J Clin Ultrasound 7269-272, August 1979
ULTRASONIC REAL-TIME GUIDANCE FOR PERCUTANEOUS PUNCTURE Masahito Saitoh, M.D., Hiroki Watanabe, M.D., Hiroshi Ohe, M.D., Shigeki Tanaka, M.D., Yasuhiro Itakura, M.D., and Seiki Date, M.D.
Real-time scanning was applied to the sonically guided puncture technique. A special puncture attachment connected to the ultrasound sector scanner was developed for this purpose. A puncture needle is introduced into the scanning plane through the canal in the attachment. Excellent real-time images of both the target lesion and the needle can be clearly seen on the oscilloscope during the puncture procedure. Puncture not only for cystic structures but also for solid masses can be made easily and safely by this new technique. Successful applications of the technique have been carried out for renal cyst puncture. percutaneous antegrade pvelography. percutaneous nephrostomy, percutaneous renal biopsy. and perineal prostatic biopsy. Indexing Words: Ultrasound * Sector scanner Real time . Puncture . Nephrostomy Renal biopsy Prostatic biopsy
-
Ultrasonically guided puncture has been carried out chiefly by Danish and American groups since it was first described in publications in 1972 I1,21. Many applications of the technique using a special transducer with a central canal have been reported (3-1 0). Using the special transducer, echoes arising from the needle tip can be recorded on the A or M mode when the tip approaches to the fluid-containing lesion. Although the technique has contributed to increased safety in the field of percutaneous puncture, it has several disadvantages: only the tip of the needle can be detected; the target lesion cannot be displayed simultaneously while the puncture is being made; echoes from the needle tip are usually hidden when the needle is located in solid masses. Accordingly, real-time scanning has been applied to the puncture technique a t our clinic in an attempt to overcome these limitations. A special puncture attachment was developed for this purpose and was connected to a mechanical sector scanner. In this report the principles of the tech-
nique and our preliminary experiences will be described. EQUIPMENT
An ASU-25-7C:': mechanical sector scanner equipped with a 3.5-MHz ultrasound transducer was used to take the ultrasound real-time images (Fig. 1).The display speed of the transducer can be varied from 10 to 30 frames per second. The display angle is also variable, from 30 to 90 degrees. The attachment consists of four parts: a fixing plate, a connector, a head, and supplementary metal fittings with a canal for needle guidance (Fig. 2A). All the parts are made of stainless steel. The plate is fixed to the scanner. The head is easily connected to the plate by the connector a t 20 degrees to the longitudinal axis of the scanner. The supplementary metal fitting with a suitable guidance canal is selected according to the size of the needle and put into the basic canal of the head. When the puncture is finished, the needle can be freed from the attachment easily by opening the metal cover (Fig. 2B). This From the Department of Urology. Kyoto Prefectural Univer- causes no interference to the following manipusity of Medicine, Kawaramachi-Hirokoji. Kyoto. Japan. lations. A puncture needle is introduced into the Manuscript received December 29, 1978; revised manu- scanning plane along the canal of the fitting in script accepted April 12, 1979. Presented in part a t t h e Conference on Ultrasonically the attachment. The needle pathway is marked Guided Puncture, Copenhagen, Denmark. September 28-29. on the oscilloscope and crosses the longitudinal 1978. axis of the scanner at a n angle of 20 degrees 8 cm For reprints contact Masahito Saitoh, M.D.. Department of Urology, Kyoto Prefectural University of Medicine. from the skin (Fig. 3). Kawaramachi-Hirokoji. Kyoto, J a p a n 602. @ 1979 by John Wiley & Sons, Inc. 0091-2751/79/040269-04 $01.00
Aloka Company. Tokyo. J a p a n .
269
2 70
M . SAIlOH E l A L
FIGURE 2. A: Head (upper left), connector (upper right), and three kinds of supplementary metal fittings with guidance canal. B: By opening the metal cover of the attachment, the needle can be released easily.
n
I
Scanner
U Attachment
Scanning Plane
8 = 2 0 degrees
B FIGURE 1. A: Anterior view of mechanical sector scanner equipped with puncture attachment. The attachment guides a Tru-cut biopsy needle at an oblique angle. B: Lateral view of the scanner.
0:Target FIGURE 3. The puncture needle crosses the longitudinal axis of the scanner at an angle of 20 degrees, 8 cm from the skin. The needle pathway is marked on the oscilloscope.
