CASE REPORTS 337

ethanol used were half of that recommended bv Colonic Infarction Following Ethanol Embolisation of the Kidney

P. D. SUTHERLAND, P. R. HOWARD and V. R. MARSHALL. Department of Urology, Flinders Medical Centre, Bedford Park, Australia

Case Report A 78-year-old male with a T4 transitional cell carcinoma of the bladder which had not responded to palliative radiotherapy presented with severe right loin pain. An intravenous urogram demonstrated obstruction of the right ureter at the vesicoureteric junction by the tumour mass. Regular intramuscular narcotic failed to alleviate the pain and after a week, nephrectomy was considered in order to relieve the pain. However, in view of the ad- vanced nature of the malignancy it was thought that embolisation of the kidney would afford less morbidity with the same result.

Ethanol was chosen as the embolising agent. Selective catheterisation of the right renal artery was performed in the supine position, using a Cobra 2 catheter which was positioned at least 2 cm into the artery. The hydroneph- rotic right kidney was fed by a single artery and had a normal arterial tree. Contrast demonstrated good posi- tion of the catheter and no reffux on injection at the planned embolisation speed; 15 ml of ethanol were injected at a rate of 1 ml/s under constant screening to avoid unseen catheter dislodgement. Excellent infarction was obtained.

Within a few hours the patient developed a fever, ab- dominal distension and a tender mass in the left iliac fossa. At laparotomy the left colon from mid-transverse to rectum was infarcted despite an intact and pulsatile in- ferior mesenteric artery. Proctocolectomy was performed and an end colostomy created. The patient’s right loin pain, the indication for infarction, settled satisfactorily. .

Comment Since the initial successful reports of the use of eth- anol, Cox et al. (1982) have reported two cases of concomitant colonic infarction identical to that observed in this patient. We feel that ethanol, which presumably refluxed into the aorta, failed to mix because of laminar aortic blood flow and passed undiluted into the first anterior blood ves- sel, the inferior mesenteric artery.

All of the previous reports of ethanol infarction have been in normal laboratory animal kidneys or hypovascular tumours. Our patient had a tense obstructed kidney and perhaps reduced renal blood flow could have increased the probability of etha- nol escape, but the speed of injection and volume of

Ellman er al. (198 l), who claimed that a major a i - vantage of the ethanol technique was a low risk of accidental embolisation. Clearly this is incorrect if our case, plus those reported by Cox er al. (1982) and Mulligan and Espinosa (1 983), are considered.

The technique needs further evaluation with re- gard to speed of injection, total dose and the type of catheter used. A balloon catheter to occlude the renal artery to avoid the escape of ethanol during injection could be considered.

It would seem that unless the reflux of ethanol can be prevented easily, the possibility of colonic infarction must counteract any benefit the tech- nique has over other established methods of renal infarction.

References Cox, G . G., Lee, K. R., Price, H. I., Gunter, K., Noble, M. J. and

Mebust, W. K. (1982). Colonic infarction following ethanol embolization of renal--cell carcinoma. Radiology, 145, 343- 346.

Ellman, B. A., Parkbill, B. J., Curry, T. S., Marcus, P. B. and Peters, P. C. (1981). Ablation of renal tumors with absolute ethanol: a new technique. Radiology, 141,619-626.

Mulligan, B. D. and Espinosa, G. A. (1983). Bowel infarction. Complication of ethanol ablation of a renal tumour. Cardio- vascular and Interventional Radiology, 6,55-51.

Requests for reprints to: V. R. Marshall, Department of Urol- ogy, Flinders Medical Centre, Bedford Park, Australia 5042.

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Left Hydronephrosis due to Retroperitoneal Barytoma

E. PRQCA, Department of Urology. Fundeni Hospital, Bucharest, Romania

Case Report A 54-year-old male was admitted with left flank pain. Two months previously, rectosigmoidoscopy and bar- ium enema had been performed and this was followed by excruciating abdominal pain due to subperitoneal rectal perforation and extravasation of the barium into the retroperitoneal space. The abdomen was opened and a left lateral sigmoid colostomy was performed. An at- tempt to drain the extravasated barium through a retro- anal incision and blunt dissection of the presacral space failed and was followed by a perineal fistula and purulent discharge.

On admission to this department, proctoscopy revealed low rectal perforation and a presacral cavity

338 BRITISH JOURNAL OF UROLOGY

Fig. 1 Pre-operative IVU of patient with retroperitoneal bary- toma.

with irregular fibrotic walls. Biopsy for tumour remained negative. Colonic fibroscopy through the stoma was also negative. On plain abdominal film the retroperitoneal space and a great part of the retroperitoneqm, mainly on the left side, were densely opaque because of the extrava- sated barium (Fig. 1). IVU showed moderate left ureterohydronephrosis. Computed I tomography con- firmed retroperitoneal barium extravasation and dila- tation of the left urinary tract (Fig. 2A).

Surgical exploration was undertaken to relieve the renal pain and ureteric compression. The retroperitoneal space was entered through a left Fey's abdominal inci-

sion. The barytoma presented as a whitish fibrotic mass, involving the retroperitoneal space and extending upwards around the aorta and left ureter. The renal ped- icle was free of fibrosis and the renal pelvis greatly dis- tended. The left ureter was dissected free with difficulty and mobilised down to the juxtavesical segment, where dissection proved to be impossible. Owing to the exten- sive thickening of the posterior peritoneum and the pres- ence of the cutaneous sigmoid stoma, neither intraperitoneal ureteric transposition nor omental wrap- ping was attempted.

The patient had an uneventful post-operative course. The renal pain quickly subsided and he remained symp- tom-free for the following 6 months. IVU and CT scan demonstrated regression of the left hydronephrosis (Fig. 2B).

Comment This is a rare complication and Vandendris and Giannakopoulos (198 1) added the seventh reported case to the literature. Rectal perforation was facilitated in this case by the previous rectal instrumentation and by the use of a long rigid rec- tal cannula. The emergency left colostomy proved to be life-saving and is recommended for similar accidents.

We felt that surgical mobilisation of the obstructed ureter was preferable to prolonged ure- teric catheterisation and steroid therapy. However, these alternative conservative measures may be necessary either as temporary treatment or if there are contraindications to operation.

Reference Vandendris, M. and Giannakopoulos, X. (1981). Retroperitoneal

barytoma. Urology, XVII, 358-359.

Requests for reprints to: E. Proca, Department of Urology, Fundeni Hospital, Bucharest, Romania.

Fig. 2A Pre-operative CT scan. Fig. 2B Post-operative CT scan.