Renal artery embolization: clinical indications and experience from over 100 cases

Endovascular Embolization of Aneurysmal Renal Arteriovenous Malformation

Renal arteriovenous malformations (AVM) represent an uncommon vascular condition characterized by an abnormal direct communication between an intrarenal artery and vein. Though asymptomatic in many individuals, treatment is often indicated if the AVM causes flank pain, hematuria, or medically refractory hypertension, or if there is an associated renal artery aneurysm. We present a case of a large right renal AVM with associated renal artery aneurysm and large varix which was incidentally found on magnetic resonance imaging of the spine. Endovascular and open surgical options were considered, including ex-vivo renal vascular reconstruction and nephrectomy. The patient was successfully treated with endovascular embolization of the AVM with coil packing of the arterial aneurysm and inflow artery. The patient recovered uneventfully with well-maintained renal function and blood pressure control. We review and discuss the literature on the etiology and treatment options for renal AVM.

Enhancing procedural decision making with cone beam CT in renal artery embolization

Cone-beam computed tomography (CBCT) has proven to be a safe and effective adjunctive imaging tool for interventional radiology. Nevertheless, limited studies have examined the application of CBCT in renal artery embolization (RAE). The objective of this study is to evaluate the role of CBCT in intra-procedural decision-making for RAE. This multicenter retrospective study included 40 consecutive patients (age: 55.9 ± 16.5 years; male, 55%) who underwent CBCT during RAE from January 2019 to January 2023. The additional information provided by CBCT was classified into Category 1 (no additional information), Category 2 (more information without changing the treatment plan), and Category 3 (valuable information that led to a change in the treatment plan). CBCT did not add unique information for four patients (10%) classified as Category 1. CBCT clarified ambiguous angiographic findings and confirmed the existing treatment plan for 19 patients (47.5%) graded as Category 2; complex vascular anatomy was explained (n = 13), and a correlation between vascular territory and target lesion was established (n = 6). CBCT offered valuable information that was not visible on digital subtraction angiography and changed the treatment plan for 17 patients categorized as Category 3; a mismatch between the vascular territory and the target lesion led to the identification of alternative (n = 3) and additional feeders (n = 8); and the extent of embolization was reduced by using automatic feeder detection software (n = 6). CBCT is an efficient tool that aids in the decision-making process during the embolization procedure by providing supplementary imaging information. This additional information enables the confident identification of target vessels, facilitates superselective embolization, prevents non-target embolization, and helps locate missing feeders.

Radical nephrectomy for a giant chromophobe renal cell carcinoma diagnosed > 17 years previously: a case report and literature review

Early diagnosis of renal cell carcinoma relies on imaging tests such as ultrasound, computed tomography, or magnetic resonance imaging. Since surgery is associated with a favorable prognosis, the standard treatment for clinically limited renal cell carcinoma remains surgical resection. Among asymptomatic patients with localized renal cell carcinoma, a small number refuse surgical treatment and survive. We report a case involving a 59-year-old female who underwent a difficult radical nephrectomy 17 years after being diagnosed with malignant tumors due to primary renal cell carcinoma.

Indocyanine green-marked fluorescence-guided off-clamp versus intraoperative ultrasound-guided on-clamp robotic partial nephrectomy: Outcomes on surgical procedure

Objectives

To compare surgical and functional outcomes between off-clamp robot-assisted partial nephrectomy with indocyanine-green tumour marking through preliminary superselective embolization and on-clamp robot-assisted partial nephrectomy with intraoperative ultrasound identification of the renal mass.

Material and methods

One hundred and forty patients with a single renal mass underwent indocyanine-green fluorescence-guided off-clamp robot-assisted partial nephrectomy with preoperative superselective embolization (Group A, 70 patients) versus intraoperative ultrasound-guided on-clamp robot-assisted partial nephrectomy without embolization (Group B, 70 patients). We assessed operative time, intraoperative blood loss, complications, length of stay, renal function, need for ancillary procedures and blood transfusions.

Results

Mean tumour size was 24 versus 25 mm in Group A versus Group B (p = 0.19). Mean operative time was 86.5 versus 121.8 min (p = 0.02), mean blood loss was 72.8 versus 214.2 mL (p = 0.02), and mean haemoglobin drop on postoperative day 1 was 1.1 versus 2.6 g/dL (p = 0.04) in Group A versus Group B. One-month creatinine, hospital stay and enucleated tumour volume were comparable. Ten postoperative complications occurred in Group A (13.3%) and 11 in Group B (15.3%). Following superselective embolization, no patients required blood transfusions versus two patients in Group B. Postoperative selective renal embolization was needed in one case per group.

Conclusions

Preoperative superselective embolization of a renal mass with indocyanine-green before off-clamp robot-assisted partial nephrectomy significantly reduces operative time and intraoperative blood loss compared to on-clamp intraoperative ultrasound-guided robot-assisted partial nephrectomy. A longer follow-up is needed to establish the effect on renal function.

A Narrative Review on Robotic Surgery as Treatment for Renal Cell Carcinoma with Inferior Vena Cava Thrombus

Renal cell carcinoma (RCC) is a common diagnosis, of which a notable portion of patients present with an extension into the venous circulation causing an inferior vena cava (IVC) tumor thrombus. Venous extension has significant implications for staging and subsequent treatment planning, with recommendations for more aggressive surgical removal, although associated surgical morbidity and mortality is relatively increased. The methods for surgical removal of RCC with IVC thrombus remain complex, particularly surrounding the use of robot-assisted surgery. Robot assistance for radical nephrectomy in this context is recently emerging. Thrombus level has important implications for surgical technique and prognosis. Other preoperative considerations may include location, laterality, size, and wall invasion. The urology literature on treatment of such tumors is largely limited to case series and institutional studies that describe the feasibility of various surgical options for these complex tumors. Further understanding of the outcomes and patient-specific risk factors would shed increased light on the optimal treatment for such cases. This narrative review provides a thorough overview on the previously reported use of robot-assisted nephrectomy in RCC with IVC thrombus to inform further studies which may optimize outcomes and guide shared decision-making.

