Percutaneous Embolization of Renal Artery Pseudoaneurysm after

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Percutaneous Embolization of Renal Artery Pseudoaneurysm after Laparoscopic Partial Nephrectomy for Renal Cell Carcinoma Chang Hee Han, Sung-Hoo Hong, Yoo Dong Won1, Joon Chul Kim, Tae-Kon Hwang

대한비뇨기과학회지 제 48 권 제 6 호 2007

From the Departments of Urology and 1Radiology, College of Medicine, The Catholic University of Korea, Seoul, Korea

가톨릭대학교 의과대학 비뇨기과학교실, 1영상의학교실

Currently, partial nephrectomy for patients with malignant renal tumors has become the procedure of choice for elective indications. Attempts have been made to use minimally invasive endoscopic procedures to replace the standard open partial nephrectomy. Laparoscopic partial nephrectomy can be technically challenging and be associated with vascular complications such as pseudoaneurysm. We report here on a case of renal artery pseudoaneurysm that occurred after laproscopic partial nephrectomy for renal cell carcinoma treated by percutaneous selective angioembolization. (Korean J Urol 2007;48:659-662) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 Key Words: Pseudoaneurysm, Laparoscopy, Nephrectomy, Embolization, Therapeutics

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한창희․홍성후․원유동 김준철․황태곤

접수일자：2006년 12월 20일 채택일자：2007년 5월 12일 교신저자: Tae-Kon Hwang Department of Urology, College of Medicine, The Catholic University of Korea 505, Banpo-dong, Seocho-gu, Seoul 150-713, Korea TEL: 02-590-1386 FAX: 02-599-7839 E-mail: tkhwang@catholic. ac.kr

Renal artery pseudoaneurysm (RAP) is a rare, but potentially

tained. The caliceal entry was then closed with a 2-0 chromic

life-threatening condition that is often difficult to diagnose but

suture. Hemostasis was achieved with the combined use of an

requires a high index of suspicion. RAPs have been well-do-

argon beam coagulator for the peripheral edges of the defect,

cumented secondary to renal vascular injury including: renal

and placement of fibrin glue (Tisseel, Baxter Inc., Deerfield,

biopsy, blunt and penetrating renal trauma, renal transplant, and

USA) into the renal defect. We used 2-0 chromic sutures with

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percutaneous procedures.

We report a case of RAP following

laparoscopic partial nephrectomy for renal cell carcinoma who was successfully treated with a percutaneous selective angioembolization.

CASE REPORT A 71-year-old woman underwent retroperitoneal laparoscopic partial nephrectomy for an incidentally detected 2.6x2.5 cm heterogeneously enhancing solid mass at lower pole of the left kidney (Fig. 1). With an indwelling dual lumen ureteral catheter, the kidney was irrigated with cold saline to cool the renal parenchyma and to confirm leakage in the collecting system. After a laparoscopic bulldog clamp was applied to the main renal artery, the tumor was resected with cold scissors, with an approximate 0.5 cm margin around the tumor main-

Fig. 1. CT scan reveals a 2.6x2.5 cm heterogeneously enhancing solid mass at the left lower renal pole.

659

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대한비뇨기과학회지：제 48 권 제 6 호 2007

a LapraTy clip (Ethicon Inc., Piscataway, USA) on the terminal

demonstrated a 3.5 cm saccular RAP of a segmental renal

end to approximate the renal defect. Once the sutures were

artery from within the tumor bed (Fig. 2). Renal angiography

passed through both edges of the renal defect, a second

demonstrated the presence of two RAPs fed by the lower

LapraTy clip was applied. Once the bulldog clamp was

segmental artery (Fig. 3). Selective angioembolizations of the

removed, hemostasis was confirmed by inspecting the site with

RAPs with histoacryl/lipiodol mixtures were performed. There

a 5 mmHg pneumoretroperitoneum. A warm ischemic time of

were no signs of postembolization syndrome or contrast

25 minutes was applied. Pathologic analysis confirmed a renal

medium induced nephrotoxicity observed. No blood transfusion

cell carcinoma, clear cell subtype, grade 2, T1aN0M0 with

was required. The patient was discharged one day after the

negative surgical margins. Three months postoperatively, the

embolization. Follow-up CT scan at 1 month after the emboli-

patient was asymptomatic and the follow-up helical CT scan

zation showed total occlusion of the RAP (Fig. 4). The patient

with 3-D reconstruction using the volume rendering technique

was asymptomatic and remained free from cancer recurrence

Fig. 2. (A) Follow-up contrast CT scan of the kidney shows a large collection of contrast in the left lower renal pole, which was compatible with a pseudoaneurysm. (B) the 3-D volume rendered CT scan with intravenous contrast demonstrates a 3.5 cm sized saccular pseudoaneurysm (white arrow) arising from the lower segmental branch of the left renal artery.

Fig. 3. Digital subtraction angiogram of the left renal artery shows a saccular pseudoaneurysm, about 3 cm in diameter, in the lower field of the remaining renal parenchyma.

Fig. 4. The follow-up 3-D volume rendered CT scan at 1 month after the embolization shows total occlusion of the pseudoaneurysm with histoacryl/lipiodol mixtures (white arrow).

