Embolization of a bleeding renal angiomyolipoma in pregnancy: case report and review

Kidney transplantation in patients with tuberous sclerosis complex

BACKGROUND

Tuberous sclerosis complex (TSC) is a disorder of the mammalian target of the rapamycin (mTOR) pathway associated with the development of multisystem tumors, including renal angiomyolipoma (AML). These renal tumors are benign by nature but locally invasive and carry a risk for the progression of chronic kidney disease (CKD) to end stage kidney disease (ESKD). The frequency of subsequent renal transplantation in this population is largely uncharacterized, although single-center data suggests that 5%-15% of adult TSC patients are kidney transplant recipients.

METHODS

This retrospective cohort study utilized United Network for Organ Sharing (UNOS) data. We included candidates waitlisted between 1987 and 2020 for a first kidney transplant with TSC-associated kidney failure. We utilized descriptive statistics to characterize the frequency of first-time kidney transplant waitlisting and transplantation among persons with TSC and the Fine-Gray subdistribution hazard model to evaluate characteristics associated with progression from waitlist.

RESULTS

We identified 200 TSC-associated kidney failure patients within the waitlist cohort. Of these, 12 were pediatric patients. Two-thirds (N = 134) of waitlisted persons were female. One hundred forty patients received a transplant with a median waitlist time of 2 years. Younger age at waitlisting was associated with a greater probability of progressing to transplant (HR 0.98 [95% CI: 0.96-0.99]). 91.8% of kidney transplant recipients survived 1-year post-transplant with a functioning allograft.

CONCLUSIONS

The majority of patients with TSC who are waitlisted for a kidney transplant progress onto transplantation with excellent 1-year post transplant patient and allograft survival.

TSC2/PKD1 contiguous deletion syndrome in a pregnant woman: A case report

TSC2/PKD1 contiguous gene deletion syndrome is a disease caused by the deletions of the TSC2 and PKD1 genes. This is a rare contiguous genomic disease with clinical manifestations of tuberous sclerosis and polycystic kidney disease. To our knowledge, this case report is the first known case of TSC2/PKD1 contiguous gene deletions in a pregnant woman. The patient had multiple renal cysts, angiomyolipoma, hypomelanotic macules, shagreen patch, subependymal giant cell astrocytoma, multiple cortical tubers, and subependymal nodules. The patient underwent genetic testing. To exclude genetic defects in the fetus, prenatal fetal genetic testing was performed after obtaining the patient's consent. We found an increasing trend in the size of renal cysts and renal angiomyolipomas in patients with polycystic kidney with tuberous sclerosis during pregnancy. Through enhanced clinical monitoring of patients and prenatal genetic testing of the fetus, timely and effective clinical intervention for the mother may be achieved, thus obtaining the best possible outcome for both mother and fetus.

Varying Outcomes among Patients with Large Angiomyolipomas according to the Treatment Method

PURPOSE

This study aimed to evaluate the outcomes of large angiomyolipoma (AML) treatment by selective arterial embolization (SAE) versus nephron-sparing surgery (NSS) using a robotic surgical system.

MATERIALS AND METHODS

Between January 2011 and June 2018, we retrospectively reviewed 25 patients who underwent robot-assisted partial nephrectomy (RAPN) or SAE for large AMLs. Ten patients underwent RAPN, and 15 underwent SAE. Patient demographics, AML characteristics, and operative and postoperative clinical outcomes were recorded and analyzed. Outcomes were compared between patients who underwent RAPN and patients who underwent SAE. Specifically, changes in renal function and size were evaluated after the treatment.

RESULTS

The mean age of the patients was 52.9 years, and 22 of 25 patients were female. The mean maximum AML diameter on computed tomography was 8.9 cm, and 8 patients had multiple masses. Twenty-two of 25 patients had moderate to high RENAL complexity. Patients who underwent SAE had more symptoms (p = 0.018) and higher RENAL complexity scores (p = 0.013) on average. On average, tumor size decreased by 99% among RAPN patients and by 58% among SAE patients (p = 0.001). Although the mean pretreatment estimated glomerular filtration rate (eGFR) was higher among RAPN patients (99.8 vs. 80.0 mL/min/1.73 m2, p = 0.043), there were no significant changes in eGFR in either group after the treatment. One patient in the RAPN group experienced complications, but the postoperative ileus resolved without intervention.

