Multiple Renal Artery Pseudoaneurysms in Patients Undergoing Renal Artery Embolization Following Partial Nephrectomy: Correlation with RENAL Nephrometry Scores

Long term renal function following selective angioembolization for iatrogenic vascular lesions after partial nephrectomy: A matched case-control study

Purpose

Partial nephrectomy is associated with a 1%–2% risk of renal iatrogenic vascular lesion (IVL) that are commonly treated with selective angioembolization (SAE). The theoretical advantage of SAE is preservation of renal parenchyma by targeting only the bleeding portion of the kidney. Our study aims to assess the long-term effect of SAE on renal function, especially that this intervention requires potentially nephrotoxic contrast load injection.

Materials and Methods

A retrospective review of patients undergoing partial nephrectomy between 2002 and 2018 was performed, and patients who developed IVL were identified. A 1:4 matched case-control analysis was performed. Paired t-test and χ² test were used for continuous and categorical variables, respectively. Multivariable logistic and Cox proportional hazards regression analyses were used to identify risk factors and confounders for SAE and postoperative renal function.

Results

Eighteen patients found to have an IVL after partial nephrectomy were matched with 72 control patients. IVL's were more common in patients after minimally invasive partial nephrectomy (89% vs. 70%, p=0.008) and in those with higher RENAL nephrometry scores (8.8±2.0 vs. 6.5±1.8, p<0.001). On multivariable analysis, lower RENAL scores proved to decrease the odds of requiring postoperative SAE. No significant difference in renal function outcomes was seen at 24 months of follow-up after surgery.

Conclusions

SAE for the management of IVL following partial nephrectomy is a safe and efficient procedure with no significant impact on short or long-term renal function. Less complex renal tumors with lower RENAL scores are less likely to require postoperative SAE.

Safety and efficacy of embolotherapy for severe hemorrhage after partial nephrectomy

BACKGROUND

Partial nephrectomy may be complicated by postoperative hemorrhage, which may be treated by transcatheter embolization.

PURPOSE

To assess the safety and efficacy of embolotherapy for hemorrhagic complications of partial nephrectomy and to analyze the potential correlation between multiple bleeding sites on angiography and surgical complexity.

MATERIAL AND METHODS

A cohort of 25 patients presenting with severe, postoperative bleeding after partial nephrectomy and treated with catheter-directed superselective embolization was included. Patients' demographics, radiological investigations before the embolization, and clinical outcome after embolization were analyzed. Mann-Whitney U test was used to analyze the potential difference in the RENAL score between patients with one or more bleeding sites in the resection area.

RESULTS

Selective renal angiography revealed multiple bleeding sites at the resection bed in 8 (32%) patients with amorphous contrast extravasation in 10 (40%) patients. Embolization with use of a microcatheter and microcoils was effective to stop the bleeding in all but one patient, the latter requiring a second embolization two days later. Transient decrease in renal function was noted in 3/25 (12%) patients with full recovery in two of the three. Patients with multiple bleeding sites did not show significantly different RENAL scores compared to patients with a single bleeding site (P = 0.148).

CONCLUSION

Embolotherapy for postoperative partial nephrectomy-related bleeding is safe and effective with a low rate of recurrent bleeding. The number of bleeding sites at the resection area did not correlate to the RENAL score.

Clinical factors that influence the occurrence of symptomatic pseudoaneurysms and arteriovenous fistulas after partial nephrectomy: multi-institutional study of renal function outcomes after one year of selective arterial embolization

PURPOSE

Renal artery pseudoaneurysms (RAPs) and arteriovenous fistulas (AVFs) are rare but potentially life-threatening complications after partial nephrectomy (PN). Selective arterial embolization (SAE) is an effective method for controlling RAPs/AVFs. We assessed the clinical factors affecting the occurrence of RAPs/AVFs after PN and the effects of SAE on postsurgical renal function.

MATERIALS AND METHODS

Four hundred ninety-three patients who underwent PN were retrospectively reviewed. They were placed in either the SAE or the non-SAE group. The effects of clinical factors, including R.E.N.A.L. scores, on the occurrence of RAPs/AVFs were analyzed. The influence of SAE on the estimated glomerular filtration rate (eGFR) during the first postoperative year was evaluated.