Chang Hee Han, et al：Angioembolization of Pseudoaneurysm after Laparoscopic Partial Nephrectomy

661

phrectomy which was found incidentally during postoperative

at the 6-month follow-up.

imaging and treated conservatively. During conservative mana-

DISCUSSION

gement, careful follow up focused on detecting any changes in size as well as number and shape of aneurysms is mandatory.

RAPs are rare, but well-documented complications of per-

Although the RAP in our case was asymptomatic, we perfor-

cutaneous renal procedures, renal trauma and partial nephrec-

med embolotherapy because the size was 3.5 cm in diameter.

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tomy.

The incidence following open partial nephrectomy is 4

reported to be less than 0.5%. Recently, 5 cases have been 5-7

reported after laparoscopic partial nephrectomy.

The natural

In recent years, percutaneous selective arterial embolization has emerged as a simple, useful and effective modality used for 7,10

managing RAPs in patients who are hemodynamically stable.

history of RAPs is variable and can result in a spontaneous

With selective angiographic embolization, the bleeding site can

resolution as well as free rupture.

be localized and treated effectively with occlusive materials,

The cause for RAP formation after laparoscopic partial ne-

resulting in minimal loss of renal parenchyma. An unstable

phrectomy is unknown. Arterial bleeding vessels that are con-

patient requires open exploration with total or partial nephrec-

tained by adjacent tissue, such as surrounding renal paren-

tomy. Certainly, the best treatment for RAPs is to prevent their

chyma, have been suggested as a possible cause for RAPs

occurrence. This involves attaining meticulous hemostasis intra-

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occurring after partial nephrectomy. Compared to the standard

operatively.

open partial nephrectomy, laparoscopic partial nephrectomy is

Clinicians should have a high index of suspicion for this

more challenging in suturing individual vessels. Most laparo-

life-threatening lesion in any patient with flank pain and

scopic surgeons over-sew the entire resection bed for hemos-

hematuria after renal biopsy, trauma, or renal surgery. The

tasis. This maneuver can cause failure to notice the bleeding

absence of hematuria does not rule out renal artery RAP. Fol-

vessels. Failure to see larger bleeding vessels when clamping

low-up imaging is recommended to document resolution of the

both arteries and veins is another possible cause. In this case,

RAP.

although freehand suturing of the renal collecting system and parenchyma is our preferred method for hemostasis, we used

REFERENCES

the LapraTy clip instead of freehand suturing to reduce the warm ischemic time and minimize the risk for renal parenchymal laceration due to the ‘cheese slicing’ effect of standard 8 knot tying. It is not clear whether the occurrence of RAP is

associated with this method. Hematuria is the most common symptom associated with RAPs and results from erosion of the RAP into the adjacent 4 renal collecting system. This may occur within 2 to 4 weeks

after injury. Although gross hematuria is common, it is not a universal finding and several reports have described patients 1,4,9

without gross hematuria.

In this case, neither microscopic

nor macroscopic hematuria were noted. For follow up and evaluation of the patients who underwent partial nephrectomy, helical CT scan with 3-D reconstruction, with arterial, venous and delayed images is the imaging modality of choice. Treatment options for RAPs are observation, aneurysmectomy with surgical repair, endovascular procedures, and total or partial nephrectomy. Observation is indicated in patients with asymptomatic aneurysms measuring less than 2 cm in diameter. 4 Albani and Novick reported a case of RAP after partial ne-

1. Swana HS, Cohn SM, Burns GA, Egglin TK. Renal artery pseudoaneurysm after blunt abdominal trauma: case report and literature review. J Trauma 1996;40:459-61 2. Dodd GD III, Tublin ME, Shah A, Zajko AB. Imaging of vascular complications associated with renal transplants. AJR Am J Roentgenol 1991;157:449-59 3. Kessaris DN, Bellman GC, Pardalidis NP, Smith AG. Management of hemorrhage after percutaneous renal surgery. J Urol 1995;153:604-8 4. Albani JM, Novick AC. Renal artery pseudoaneurysm after partial nephrectomy: three case reports and a literature review. Urology 2003;62:227-31 5. Moore CJ, Rozen SM, Fishman EK. Two cases of pseudoaneurysm of the renal artery following laparoscopic partial nephrectomy for renal cell carcinoma: CT angiographic evaluation. Emerg Radiol 2004;10:193-6 6. Wright JL, Porter JR. Renal artery pseudoaneurysm after laparoscopic partial nephrectomy. Urology 2005;66:1109 7. Negoro H, Kawakita M, Koda Y. Renal artery pseudoaneurysm after laparoscopic partial nephrectomy for renal cell carcinoma in a solitary kidney. Int J Urol 2005;12:683-5 8. Orvieto MA, Chien GW, Laven B, Rapp DE, Sokoloff MH,

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Shalhav AL. Eliminating knot tying during warm ischemia time for laparoscopic partial nephrectomy. J Urol 2004;172: 2292-5 9. Lee RS, Porter JR. Traumatic renal artery pseudoaneurysm: diagnosis and management techniques. J Trauma 2003;55: 972-8

10. Klein GE, Szolar DH, Breinl E, Raith J, Schreyer HH. Endovascular treatment of renal artery aneurysms with conventional non-detachable microcoils and Guglielmi detachable coils. Br J Urol 1997;79:852-60