This report highlights a serious complication of PCLS despite correct placement of the needle.
This is the second of such reports in the indexed literature.7
It has been suggested that such complications are often under reported and, therefore, not taken in to consideration during informed consent.7
It is unlikely that the injection was made directly into the pelvi-ureteric system, because most of the ureter was spared and also the location of the needle tip was confirmed by preliminary contrast injection. It is clear that damage to neighbouring structures is possible despite the needle tip being in the correct plane because of unperceived and unpredictable spread of the injected solution beyond the point of injection and even across tissue planes if they had been breached in the process of needle positioning. The severity of pelvi-ureteric injury could also vary with the sclerosant type, volume, concentration and contact time, and could manifest as late strictures to early necrotic disruption with extravasation of urine as observed in this patient.
It may be possible to overcome such a complication by the use of ablative methods whose field of effect is more localised and predictable.14
Laser and radiofrequency heat are two such methods. Heat spread is limited to less than 1 mm from the needle tip minimising the potential for widespread damage to adjacent structures. This is evidenced during repeat procedures after laser and radiofrequency sympathectomy where the potential space in which the sympathetic chain lies remains unobliterated in contrast to the fibrous obliteration observed after chemical and surgical sympathectomy. Dominkus et al
have reported encouraging results using radiofrequency lumbar sympatholysis in peripheral vascular disease14
and comparison with chemical injection has shown similar effectiveness.15
Timely management of this injury was crucial to salvage the kidney. When the urinary leak was diagnosed it was thought to be due to a minor ureteric defect; thus, the attempt to treat it with a J stent. The extent of the damage was clearly underappreciated at the time and the J stent neither entered the renal pelvis nor drained the extravasated urine. This delay in drainage allowing continuous perinephric accumulation of urine mixed with injected alcohol resulted in marked inflammation and fibrosis in the surrounding area. Hence, it is advisable to drain the pelvis percutaneously and explore injuries early to enable safe debridement and direct anastomotic repair.16
When intervention is delayed, as in this patient, any attempt to mobilise the pelviureteric region could damage adjacent viscera and blood vessels; hence, calicoureteroplasty,16
as in our patient. Success rates of 70–90% have been reported for this procedure, while a failed procedure leads to loss of the kidney.17
Finally, we need to consider risk versus benefit from PCLS for unreconstructable peripheral arterial occlusive disease. Rare but serious complications may be acceptable if the benefits are substantial. However, a systematic review of the scientific literature on the subject failed to show benefit.18
In the light of this evidence it may be argued that lumbar sympathectomy should not be considered as a treatment option for complications of unreconstructable peripheral arterial occlusive disease.
- PCLS, despite x-ray guidance and correct positioning of the needle, is not without serious risk.
- This may be because of unpredictable spread of injected sclerosant solution across tissue planes.
- Alternative techniques with precise localised ablative effect, such as laser and radiofrequency, need to be explored.
- There is no evidence that lumbar sympathectomy is beneficial in the management of unreconstructable peripheral arterial occlusive disease.