RESULTS

Thirty-three (6.7%) patients experienced RAPs/AVFs within 8 days of the median interval between PN and SAE. The SAE group had significantly higher R.E.N.A.L. scores, higher N component scores, and higher L component scores (all, p <0.05). In the multivariate analysis, higher N component scores were associated with the occurrence of RAPs/AVFs (Odds ratio: 1.96, p=0.039). In the SAE group, the mean 3-day postembolization eGFR was significantly lower than the mean 3-day postoperative eGFR (p <0.01). This difference in the eGFRs was still present 1 year later.

CONCLUSIONS

Renal tumors located near the renal sinus and collecting system were associated with a higher risk for RAPs/AVFs after PN. Although SAE was an effective method for controlling symptomatic RAPs/AVFs after PN, a procedure-related impairment of renal function after SAE could occur and still be present at the end of the first postoperative year.

Selective Trans-arterial Embolization of Iatrogenic Vascular Lesions Did Not Influence the Global Renal Function After Partial Nephrectomy

OBJECTIVE

To evaluate the renal function outcomes after selective trans-arterial embolization (SAE) of iatrogenic vascular lesions (IVL), including pseudoaneurysm and arteriovenous fistula, following partial nephrectomy (PN).

MATERIALS AND METHODS

A multi-institutional study was conducted including consecutive patients who underwent PN between January 2009 and March 2019. Two surgical approaches were used: open and robot-assisted PN. Patients with SAE were identified and matched (1:2) with patients without IVL. The matching criteria were age, gender, Charlson score, creatinine clearance, RENAL score, and tumor size. The primary outcome was the evolution of global renal function at 6-months postoperatively.

RESULTS

A total of 493 consecutive PN (360 open PN and 133 robot-assisted PN) were included. IVL occurred in 17 cases (3.4%) without statistical difference according to the surgical approach (P = .78). Patients from embolization group were matched to 34 cases without postoperative IVL. Groups were comparable concerning clinical, tumor and surgical characteristics. The clinical success of SAE, defined as the absence of recourse to a second embolization or a total nephrectomy, was obtained in 16 (94.1%) cases. No minor or major complications were reported after SAE. The preoperative estimated glomerular filtration rate (eGFR) was similar between control group (93 [85-102] ml/min) and embolization group (95 [83-102] ml/min) (P = .99). Median (IQR) eGFR between control group (87 [72-95] ml/min) and embolization group (83 [76-93] ml/min) at a follow-up of 6 months showed no significant difference (P = .73).

CONCLUSION

IVL are rare complications of PN. SAE is an effective and minimally invasive management tool, with no deleterious effect on global renal function.

Performing an early systematic Doppler-ultrasound fails to prevent hemorrhagic complications after complex partial nephrectomy

Background:

The aim of this work was to assess the clinical relevance of a systematic postoperative Doppler-ultrasound (DU) after complex partial nephrectomy (PN).

Materials and methods:

All patients who underwent open, laparoscopic or robotic PN from 2014 to 2017 at our institution were included. Postoperative hemorrhagic complications (HCs) were defined as the occurrence of blood transfusion, hemorrhagic shock, arterial embolization, or re-hospitalization for hematoma. DU was systematically performed between post-op day 4 and 7 for every complex tumor (RENAL score ⩾ 7). DU was considered positive in the presence of pseudoaneurysm (PA) or arteriovenous fistula (AVF).

Results:

Among 194 patients, 117 underwent DU (60.3%). We reported 22 HCs (11.3%) requiring 8 selective embolization procedures (4.1%). HCs occurred during the hospital stay in 17 patients (77.3%), thus directly diagnosed on a computed tomography scan. Among the five patients (22.7%) with HC occurring after hospital discharge, between day 7 to 15, four had a previously negative systematic DU. Overall, systematic DU was positive in only five patients (4.3%) with only one patient of 194 (0.5%) undergoing preventive embolization of a PA-AVF. The negative predictive values (NPVs) and positive predictive values of DU were respectively 96.5% and 5%, with 20% sensitivity and 96.5% specificity.

Conclusions:

Our results may suggest offering systematic DU in patients under antiplatelet therapies, with high tumor size (>T1b), or early postoperative hemoglobin variations. A high NPV of DU might be counterbalanced by its low sensibility. Since all secondary HCs occurred between postoperative day 7 to 15, our results may suggest differing DU in selected cases.