Background We describe two patients who underwent low‐dose‐rate prostate brachytherapy after embolization for pelvic arteriovenous malformation. Case presentation Case 1: A 76‐year‐old man was referred for definitive treatment of intermediate‐risk prostate cancer (prostate‐specific antigen 8.667 ng/mL, cT2aN0M0, Gleason score 3 + 4 = 7). We planned low‐dose‐rate brachytherapy. However, magnetic resonance imaging and computed tomography demonstrated a large pelvic arteriovenous malformation. We performed embolization of the arteriovenous malformation before initiating treatment to lower the risk of rupture of the arteriovenous malformation during low‐dose‐rate brachytherapy. Case 2: A 69‐year‐old man was referred for the definitive treatment of high‐risk prostate cancer (prostate‐specific antigen 5.81 ng/mL, cT2aN0M0, Gleason score 4 + 4 = 8) with a pelvic arteriovenous malformation. Similar to Case 1, we performed embolization of the arteriovenous malformation before initiating treatment. In both cases, low‐dose‐rate brachytherapy could be performed without complications. Conclusions Low‐dose‐rate brachytherapy after transcatheter embolization of pelvic arteriovenous malformations can safely and effectively treat localized prostate cancer with pelvic arteriovenous malformations.
Background: Transplant renal artery dissection is a rare and serious event that can cause allograft dysfunction and activation of the renin-mediated renovascular hypertension. Most cases are induced by percutaneous transluminal angioplasty, arteriosclerotic disease, or fibromuscular dysplasia. We observed a case of transplant renal artery dissection induced by unusual causes during kidney transplantation. Case presentation: A 35-year-old woman, whose mother donated a kidney to her, underwent ABO-incompatible living kidney transplantation. The allograft had one renal artery and vein that were anastomosed to the internal iliac artery and external iliac vein, respectively. Although careful handling was performed in all procedures including vascular clamping, Doppler ultrasonography (US) immediately after reperfusion showed an increase in the systolic blood velocity and urine output was not observed. Arterial anastomotic stenosis was suspected, but upon exploration, a renal artery dissection was detected in the middle portion of the donor artery. The part of the transplant renal artery was resected, and cold reflux was started again. At the resected part of transplant renal artery, dissection was identified. After re-anastomosis, Doppler US revealed that the blood flow of the renal artery was adequate without an increase in the systolic blood velocity, and sufficient blood flow was observed throughout the allograft. Urine output was also observed as soon as blood flow returned, and serum creatinine level decreased to 0.95 mg/dL after surgery. The cause of injury might have been vascular clamping in order to drain the air and check bleeding at the anastomosis. Conclusions: Our case reaffirmed that careful handling is needed in all procedures, including donor nephrectomy, cannulation for transplant perfusion, vascular clamping, and anastomosis, even without any evidence of arteriosclerosis. Kidney transplant recipients commonly have atherosclerosis and hypertension, which are risk factors for arterial dissection. Early diagnosis and intervention can lead to the prevention of allograft dysfunction. Therefore, close monitoring of allograft blood flow by Doppler US during surgery should be considered.
Background: Arterial reconstruction is one of the paramount procedures in kidney transplantation (KT) and greatly important if the procured kidney has multiple renal arteries (MRA). Despite various established techniques for arterial reconstruction, sometimes, the surgeon finds performing arterial anastomoses challenging in case of MRA. In our case, the donor's gonadal vein and recipient's internal iliac artery graft were used for arterial anastomoses, and 3 years after KT, the allograft did not present vascular complications. Case presentation: A 34-year-old man underwent ABO-incompatible preemptive living KT. The allograft had three renal arteries and four renal veins. After donor nephrectomy, arterial reconstruction was performed on a back table. These arteries were reconstructed into one piece using the recipient's internal iliac artery graft. The two arteries at the middle of the renal hilum were reconstructed using the conjoined method. As the superior renal artery was too short to anastomose, the donor's gonadal vein was used for extension. The internal iliac artery graft was anastomosed to the original internal iliac artery. Intraoperative Doppler ultrasonography revealed that the blood flow in each renal artery was adequate, resulting in sufficient blood flow throughout the allograft. The allograft function was maintained with a serum creatinine level of approximately 0.9 mg/dL without vascular complications 3 years after KT. Conclusions: The donor's gonadal vein can be a candidate for extension of the renal artery in the allograft with MRA. Further follow-up is needed for the assessment of long-term outcomes.
BackgroundPage kidney phenomenon is caused by strong renal parenchymal compression and leads to renal hypoperfusion and microvascular ischemia, resulting in renal dysfunction and hypertension. Although the development of Page kidney phenomenon in allograft is rare, most of its cases are induced by allograft biopsy or trauma. We observed a case of Page kidney phenomenon that was induced by unusual causes immediately after kidney transplantation.Case presentationA 66-year-old man, whose wife donated a kidney, underwent ABO-compatible living kidney transplantation. The allograft had three renal arteries that were trimmed and formed into one piece on the back table, and subsequently, it was anastomosed to the internal iliac artery. Intraoperative Doppler ultrasonography (US) revealed adequate blood flow of each renal artery. Urine output was also observed as soon as allograft blood flow was reperfused. After the surgery, the urine output decreased, and serum creatinine level increased to 6.0 mg/dL. Doppler US did not show evidence of acute rejection, ureteral obstruction, or anastomotic stenosis of the renal arteries. On postoperative day 7, surgical exploration was performed and revealed that the blood flow of each renal artery was adequate but subcapsular hematoma was detected at the upper pole of the allograft. Capsulotomy and hematoma evacuation were performed. Subsequently, urine output increased and serum creatinine level decreased up to 1.7 mg/dL. Allograft sample was obtained 1 h after the transplantation from the lower pole of the allograft. Although the cause of subcapsular bleeding was unclear in this case, a small cyst of the allograft, which might have ruptured during donor nephrectomy, was located in the middle of the hematoma, and oozing around the cyst was observed.ConclusionsOur case indicated that the small ruptured cyst of the allograft could be the cause of subcapsular hematoma and Page kidney phenomenon. Subcapsular hematoma caused by oozing over time could be difficult to diagnose using Doppler US, and thus, other imaging modalities, such as computed tomography, should be considered. Knowledge of the Page kidney phenomenon in the allograft can lead to early diagnosis and intervention, resulting in better outcomes for recipients with allograft dysfunction.
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