A systematic review and meta-analysis on the efficacy of preoperative renal artery embolization prior to radical nephrectomy for renal cell carcinoma: Is it necessary?

INTRODUCTION

Radical nephrectomy for Renal Cell Carcinoma (RCC) is still the treatment of choice for all stages except for stage I and IV, which need patient selectivity. The purpose of Renal Artery Embolization (RAE) pre-operative before radical nephrectomy is to facilitate resection, reduce bleeding, and reduce the time to surgery, but the necessity of this procedure is still debatable. This study investigates the efficacy of pre-operative Renal Artery Embolization (PRAE) before radical nephrectomy for RCC patients.

METHODS

The systematic searches based on PRISMA guidelines were conducted in Pubmed, Scopus, Web of Science, Medrxiv, and ScienceDirect databases with pre-defined keywords. Both analyses, quantitative and qualitative, were performed to assess blood loss, transfusion rate, surgical time, Intensive Care Unit (ICU) stay, and hospital stay.

RESULTS

A total of 921 patients from 8 eligible studies were included. The blood loss was significantly lower in the PRAE group compared to the control group (p = < 0.00001; SMD -20 mL; 95%CI -0.29, -0.12). There is no statistically significant difference between RAE and without RAE in the transfusion rate nephrectomy (p = 0.53, OR 0.65; 95% CI 0.16, 2.57), mean operative time (p = 0.69; SMD 5.91; 95% CI -23.25, 35.07), mean length of hospital stay (p = 0.05; SMD 0.56; 95% CI 0.00, 1.12), and mean length of stay in the ICU (p = 0.45; SMD 11.61; 95% CI -18.35, 41.57) Conclusions: PRAE before radical nephrectomy significantly reduces blood loss in RCC patients but is similar in the surgical time, transfusion rate, and length of hospital stay and ICU stay.

Predictive factors of selective transarterial embolization failure in acute renal bleeding: a single-center experience

PURPOSE

Transarterial embolization of renal artery branches (RTE) is a minimally invasive procedure commonly performed in life-threatening renal bleeding of different etiologies. Despite the widespread use of RTE, no consensus guidelines are currently available. Our aim was to investigate clinical and technical efficacy and to identify potential predictors for clinical failure of this procedure.

METHODS

All the RTE procedures performed in our Interventional Radiology unit in last 10 years were retrospectively collected and analyzed. All selected patients underwent both pre-procedural computed tomography angiography (CTA) and post-procedural CTA within 30 days. Clinical success was considered as primary endpoint. Demographic, laboratory, and diagnostic findings predictive of clinical failure of RTE were identified.

RESULTS

Over a total of 51 patients enrolled, 27 (53%) were females and 33 (64.7%) had a renal bleeding of iatrogenic origin. Technical and clinical success was 100% and 80.4%, respectively. Hematoma volumes > 258.5 cm3 measured at CTA, higher pre- and post-procedural serum creatinine (Scr) levels, an increase in Scr value > 0.135 mg/dl after the procedure, a worse post-procedural estimated glomerular filtration rate (eGFR), a post-procedural reduction of eGFR < 3.350 ml/min, and a post-procedural reduction of platelet count (PLT) > 46.50 × 103/mmc showed a significantly higher rate of clinical failure.

CONCLUSION

RTE is a safe and effective procedure in the management of acute renal bleeding of various origins. Hematoma volume, Scr, PLT, and eGFR values were found to be predictive factors of poor clinical outcome and should be closely monitored.

Technical Tips for Performing Suprahepatic Vena Cava Tumor Thrombectomy in Renal Cell Carcinoma without Using Cardiopulmonary Bypass

Radical nephrectomy with tumor thrombectomy for advanced renal cell carcinoma is an oncologically relevant approach that can achieve long-term survival even in the presence of distant metastases. However, the surgical techniques pose significant challenges. The objective of this clinical review was to present technical recommendations for tumor thrombectomy in the vena cava to facilitate surgical treatment. Transesophageal echocardiography is required to prepare for this procedure. Cardiopulmonary bypass should be considered when the tumor thrombus has invaded the cardiac chamber and clamping is not feasible because of the inability to milk the intracardiac chamber thrombus in the caudal direction. Prior to performing a cavotomy, it is crucial to clamp the contralateral renal vein and infrarenal and suprahepatic inferior vena cava (IVC). If the suprahepatic IVC is separated from the surrounding tissue, it can be gently pulled down toward the patient's leg until the lower margin of the atrium becomes visible. Subsequently, the tumor thrombus should be carefully pulled downward to a position where it can be clamped. Implementing the Pringle maneuver to reduce blood flow from the hepatic veins to the IVC during IVC cavotomy is simpler than clamping the hepatic veins. Sequential clamping is a two-stage method of dividing thrombectomy by clamping the IVC twice, first suprahepatically and then midretrohepatically. This sequential clamping technique helps minimize hypotension status and the Pringle maneuver time compared to single clamping. Additionally, a spiral cavotomy can decrease the degree of primary closure narrowing. The oncological prognoses of patients can be improved by incorporating these technical recommendations.

Renal arterial embolization: Indications, angiographic findings, and outcomes in a series of 170 patients

Background

The lack of overall experience and reporting on angiographic findings in previously published studies of renal arterial embolization (RAE) compelled us to report our overall experience on a series of patients.

