Superselective Renal Artery Embolization in the Treatment of Iatrogenic Bleeding into the Urinary Tract

Abstract

BackgroundThe aim of this study was to evaluate the efficacy of superselective renal artery embolization in patients with bleeding into the urinary system.Material/MethodsFrom 2007 to 2012, 20 patients were treated with superselective renal artery embolization for bleeding after percutaneous nephrolithotomy (PCNL), nephron-sparing surgery (NSS), including 1 patient with AVF after PCNL. During the procedure, embolization material was injected through a microcatheter to stop the bleeding. Embolization materials included a mixture of cyanoacrylate and lipiodol, embolization coils, and Spongostan. Clinical evaluation included remission of hematuria and normalization of blood morphotic elements.ResultsThe cause of bleeding into the urinary tract was damage to vessels (all cases): with coexisting false aneurism (8 cases); with coexisting arterio-venus fistula (1 case); and with coexisting intrarenal hematoma (3 cases). The bleeding occurred 2–5 days after PCNL and NSS, and 10 days after PCNL with AVF. The mean hematocrit level was 22%–24%. Technical success was achieved in 20 cases. Clinical success was achieved in 19 cases. One patient with hematuria after PCNL with AVF needed a second endovascular treatment to stop bleeding.ConclusionsSuperselective renal artery embolization is an effective procedure in the treatment of iatrogenic bleeding into the urinary tract after PCNL and NSS.

Embolização arterial superseletiva para tratamento de angiomiolipoma em paciente com rim único

“…As materials have evolved and experience has been accrued with endovascular procedures, indications have come to include a vast spectrum of conditions including angiomyolipomas, vascular malformations, preoperative embolizations with the objective of attenuating intraoperative bleeding, 2,6 bleeding caused by iatrogenic injuries (percutaneous nephrolithotomy, biopsy, nephrostomy), ruptures of renal masses and penetrating and blunt renal traumas. 7,8 The availability of low profile catheters and more precise embolic agents have dramatically reduced morbidity associated with the procedure. 6 The majority of RAMLs are diagnosed incidentally, 2,3 because 60% are asymptomatic; and while the tumoral growth rate is unpredictable, the tendency is that growth will occur.…”

“…2 Criteria for intervention include diameter greater than 4 cm (some authors state 3.5 cm), intratumoral aneurysms larger than 4-5 mm 1,2 and pain, active hemorrhage, 1 multiple RAMLs, bilateral RAMLs or unilateral RAML when the patient only has one kidney, and patients with tuberous sclerosis complex. 1,2,7 Several different studies have demonstrated the efficacy of embolization for treatment and prevention of hemorrhage. [1][2][3][4] The procedure can be performed under local anesthesia, with or without sedation, but some authors believe that the procedure can be conducted more quickly and with greater safety under general anesthesia.…”

“…3,6-8 Furthermore, it will often enable preservation of more functional nephrons than surgical resection. 3,7 In the case described above, factors such as extending the duration of the procedure, the need for additional injections of iodinated contrast and the possibility of ischemia of the renal parenchyma because of failure to obtain superselective catheterization in a patient with only one kidney all contributed to the decision to end the procedure without having achieved embolization of the tumor located at the upper pole of the kidney. Considering the diameter of the tumor, it is likely that another attempt will be made at embolization directed specifically at this tumor, depending on the opinion of the treating urologist.…”

“…2 Also important are the minimally invasive character of the endovascular procedure, the low rate of early and late complications, the possibility of being performed under local anesthesia, and minimal intraoperative bleeding. 7 In cases with active hemorrhage, the procedure has success rates of up to 86%, in addition to provoking gradual reduction of the tumor. As an elective procedure it prevents hemorrhages in up to 94% of cases, and duration of hospital stay does not tend to exceed 24 hours.…”

“…3 Nowadays, embolization is the method of choice because of its minimally invasive character, because it prevents tumour rupture over the long term, because it has the capacity to preserve the normal renal parenchyma adjacent to the tumor, 1-3,5-8 and because it is associated with a low rate of complications. 1,4,6,7 The role of embolization in the presence of bleeding is already well-established. However, there is no consensus on when to intervene preventively.…”