J CATHETERS
4. CYSTOSTOMY
5. EMBOLIZATION OR EXCLUSION OF RENAL ARTERIES
6. TUMOR ABLATION
PERCUTANEOUS RENAL BIOPSY
• PERCUTANEOUS RENAL BIOPSY CONSISTS OF OBTAINING TISSUE FOR
PATHOLOGICAL OR CYTOLOGICAL ANALYSIS. IT CAN BE NON-LOCALIZED
WHEN EVALUATING A DIFFUSE PARENCHYMAL DISEASE,
• OR LOCALIZED WHEN THERE IS AN ISOLATED LESION FROM WHICH THE
SAMPLE IS OBTAINED.
PROCEDURE
• THE PERCUTANEOUS APPROACH WITH THE PATIENT IN PRONE POSITION (NATIVE
KIDNEY) OR SUPINE (TRANSPLANTED KIDNEY), USING AUTOMATIC OR SEMIAUTOMATIC
NEEDLES OF 16-18G, ALWAYS WITH A PATH AWAY FROM THE RENAL HILUM.
• NON-LOCALIZED BIOPSIES ARE TAKEN FROM THE RENAL CORTEX,
• LOCALIZED BIOPSIES SHOULD HAVE A PATHWAY THAT CONTAINS HEALTHY
PARENCHYMA BETWEEN THE CAPSULE AND THE LESION TO REDUCE THE RISK OF
HEMORRHAGE.
• AT LEAST 2 SAMPLES OF 1 CM IN LENGTH SHOULD BE OBTAINED THAT INCLUDE A
MINIMUM OF 5 GLOMERULI IF A GLOMERULAR LESION IS BEING EVALUATED, 6-10
GLOMERULI FOR TUBULOINTERSTITIAL INJURY AND 7 GLOMERULI IN
TRANSPLANTED KIDNEY.
INDICATIONS
1. UNEXPLAINED ACUTE OR PROGRESSIVE RENAL FAILURE
2. NEPHROTIC SYNDROME OR PROTEINURIA
3. PERSISTENT HEMATURIA
4. SYSTEMIC DISEASES WITH RENAL INVOLVEMENT (SUCH AS LUPUS OR
SCLERODERMA)
5. RENAL TRANSPLANT DYSFUNCTION
CONTRAINDICATIONS
1.COAGULOPATHY
2.ARTERIAL HYPERTENSION
Longitudinal section of ultrasound showing localized renal
biopsy of a mass in the upper pole of the left kidney
Axial ultrasound section showing perirenal hematoma
as a biopsy complication
COMPLICATIONS
1. HEMATOMAS
2. HEMATURIA (SELF LIMITED)
3. ARTERIOVENOUS FISTULA FORMATION OR
PSEUDOANEURYSM THAT USUALLY RESOLVES
SPONTANEOUSLY
4. INJURY TO OTHER ORGANS SUCH AS THE COLON OR LUNG.
2 - PERCUTANEOUS NEPHROSTOMY
Percutaneous nephrostomy is the placement of external drainage in
the renal collecting system.
PROCEDURE
• AS FOR THE RENAL BIOPSY, THE POSITION OF THE PATIENT MUST BE PRONE
(NATIVE KIDNEY) OR SUPINE (TRANSPLANTED KIDNEY), AND THE APPROACH
MUST BE MADE BY BRODEL'S AVASCULAR PLANE, WHICH IS ABOUT 20-30º
FROM THE PLANE SAGITTAL.
• ONCE THE DESIRED CALYX HAS BEEN IDENTIFIED (IDEALLY IN THE LOWER
POLE OF THE KIDNEY), THE PUNCTURE IS PERFORMED UNDER LOCAL
ANESTHESIA AND WITH SELDINGER TECHNIQUE THE CATHETER IS PLACED
WITHIN THE RENAL COLLECTING SYSTEM, IDEALLY IN THE PELVIS, POSITION
WHICH IS CONFIRMED BY PYELOGRAPHY
CONTRAINDICATIONS
1. THE ONLY CONTRAINDICATION, WHICH IS RELATIVE, IS COAGULOPATHY
Control pyelography after placement of left
nephrostomy, where adequate position and functioning
are confirmed.
3 - PLACEMENT OF DOUBLE J
CATHETERS
• THE PLACEMENT OF DOUBLE J CATHETERS FOLLOWS THE SAME STEPS FOR
THE PLACEMENT OF THE NEPHROSTOMY BUT THE GUIDE AND CATHETER ARE
ADVANCED TO THEIR FINAL POSITION: PROXIMAL WITHIN THE RENAL PELVIS
AND DISTALLY WITHIN THE BLADDER
Placement of bilateral double-J catheters
INDICATIONS
1. RENAL LITHIASIS
2. URETERAL FISTULA
3. URETERAL STENOSIS
4. URINOMA (URINE COLLECTION IN THE
PERIRENAL FAT )
5. RISK OF DISPLACEMENT OF A NEPHROSTOMY
CONTRAINDICATIONS
1. THE ONLY CONTRAINDICATION, WHICH IS RELATIVE, IS COAGULOPATHY
COMPLICATIONS
1. clogging or embedding of the catheter, its distal migration
2. ureteral rupture
4 - CYSTOSTOMY
• CYSTOSTOMY IS THE PLACEMENT OF A PERCUTANEOUS DRAINAGE CATHETER
INTO THE BLADDER ABOVE THE PUBIC SYMPHYSIS.