Materials and methods

A retrospective study was performed analyzing data of patients enrolled for RAE between 2010 and 2019. History, physical examination, and laboratory data were reviewed for all patients. Abdominal ultrasound was the initial imaging study, and all patients underwent subsequent computed tomography or magnetic resonance imaging. The outcome of RAE was determined based on radiographic and clinical findings.

Results

Data from 202 patients were analyzed, with a mean age of 45 ± 15 years, and 71.3% of patients were male. Iatrogenic injury was the most common indication for RAE (54%), followed by renal tumors, trauma, and spontaneous, in 27.7%, 10.4%, and 8.4% of patients, respectively. Renal angiography revealing pseudoaneurysm alone or with other pathology in the lower pole of the kidney was the most common finding (40.6%), whereas no lesions were identified on angiography in 32 patients (15.8%), after which RAE was subsequently aborted. Renal arterial embolization was successful in 158 of 170 patients (92.9%) after 1 or more trials (maximum of 4). Microcoil alone or with other embolic materials was the most commonly used material for embolization (85%).

Conclusions

Iatrogenic injury was the most common indication for RAE. Pseudoaneurysm alone or with other lesions was the most common lesion on renal angiography; however, angiography showed a negative result in 16% of patients, even those with symptoms. When lesions are present on angiography, the overall success of repeated trials of RAE reached 92.9%.

Clinical application of superselective transarterial embolization of renal tumors in zero ischaemia robotic-assisted laparoscopic partial nephrectomy

Objective

To assess the feasibility and safety of zero ischaemia robotic-assisted laparoscopic partial nephrectomy (RALPN) after preoperative superselective transarterial embolization (STE) of T1 renal cancer.

Methods

We retrospectively analyzed the data of 32 patients who underwent zero ischaemia RALPN after STE and 140 patients who received standard robot-assisted laparoscopic partial nephrectomy (S-RALPN). In addition, we selected 35 patients treated with off-clamp RALPN (O-RALPN) from September 2017 to March 2022 for comparison. STE was performed by the same interventional practitioner, and zero ischaemia laparoscopic partial nephrectomy (LPN) was carried out by experienced surgeon 1-12 hours after STE. The intraoperative data and postoperative complications were recorded. The postoperative renal function, routine urine test, urinary Computed Tomography (CT), and preoperative and postoperative glomerular filtration rate (GFR) data were analyzed.

Results

All operations were completed successfully. There were no cases of conversion to opening and no deaths. The renal arterial trunk was not blocked. No blood transfusions were needed. The mean operation time was 91.5 ± 34.28 minutes. The mean blood loss was 58.59 ± 54.11 ml. No recurrence or metastasis occurred.

Conclusion

For patients with renal tumors, STE of renal tumors in zero ischaemia RALPN can preserve more renal function, and it provides a safe and feasible surgical method.

Prophylactic Steroids for Preventing Postembolization Syndrome after Transcatheter Arterial Embolization of Renal Angiomyolipoma: A Comparative Study

Purpose

Postembolization syndrome (PES) after renal arterial embolization (RAE) can reduce the patient's tolerance of the procedure and extend the length of hospital stay. We aimed to assess the efficacy of steroid administration in preventing PES in patients undergoing RAE for angiomyolipoma (AML).

Material and Methods

Between May 2004 and March 2020, 29 RAE procedures in 26 patients with AML were performed. Patient information, including age, sex, tumor size, tuberous sclerosis complex-associated/sporadic AML, hemorrhagic/nonhemorrhagic AML, embolic material, steroid use, medication type, some blood laboratory parameters, hospital stay, and PES occurrence were retrospectively obtained. The prophylactic steroid protocol used in the study was as follows: 250 mg of intravenous methylprednisolone (Solu-Medrol) 2 h before the RAE procedure, followed by 2 days of intravenous prednisolone (Predonine; 2 mg/kg/day), which was tapered by halving the dose every 2 days within the course of 2 weeks. After the discharge, intravenous prednisolone was changed to oral prednisolone (Predonine). PES was defined as the presence of fever, pain, nausea, or vomiting. Data were compared between the steroid and non-steroid groups and between PES and non-PES groups.

Results

The PES incidence rate was 76%, and a comparison between the steroid and non-steroid groups revealed that steroid use significantly decreased the incidence of PES (P < 0.001), including fever (P < 0.001), pain (P = 0.005), and nausea (P = 0.028). The use of anti-inflammatory drugs during the hospital stay was significantly lower in the steroid group (P = 0.019). Moreover, in the steroid group, C-reactive protein level was significantly lower (P = 0.006), whereas white blood cell count was significantly higher (P = 0.004). Conversely, the median length of hospital stay was not significantly shorter in the steroid group (P = 0.292).

Conclusions

The prophylactic use of steroids before and after embolization of renal AML may be effective in preventing PES in this small retrospective study.

The Role of Renal Artery Embolisation in the Management of Blunt Renal Injuries: A Review

Renal injuries are the most common urinary tract injury secondary to external abdominal trauma. They are caused by blunt, penetrating and iatrogenic mechanisms. Despite the high number of blunt renal injuries, little evidence is available to guide management, especially with the evolution of embolisation as a minimally invasive treatment. Consequently, clinical practice is driven by results of observational studies and anecdote. We have reviewed the current trends in practice when using renal artery embolisation in the management of blunt renal injuries. Three key principles are highlighted. First, high-grade blunt renal injuries can be successfully managed with embolisation. Second, embolisation should be considered when there is radiological evidence of active contrast extravasation, pseudoaneurysm or arteriovenous fistula. Third, embolisation can be used to manage blunt renal injuries in haemodynamically unstable patients. Beyond this, evidence regarding optimal technique, CT indications, clinical status, comorbidities and complications are inconclusive. We discuss the implications for clinical practice and how these findings should define the agenda for future clinical research.