CONCLUSIONS

Both RAPN and SAE were effective and feasible treatment options for large AMLs. The AML characteristics and the condition of the patient might be important in determining the appropriate treatment method.

Management of renal tumors during pregnancy: case reports

BACKGROUND

Renal tumors during pregnancy are rare and the treatment requires evaluation of both the patient and the fetus. No consensus or guidelines has been proposed or verified in this field. We successfully managed three renal tumor cases during pregnancy and reviewed the relative literature.

CASE PRESENTATION

In the first renal cell carcinoma case diagnosed in the 21st week of pregnancy, laparoscopic retroperitoneoscopic partial nephrectomy was performed in the 26th week of pregnancy. In the second renal cell carcinoma case diagnosed in the 3rd week of pregnancy, laparoscopic retroperitoneoscopic radical nephrectomy was carried out after the abortion. In the third angiomyolipoma case who was diagnosed before pregnancy but received no treatment, we performed laparoscopic retroperitoneoscopic partial nephrectomy during the 17th week of pregnancy due to the rapid enlargement of the tumor.

CONCLUSION

Although no consensus or guidelines for the management of renal tumors in pregnant patients has been proposed or verified, the general rules of kidney tumor management in non-pregnant patients and the guidelines for surgery in pregnancy could be referred to. Renal tumors found in pregnant patients require an individualized treatment regimen involving surgical timing, routes, techniques, and excision ranges, which should be decided by both the patients and the surgical teams.

Spontaneous rupture of enormous renal angiomyolipoma in a pregnant tuberous sclerosis patient: a rare case

Background

Renal angiomyolipoma (RAML) is a rare benign kidney tumour comprised of adipose tissue, smooth muscle, and blood vessels. It can cause fatal complications if it ruptures. Although there have been reports of RAMLs rupturing, it is unusual to see RAMLs rupture during pregnancy, especially in pregnant women with tuberous sclerosis (TSC). Moreover, we reported a rare complication after selective arterial embolization (SAE) for the first time, which called aseptic liquefaction necrosis.

Case presentation

The case is a 16-week-pregnant woman with TSC who presented with severe flank pain, which was secondary to the rupture of a large, previously unknown RAML. This was confirmed by emergency computed tomography and successfully treated with selective arterial embolization after the patient received counselling and provided prior informed written consent for medical termination of pregnancy (MTP). The patient underwent abortion 3 weeks after the SAE. The patient required drainage 2 months after the SAE because of aseptic liquefaction necrosis. During follow-up, the patient’s lesion remained stable.

Conclusion

RAML rupture is a rare but rather serious complication in pregnant tuberous sclerosis patients. Selective arterial embolization (SAE) should be performed immediately, and the status of the pregnancy needs to be assessed by a multidisciplinary team. We also report for the first time the rare complication of aseptic liquefaction necrosis after SAE of RAML, for which percutaneous drainage is effective.

Diagnostic value of ultrasound in the spontaneous rupture of renal angiomyolipoma during pregnancy: A case report

BACKGROUND

Spontaneous rupture and hemorrhage of renal angiomyolipoma (RAML) is a life-threatening clinical emergency. When it occurs during pregnancy, it is compared to a “bomb explosion,” which makes the diagnosis and treatment more challenging. An ultrasound examination is a quick and safe examination with the benefit of no radiation exposure, which is always preferred for pregnant women. Currently, cases of spontaneous rupture and hemorrhage of RAML during pregnancy are rare, as is the diagnostic value and characteristics of ultrasound. The lack of understanding of the condition among ultrasound doctors makes it prone to misdiagnosis. In this study, we present the case of a pregnant woman who was preliminarily diagnosed with spontaneous rupture and hemorrhage of the left RAML using ultrasound and discuss the ultrasound characteristics.

CASE SUMMARY

A 38-year-old woman in her 19^th wk of pregnancy (G2P1) was referred to our clinic for a sudden, persistent pain on the left side of the waist. She had not undergone any previous related abdominal examination. Ultrasound of the urinary system revealed a giant nonhomogenous lump in the left kidney area. The diagnosis was considered spontaneous rupture and hemorrhage of the left RAML in pregnancy via ultrasound. Her left-side waist pain continued to be intense. Subsequently, she underwent computed tomography, which led to the same diagnosis. Based on many factors, the patient underwent left nephrectomy after the induction of labor. The pathological result was the rupture and hemorrhage of a vascular leiomyoma lipoma.

