TECHNIQUE OF RENAL PHLEBOGRAPHY THROUGH THE LEFT SPERMATIC VEIN. AN AID TO THE MANAGEMENT OF

RENAL CARCINOMA

By E. PROCA Hospital Panduri, Bucharest, Rumania

RENAL tumours are spread by the blood stream as well as by thelymphatics and by direct extension. Riches (1963) has shown that invasion of the renal vein is three times as common in highly malignant tumours as in those of low malignancy. He reported invasion of the renal vein in 37 per cent. of all tumours, 53 per cent. in high-grade tumours and 18 per cent. in low-grade tumours. Robson (1963) found venous invasion in 20.9 per cent. (thirteen cases of sixty-two tumours) and Petkovic (1965) 10 per cent. (seventeen cases of 167 patients).

The presence of tumour in the renal vein does not mean that the renal neoplasm is inoperable, even if the tumour extends into the inferior vena cava. The post-operative survival rate in such cases does, however, drop and the better survival rate of low-grade tumours tends to be neutralised (Riches).

Renal phlebography provides very useful information about the condition of the renal vein. Besides demonstrating partial or total occlusion, it can show the presence of extrinsic com- pression and the state of the intrarenal and perirenal venous network. It will also help in deciding the best approach to the kidney and the renal pedicle.

Farina (1947), Martorell (1948), Duff and Granger (1951), Uhlir (1953), Purriel et al. (1954), Keshihian and Spencer (1954), and Couvelaire and Auvert (1956) performed phlebography of the inferior vena cava either by injecting the opaque medium into the femoral vein or by intro- ducing a catheter into the long saphenous vein and advancing it into the inferior vena cava. These techniques provided valuable information about the right renal vein and the inferior vena cava itself (displacement, compression, invasion), but failed to demonstrate the left renal vein.

A method of outlining the left renal vein through the left spermatic vein was consequently developed in 1958 in the Hospital Panduri and the procedure has now been performed on twenty- seven occasions. The method is simple, needs no special instruments, and is safe to carry out. No complications have been encountered. Leger (1 959) and Peluffo and Paez (I 964) subsequently used a similar technique with good results.

Other methods of outlining the left renal vein have been used, e.g., retrograde catheterisation through the right auricle (Dalla Palma and Servello, 1956), and selective renal phlebography based on the same principle as that of selective renal aortography (Caron et al., 1963). These methods, although perhaps more informative, are not easy to perform and carry an element of risk.

Technique.-Under local ansesthesia a short skin incision is made just below the left superficial inguinal ring. The spermatic cord is exposed and brought out through the skin incision. A vein from the anterior part of the pampiniform network, as near as possible to the vas deferens, is mobilised and a loose ligature applied. An intramuscular needle (on the end of a 20 ml. syringe) is passed into the vein and the waiting ligature is tied firmly round it ; 20 ml. Urografin (70 per cent.) (other contrast media may be used) is injected as rapidly as possible.

The first X-ray exposure is made just before the injection is finished. A second film may be taken at the very end of the injection. The needle is then withdrawn, the vein ligated, the spermatic cord replaced in its normal position and the skin closed with one or two sutures.

Normal Findings.-A single or double spermatic vein running upwards to the left renal vein which is only partially filled is shown in Figures 1 and 2. In Figure 3 the renal vein is more fully

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outlined and its main tributaries are shown. Reflux into the main adrenal vein is shown in Figure 4, and a moderate collateral circulation and reflux of the dye downwards is seen in Figures

FIG. 1 FIG. 2 FIG. 3

Figs. 1 and 2.--Single spermatic vein. Left renal vein inadequately outlined ; no collateral circulation. Normal finding.

Fig. 3.-GOOd filling of left renal vein. Normal finding. Some opaque medium can be seen in left colon (previous opaque enema).

FIG. 4 FIG. 5 FIG. 6 Fig. 4.-Reflux into the main adrenal vein. Normal finding. Figs. 5 and 6.-Moderate downward reflux. Normal finding.

5 and 6. The appearances seen in the last two figures are probably related to the speed of the injection rather than to any pathological condition.

Abnormal Findings.-1. Displacement of the renal vein (Fig, 7). 2. Filling of the perirenal venous network with numerous anastomoses with the spermatic

vein (Fig. 8).

R E N A L P H L E B O G R A P H Y T H R O U G H T H E L E F T S P E R M A T I C VEIN 503

FIG. I FIG. 8 FIG. 9

Fig. 7.-Downward displacement of left renal vein. Fig. 8.-Displacement of left renal vein and numerous anastomoses between the perirenal network and the

spermatic vein. Pathological finding. Fig. 9.-The renal vein is not filled. Abundant collateral circulation and downward reflux. Pathological

finding.

FIG. 10 FIG. 1 1

Fig. IO.-Filling defects of the renal vein, stasis, coltateral circulation and reflux into the hypogastric system. Pathological finding.

Fig. 1 I.-Filling defect of the spermatic vein with refilling through a rich collateral network suggesting thrombosis. The renal vein is not filled. Pathological finding.

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3. Failure of filling of the renal vein associated with marked collateral circulation and down- ward reflux (Fig. 9).

4. Filling defect in the renal vein, stasis, collateral circulation and reflux into the hypogastric system (Fig. 10).

5. Segmental filling defect of the spermatic vein with refilling, suggesting thrombosis (Fig. 11).

These abnormal findings are produced not only by thrombosis of the renal or spermatic veins but also by extrinsic compression of the veins by the tumour and enlarged lymph nodes. Adhesions may have the same effect. When an " asymptomatic " varicocele is present, spermato- graphy has always been found to produce abnormal results.

The method has limited indications, but it is easy to perform and can provide valuable information in the investigation of a left renal tumour.

REFERENCES

CARON, J., BOUTE, G., and RIBET, M. (1963). J. Radiol. Electrol., 44, 329. COUVELAIRE, R., and AUVERT, J. (1956). J. Urol. Ndphrul., 62, 21. DALLA PALMA, L., and SERVELLO, M. (1956). Presse MJd., 64, 150. DUFF, P. A., and GRANGER, W. H. (1951). J . Urul., 65, 368. FARINA. Quoted by Couvelaire and Auvert (1956).

KESHIHIAN, J. M., and SPENCER, W. H. (1954). Ann. Surg., 140, 829. LEGER, L. (1959). Presse MJd., 67, 1826. MARTORELL. Quoted by Couvelaire and Auvert (1956). PELUFFO and PAEZ. Quoted by Couvelaire and Auvert (1956). PURRIEL, P., ARCOS PEREZ, M., and DUBRO, J. (1954). Rev. mdd.-chir. Mal. Fuie, 29, 53. PETKOVIC, S., and MUTAVDZIC, M. (1965). J. Urul. NPphrul., 71, 121. RICHES, Sir ERIC (1963). Ann. R. Cull. Surg. Engl., 32, 201. ROBSON, C. (1963). J. Urul., 89, 73. UHLIR, K. (1953). J. Urol. Ndphrol., 59, 496.

GALMARINI, D., FASSATI, L. R., SANOLT, P. G., and FIORT, D. (1964). Chirurgia (Torino), 19, 335.