Immediate and delayed migration of Onyx embolisation into the renal collecting system

We present a case of Onyx embolisation of a renal pseudoaneurysm following partial nephrectomy with collecting system involvement with subsequent migration of Onyx into the renal collecting system resulting in renal obstruction. This occurred both immediately after embolisation and again 8 years after embolisation. Both cases required ureteroscopic surgical intervention. In the first instance, the pieces were removed using basket extraction. In the second, laser lithotripsy was used in addition to basket extraction. While there are a few cases of embolisation coils eroding into the renal collecting system, this is the second reported case of Onyx migration and the first where ureteroscopy with laser lithotripsy was used. The patient is doing well and undergoing surveillance ultrasounds to ensure there is no further Onyx migration. This may be a consideration for patients with pseudoaneurysm embolisation especially in the setting of prior collecting system damage.

Embolization for the treatment of renal artery pseudoaneurysm following surgical nephrolithotomy: A case report

Renal artery pseudoaneurysm is a rare but serious complication following trauma or renal surgery, leading to hematuria and deterioration of renal function. Selective renal artery embolization is an interventional radiologic procedure that can be used to treat these complications. We report a case of a 62 years old woman who developed hematuria following a segmental renal artery pseudoaneurysm after staghorn stones surgical nephrolithotomy, a selective embolization with steel coils was successfully performed.

Spontaneous retroperitoneal hematoma induced by vitamin K antagonist therapy: A case report

Vitamin K antagonists (VKA) are recommended in patients with mechanical heart valves. Major bleeding events remain the most life-threatening complication of this therapy and sometimes it can occur in unusual anatomic areas. Spontaneous retroperitoneal hematoma is one of the rare complications of anticoagulation therapy, which needs to be recognized early and managed promptly. Here, we report a case of a 40-year-old woman with mechanical heart valve treated with acenocoumarol, who was admitted to the emergency department with abdominal pain and whose investigations came back in favor of a massive retroperitoneal hematoma. The patient was successfully treated through conservative management resulting in a good outcome. Clinicians should be careful when prescribing VKA and should always think of retroperitoneal bleeding in the event of abdominal pain or a sudden decrease in the hemoglobin levels of anticoagulated patients.

SUPERSELECTIVE EMBOLIZATION OF THE RENAL ARTERIES AS A MONOTHERAPY OF KIDNEY TUMOR IN A PATIENT WITH HIGH ANESTHESIOLOGIC RISK

Introduction: Renal artery embolization is a minimally invasive X-ray endovascular operation that is used in the treatment of various urological diseases. This operation is of increasing interest due to its ability to occlude not only proximal, but also distal renal vessels with a low risk of complications. Recent developments in endovascular technology make embolization one of the effective and safe methods applicable to stop renal bleeding, preoperative preparation for surgical treatment of renal malignant tumors, and first-line treatment for angiomyolipomas. For a certain category of patients, renal artery embolization is practically no alternative method of treatment. This applies to comorbid patients with kidney tumors and aggravated somatic status, in whom the anesthetic risk makes open or laparoscopic surgical treatment impossible, and embolization can reduce symptoms, improve the quality of life of such patients and prolong the patient's life.Clinical case: we demonstrate the experience of X-ray surgical treatment of cT1aN0M0 left kidney cancer in an 80-year-old patient.Conclusion: Embolization of renal arteries in some cases can be an effective and safe alternative treatment for renal cell carcinoma in somatically burdened patients who cannot perform surgical treatment.

Prevalence and risk factors of myocardial and acute kidney injury following radical nephrectomy with vena cava thrombectomy: a retrospective cohort study

BACKGROUND

Radical nephrectomy with thrombectomy is the mainstay treatment for patients with renal cell carcinoma with vena cava thrombus. But the procedure is full of challenge, with high incidence of major complications and mortality. Herein, we investigated the incidence and predictors of myocardial injury and acute kidney injury (AKI) in patients following radical nephrectomy with inferior vena cava thrombectomy.

METHODS

Patients who underwent nephrectomy with thrombectomy between January 2012 and June 2020 were retrospectively reviewed. Myocardial injury was diagnosed when peak cardiac troponin I was higher than 0.03 ng/ml. AKI was diagnosed according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Multivariable logistic regression models were used to identify predictors of myocardial injury or AKI after surgery.

RESULTS

A total of 143 patients were included in the final analysis. Myocardial injury and AKI occurred in 37.8 and 42.7% of patients after this surgery, respectively. Male sex (odds ratio [OR] 0.27, 95% confidence interval [CI] 0.10-0.71; P = 0.008) was associated with a lower risk, whereas high level Mayo classification (compared with Mayo level I + II, Mayo level III + IV: OR 4.21, 95% CI 1.42-12.4; P = 0.009), acute normovolemic hemodilution before surgery (OR 2.66, 95% CI 1.10-6.41; P = 0.029), long duration of intraoperative tachycardia (per 20 min: OR 1.49, 95% CI 1.10-2.16; P = 0.036), and long duration of surgery (per 1 h, OR 1.48, 95% CI 1.03-2.16, P = 0.009) were associated with a higher risk of myocardial injury. High body mass index (OR 1.18, 95% CI 1.06-1.33; P = 0.004) and long duration of intraoperative hypotension (per 20 min: OR 1.30, 95% CI 1.04-1.64; P = 0.024) were associated with a higher risk, whereas selective renal artery embolism before surgery (OR 0.20, 95% CI 0.07-0.59, P = 0.004) was associated with a lower risk of AKI.

