Iatrogenic ureteric stricture post image guided renal cryoablation in a patient with von hippel-lindau syndrome

Abstract

A 53-year-old lady is known to have Von Hippel-Lindau syndrome with a long history of previous renal cell carcinomas (RCCs) in both kidneys. She was treated by partial nephrectomy for a right peripheral RCC and subsequently image guided radiofrequency ablation (RFA) of a left central RCC. She developed another de novo RCC adjacent to the right pelvic-ureteric junction (PUJ) 4 years after the initial RFA. Due to the close proximity to the PUJ and visibility of an ice ball with cryoablation (CRYO), the consensus from the MDT was that CRYO would be safer than RFA and she subsequently underwent percutaneous image guided CRYO to treat the small de novo RCC. Unfortunately, during the 1-month imaging follow up, she developed moderate hydronephrosis and a ureteric stricture needing long-term ureteric stent management. This case highlights the risk of ureteric injury caused by the thermal effect of the ice ball during image guided renal CRYO. Therefore, it is vital that all interventional radiologists adopt various manoeuvres to protect the ureter from the ice ball during CRYO in order to avoid the development of latent ureteric stricture.

Memokath for treating ureteric stricture post cryoablation of renal mass: A case report of rare complication and proposed alternative management

“…Ablation of small renal masses is associated with complications like; hemorrhage, vascular injury, and urothelial injury resulting in urine leak or stricture [6] . The stricture due to thermal injury is higher in radiofrequency ablation than in cryoablation, in which the stricture formation is very rare with one case report in literature [ 3 , 4 , 7 ]. The cause of ureteric stricture is the involvement of the upper ureter with the cryoablation created during the freezing-thawing cycles of cryoablation [8] .…”

“…A search of the PubMed database was undertaken on 01/08/2022 with the search terms ((((ureteral) OR (ureteric)) AND (stricture)) OR (Narrowing)) AND (cryoablation) Filters applied: in the last 10 years, Humans, English . The search yielded 24 results of which only one paper was identified as report of iatrogenic ureteric stricture post image guided renal cryoablation [4] .…”

“…Studies showed that cryoablation has a better complication profile when compared to RFA. The Iatrogenic development of upper ureteric stricture and pelvicalyceal system injury is up to 25% in RFA compared to cryoablation, as only one case iatrogenic stricture post cryoablation reported in literature [ 3 , 4 ]. The definitive treatment of iatrogenic upper ureteric stricture is ureteral reconstructive, but the challenge is when the reconstructive surgery cannot be done, which necessitates drainage by a regularly changed ureteral stent or nephrostomy tube insertion, both of which can result in significant effects on quality of life.…”