Interventional Uro-Radiology

Current Practices and Aspirations

in Mauritius
Dr Tejas GHOORAH
RADIOLOGIST
MBBS, DipPGM, MD Radiodiagnosis, MRCR UK
 Disclaimer
• No actual or potential conflict of interest
in relation to this presentation.
 Areas of intervention
• Renal biopsy
• Drain insertion - Renal abscess / Urinomas
• Percutaneous Nephrostomy – PCN
Renal access for PCNL
Antegrade ureteric stent insertion
Balloon dilatation of ureteral strictures
• Radiation Oncology - Ablation of renal tumours
• Urinary tract fistula
• Suprapubic Cystostomy
• Renal Trauma
• Embolisation - Renal Embolization
Varicocele embolization
Benign Prostatic Hypertrophy
• Haemodialysis fistula
• Renal Artery Dernervation for Resistant hypertension
 Renal Biopsies
• Non-targeted
– differentiate etiologies of acute kidney
injury (AKI) or chronic kidney disease (CKD)
in a patient who is thought to have a chance
for recoverable renal function
• Targeted
– Renal Tumours
Renal Mass Biopsies

Non-fat or complex mass lower pole

Renal Mass Biopsies

Mass at upper pole of the left kidney.

 Renal Mass Biopsies

Small Mass at lower pole of the left kidney.

 Renal Mass Biopsies

Persistent haematuria, mass at the upper Mass at the upper pole of the left kidney
pole of the right kidney Non-contrast CT
 45 year Male with prior history of right nephrectomy for RCC.
Left kidney mass appreciated on CECT, hydrodissected to move bowel.
 Percutaneous nephrostomy
• Image-guided placement of a catheter
through a calyx into the renal collecting
system
Percutaneous nephrostomy
• Blocked kidneys
• Often due to stones or malignancy
• Patients frequently septic
• Common emergency procedure
Percutaneous nephrostomy
• Temporary urinary diversion
• Urinary access for endourological
intervention
• Other indications: Mx of urinary fistulas,
ureteric leak, pyosepsis
 Techniques
• Trocar technique

• Seldinger technique
Puncture, Decompress, Opacify
Puncture, Decompress, Opacify
Puncture, Decompress, Opacify
Puncture, Decompress, Opacify
Beware of PUS, the LAVA Sign
Know your devices, Learn how to use them
 Abscesses/Urinoma
• Drainage by pigtail insertion.

Peri-graft collection
 Kidney Stones
• Major cause of morbidity and mortality

Jackstones

staghorn
 Large Stone
• Team approach with the urologists
 Large Stone
• Team approach with the urologists

Urologists puts contrast in the kidney via a catheter up the ureter

 Large Stone
• Telescopic dilators over the guidewire
• Urologist put the scope in here in which
they can put instruments inside.
 Snare
• After procedure
• Stent – blood,
tiny stone
 Ureteric stricture
• Benign and malignant conditions

Courtesy of Dr P. Haslam, Freemon Hospital, Newcastle

Interventional Oncology
• Rapidly growing area
• Ablative therapy vs Open/Laparoscopic/
Robotic nephrectomy
• Patients with anaesthetic risk
• Recurrent renal tumours – VHL
• Avoidance of dialysis
• Small tumours
Interventional Oncology
• Small tumours – Do nothing?
• Partial nephrectomy – 4-30% have
significant complications.
• Relatively slow growing tumour
• Average growth rate 2.6mm/yr, 23% no
growth
• 14-25% tumours have high grade disease.
• Metastatic rate 1-6%
 Ablation Therapy
• RFA – Radiofrequency ablation
• Cryotherapy – freeze it
• Microwave ablation
• IRE – electrocute the tumour
 RF Ablation

Ionic agitation from alternating current causes tissue coagulation

through frictional heating. Tissue desiccation increases impedance
which eventually decreases current flow
 RF Ablation

Single electrode Cluster electrodes Multiple electrodes

2.0cm Mass 2.5cm Mass 4.0cm Mass
Exposure 6minutes Exposure 12minutes Exposure 25minutes
Radiofrequency Ablation
Radiofrequency Ablation

Courtesy of Dr P. Haslam, Freemon Hospital, Newcastle

CT GUIDED RFA

Courtesy of Dr P. Haslam, Freemon Hospital, Newcastle

 CT GUIDED RFA
• Allows visualization of tumour and
adjacent structure.
• Inadvertent thermal injury can be
anticipated and steps to minimize the
risk.
• Detect procedure related complications.
 Renal Cryoablation
• Larger tumours
• Allows monitoring of ablation zone
• Adjacent structures avoided
• Cell death up to 3mm inside ablation
zone.
Cryoablation - Technique

Courtesy of Dr P. Haslam, Freemon Hospital, Newcastle

 Renal Cryoablation
• Freeze thaw cycle 10minutes x 2
• Monitor ablation zone every 2 minutes.
• Extend ice ball 5mm beyond tumour. 