CONCLUSION

Ultrasound examination plays an important role in the diagnosis of the spontaneous rupture and hemorrhage of RAML during pregnancy.

Wunderlich's syndrome in pregnancy: a shocking triad

Wunderlich’s syndrome, non-traumatic renal haemorrhage into the subscapular and perinephric space, in pregnancy, is a very rare clinical entity. We describe a case of Wunderlich’s syndrome in a 29-year-old gravida 5 para 4 who presented to our emergency department with sudden onset severe left flank pain. On assessment, she was clinically shocked—hypotensive, tachycardic and perfused poorly peripherally. Ultrasound of the abdomen and pelvis and subsequent MRI of the left kidney revealed a large hypervascular exophytic lesion arising from the left renal pole—appearance consistent with an angiomyolipoma. This specific presentation is clinically characterised as Lenk’s triad—acute flank pain, flank mass and hypovolaemic shock. The patient was adequately resuscitated and interventional radiological embolisation of the mass was performed. She went on to have an uneventful pregnancy and delivered vaginally after induction at 38 weeks of gestation.

Wunder-women: Systematic review of causes, treatment and outcomes of Wunderlich syndrome during pregnancy

Objective:

The objective of this article is to conduct a contemporary literature review on Wunderlich syndrome, or spontaneous renal haemorrhage (SRH), among pregnant women to describe contemporary aetiology, investigations and management patterns.

Methods:

A systematic review of MEDLINE and CENTRAL in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. All articles, including case reports and case series on SRH published from 2000 to 2016, were included. Full-text manuscripts describing SRH among pregnant women were reviewed for clinical parameters, which were collated and analysed.

Results:

Twenty cases of SRH in pregnant women were identified. The median age and gestation were 32.1 years and 26.5 weeks, respectively, with SRH most commonly occurring in the third trimester (nine patients; 45%) and due to renal neoplasm, specifically angiomyolipoma (AML; 12 patients; 60%), followed by renal artery aneurysm (RAA; five patients; 25%). Surgical intervention (55%) was most commonly used for acute SRH. Foetal demise was not uncommon (15%).

Conclusions:

SRH in pregnant women is an uncommon but complex urological and obstetric emergency with potentially catastrophic consequences. A multidisciplinary approach is key to timely diagnosis and appropriate management considering the well-being both of mother and foetus. Pre-emptive diagnosis and intervention may reduce complications.

Level of evidence:

4

The Risks of Renal Angiomyolipoma: Reviewing the Evidence

Renal angiomyolipoma (RAML), though a rare benign tumor, may impose a significant morbidity or even mortality due to its unique characteristics and the complications subsequent to its treatment. The classic tumor variant is composed of smooth muscular, vascular, and fatty components. The most straightforward diagnosis is when the fat component is abundant and gives a characteristic appearance on different imaging studies. In fat-poor lesions, however, the diagnosis is difficult and presumed a renal cell carcinoma. Yet, some variants of RAML, though rare, express an aggressive behavior leading to metastasis and mortality. The challenge lies in the early detection of benign variants and identifying aggressive lesions for proper management. Another challenge is when the vascular tissue component predominates and poses a risk of hemorrhage that may extend to the retroperitoneum in a massive life-threatening condition. The predicament here is to identify the characteristics of tumors at risk of bleeding and provide a prophylactic treatment. According to the clinical presentation, different treatment modalities, prophylactic or therapeutic, are available that span the spectrum of observation, embolization, or surgery. Renal impairment may result from extensive tumor burden or as a complication of the management itself. Improvement of diagnostic techniques, super-selective embolization, nephron-sparing surgery, and late treatment with the mammalian target of rapamycin inhibitors have provided more effective and safe management strategies. In this review, we examine the evidence pertaining to the risks imposed by RAML to the patients and identify merits and hazards associated with different treatment modalities.