JOURNAL OF CLINICAL ULTRASOUND
271
PROCEDURE AND RESULTS
The attachment is sterilized by autoclave, and the scanner is put into a box filled with formalin gas overnight. A standard puncture procedure for the kidney is followed. Routine ultrasound evaluation must be made before the puncture in order to supply the data needed (e.g., kidney position, depth, and size). The patient is prone. A small pillow may be placed under the abdomen to press the kidney up. The skin is sterilized. Sterile jelly is used as the acoustic coupling medium. The area of the puncture target is scanned using the gassterilized scanner for regulating the optimum scanning condition on the oscilloscope. The sterile puncture attachment is mounted on the scanner. The supplementary metal fitting appropriate to the needle size is placed into the basic canal of the attachment. The scanner should be positioned on the skin surface so that the needle pathway crosses the target on the oscilloscope. The needle guided by the attachment is advanced to the desired depth along the pathway under direct monitoring. Every target lesion over 2 cm in depth that can be visualized by ultrasound can be punctured accurately without changing the angle of guidance (Fig. 3 ) . The patient should be asked to hold his breath until the needle approaches the target. When the puncture is finished, the scanner is released from the needle, and the subsequent manipulations can be performed freely (e.g., aspiration, tubing, and biopsy). To date, successful applications of this technique at our clinic have included the following: renal cyst puncture, 5 cases (Fig. 4); antegrade pyelography, 3 cases; percutaneous nephrostomy, 3 cases; percutaneous renal biopsy, 12 cases (Fig. 5 ) ;perineal prostatic biopsy, 5 cases. No complication occurred except for transient hematuria in 1 case of nephrostomy and 1 case of prostatic biopsy.
FIGURE 4. Renal cyst puncture. A 21-gauge puncture needle introduced into a cyst in the lower pole of the kidney can be seen clearly by a longitudinal sector scan.
which covers a wide skin area, the puncture site was a considerable distance from the target. Puncture was also sometimes obstructed by the rib or the ileac bone. For that reason the sector scanner was thought to be more suitable because of its compact size and the smaller contact area required. By the use of this scanner, interference from the ribs or the iliac bone was minimized, and the distance between the skin and the target was reduced. Recent advances in ultrasound technology have produced real-time scanners of compact size providing excellent real-time images. Complete images of the needle and the target lesion can be monitored during the entire puncture procedure. Echoes from the needle are strong enough for discrimination even in solid masses. Both the display and the puncture method are very simple. No unusual skill is required. The technique has been shown to have a high level of practicability, especially in percutaneous renal biopsy, which until now has been carried
DISCUSSION
The central canal transducer has proved successful in the field of percutaneous puncture, even though the cross-sectional picture of the target organ could not be displayed during the puncture. In 1977 Pedersen ( 1 1 ) described the application of a multitransducer with a special puncture adapter for guidance of needles for amniocentesis, renal mass, renal cyst, or pericardiocentesis. He suggested that real-time guidance contributed additional safety to the already established field of sonically guided percutaneous puncture. For our first trial, a n electrical linear scanner was used, However, when a needle was guided obliquely from one end of this type of scanner, VOL. 7, NO.4, AUGUST 1979
FIGURE 5. Percutaneous renal biopsy. The entire image of a Tru-cut biopsy needle introduced into the parenchyma in the lower pole of the kidney can be seen clearly.
M . SAITOH ET A L .