Suprapubic cystostomy
PROCEDURE
• THE PATIENT SHOULD BE IN A SUPINE POSITION, WITH A FULL
BLADDER (THIS CAN BE DONE THROUGH A BLADDER CATHETER
WITH NORMAL SALINE) AND THE IDEAL APPROACH IS MEDIAN
OR PARAMEDIAN IMMEDIATELY ABOVE THE PUBIC SYMPHYSIS.
• THE PUNCTURE CAN BE PERFORMED DIRECTLY WITH THE
CATHETER SET ON A TROCAR (TROCAR TECHNIQUE), OR WITH
AN EXCHANGE SYSTEM USING THE SELDINGER TECHNIQUE.
• ONCE THE PROCEDURE IS FINISHED, THE POSITION OF THE
CATHETER MUST BE CONFIRMED WITH THE INJECTION OF
CONTRAST MEDIUM.
INDICATIONS
1. BLADDER OUTLET OBSTRUCTION IN PATIENTS
WITH PROSTATIC DISEASE
2. URINARY INCONTINENCE
3. NEUROGENIC BLADDER
4. BLADDER FISTULA
5. URETHRAL TRAUMA
CONTRAINDICATIONS
1. THE ONLY CONTRAINDICATION IS
COAGULOPATHY.
COMPLICATION
S
1. DEVELOPMENT OF BLADDER
STONES
2. URINARY LEAKAGE
3. MIGRATION OF THE CATHETER
Imaging-guided Percutaneous Large-Bore Suprapubic
Cystostomy
5 - EMBOLIZATION OR EXCLUSION OF
RENAL ARTERIES
• EMBOLIZATION OR EXCLUSION OF RENAL ARTERIES CONSISTS OF THE
OCCLUSION OF RENAL BLOOD VESSELS, BOTH MAJOR AND MINOR CALIBER.
PROCEDURE
• THE MOST WIDELY USED ACCESS IS THE FEMORAL ARTERY, THROUGH WHICH
SELECTIVE OR SUPRASELECTIVE CATHETERIZATION OF THE RENAL ARTERY
OR ITS BRANCHES IS PERFORMED TO ADMINISTER DIFFERENT EMBOLIZING
AGENTS IN THE DESIRED LOCATION.
• AMONG THE MOST COMMON EMBOLIZING AGENTS ARE PARTICLES, COILS,
ETHANOL AND ONYX.
INDICATIONS
1. SEVERE RENAL TRAUMA
2. PSEUDO ANEURYSMS AND FISTULAS
3. ANGIOMYOLIPOMAS WHEN ACUTE BLEEDING OCCURS
4. COMPLETE RENAL OCCLUSION IN DYSFUNCTIONAL KIDNEYS WHEN
PATIENTS ARE NOT CANDIDATES FOR SURGERY
5. AND AS PRE-SURGICAL OR PALLIATIVE MANAGEMENT IN PATIENTS WITH
RENAL CELL CARCINOMA.
COMPLICATIONS
1. HEMATURIA
2. RUPTURE OF ANEURYSMS DURING THE PROCEDURE
3. ARTERIAL INJURY
4. POST EMBOLIZATION SYNDROME (FEVER, NAUSEA/VOMITING, AND PAIN.)
5. FORMATION OF BRUISES AND ABSCESSES
6 - TUMOR ABLATION
• TUMOR ABLATION CONSISTS IN THE DIRECT LOCAL PERCUTANEOUS
DESTRUCTION OF THE MALIGNANT TISSUE THROUGH THE APPLICATION OF
ENERGY (RADIOFREQUENCY, FREEZING, MICROWAVES) OR CHEMICAL
SUBSTANCES.
PROCEDURE
• RFA (RADIOFREQUENCY ABLATION) AND CA (CRYOABLATION) ARE TYPICALLY
PERFORMED UNDER SEDATION AND ANALGESIA. THE ABLATION PROBE IS
INSERTED PERCUTANEOUSLY INTO THE TARGET LESION UNDER
TOMOGRAPHIC GUIDANCE.
Radiofrequency thermal ablation of Renal tumors
INDICATIONS
1. PATIENTS WITH COMORBIDITIES WHO ARE NOT ELIGIBLE
FOR SURGERY BECAUSE OF THEIR POOR GENERAL
CONDITION.
2. THERMAL ABLATION TECHNIQUES ARE SUITABLE FOR
PATIENTS WITH GENETIC DISORDERS THAT INCREASE THE
LIKELIHOOD OF MULTIPLE BILATERAL RENAL TUMORS (VON
HIPPEL-LINDAU SYNDROME, TUBEROUS SCLEROSIS, BIRT-
HOGG-DUBÉ SYNDROME).
3. PATIENTS REFUSE TO CONSENT TO SURGERY.
COMPLICATIONS
1. POST-ABLATION SYNDROME (MYALGIA, FEVER, NAUSEA <48
H)
2. SELF-LIMITING HEMATURIA
3. SELF-LIMITING PERIRENAL HEMATOMA
4. TEMPORARY NERVE INJURY (INTERCOSTAL OR
GENITOFEMORAL)
5. URETRAL STENOSIS
6. URINARY RETENTION DUE TO OCCLUDING BLOOD CLOT
7. PNEUMOPERITONEUM
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