Management of Severe Bleeding Following Partial Nephrectomy With Selective Renal Artery Embolization: A Case Report

ABSTRACT

We describe the immediate and short-term effects of selective transcatheter embolization of the renal artery used to treat severe bleeding that followed nephron-sparing surgery. The patient was a 27-year-old male with renal cell carcinoma that was associated with von Hippel Lindau syndrome. Partial nephrectomy was performed to remove a tumor mass. On the 7^th postoperative day, the patient demonstrated macrohematuria, strong flank pain, a significant drop in hemoglobin level, and an increase in creatinine level. CT scan indicated the presence of hemorrhagic blots in the left renal pelvis and left ureter and disorganization of the caliceal group on the upper pole. Selective embolization was performed. Three months later, creatinine level measurements (1.4 mg/dL) showed relatively good function of the remaining kidney. A MAG3 nephrogram revealed a 65-35 split function. The immediate radiologic and clinical success of selective transcatheter embolization in this complication of partial nephrectomy is discussed.

Stavros N Charalambous, Aristidis Karelis, Asterios Fotas, Ioannis Vouros, Athanasios Papathanasiou, Vasilios Rompis

Urological Department, Ippokratio General Hospital, Thessaloniki, Greece

Submitted July 3, 2010 - Accepted for Publication October 23, 2010

KEYWORDS: Partial nephrectomy; Embolization; Renal artery bleeding; von Hippel-Lindau syndrome.

CORRESPONDENCE: Stavros Charalambous MD, PhD, FEBU, Consultant Urologist, Urological Department, Ippokratio General Hospital, 49 Kostantinoupoleos str., 54642 Thessaloniki, Greece ().

CITATION: UroToday Int J. 2010 Dec;3(6). doi:10.3834/uij.1944-5784.2010.12.09

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; PN, partial nephrectomy; VHL, von Hippel-Lindau.

INTRODUCTION

Partial nephrectomy (PN) is an alternative surgical treatment that is widely accepted in order to avoid total nephrectomy in many cases of renal tumors. Initially, this form of operation was used in patients with a solitary kidney, bilateral renal tumors, or renal insufficiency. More recently, it is also the surgical option for small-sized tumors in patients with a normal contralateral kidney [1]. Today, PN is also indicated for renal tumors that invade renal parenchyma and might affect the collecting system [2]. European Association of Urology guidelines recommend, "Whenever technically feasible, nephron-sparing surgery is the standard procedure for solitary renal tumors up to a diameter of 7 cm" [3].

The efficacy of PN is similar to that of radical nephrectomy [4,5,6]. Early or late complications of the procedure are relatively rare. The most common complication is early postoperative hemorrhage, with an incidence up to 5.26% [7,8]. Management of this rare complication with transcatheter-selective renal artery embolization is successful [9]. In the present case report, we evaluate the immediate and short-term effects of transcatheter embolization used to treat severe bleeding after partial nephrectomy in a young patient with renal cell carcinoma.

CASE REPORT

A 27-year-old male patient was admitted to our clinic. He was diagnosed with a subdense, round, cystic lesion in the upper pole of the left kidney that was suggestive of malignancy. In 2008, he was diagnosed with von Hippel-Lindau (VHL) syndrome, and the cyst was incidentally discovered during his periodic imaging surveillance with abdominal computed tomography (CT) (Figure 1). A contrast-enhanced magnetic resonance image of the kidneys in 2009 showed a cystic lesion of the left kidney with septation that enhanced after contrast administration (Figure 2). The cyst size was larger in diameter (3.8 cm) in 2009 than it was in the 2008 CT scans (3.0 cm).

In his recent medical history, the patient had microscopic hematuria and high blood pressure, which responded well to antihypertensive drugs. In his past medical history, the patient underwent orchiectomy in 2001 because of a seminoma tumor. In 2004, a hemangioblastoma of the cerebellum was detected and neurosurgical excision was performed. The patient's performance status was good.

Surgical exploration of the left kidney was suggested to the patient, and in June 2009 a detailed informed consent was obtained. The surgical exploration was performed under general anesthesia with the patient in a lateral position. Surgery revealed a tumor mass. Partial nephrectomy was performed, using warm ischemia for less than 35 minutes and sutures during renorrhaphy for the closure of the renal defect. Sterile absorbable patches that consisted of equine collagen coated with fibrin glue components, human fibrinogen, and human thrombin were also applied in order to shorten time to hemostasis. No blood transfusions were required intraoperatively.