2 72
out blind or by use of image-amplification fluoros- 2. Holm HH. Kristensen J K , Rasmussen S N , e t al: Ultrasound as a guide in percutaneous puncture copy. Sonography has also been employed for technique. Ultrasonics 10:83, 1972. localization of the kidney before biopsy (12-14). With previous ultrasound techniques, display was 3. Rasmussen SN, Holm HH, Kristensen J K , e t al: Ultrasonically guided liver biopsy. Preliminary impossible while the puncture was being made. communications. Br Med J 27500, 1972. Although, most recently, computed tomography 4. Bang J, Northeved A: A new ultrasonic method for has also been used for this purpose (15), the transabdominal amniocentesis. Am J Obstet image is not in real time. The procedure also Gynecol 114:599, 1972. takes much time and is expensive. By the use of 5 . Goldberg BB, Pollack HM: Ultrasonically guided the technique described here, the advance of the pericardiocentesis. Am J Cardiol 31:490, 1973. needle into the selected kidney site can be seen 6. Goldberg BB, Pollack HM: Ultrasonically guided renal cyst aspiration. J Urol 1 0 9 5 , 1973. clearly during the entire puncture procedure. U1trasound is noninvasive. The puncture can be 7. Goldberg BB, Meyer H: Ultrasonically guided suprapubic urinary bladder aspiration. Pediatrics made even in the nonvisualized kidney. Since the 51:70, 1973. equipment is portable, the puncture can be performed anywhere (e.g., in the examination room, 8. Kristensen J K , Holm HH. Rassmussen SN, e t al: Ultrasonically guided percutaneous puncture of in the operating room, and a t bedside). renal masses. Scand J Urol Nephrol 6:49, 1972. This new technique is useful not only in urol- 9. Pedersen J F : Percutaneous nephrostomy guided by ogy but also for general purposes, and it can be ultrasound. J Urol 112:157, 1974. applied to various organs or lesions if they can be 10. Hancke S, Holm HH, Koch F: Ultrasonically visualized by ultrasound. It is certain that the guided percutaneous fine needle biopsy of the pantechnique described here provides ideal guidance creas. S u r g Gynecol Obstet 140:361, 1975. for the needle and contributes to increased safety 11. Pedersen J F : Percutaneous puncture guided by ultrasonic multitransducer scanning. J Clin U1and higher accuracy in the field of percutaneous trasound 5:175, 1977. puncture.
13
ACKNOWLEDGMENT
We wish to thank Mr. Kenjiro Giga, director of the Engineering Department of Aloka Company for his assistance in developing the attachment. REFERENCES 1. Goldberg BB, Pollack HM: Ultrasonic aspiration transducer. Radiology 102187, 1972.
12. Kristensen J K , Bartels E, Jorgensen HE: Percutaneous renal biopsy under the guidance of ultrasound. Scand J Urol Nephrol 8:223, 1974. 13. Goldberg BB, Pollack HM, Kellerman E: U1trasonic localization for renal biopsy. Radiology 115:167. 1975. 14. Mailloux LU, Mossey RT, McVicar MM: Ultrasonic guidance for renal biopsy. Arch Intern Med 138:438, 1978. 15. Haaga J R , Alfidi R: Precise biopsy localization by computed tomography. Radiology 1 18:603, 1976.
JOURNAL OF CLINICAL ULTRASOUND
ULTRASONIC REAL-TIME GUIDANCE FOR PERCUTANEOUS PUNCTURE Masahito Saitoh, M.D., Hiroki Watanabe, M.D., Hiroshi Ohe, M.D., Shigeki Tanaka, M.D., Yasuhiro Itakura, M.D., and Seiki Date, M.D.
Real-time scanning was applied to the sonically guided puncture technique. A special puncture attachment connected to the ultrasound sector scanner was developed for this purpose. A puncture needle is introduced into the scanning plane through the canal in the attachment. Excellent real-time images of both the target lesion and the needle can be clearly seen on the oscilloscope during the puncture procedure. Puncture not only for cystic structures but also for solid masses can be made easily and safely by this new technique. Successful applications of the technique have been carried out for renal cyst puncture. percutaneous antegrade pvelography. percutaneous nephrostomy, percutaneous renal biopsy. and perineal prostatic biopsy. Indexing Words: Ultrasound * Sector scanner Real time . Puncture . Nephrostomy Renal biopsy Prostatic biopsy
-
Ultrasonically guided puncture has been carried out chiefly by Danish and American groups since it was first described in publications in 1972 I1,21. Many applications of the technique using a special transducer with a central canal have been reported (3-1 0). Using the special transducer, echoes arising from the needle tip can be recorded on the A or M mode when the tip approaches to the fluid-containing lesion. Although the technique has contributed to increased safety in the field of percutaneous puncture, it has several disadvantages: only the tip of the needle can be detected; the target lesion cannot be displayed simultaneously while the puncture is being made; echoes from the needle tip are usually hidden when the needle is located in solid masses. Accordingly, real-time scanning has been applied to the puncture technique a t our clinic in an attempt to overcome these limitations. A special puncture attachment was developed for this purpose and was connected to a mechanical sector scanner. In this report the principles of the tech-