Wunderlich Syndrome due to Ruptured Pseudoaneurysm of Angiomyolipoma in First Trimester: A Rare Case Report

Angiomyolipoma (AML) is a rare benign tumour of kidney which demonstrates rapid growth during pregnancy due to hormonal stimulation, leading to rupture. Majority of reported ruptured AMLs are in third trimester. We report a case of ruptured angiomyolipoma at 10th week of gestation, the earliest rupture known in singleton pregnancy. The AML had pseudo-aneurysm formation with extra-tumoural rupture during pregnancy, a finding never reported in literature yet. The patient had active bleeding with expanding peri-nephric haematoma during initial two days of conservative management. Hence, after counselling and taking prior informed written consent for Medical Termination of Pregnancy (MTP), computed tomography scan of abdomen with angiography followed by emergency coil embolization of the bleeding right upper polar segmental artery was done. After stabilization, MTP was done at 12th week of gestation. Counselling and consent for continuing or aborting the pregnancy is of utmost importance for best possible outcome for patient and foetus.

Successful Pregnancy Outcome in a Patient with Solitary Kidney Affected by Angiomyolipoma: A Rare Case

Renal angiomyolipoma is a rare benign tumour and its occurrence during pregnancy is even rare. It is usually diagnosed incidentally. It can increase in size during pregnancy and can present acutely as rupture with retroperitoneal haemorrhage, mechanism of which is still unclear. We present a case of successful pregnancy outcome in a patient with congenital solitary kidney affected by angiomyolipoma, diagnosed incidentally at 19 years of age. The patient had conceived twice. Her antenatal and post partum period was uneventful both the times.

Yolk sac tumor of the ovary in a young girl with tuberous sclerosis: A case report and review of the literature

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We reported the first tuberous sclerosis patient with an ovarian yolk sac tumor.

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Although angiomyolipoma is a common benign tumor in TS patients, abdominal malignancies must be considered.

Renal angiomyolipoma during pregnancy: Case report and literature review

Renal angiomyolipoma is a rare tumor that can be either sporadic or found together with tuberous sclerosis or pulmonary lymphangioleiomyomatosis. These tumors are hormone sensitive and therefore tend to grow during pregnancy and their main complication is the risk of rupture. Optimal management is still controversial because there are very few cases reported in the literature. We expect that the case of our patient, who delivered her baby vaginally at 36 weeks of gestation and underwent definitive treatment (nephrectomy) thereafter, to further enhance the knowledge about the management of these rare tumors during pregnancy.

Renal angiomyolipoma and lymphangioleiomyomatosis in pregnancy

This is a literature review for management of angiomyolipoma (AML), lymphangioleiomyomatosis (LAM) and tuberous sclerosis (TS) during pregnancy, prompted by a case of a 23-year-old woman who presented with generalised itching at 31 weeks' gestation and was found to have a large vascular retroperitoneal mass in the lower pole of the left kidney. Magnetic resonance imaging (MRI) was suggestive of angiomyolipoma with multiple large aneurysms and haemorrhage within the tumour. She was delivered at 38 weeks by elective caesarean section, to avoid the risk of rupture and bleeding from the aneurysms during labour. Further imaging, with MR angiogram, computed tomography (CT) of the abdomen and pelvis and high resolution CT (HRCT) of the chest, confirmed lymphangioleiomyomatosis with left AML. She had embolisation of the AML performed twice, 8 weeks apart after delivery and subsequently had a left nephrectomy.

Selective arterial embolisation of bilateral angiomyolipomata in a symptomatic pregnant female

Renal angiomyolipoma (RA) is a rare benign tumour that can expand rapidly during pregnancy due to oestrogen and other hormonal factors. Complications associated with expanding renal angiomyolipomata are spontaneous retroperitoneal haemorrhage secondary to acute rupture and thrombosis of the renal vein or inferior vena cava. MRI is recommended for diagnostic purposes in pregnancy; however, this modality is not always readily available. In the present report, we describe the first case of bilateral selective arterial embolisation for renal angiomyolipomata presenting symptomatically in a previously healthy pregnant female.

Hereditary renal tumor syndromes: imaging findings and management strategies

OBJECTIVE

It is not rare for the radiologist to identify multiple renal masses and be the first to raise the possibility of a hereditary renal tumor syndrome. Characteristic renal and extrarenal imaging findings aid in making the correct diagnosis. The imaging findings, screening guidelines, and management techniques for the most common hereditary renal tumor syndromes are reviewed.

