Renal artery pseudoaneurysm following laparoscopic partial nephrectomy.

Department of Urology, Montefiore Medical Center, Bainbridge, Bronx, New York, USA.
Urology (Impact Factor: 2.42). 08/2009; 74(4):819-23. DOI: 10.1016/j.urology.2009.03.056
Source: PubMed

ABSTRACT To present our experience with the management of renal artery pseudoaneurysms following laparoscopic partial nephrectomy (LPN).
Our bi-institutional LPN database of 259 patients from July 2001 to April 2008 was queried for patients diagnosed with a postoperative renal artery pseudoaneurysm. Demographic data, perioperative course, complications, and follow-up studies in identified subjects were analyzed. Postembolization success was defined as symptomatic relief, resolution of hematuria, and a stable hematocrit and serum creatinine.
We identified 6 patients (2.3%) who were diagnosed with a renal artery pseudoaneurysm after LPN. The mean age of our cohort was 61.2 years (49-76), mean operative time was 208 minutes (140-265), and mean estimated blood loss was 408 mL (50-800). Patients presented at a mean of 12.6 days (5-23) after the initial surgery. Five patients had gross hematuria and a decreased hematocrit, with 1 patient presenting with clinical symptoms of hypovolemia. The sixth patient was incidentally diagnosed. The diagnosis of a renal artery pseudoaneurysm was confirmed in all cases by angiography. Selective angioembolization was successfully performed in all patients. At a median follow-up of 8.3 months all patients (100%) remained without any evidence of recurrence.
Although pseudoaneuryms are a rare postoperative complication of LPN, they are potentially life-threatening. Early identification and proper management can help reduce the potential morbidity associated with pseudoaneurysms. Our experience demonstrates the feasibility and supports the use of selective angioembolization as an excellent first-line option for patients who present with this form of delayed bleeding.

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    ABSTRACT: Objective: To report one of the largest series of clinical and renal function outcomes of treated iatrogenic vascular lesions (IVL) following partial nephrectomy (PN). Angioembolization (AE) is the treatment of choice for these lesions, but the additional renal injury conferred by this treatment has not been well described. Subjects/Patients: Patients that underwent open (OPN), laparoscopic (LPN) or robotic partial nephrectomy (RPN) from 2002-2012 were identified and those with AE were selected. Patients' charts were reviewed and renal function was analyzed using estimated GFR (eGFR) and progression of chronic kidney disease (CKD) classification before and after PN and AE. Results: 849 patients underwent PN and 28 (3.3%) developed an IVL. 20 (71%) presented with gross hematuria at a mean of 10.2 ± 7.7 days after PN and eight (28%) required transfusion. All patients had identifiable IVL at the time of selective AE and technical success was achieved in 24/28 (86%) although 4 required subsequent additional AE. The paired decrease in eGFR after PN was significant (p<0.01), while the paired change in eGFR after AE was not either with short-term (2.8 days) or intermediate-term (362 days) follow-up (p=0.50). Four patients experienced transient worsening in CKD classification after AE, although 3 experienced CKD stage improvement. Conclusion: Selective angioembolization for iatrogenic vascular lesions following partial nephrectomy is safe, efficacious and does not lead to a significant impairment of renal function. It remains the preferred approach for the evaluation and management of post-partial nephrectomy hemorrhage.
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    ABSTRACT: A patient with a pseudoaneurysm of the right renal artery underwent treatment with percutaneous approach. No complications were observed. Based on the experience described in this report, a percutaneous ultrasound guided approach can be proposed in selected patients. Renal insufficiency and allergic reactions are potential contraindications to angiography with conventional ionic iodinated contrast dye in patients who need endovascular stent-graft placement. Real-time contrast-enhanced ultrasound (CEUS) guided endovascular procedures may provide an alternative to overcome these limitations. We report an endovascular renal artery repair in a solitary kidney patient with an asymptomatic infrarenal aortic aneurysm and renal insufficiency due to phenacetin abuse. The precise placement of the stent-graft was performed with CEUS and intraprocedural angiographic fluoroscopy without the use of any nephrotoxic contrast dye. During follow-up, CEUS was used to exclude endoleaks, stent-graft failure or malposition.
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