title: Effect of intentional cryo-injury to the renal collecting system.
abstract: OBJECTIVE
  We determined the short-term and long-term sequelae of intentional cryoablation of the renal pelvicaliceal system and evaluated whether continuous irrigation of the renal pelvicaliceal system with warm saline protects it against cryo-injury.
  
  
  METHODS
  In 12 swine open bilateral renal cryoablation using an argon gas based system was performed to create a cryolesion in the lower pole that was intentionally extended into the collecting system. A single cryoprobe was used to create a 3 cm ice ball in group 1 (6 animals) and 2, 3 mm cryoprobes were used to create a 4.5 cm ice ball in group 2 (6). In all 12 right kidneys pelvicaliceal warming (range 38C to 42C) was performed using continuous retrograde saline irrigation through an indwelling 5Fr ureteral catheter. In all 12 left kidneys cryoablation was performed without pelvicaliceal warming. Real-time confirmation of caliceal involvement by the cryolesion was obtained by retrograde ureteropyelogram. Immediately after cryo-injury 6 left and 6 right kidneys were harvested for histology and the animals with a solitary kidney were followed for 1 to 3 months.
  
  
  RESULTS
  Nadir cryoprobe tip temperature was -136C with a mean cryolesion time of 10.5 minutes. Cryolesion size was comparable in the right vs left kidneys in groups 1 and 2 (2.9 vs 3.0 and 4.7 vs 4.6 cm, respectively). Similarly cryoablation time was comparable between the right and left kidneys in groups 1 and 2 (11.3 vs 10.8 and 11.9 vs 12.2 minutes, respectively). Two animals died of aspiration pneumonia (1) and wound dehiscence (1). In all 10 surviving animals no instance of urinary extravasation was noted. At 1-month followup regrowth of normal urothelium occurred with some scarring of the lamina propria or underlying smooth muscle. Adjacent renal parenchyma was replaced by fibrous scar. At 3 months the cryo-injured collecting system was completely healed with a fibrous scar. There were no appreciable histological differences between the kidneys with or without warm pelvicaliceal irrigation.
  
  
  CONCLUSIONS
  Our data suggest that absent physical puncture injury of the collecting system with the cryoprobe tip the cryodamaged renal collecting system heals by secondary intention in a watertight manner. These data have clinical relevance for facilitating cryoablation of a small, localized, central renal tumor in proximity to the pelvicaliceal system.
authors.affiliation: Section of Laparoscopic and Minimally Invasive Surgery, Urological Institute, and Department of Pathology, Cleveland Clinic Foundation, Ohio 44195, USA.
authors.forename: Gyung Tak
authors.initials: GT
authors.lastname: Sung
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
authors.forename: Thomas H S
authors.initials: TH
authors.lastname: Hsu
authors.forename: Anoop M
authors.initials: AM
authors.lastname: Meraney
authors.forename: Marek
authors.initials: M
authors.lastname: Skacel
authors.forename: Jenifer A
authors.initials: JA
authors.lastname: Brainard
authors.forename: Erick M
authors.initials: EM
authors.lastname: Remer
mesh_terms: D000818:Animals; D003452:Cryosurgery / Q000009:adverse effects; D007668:Kidney / Q000601:surgery*; D007682:Kidney Pelvis / Q000293:injuries / Q000473:pathology*; D007685:Kidney Tubules, Collecting / Q000293:injuries / Q000473:pathology*; D010535:Laparoscopy; D013552:Swine