CONCLUSION

Hereditary renal tumor syndromes have specific screening guidelines and unique management techniques in which imaging plays a central role.

Embolization of renal hemorrhage in pregnancy

BACKGROUND

Selective embolization in pregnancy for treatment of renal hemorrhage has been reported infrequently in the literature; the possibility of minimizing radiation dose to the fetus by using dose-sparing fluoroscopy techniques is not commonly appreciated by the obstetric community.

CASE

We describe performing partial renal embolization with the use of all available radiation dose-sparing techniques. The patient had no further complications, and she and her newborn were well postpartum. A dose reconstruction indicated that the fetal dose from the procedure was less than 5 mGy.

CONCLUSION

When faced with a symptomatic renal hemorrhage in pregnancy, a renal angiogram and embolization by an experienced interventional radiologist are effective treatment options that can be performed with minimal fetal radiation risk.

Lymphangiomyomatosis discovered by massive hemoptysis during general anesthesia -A case report-

Lymphangiomyomatosis (LAM) is a rare lung disease that is characterized by the progressive proliferation of atypical smooth muscle-like cells, which leads to severe respiratory impairment and death. Dyspnea, cough, recurrent pneumothorax, and hemoptysis are the most common clinical symptoms of LAM. We report a 29-year-old female patient with massive hemoptysis during laparoscopic gynecologic surgery under general anesthesia, who was diagnosed with pulmonary LAM.

[Guidelines for the management of tuberous sclerosis complex renal disease]

PURPOSE

To review existing literature and deduce guidelines for the management of renal disease in patients with tuberous sclerosis complex (TSC).

PATIENTS

After review of literature, a core panel of five physicians wrote a draft that was evaluated by 14 reviewers who used a 9-level scale (1: total disagreement; 9: total agreement). The guidelines were then reformulated until each item received a median score superior or equal to 8.

RESULTS

Forty-eight to 80 % of TSC patients have significant renal involvement including angiomyolipomas (AMLs), cysts, malignant tumors and renal insufficiency. It is recommended to perform an abdominal ultrasound (and serum creatinine if abnormal ultrasound) when TSC is diagnosed. This work-up will be repeated every 3-5years if normal. Associated autosomal dominant polycystic kidney disease must be suspected in case of numerous and large cysts. After the age of 20, follow-up should use computed tomography (CT) or MRI that are more precise than ultrasound for the measurement of AMLs. Biopsy of a renal mass should be discussed in case of calcifications, necrosis or rapid growth. Females with TSC should undergo screening for pulmonary lymphangioleiomyomatosis by CT at the age of 18, and, if negative at the age of 30-40. Acute bleeding should be treated with percutaneous embolization. Asymptomatic angiomyolipomas with several risk factors (size>80mm, predominant vascular component, micro-aneurysms) should undergo prophylactic treatment, if possible using embolization. The role of mTOR inhibitors in the management of angiomyolipomas needs to be defined.

CONCLUSION

Standardization of follow-up and treatment is necessary to improve the management of TSC renal involvement.

Renal angiomyolipoma during pregnancy: review of the literature

The incidence of renal angiomyolipoma (RA) is 0.3% in the general population, and even more infrequent during pregnancy. Pregnancy can increase the risk of rupture, although the causal mechanism is still not clearly defined. We completed a Medline literature search for articles on RA and pregnancy and its complications. We identified 16 articles (all case reports), but selected only 13 because of unavailable data in the 3 other articles. We report the case of a 30-year-old primiparous woman who presented at the emergency ward with a non-reassuring pattern at fetal monitoring; an urgent cesarean section was decided and carried out. After surgery, a wide retroperitoneal hematoma was observed caused by the rupture of an RA. Conservative management by means of arterial embolism was done and the patient was discharged on postoperative day 10. RAs seem to have a higher risk of rupture during pregnancy, but they should be managed conservatively when hemodynamically possible. Individualization of each case is necessary in order to achieve the best outcome for both the mother and fetus.

