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Mahmud H, Haitovic B, Zilberman DE, Rosenzweig B, Laufer M, Portnoy O, Fridman E, Dotan ZA. Robotic partial nephrectomy is associated with a significantly decreased rate of postoperative pseudoaneurysm compared to open and laparoscopic partial nephrectomy. J Robot Surg 2024; 18:241. [PMID: 38833079 DOI: 10.1007/s11701-024-01999-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Accepted: 05/27/2024] [Indexed: 06/06/2024]
Abstract
While partial nephrectomy offers oncologic efficacy and preserves renal function for T1 renal tumors, renal artery pseudoaneurysm (RAP) remains a rare but potentially life-threatening complication. This study compared RAP incidence across robotic-assisted (RAPN), laparoscopic (LPN), and open (OPN) partial nephrectomies in a large tertiary oncological center. This retrospective study analyzed 785 patients undergoing partial nephrectomy between 2012 and 2022 (398 RAPN, 122 LPN, 265 OPN). Data included demographics, tumor size/location, surgical type, clinical presentation, treatment, and post-operative outcomes. The primary outcome was RAP incidence, with secondary outcomes including presentation, treatment efficacy, and renal function. Seventeen patients (2.1%) developed RAP, presenting with massive hematuria (100%), hemorrhagic shock (5.8%), and clot retention (23%). The median onset was 12 days postoperatively. RAP occurred in 4 (1%), 4 (3.3%), and 9 (3.4%) patients following RAPN, LPN, and OPN, respectively (p = 0.04). Only operative length and surgical approach were independently associated with RAP. Selective embolization achieved immediate bleeding control in 94%, with one patient requiring a second embolization. No additional surgery or nephrectomy was needed. Estimated GFR at one year was similar across both groups (p = 0.53). RAPN demonstrated a significantly lower RAP incidence compared to LPN and OPN (p = 0.04). Emergency angiographic embolization proved effective, with no long-term renal function impact. This retrospective study lacked randomization and long-term follow-up. Further research with larger datasets and longer follow-ups is warranted. This study suggests that robotic-assisted partial nephrectomy is associated with a significantly lower risk of RAP compared to traditional approaches. Emergency embolization effectively treats RAP without compromising long-term renal function.
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Affiliation(s)
- Husny Mahmud
- Department of Urology, Affiliated to the Faculty of Medicine, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Tel Aviv, Israel.
| | - Boris Haitovic
- Unit of Interventional Radiology, Affiliated to the Faculty of Medicine, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Tel Aviv, Israel
| | - Dorit E Zilberman
- Department of Urology, Affiliated to the Faculty of Medicine, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Tel Aviv, Israel
| | - Barak Rosenzweig
- Department of Urology, Affiliated to the Faculty of Medicine, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Tel Aviv, Israel
| | - Menachem Laufer
- Department of Urology, Affiliated to the Faculty of Medicine, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Tel Aviv, Israel
| | - Orith Portnoy
- Diagnostic Imaging Department, Affiliated to the Faculty of Medicine, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Tel Aviv, Israel
| | - Eddie Fridman
- Pathology Department, Affiliated to the Faculty of Medicine, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Tel Aviv, Israel
| | - Zohar A Dotan
- Department of Urology, Affiliated to the Faculty of Medicine, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Tel Aviv, Israel
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Mavuduru RM, Mohd Ziauddin SA, Bora GS, Gorsi U. Renal artery pseudoaneurysm following robot assisted nephron sparing surgery: two case reports. J Med Case Rep 2024; 18:191. [PMID: 38637904 PMCID: PMC11027276 DOI: 10.1186/s13256-024-04510-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/15/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Renal artery pseudoaneurysm following partial nephrectomy is a rare entity, the incidence of this entity is more common following penetrating abdominal injuries, percutaneous renal interventions such as percutaneous nephrostomy(PCN) or Percutaneous nephrolithotomy (PCNL). Although rare, renal artery pseudoaneurysm can be life threatening if not managed timely, they usually present within two weeks postoperatively with usual presenting complains being gross haematuria, flank pain and/or anaemia. CASE PRESENTATION We report case of two female patients 34 and 57 year old respectively of South Asian ethnicity, presenting with renal artery pseudoaneurysm following left sided robot assisted nephron sparing surgery for interpolar masses presenting clinically with total, painless, gross haematuria with clots within fifteen days postoperatively and their successful treatment by digital subtraction angiography and coil embolization. CONCLUSION Renal artery aneurysm is a rare fatal complication of minimally invasive nephron sparing surgery however considering the preoperative and intraoperative risk factors for its development and prompt suspicion at the outset can be life saving with coil embolization of the bleeding arterial aneurysm.