CONCLUSION

Myocardial injury and AKI were common in patients recovering from radical nephrectomy with inferior vena cava thrombectomy. Whether interventions targeting the above modifiable factors can improve outcomes require further studies.

Endovascular management of a large renal artery aneurysm: a case report and review of the literature

Background

A renal artery aneurysm is a rare clinical presentation that can be found incidentally on imaging or during workup for refractory hypertension. Its presentation can be similar to that of a renal artery pseudoaneurysm, but the etiologies of the two vascular lesions differ. We present a patient who had an incidental finding of a large renal artery aneurysm that was managed with endovascular embolization. We also describe the literature surrounding the etiology, presentation and management of both renal artery aneurysms and renal artery pseudoaneurysms.

Case presentation

A 62-year-old man was referred to a urologic oncologist for workup of a newly found renal mass. Initial imaging with computed tomography showed a homogenous, well-circumscribed mass arising from the right kidney. Further evaluation with Doppler ultrasonography demonstrated pulsatile flow within the renal mass that was concerning for a renal artery pseudoaneurysm. The patient initially underwent a diagnostic angiogram by interventional radiology and was found to have a true renal artery aneurysm. Interventional radiology considered placement of a covered stent or angioembolization, but treatment was deferred due to concern for compromising the patient’s renal function. Patient was subsequently transferred to a neighboring hospital for management by vascular surgery. After considering both open surgical and endovascular approaches, the patient ultimately underwent angioembolization of the renal artery aneurysm. Short-term follow-up showed successful exclusion of the aneurysm with minimal adverse effects to the patient.

Conclusions

Our case report documents a unique case of an incidentally found large renal artery aneurysm that was successfully managed with endovascular embolization. Renal artery aneurysms and renal artery pseudoaneurysms, which can present similarly on imaging, are important diagnostic considerations in a patient presenting with a new renal mass. While open surgical approaches can be used to repair aneurysms, endovascular approaches using stenting or angioembolization are safe and effective options for treating renal aneurysms and renal pseudoaneurysms.

Predictors of renal angioembolization outcome: A retrospective analysis with 148 patients at a tertiary urology institute

Objective

The aim of this study was to evaluate the predictor of unsuccessful outcome of renal angioembolization (RAE). Knowing those predictors may help in avoiding unnecessary RAE procedures and their associated side effects, while helping to prepare for an alternate procedure and improving patient's overall satisfaction.

Methods

A retrospective analysis between January 2006 and December 2018 was performed, and the indications for RAE were classified into post-traumatic, iatrogenic, renal tumors, and spontaneous. Patients who underwent RAE prior to nephrectomy were eliminated. Computed tomography angiography was performed in patients with normal renal function and those who had no contrast allergy, otherwise magnetic resonance angiography was performed. For the purpose of statistical analysis, we stratified patients into two main categories based on the final outcome—successful or failed.

Results

Of 180 patients, 32 with negative angiography were eliminated, leaving 148 patients; 136 (91%) had successful outcomes after one or more trials and 12 had unsuccessful outcomes. The mean age was 45±15 years, and 105 (71%) were male. Neither gender, side of the lesion, presence of hematuria, indication for RAE, nor the type of lesion affected the outcome. On the other hand, renal anatomy with presence of accessory artery was the only predictor to failed RAE (p=0.001). Failed RAE trial was a predictor for nephrectomy as a secondary procedure (p=0.03).

Conclusion

No pre-procedural predictors could anticipate the RAE outcome, and different indications can be scheduled to RAE, which is equally effective. The presence of accessory renal artery on diagnostic angiography is the only factor that may predict the failure of the procedure.

Perioperative Blood Loss after Preoperative Prostatic Artery Embolization in Patients Undergoing Simple Prostatectomy: A Propensity Score‒Matched Study

PURPOSE

To assess perioperative blood loss following prostatic artery embolization (PAE) before surgery in patients undergoing simple prostatectomy.

METHODS

A retrospective chart review was used to identify 63 patients (mean age, 65.3 ± 8.0 years) with prostatic hypertrophy and severe lower urinary tract symptoms who underwent prostatectomy from September 2014 to December 2019, 18 (28.5%) of whom underwent PAE before surgery. Demographic data, pertinent laboratory results, procedural or operative information, hospital course details, and pathology reports were obtained. A 2:1 propensity score‒matching analysis was performed to compare intraoperative blood loss in patients who underwent prostatectomy alone with intraoperative blood loss in those who first underwent bilateral PAE before surgery.

RESULTS

Sixteen (89%) of the 18 patients underwent bilateral PAE before surgery. Thirty-two patients who underwent prostatectomy without embolization before surgery were selected for the 2:1 propensity score‒matched analysis based on age, race, surgery type, prostate gland size, and comorbidities. The mean estimated blood loss (EBL) for prostatectomy alone was 545 ± 380 mL (mean ± standard deviation). There was a statistically significant reduction in the EBL for patients who underwent bilateral PAE (303 ± 227 mL, P < .01). The operative time was also significantly decreased for patients who underwent PAE before surgery (P < .05). For patients who underwent PAE, there were no complications related to the procedure.

CONCLUSIONS

Bilateral PAE before surgery appears to be safe and may be effective in reducing perioperative bleeding and operative time.

Preoperative embolization of renal cell carcinoma prior to partial nephrectomy: A systematic review and meta-analysis

PURPOSE

To evaluate the safety and efficacy of preoperative renal artery embolization of renal cell carcinoma in reducing intraoperative blood loss during subsequent partial nephrectomy through a systematic review and meta-analysis of current literature.