• Joules Thompson Effect

Courtesy of Dr P. Haslam, Freemon Hospital, Newcastle
Courtesy of Dr P. Haslam, Freemon Hospital, Newcastle
 Microwave Ablation
• Higher Temperatures
• Quicker
• More predictable?

Water
molecules acts
as a heat
source
 Microwave Ablation
RFA MWA
• RFA is current based, • Electromagnetic field around
grounding pads the probe heating tissue
• Heating dependent on through water molecules
impedance • Field shape is determined by
• Impedance varies with flow of electrons within the
probe and material close to
tissue and ablation
the probe, ie the targeted
• Current rapidly drops off tissue.
with distance
• It does give you a bigger area
for ablation.
Active VS Passive Heating
• Active and passive zone components of
a thermal ablation zone
Microwave RF Ablation

60seconds, 100Watt
Microwave RF Ablation

1 week post procedure

Courtesy of Dr P. Haslam, Freemon Hospital, Newcastle
Multiple Microwave Antennae
The Ideal Ablation Technique
• Predictable ablation
• Capable of large volume ablation
• Can ablate different types of tissues
• No thermal / electrical sink effects
• Surrounding structure are not damaged.
 IRE
Irreversible Electroporation (NanoKnife)
• Nonthermal mechanism of action of killing
tumor cells in areas previously contraindicated
for thermal ablation.
• Permanent nanopores created in cell
membrane
• Apoptosis of the cell
• Cell debris cleared
 IRE
Cellular VS Non-cellular tissue effects
• Cells in ablation zone are
irreversibly porated.
• Collagenous structures are
not affected
– Intact adventitia & laminae
visible at 2 days with no
smooth muscle cells present.
– Endothelium largely
repopulates at 2 days
– Smooth muscle repopulated
at 2 weeks
 IRE
Cardiac Gating
 IRE
• Close to collecting system

• Close to Vessels

• Failed thermal ablation

 IRE
• GA

• CT Guided

• Parallel needles, difficult

 NanoKnife System
• NanoKnife Generator MRU 15 Million
• Up to 6 monopolar electrodes
– One activator RFIDMonopolar electrode Rs150,000
– Up to 5 RFID Monopolar electrodes Rs15,000
Benign Prostatic Hypertrophy
• Persistent Haematuria secondary to BPH
• Haemorrhage stopped by embolization
• 90% decrease in PSA
• 62% prostate volume reduction in 12 months
• Improvement in symptoms of BPH, IPSS from
24 to 13

DeMeritt JS et al JVIR 2000;11:767-770

Benign Prostatic Hypertrophy

Courtesy of Dr P. Haslam, Freemon Hospital, Newcastle

CONE BEAM CT
Benign Prostatic Hypertrophy

Courtesy of Dr P. Haslam, Freemon Hospital, Newcastle

 Renal Trauma
• Management
– Hammer CC, Santucci Ra. Effect of an institutional policy on
non operative Treatment of grade I to IV renal injuries. JUrol
2003 169, 1751-1753

• Conservative Whenever Possible

• The nephrectomy is low when not operated
upon!
• Surgery when unstable or grade 5 vascular
injury?
Grey Turner’s and Fox’s Sign
Courtesy of Dr P. Haslam, Freemon Hospital, Newcastle
Courtesy of Dr P. Haslam, Freemon Hospital, Newcastle
 Varicocele
• 10-15% prevalence
• 25-80% in infertile man
• Left 70% commonest
• Bilateral < 30%
• Right sided 1-3%
• Simple out patient procedure
• Accessing the IVC and insert the catheter, left
renal vein, and gonadal vein
 Varicocele
• Mechanism
– Valvular incompetence
– Nutcracker phenomenon
– Retroperitoneal masses

• Indicated
– Pain
– Infertility
– Testicular atrophy in adolescent
Varicocele
Varicocele
Courtesy of Dr P. Haslam, Freemon Hospital, Newcastle
 Haemodialysis Fistula
• Fistula require > 500ml/s of flow per minute
for optimum function.
• Native AVF start at the wrist in the non-
dominant hand i.e radio-cephalic (Brescia-
Cimino), gradually progressing proximally
• Arteriovenous Graft have the advantage that
they can be used immediately while AVF
require maturation.
 Mechanical Thrombectomy
• Trerotola is a mechanical thrombectomy catheter
with a rotating basket that spins relatively high
velocity when attached to disposable handle
motor.
Percutaneous Transluminal Angioplasty
Venoplasty
Post Venoplasty
Renal Artery Denervation
• Resistent hypertension
Renal Artery Denervation
Renal Artery Denervation
THANK YOU

Tel: 52545251
drtghoorah@gmail.com
Dr Tejas GHOORAH
RADIOLOGIST
 Tel: 52545251
drtghoorah@gmail.com
Dr Tejas GHOORAH
RADIOLOGIST