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Affiliation(s)
| | | | | | - Ujjwal Gorsi
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
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Yasuda Y, Attawettayanon W, Nguyen JK, Kattar J, Lachowski M, Voros G, Kazama A, Campbell RA, Krishnamurthi V, Eltemamy M, Campbell SC. Neocapsular reconstruction for challenging partial nephrectomy: A feasibility study in a porcine model and recent clinical experience. Int J Urol 2023; 30:1165-1174. [PMID: 37665182 DOI: 10.1111/iju.15293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/22/2023] [Indexed: 09/05/2023]
Abstract
OBJECTIVES Multifocal renal masses and large central-endophytic tumors can be challenging for partial nephrectomy (PN) due to the paucity of capsule remaining after tumor removal. Our objective was to develop a neocapsule to provide tamponade and test its feasibility/safety in a porcine model. METHODS Eight live pigs (50-70 kg) underwent unclamped open right flank PN. Renal defects were 1 cm deep and had moderate ongoing venous bleeding. A 6 × 9 inch sheet of Nu-knit® was used for neocapsular reconstruction with Fibrillar™ packing to provide modest tamponade and preclude ongoing bleeding. Blood chemistry and hemoglobin (Hb) levels were drawn preoperatively and postoperative Days 3/5/8. On postoperative Day 8, euthanasia was performed, and both kidneys were inspected and analyzed for histologic changes. RESULTS PN defects ranged from 1 × 1 × 1 cm to 4 × 2 × 1 cm; four pigs had PN performed in both poles and four in one pole. Neocapsular reconstruction was successful (n = 8), with no perioperative complications. Median baseline Hb was 10.4 g/dL, and median Hb postoperative Days 3/5/8 were 10.0/10.8/10.6 g/dL, respectively. Median baseline serum creatinine (SCr) was 1.9 mg/dL, and median SCr postoperative Days 3/5/8 were 1.5/1.4/1.5 mg/dL, respectively. At sacrifice, no significant hematomas were observed. Other than adjacent to the PN site, there were no significant histologic changes in the parenchyma for operative kidneys versus controls. Based on our experience, we recently performed neocapsular reconstruction safely/effectively after extensive PN for multifocal tumors and for an allograft with difficult-to-manage subcapsular hematoma. CONCLUSIONS Neocapsular reconstruction after PN or capsular trauma appears feasible and safe and may be considered to reduce the risk of perioperative bleeding. However, further study will be needed to confirm the utility/efficacy of this approach.
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Affiliation(s)
- Yosuke Yasuda
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Tokyo Medical and Dental University, Graduate School, Tokyo, Japan
| | - Worapat Attawettayanon
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Division of Urology, Department of Surgery, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Songkhla, Thailand
| | - Jane K Nguyen
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Robert J Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jackie Kattar
- Department of Innovations, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mary Lachowski
- Department of Innovations, Cleveland Clinic, Cleveland, Ohio, USA
| | - George Voros
- Department of Innovations, Cleveland Clinic, Cleveland, Ohio, USA
- Biological Resources Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Akira Kazama
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Urology, Molecular Oncology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Rebecca A Campbell
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Mohamad Eltemamy
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Steven C Campbell
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Bonala N, Bhargavi V, Subbanna I, KS B, Patel R. Endovascular Rescue for Renal Artery Pseudoaneurysms following Minimally Invasive Robot-Assisted Partial Nephrectomy—A Case Series. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2022. [DOI: 10.1055/s-0041-1741528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractNephron sparing surgery or partial nephrectomy has been employed ever since in cases of renal tumors with an aim to preserve the function of residual kidney. Lately, there has been increasing adoption in robot-assisted techniques for partial nephrectomy. However, renal surgeries of any kind have always been a hazard for postoperative vascular complications owing to high vascularity of the renal tissues, of which renal artery pseudoaneurysm is one of the most fatal complications. We present a case series where highly super-selective embolization rescues the patient and augments the nephron sparing nature of the precise robot-assisted partial nephrectomy.