MATERIALS AND METHODS

The PubMed database was searched for articles published from 1970 to 2018 describing patients with renal cell carcinoma who underwent partial nephrectomy with and without preoperative embolization of the tumor. Demographic data, procedural techniques, and surgical outcomes were obtained when available. A random-effects meta-analysis was performed to determine estimated blood loss in both groups of patients.

RESULTS

The literature search identified 14 relevant articles for systematic review, of which 4 articles provided sufficient data to be included in the meta-analysis. 270 patients (173 males, 97 females) underwent partial nephrectomy for RCC, of whom 222 received pre-operative embolization. There were 48 patients in our cohort that underwent partial nephrectomy for RCC without preoperative embolization. Random-effects meta-analysis demonstrated a significant difference between EBL in patients undergoing RAE prior to partial nephrectomy vs partial nephrectomy without preoperative embolization, with EBL of 154.0 ± 22.6 mL (n = 222) and 353.4 ± 69.6 mL (n = 478), respectively (p < 0.0001). Major complications occurred in 4.9% of patients undergoing pre-operative embolization followed by partial nephrectomy, whereas major complications occurred in 10.9% of patients undergoing partial nephrectomy without embolization (p = 0.01). Minor complications occurred in 5.8% of patients undergoing embolization and partial nephrectomy and in 19.0% of patients undergoing partial nephrectomy without embolization (p < 0.0001).

CONCLUSION

Renal artery embolization prior to surgical resection of renal cell carcinoma is safe and significantly reduces intraoperative blood loss in patients undergoing partial nephrectomy.

Perioperative and oncological outcomes of renal cell carcinoma with venous tumour thrombus

AIM

The aim of the present study is to report the perioperative and long-term surgical outcomes of renal cell carcinoma (RCC) with venous tumour thrombus (VTT).

MATERIALS AND METHODS

Data of 34 patients (males = 23, females = 11) from 2009 to 2020 who underwent radical nephrectomy with thrombectomy for RCC and VTT was retrospectively analysed. The parameters recorded include tumour laterality, size, level of thrombus, surgical approach, blood loss, transfusion rates, operative time, hospital stay, Clavien complications, tumour histology, follow-up duration, local recurrence, distant metastasis, overall and cancer-specific survival rates.

RESULTS

The extent of thrombus was level I in thirteen, level II in twelve, level III (a-1, b-2, c-1, d-2) in six and level IV in three patients respectively. Mean operative time was 320 (±145) min, mean blood loss was 1371.15 (±1020.8) ml and mean hospital stay was 9.6 (±7.4) days. Mean transfusion rate was 6.4 (±3.2) units. Three patients died within the first 30 days of surgery. Cardiopulmonary bypass (CPB) was utilized in three patients. Median follow-up period was 58 (Range: 4-101) months. A statistically significant correlation was found between operative time (p = 0.014) and median survival (p = 0.003) respectively and tumour thrombosis level. Nine patients died due to metastasis, and ten due to unrelated causes. The estimated actuarial survival rates at a median of 58 months were 35.3%.

CONCLUSION

An accurate preoperative assessment of the thrombus extent with the involvement of a multidisciplinary team approach is crucial in achieving optimal surgical outcomes in patients of RCC with VTT, particularly with level III and IV thrombus.

European Association of Urology Section of Urolithiasis and International Alliance of Urolithiasis Joint Consensus on Percutaneous Nephrolithotomy

CONTEXT

Although percutaneous nephrolithotomy (PCNL) has been performed for decades and has gone through many refinements, there are still concerns regarding its more widespread utilization because of the long learning curve and the potential risk of severe complications. Many technical details are not included in the guidelines because of their nature and research protocol.

OBJECTIVE

To achieve an expert consensus viewpoint on PCNL indications, preoperative patient preparation, surgical strategy, management and prevention of severe complications, postoperative management, and follow-up.

EVIDENCE ACQUISITION

An international panel of experts from the Urolithiasis Section of the European Association of Urology, International Alliance of Urolithiasis, and other urology associations was enrolled, and a prospectively conducted study, incorporating literature review, discussion on research gaps (RGs), and questionnaires and following data analysis, was performed to reach a consensus on PCNL.

EVIDENCE SYNTHESIS

The expert panel consisted of 36 specialists in PCNL from 20 countries all around the world. A consensus on PCNL was developed. The expert panel was not as large as expected, and the discussion on RGs did not bring in more supportive evidence in the present consensus.

CONCLUSIONS

Adequate preoperative preparation, especially elimination of urinary tract infection prior to PCNL, accurate puncture with guidance of fluoroscopy and/or ultrasonography or a combination, keeping a low intrarenal pressure, and shortening of operation time during PCNL are important technical requirements to ensure safety and efficiency in PCNL.

PATIENT SUMMARY

Percutaneous nephrolithotomy (PCNL) has been a well-established procedure for the management of upper urinary tract stones. However, according to an expert panel consensus, core technical aspects, as well as the urologist's experience, are critical to the safety and effectiveness of PCNL.

iRESCUE - Interventional embolization of Renal artEries after SurgiCal or traUmatic injury with hEmorrhage

OBJECTIVES

To evaluate the efficacy and safety of urgent percutaneous embolization for the treatment of acute renal hemorrhage.

MATERIALS AND METHODS

All patients undergoing endovascular embolization at our hospital for bleeding from renal artery branches between January 2010 and June 2020 were retrospectively evaluated. Periprocedural characteristics, technical details, clinical outcomes, and complications were documented.