During the 7^th postoperative day, macrohematuria was present and the patient complained of strong flank pain. A significant drop of the hemoglobin level was noticed. He was treated conservatively with blood transfusions and analgesics were administered. A significant increase in his blood pressure occurred (170/110 mmHg). Creatinine levels also increased significantly, from 1.15 mg/dL preoperatively to 1.6 mg/dL postoperatively. An emergency CT scan indicated the presence of hemorrhagic blots in the left renal pelvis and left ureter (Figure 3). Disorganization of the caliceal group on the upper pole was also noticed.

Selective embolization was chosen (Figure 4). Under local anesthesia in the right groin, a steath catheter was placed in the common femoral artery. The segmental arteries feeding the blood extraction were identified. Coils were positioned and Gelfoam pledgets (Pfizer; Belgium NV) were also used as embolizing material. Macrohematuria was controlled. The patient was released after 7 days.

Two weeks later, a nephrogram with 99mTc-MAG3 indicated that the left renal artery was not totally occluded. Significant decrease in the left renal function was noticed (75-25 split function). Three months later, the creatinine level measurements showed relatively good function of the remaining kidney (1.4 mg/dL). A second MAG3 nephrogram revealed a 65-35 split function

Biopsy results confirmed the initial diagnosis of RCC. The subtype was a clear cell carcinoma with Fuhrman grade 1-2. The tumor was evaluated as pT1a according to the TNM classification. No positive surgical margins have been detected.

DISCUSSION

The primary cause of morbidity and mortality in VHL disease is the malignant degeneration of renal cysts. Prevalence of renal carcinoma has reached 75% in autopsy series [4,5]. A nephron-sparing approach is used in such patients in order to preserve renal function. Despite the wide acceptance of the procedure, it still remains challenging. During the early postoperative period, hemorrhage is the most common complication, with an incidence between 0% and 5.26% [4,5]. Intraparenchymal lessions, arteriovenus fistulas, urinomas, and arterial aneuryrsms have also been reported [8,9,10]. In these cases, the role of the interventional radiologist is to manage these complications.

International studies and clinical experience show that angiographic embolization after PN is feasible [11]. In this procedure, there are aspects that must be evaluated. One of these aspects is the preintervention findings of the patients that will continue after the procedure. For example, borderline creatinine levels and renal dysfunction might exist preoperatively or might be induced during PN by loss of renal parenchyma. For these reasons, nephrotoxic contrast agent application should be evaluated for every patient separately and always with a minimizing tendency. The new generation of scanners could help in the identification of accessory renal arteries [12]. Another important aspect of the procedure is the need to prevent further hemorrhage of the feeding vessel while sparing renal parenchyma. Superselection of the feeding branches can minimize the loss of renal tissue [11].

It is well understood that the primary goal of embolization is cessation of the bleeding. Embolizing material can be placed in columnar, segmental, and interlobar artery levels. Our patient presented bleeding from a segmental artery. Embolization of such an artery can lead to major parenchymal infarction and reduced kidney function. If renal function before embolization is not impaired, more extensive parenchymal loss is still preferred over total nephrectomy [13]. We preferred occlusion of this vessel over total nephrectomy because of the young age of the patient and his past medical history of VHL disease. In our patient, permanent occlusion of the feeding vessel contributing to renal bleeding showed that embolization was successful, although elevation of the serum creatinine level was indicative of loss of renal parenchyma after embolization. Generally, it is necessary to avoid occlusion of the proximal great vessels or the smaller vessels in order to keep parenchymal loss to a minimum [13].

Close surveillance of renal function and hemoglobin levels must follow embolization treatment. The development of newer superselective coaxial catheters has led to more directed therapy, less nontarget tissue ablation, and greater nephron preservation [14]. Currently, microvascular catheters and microcoils are available that can precisely cannulate the distal traumatized vessel. Microcoils are desirable because of their accuracy and radiopacity [15]. The main disadvantage of coils is that usually more than 1 coil is required for adequate occlusion, which increases the cost and procedure time [16].

Postembolization syndrome consists of pain and hyperpyrexia. It has been documented after selective embolization with polyvinyl alcohol (PVA) particles and gelatin sponges. These materials have the potential to reflux and cause the undesired ablation of untargeted tissue [15]. The incidence of renal artery dissection after catheter-based therapy has been reported to be as high as 7.5% [17]. Our patient did not present with any of these complications. Generally, the efficiency of percutaneous transcatheter embolization depends on the appropriate choice of the embolization material. The material should be chosen according to the site, size, and flow pattern of the vessels to be occluded [18].

CONCLUSION

Renal artery embolization appears to be an efficient and feasible method for patients with renal hemorrhaging after partial nephrectomy. It is less invasive than total nephrectomy, with a low complication rate and well-accepted effectiveness.

REFERENCES

Van Poppel H, Dilen K, Baert L. Incidental renal cell carcinoma and nephron sparing surgery. Curr Opin Urol. 2001;11(3):281-286.

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