Conservative management of a retroperitoneal hemorrhage following a ruptured renal angiomyolipoma in pregnancy

Retroperitoneal hemorrhage following ruptured renal angiomyolipoma is usually managed surgically or by embolization. But when the same episode occurs in pregnancy, surgery which predisposes to preterm delivery and its subsequent sequelae, the unknown influences of radiation exposure on the fetus makes the management of such cases very challenging. A 21-year-old woman was seen in the emergency unit at the 25th week of her pregnancy with complaints of sudden onset left flank pain radiating to the back, nausea and hematuria. Abdominal magnetic resonance imaging (MRI) revealed masses consistent with angiomyolipoma in the upper pole of the left kidney with evidence of recent bleeding and the center of the right kidney measuring 11.5 × 9.5 cm and 3.5 cm, respectively. The patient received three units of red blood cell concentrate due to fall in hematocrit level resulting in hemodynamically stable condition until term. At term, an infant weighing 3510 g was delivered through elective cesarean section. To avoid iatrogenic preterm delivery and unnecessary fetal exposure to radiation, conservative management of ruptured angiomyolipoma in pregnancy may be considered as a treatment option in hemodynamically stable patients.

Urologic emergencies in pregnancy

The management of urological emergencies during pregnancy presents unique clinical challenges for the treating physician. Clinical signs and symptoms are often subtle while diagnostic and therapeutic options are limited in treating patients to avoid fetal morbidity. A high index of suspicion with early diagnosis and treatment are essential for the management of genitourologic emergencies in pregnant women. It is essential for patients to be managed on an individual basis using a multidisciplinary approach.

Endovascular therapy for patients with renal angiomyolipoma presenting with retroperitoneal haemorrhage

We report our experience treating four patients with acutely bleeding angiomyolipoma (AML) of sizes between 4 and 12 cm who were managed with endovascular embolisation with a mean follow-up of 10 months. In our case series, we demonstrate that endovascular embolisation in the acute setting for bleeding AMLs is a viable treatment option. AML should be in the differential diagnosis of acutely bleeding renal masses, even when there is no fat assessed by computed tomography (CT) imaging in the renal mass.

Retroperitoneal haematomas in obstetrics: literature review

INTRODUCTION

There is paucity of literature on retroperitoneal haemorrhage/haematomas (RH) as these cases are extremely rare in obstetrics. Experience is available mostly from case reports and therefore the incidence of RH in obstetrics is unknown.

METHODS

Literature search in Medline/Pubmed and Google scholar using MeSH; aneurysm, haematoma, haemorrhage, obstetrics and retroperitoneal.

AETIOLOGY AND PATHOGENESIS

This article discusses aetiology, pathogenesis, diagnostic difficulties and dilemmas, as well as misleading symptoms that often mimic common clinical conditions.

DIAGNOSIS AND MANAGEMENT

Management of RH is complex and continues to improve with advancements in the investigative strategies, treatment options and critical care specialty. Further the authors highlight the importance of basic principles of clinical examination, the need for multidisciplinary input and the current trend in the management options.

Interventional radiology in the diagnosis, management, and follow-up of pseudoaneurysms

Arterial wall disruption, as a consequence of inflammation/infection, trauma (penetrating or blunt), or iatrogenic causes, may result in pseudoaneurysm formation. Currently, iatrogenic causes are increasing as a result of the growth of endovascular intervention. The frequency of other causes also seems to be increasing, but this may simply be the result of increased diagnosis by better imaging techniques, such as multidetector contrast-enhanced computed tomography. Clinically, pseudoaneurysms may be silent, may present with local or systemic signs, or can rupture with catastrophic consequences. Open surgical repair, previously the mainstay of treatment, has largely been replaced by image-guided occlusion methods. On the basis of an experience of over 100 pseudoaneurysms, treatments at various anatomical sites, imaging modalities used for accurate diagnosis, current changing therapeutic options for pseudoaneurysm management, approved embolization agents, and clinical follow-up requirements to ensure adequate treatment will be discussed. Image-guided direct percutaneous and endovascular embolization of pseudoaneurysms are established treatment options with favorable success rates and minimal morbidity. The pendulum has now swung from invasive surgical repair of pseudoaneurysms to that of image-guided interventional radiology.

Urologic malignancies in pregnancy

Urologic tumors during pregnancy are rare. Presenting symptoms of malignancies may be mistaken as typical symptoms in pregnancy. Evaluation and treatment of tumors of the adrenal gland, kidney, ureter, bladder, and urethra are reviewed based upon stage and type of tumor and stage of pregnancy.