RESULTS

Seventy-six patients with a mean age of 67.3 ± 12.9 underwent 86 procedures. The most common cause of hemorrhage was iatrogenic (63/76), including 44 patients presenting after partial nephrectomy. Bleeding was successfully controlled in 80 of 86 procedures (92.8 % technical success), and clinical success (defined as control of bleeding with endovascular embolization) was achieved in 72 of 76 patients (94.5 %) with embolization, including seven patients undergoing re-intervention. In univariate analysis, risk factors for clinical failure were antiplatelet agents (p = 0.033), and technical failure (p < 0.001); and technical failure was the only significant risk factor in multivariate analysis. Only one patient (1.3 %) needed nephrectomy. AKI was seen after 16 (21 %) procedures, and preprocedural increased creatinine (≧1.8) and decreased GFR (<60) were risk factors for AKI (p = 0.022 and p = 0.020). In all patients except one, renal functions returned to baseline. One patient died because of pulmonary embolism (in-hospital mortality 1.3 %).

CONCLUSION

Interventional embolization is feasible, safe, and effective in the treatment of renal hemorrhages. Among others, the complication management with minimally invasive procedures allows urologists to safely perform partial nephrectomy even in patients with central, large, and endophytic tumors, thereby preserving kidney function in these patients.

Hemorrhagic complications after percutaneous nephrolithotomy: angiographic diagnosis and management by transcatheter arterial embolization

Objective

To identify the main hemorrhagic complications after percutaneous nephrolithotomy, as well as the results obtained with transcatheter arterial embolization (TAE) at an interventional radiology center.

Materials and Methods

This was a retrospective analysis of patients undergoing TAE for the treatment of hemorrhagic complications after percutaneous nephrolithotomy. All patients underwent computed tomography angiography (CTA).

Results

We evaluated a total of nine patients. At emergency department readmission, the most common symptom was macroscopic hematuria, which was seen in five patients. Three patients had an isolated pseudoaneurysm, two had a pseudoaneurysm together with active bleeding (perirenal hematoma), and one had a pseudoaneurysm together with arteriocalyceal fistula. Arteriovenous fistula was diagnosed in three patients and was not seen in combination with other vascular lesions. We did not identify arteriocalyceal fistula in isolation. Five patients underwent TAE with 6 × 15 mm and 6 × 20 mm microcoils. Four patients underwent TAE with n-butyl-2-cyanoacrylate and ethiodized oil. Follow-up CTAs revealed no complications.

Conclusion

Because of its high diagnostic accuracy, CTA provides the interventional radiologist with valuable data for individualized therapeutic planning. The TAE procedure is safe and effective. It can therefore be used as a first-line treatment for hemorrhagic complications resulting from percutaneous renal procedures.

Natural History of Asymptomatic Pseudoaneurysm Soon After Robot-assisted Partial Nephrectomy: Single-center Prospective Study

OBJECTIVE

To prospectively investigate the natural history of asymptomatic pseudoaneurysm after robotic-assisted partial nephrectomy.

METHODS

Robotic-assisted partial nephrectomy was undertaken for 67 patients between July 2014 and July 2018. Patients who could not undergo enhanced CT were excluded, so 60 patients were finally included in the present study. We prospectively investigated the presence of pseudoaneurysm based on early enhanced CT scan on postoperative day 7. According to our treatment policy, patients with symptomatic pseudoaneurysm underwent selective transarterial embolization. Meanwhile, patients with asymptomatic pseudoaneurysm were observed with follow-up CT imaging, regardless of the size of the aneurysm.

RESULTS

Overall incidence of pseudoaneurysm on postoperative day 7 was 18% (11/60 cases). The median size of the pseudoaneurysm was 9 mm (quartile: 6-12 mm). Two patients with symptomatic pseudoaneurysm underwent selective transarterial embolization. Nine patients had asymptomatic pseudoaneurysm; in 8 of these it disappeared without therapeutic intervention. The median period from surgery to confirmed disappearance of the aneurysm was 19 days (quartile 14-32 days). In the remaining 1 patient, small asymptomatic pseudoaneurysm (2 mm) could still be observed even 1 year after surgery.

CONCLUSION

Our study showed high incidence of pseudoaneurysm 1 week after robotic-assisted partial nephrectomy that mostly disappeared without therapeutic intervention. Routine enhanced CT screening and pre-emptive embolization may not be necessary for asymptomatic renal artery pseudoaneurysm.

A case of acute bleeding from a small, asymptomatic renal angiomyolipoma (AML) during pneumoperitoneum induction for a rectal tumor resulting in acute hematuria and anemia

Angiomyolipoma (AML) is a benign renal mesenchymal tumor. Active surveillance is considered the most appropriate option for most AMLs. The major complication of AML is its spontaneous bleeding in the retroperitoneum that could be life-threatening for the patient. In this case, acute bleeding from a sporadic AML was reported immediately after the induction of a 12 mmHg pneumoperitoneum during a planned laparoscopic resection of the rectum for oncological reasons. After immediate stabilization the patient underwent angiography of the renal artery and super-selective vascular embolization. Although rare, spontaneous rupture of asymptomatic AML should always be considered, especially in intraoperative setting.

Value of Angioembolization in the Treatment of Iatrogenic Renal Vascular Injury Assisted by 3-Dimensional Digital Subtraction Angiography

BACKGROUND This study was conducted to investigate the reliability and efficacy of polyvinyl alcohol combined with coils in the embolization of iatrogenic renal vascular injury with the assistance of 3-dimensional digital subtraction angiography (3D-DSA). MATERIAL AND METHODS Twenty-six patients with minimally invasive renal bleeding who underwent transarterial embolization from January 2012 to January 2019 in our hospital were included in the study. We obtained demographic data from these patients, as well as information on clinical presentation, renal procedures used for treatment, and perioperative details. The changes in renal function tests, serum hemoglobin, serum hematocrit, and technetium Tc 99m dimercaptosuccinic acid (99mTc-DMSA) levels pre- and postembolization were compared. In addition, the embolic area and the technical and clinical success rates were analyzed. Finally, an angiographic manifestation of the renal artery, 3D-DSA, and the effect of embolization were analyzed retrospectively. RESULTS All patients achieved technical and clinical success after embolization (100%, 26/26). There were no significant differences between pre- and postoperative estimated glomerular filtration rate, serum parameters, and 99mTc-DMSA. The embolic area was 12%±10%. Patients did not exhibit severe complications during the follow-up period. CONCLUSIONS Proximal embolization technique assisted by 3D-DSA for renal iatrogenic hemorrhage and vascular lesions is both safe and efficacious, offering high rates for both clinical and technical success. It maximizes the protection of the kidney and reduces the rate of renal resection.