nique and our preliminary experiences will be described. EQUIPMENT
An ASU-25-7C:': mechanical sector scanner equipped with a 3.5-MHz ultrasound transducer was used to take the ultrasound real-time images (Fig. 1).The display speed of the transducer can be varied from 10 to 30 frames per second. The display angle is also variable, from 30 to 90 degrees. The attachment consists of four parts: a fixing plate, a connector, a head, and supplementary metal fittings with a canal for needle guidance (Fig. 2A). All the parts are made of stainless steel. The plate is fixed to the scanner. The head is easily connected to the plate by the connector a t 20 degrees to the longitudinal axis of the scanner. The supplementary metal fitting with a suitable guidance canal is selected according to the size of the needle and put into the basic canal of the head. When the puncture is finished, the needle can be freed from the attachment easily by opening the metal cover (Fig. 2B). This From the Department of Urology. Kyoto Prefectural Univer- causes no interference to the following manipusity of Medicine, Kawaramachi-Hirokoji. Kyoto. Japan. lations. A puncture needle is introduced into the Manuscript received December 29, 1978; revised manu- scanning plane along the canal of the fitting in script accepted April 12, 1979. Presented in part a t t h e Conference on Ultrasonically the attachment. The needle pathway is marked Guided Puncture, Copenhagen, Denmark. September 28-29. on the oscilloscope and crosses the longitudinal 1978. axis of the scanner at a n angle of 20 degrees 8 cm For reprints contact Masahito Saitoh, M.D.. Department of Urology, Kyoto Prefectural University of Medicine. from the skin (Fig. 3). Kawaramachi-Hirokoji. Kyoto, J a p a n 602. @ 1979 by John Wiley & Sons, Inc. 0091-2751/79/040269-04 $01.00
Aloka Company. Tokyo. J a p a n .
269
2 70
M . SAIlOH E l A L
FIGURE 2. A: Head (upper left), connector (upper right), and three kinds of supplementary metal fittings with guidance canal. B: By opening the metal cover of the attachment, the needle can be released easily.
n
I
Scanner
U Attachment
Scanning Plane
8 = 2 0 degrees
B FIGURE 1. A: Anterior view of mechanical sector scanner equipped with puncture attachment. The attachment guides a Tru-cut biopsy needle at an oblique angle. B: Lateral view of the scanner.
0:Target FIGURE 3. The puncture needle crosses the longitudinal axis of the scanner at an angle of 20 degrees, 8 cm from the skin. The needle pathway is marked on the oscilloscope.
JOURNAL OF CLINICAL ULTRASOUND
271
PROCEDURE AND RESULTS
The attachment is sterilized by autoclave, and the scanner is put into a box filled with formalin gas overnight. A standard puncture procedure for the kidney is followed. Routine ultrasound evaluation must be made before the puncture in order to supply the data needed (e.g., kidney position, depth, and size). The patient is prone. A small pillow may be placed under the abdomen to press the kidney up. The skin is sterilized. Sterile jelly is used as the acoustic coupling medium. The area of the puncture target is scanned using the gassterilized scanner for regulating the optimum scanning condition on the oscilloscope. The sterile puncture attachment is mounted on the scanner. The supplementary metal fitting appropriate to the needle size is placed into the basic canal of the attachment. The scanner should be positioned on the skin surface so that the needle pathway crosses the target on the oscilloscope. The needle guided by the attachment is advanced to the desired depth along the pathway under direct monitoring. Every target lesion over 2 cm in depth that can be visualized by ultrasound can be punctured accurately without changing the angle of guidance (Fig. 3 ) . The patient should be asked to hold his breath until the needle approaches the target. When the puncture is finished, the scanner is released from the needle, and the subsequent manipulations can be performed freely (e.g., aspiration, tubing, and biopsy). To date, successful applications of this technique at our clinic have included the following: renal cyst puncture, 5 cases (Fig. 4); antegrade pyelography, 3 cases; percutaneous nephrostomy, 3 cases; percutaneous renal biopsy, 12 cases (Fig. 5 ) ;perineal prostatic biopsy, 5 cases. No complication occurred except for transient hematuria in 1 case of nephrostomy and 1 case of prostatic biopsy.
