Sonographically Guided Percutaneous Puncture of Renal Cysts

Aspiration of renal masses dates back to 1861, when Thompson “repeatedly emptied by tapping an enormous sac connected with the kidney” (Buttarazzi et al. 1968). Fish (1939) probably was the first to recommend exploration of a suspected cyst with the aspirating needle. In 1939, he presented an air-filled cystogram and published two cases that were successfully treated by aspiration and instillation of 50% dextrose as a sclerosing agent. Dean (1939) advocated puncture as the treatment for renal cysts, based on 15 cases of his own. He was supported by Wheeler (1941), who, at a meeting of the New England Section of the AU A, drew attention to “hypernephric cysts.” In the following discussion, Deming, to our knowledge, was the first to suggest the injection of contrast material into the cyst. Lindblom (1946) reported a series of five cystograms performed by the instillation of 2–7 cc 35% diodrast. Ever since, an increasing number of authors have favored aspiration in the diagnostic workup of renal cysts (Phillips 1963; Witherington and Rinker 1966; Pearman 1966; Klosterhalfen 1963; Lang 1966). The danger of seeding a malignant tumor in the site of needle puncture has been conjectured but never been proven (Devine et al. 1968). Lang (1966) stressed, above all, the diagnostic value of cyst puncture. He inaugurated the double-contrast technique with introduction of air and contrast material into the cyst; additionally, he recommends qualitative and quantitative assessment of the aspirated fluid for fat together with a Papanicolaou smear. Beginning at the end of the 1960s, ultrasound has increasingly been instituted as a means of differential diagnosis of renal masses (Goldberg et al. 1971; Pollack et al. 1974; Sanders 1975). Cyst puncture under fluoroscopic guidance after sonographic evaluation seems to be the most widely practiced method, but aspiration under ultrasound guidance has been favored with the introduction of enhanced technical equipment (Lang 1977). In a survey of 5674 cases, Lang (1977) reported an incidence of major complications of cyst aspiration of 0.75%–1.4% (perirenal hematoma, pneumothorax, arteriovenous fistulae, traumatic urinomas). Flexible puncture equipment and the extensive experience of the investigator lessened the risk of complications.