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Affiliation(s)
- Nagateja Bonala
- Department of Interventional Radiology, HCG Hospital, Bengaluru, Karnataka, India
| | - Vidya Bhargavi
- Department of Interventional Radiology, HCG Hospital, Bengaluru, Karnataka, India
| | - Indushekhar Subbanna
- Department of Interventional Radiology, HCG Hospital, Bengaluru, Karnataka, India
| | - Bharath KS
- Department of Interventional Radiology, HCG Hospital, Bengaluru, Karnataka, India
| | - Rajkumar Patel
- Department of Uro-oncology and Robotic Surgery, HCG Hospital, Bengaluru, Karnataka, India
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Otaño-Rivera V, Chelluri R, Guzzo TJ, Wein AJ, Mucksavage P. Detection of renal artery pseudo-aneurysm six months after robotic assisted partial nephrectomy in a patient whose only complaint was flank pain. Urol Case Rep 2020; 33:101259. [PMID: 32489893 PMCID: PMC7260674 DOI: 10.1016/j.eucr.2020.101259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 05/12/2020] [Accepted: 05/17/2020] [Indexed: 01/04/2023] Open
Abstract
Renal artery pseudoaneurysm (RAP) is a potentially life-threatening complication after partial nephrectomy (PN). Studies suggests that most cases present within 15 days post operatively with one of three classic symptoms: gross hematuria, flank pain and/or anemia. However, there are a limited number of reports in the literature regarding delayed RAP (≥four months). To the best of our knowledge we report the first case of RAP six months following robotic-assisted PN.
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Affiliation(s)
- Victor Otaño-Rivera
- Division of Urology, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Raju Chelluri
- Division of Urology, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Thomas J Guzzo
- Division of Urology, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Alan J Wein
- Division of Urology, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Phillip Mucksavage
- Division of Urology, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
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Chavali JSS, Bertolo R, Kara O, Garisto J, Mouracade P, Nelson RJ, Dagenais J, Kaouk JH. Renal Arterial Pseudoaneurysm After Partial Nephrectomy: Literature Review and Single-Center Analysis of Predictive Factors and Renal Functional Outcomes. J Laparoendosc Adv Surg Tech A 2018; 29:45-50. [PMID: 30300074 DOI: 10.1089/lap.2018.0364] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION AND OBJECTIVE Partial nephrectomy (PN) represents the current surgical standard for T1 tumors. Renal arterial pseudoaneurysm is a rare but potentially life-threatening complication reported after PN. The aim of this study was to identify the factors associated with the occurrence of pseudoaneurysm after PN, specifically focusing on those requiring management with selective embolization. A literature review of the topic was performed. METHODS A retrospective review of the institutional PN database was performed from January 2011 to December 2016. Patients who underwent embolization for pseudoaneurysm represented a separated cohort to be compared with other patients (controls). Patients' and tumors' characteristics were considered. Univariable and multivariable analyses were used to test their eventual association with the occurrence of pseudoaneurysm. RESULTS A total of 1417 cases were evaluated. At a median of 21 days (interquartile range = 10-34), 20 patients (1.4%) developed postoperative pseudoaneurysm. The majority of patients (70%) presented with gross hematuria. The clinical suspicion was confirmed by contrast-enhanced computed tomography scan with angiography. Selective embolization was performed using endovascular coils. Technical success and clinical success rates were 100% and 95%, respectively. No difference was found in percentage estimated glomerular filtration rate (eGFR) preserved between patients who underwent embolization versus controls (median 82.6% versus 86.3%, P = .35). No differences in age, baseline renal function (as assessed by glomerular filtration rate [GFR]), tumor size, and R.E.N.A.L. were found between patients who reported and did not report pseudoaneurysm. In patients who developed pseudoaneurysm, longer operative time (225.6 minutes versus 193 minutes, P = .04), and cold ischemia time (48 minutes versus 29 minutes, P = .03) were reported. CONCLUSION In our series, the occurrence of pseudoaneurysm was associated with longer operative and cold ischemia times. In patients who underwent selective embolization, renal function remained comparable with that of controls.
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Affiliation(s)
- Jaya Sai S Chavali
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Riccardo Bertolo
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Onder Kara
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Juan Garisto
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Pascal Mouracade
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ryan J Nelson
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Julien Dagenais
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jihad H Kaouk
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
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