FIGURE 4. Renal cyst puncture. A 21-gauge puncture needle introduced into a cyst in the lower pole of the kidney can be seen clearly by a longitudinal sector scan.
which covers a wide skin area, the puncture site was a considerable distance from the target. Puncture was also sometimes obstructed by the rib or the ileac bone. For that reason the sector scanner was thought to be more suitable because of its compact size and the smaller contact area required. By the use of this scanner, interference from the ribs or the iliac bone was minimized, and the distance between the skin and the target was reduced. Recent advances in ultrasound technology have produced real-time scanners of compact size providing excellent real-time images. Complete images of the needle and the target lesion can be monitored during the entire puncture procedure. Echoes from the needle are strong enough for discrimination even in solid masses. Both the display and the puncture method are very simple. No unusual skill is required. The technique has been shown to have a high level of practicability, especially in percutaneous renal biopsy, which until now has been carried
DISCUSSION
The central canal transducer has proved successful in the field of percutaneous puncture, even though the cross-sectional picture of the target organ could not be displayed during the puncture. In 1977 Pedersen ( 1 1 ) described the application of a multitransducer with a special puncture adapter for guidance of needles for amniocentesis, renal mass, renal cyst, or pericardiocentesis. He suggested that real-time guidance contributed additional safety to the already established field of sonically guided percutaneous puncture. For our first trial, a n electrical linear scanner was used, However, when a needle was guided obliquely from one end of this type of scanner, VOL. 7, NO.4, AUGUST 1979
FIGURE 5. Percutaneous renal biopsy. The entire image of a Tru-cut biopsy needle introduced into the parenchyma in the lower pole of the kidney can be seen clearly.
M . SAITOH ET A L .
2 72
out blind or by use of image-amplification fluoros- 2. Holm HH. Kristensen J K , Rasmussen S N , e t al: Ultrasound as a guide in percutaneous puncture copy. Sonography has also been employed for technique. Ultrasonics 10:83, 1972. localization of the kidney before biopsy (12-14). With previous ultrasound techniques, display was 3. Rasmussen SN, Holm HH, Kristensen J K , e t al: Ultrasonically guided liver biopsy. Preliminary impossible while the puncture was being made. communications. Br Med J 27500, 1972. Although, most recently, computed tomography 4. Bang J, Northeved A: A new ultrasonic method for has also been used for this purpose (15), the transabdominal amniocentesis. Am J Obstet image is not in real time. The procedure also Gynecol 114:599, 1972. takes much time and is expensive. By the use of 5 . Goldberg BB, Pollack HM: Ultrasonically guided the technique described here, the advance of the pericardiocentesis. Am J Cardiol 31:490, 1973. needle into the selected kidney site can be seen 6. Goldberg BB, Pollack HM: Ultrasonically guided renal cyst aspiration. J Urol 1 0 9 5 , 1973. clearly during the entire puncture procedure. U1trasound is noninvasive. The puncture can be 7. Goldberg BB, Meyer H: Ultrasonically guided suprapubic urinary bladder aspiration. Pediatrics made even in the nonvisualized kidney. Since the 51:70, 1973. equipment is portable, the puncture can be performed anywhere (e.g., in the examination room, 8. Kristensen J K , Holm HH. Rassmussen SN, e t al: Ultrasonically guided percutaneous puncture of in the operating room, and a t bedside). renal masses. Scand J Urol Nephrol 6:49, 1972. This new technique is useful not only in urol- 9. Pedersen J F : Percutaneous nephrostomy guided by ogy but also for general purposes, and it can be ultrasound. J Urol 112:157, 1974. applied to various organs or lesions if they can be 10. Hancke S, Holm HH, Koch F: Ultrasonically visualized by ultrasound. It is certain that the guided percutaneous fine needle biopsy of the pantechnique described here provides ideal guidance creas. S u r g Gynecol Obstet 140:361, 1975. for the needle and contributes to increased safety 11. Pedersen J F : Percutaneous puncture guided by ultrasonic multitransducer scanning. J Clin U1and higher accuracy in the field of percutaneous trasound 5:175, 1977. puncture.
13
ACKNOWLEDGMENT
We wish to thank Mr. Kenjiro Giga, director of the Engineering Department of Aloka Company for his assistance in developing the attachment. REFERENCES 1. Goldberg BB, Pollack HM: Ultrasonic aspiration transducer. Radiology 102187, 1972.
12. Kristensen J K , Bartels E, Jorgensen HE: Percutaneous renal biopsy under the guidance of ultrasound. Scand J Urol Nephrol 8:223, 1974. 13. Goldberg BB, Pollack HM, Kellerman E: U1trasonic localization for renal biopsy. Radiology 115:167. 1975. 14. Mailloux LU, Mossey RT, McVicar MM: Ultrasonic guidance for renal biopsy. Arch Intern Med 138:438, 1978. 15. Haaga J R , Alfidi R: Precise biopsy localization by computed tomography. Radiology 1 18:603, 1976.
JOURNAL OF CLINICAL ULTRASOUND