Renal Artery Embolization for Acute Renal Hemorrhage: A Single-Center Experience

Background

Emergency renal artery embolization (RAE) is a useful method in treating renal trauma and bleeding renal tumors. The aim of this study was to evaluate the clinical efficacy and safety of emergency RAE, and factors associated with RAE failure.

Methods

This retrospective study included patients treated with emergency RAE for acute renal hemorrhage between 1 January 2009 and 31 October 2019 in Srinagarind Hospital. The embolization was performed using coils, glues, and/or gel foams. Factors associated with unsuccessful outcomes were analyzed using univariate and multivariate regression analyses.

Results

A total of 94 patients were treated at the center during the study period with the clinical success rate of 91.5%. The most common cause of acute renal hemorrhage was iatrogenic injury (76.5%). Factors associated with unsuccessful RAE according to multivariate analyses were hypertension (adjusted odds ratio [AOR] 24.2) and ruptured tumor/aneurysm (AOR 26.8).

Conclusion

RAE is an effective procedure for acute renal hemorrhage. Hypertension and ruptured tumor/aneurysm were negative predictors for success.

Decreased hemoglobin as a quantifiable indicator of renal arterial embolization in post-percutaneous nephrolithotomy hemorrhage

To determine quantifiable indicators for post-percutaneous nephrolithotomy (PCNL) renal arterial embolization. A total of 2043 patients who underwent PCNL from September 2012 to March 2018 were reviewed retrospectively. Post-operative hemorrhage patients were extracted and divided into two groups according to treatment methods (conservative methods or super-selective renal arterial embolization [SRAE]). Demographic characteristics and hemorrhage outcomes were compared between the two groups by univariable analysis. Multivariable logistic regression was used to reveal the association between hemorrhage outcome factors and SRAE. A receiver operating characteristic (ROC) curve was drawn to determine the optimized cut-off value for SRAE. We identified 71 patients who had post-PCNL hemorrhage. Seventeen and 54 patients comprised the SRAE and conservative groups, respectively. No significant differences in demographic characteristics were found between the two groups. Univariate analysis showed that the differences in decreased hemoglobin (Hb), hemorrhage types, and transfusion were significant between the two groups (p < 0.001). Multivariable analysis showed that the decreased Hb was closely associated with the risk of SRAE. The ROC curve showed that an adjusted Hb decrease of 3.45 g/dL was an optimum indicator (AUC = 0.925). Decreased Hb is an indicator for SRAE after PCNL. When the adjusted decrease in Hb is ≥ 3.45 g/dL, SRAE should be performed regardless of the manifestations of hemorrhage.

Profile of renal artery embolization (RAE) for renal trauma: A comparison of data from two major trauma center

OBJECTIVE

To evaluate usage of renal artery embolization (RAE) for renal injuries and discuss the indications for this treatment.

MATERIALS AND METHODS

A retrospective study was performed evaluating the electronic medical records of all patients with renal trauma admitted to two major comprehensive hospitals in Shantou city from January 2006 to December 2015.

RESULTS

There were 264 and 304 renal traumatic patients admitted to hospital A and B, respectively. LGRT was the reason for presentation in the majority of patients (522, 91.9%). A total of 534 (94.0%) patients were treated conservatively. RAE was performed in 9 patients from 2012 to 2015 at hospital A, including in 6 patients (6/9, 66.7%) with LGRT, and 3 patients (3/9, 33.3%) with HGRT. No patient underwent interventional therapy (RAE) at hospital B during the same period. No significant differences in the operative rate of hospital A were observed between the two time periods (2006-2011 and 2012-2015). The operative rate for LGRT between the two hospitals from 2006 to 2011 and 2012 to 2015 was not significantly different. Hospital A showed a significant decrease in the rate of conservative treatment for patients with LGRT. In the univariate and multivariate analyses, the AAST renal grade both were significantly associated with undergoing RAE.

CONCLUSIONS

LGRT was present in the majority of patients, and most cases of renal trauma could be treated with conservative treatment. RAE was well utilized for the treatment of renal trauma. However, some patients with LGRT were treated with unnecessary interventional therapy.

Initial Experience With the Microvascular Plug in Selective Renal Artery Embolization

Purpose:

To evaluate the safety and efficacy of the microvascular plug (MVP) for selective renal artery embolization.

Methods:

Retrospective review was performed on a cohort of 6 patients undergoing renal artery embolization using the MVP between July 2015 and August 2018. Patients’ demographics, indication for embolization, technical details of the embolization procedure, and clinical events were gathered from the patients’ electronic medical records.

Results:

The patients underwent selective renal artery embolization with a MVP for iatrogenic vascular injuries (n = 3), traumatic vascular injuries (n = 2), and for elective embolization of an angiomyolipoma (n = 1), in native kidneys (n = 4) or in renal allografts (n = 2). Immediate occlusion of the feeding artery was achieved with 1 MVP device in 4 patients. In 1 patient, a second MVP was needed, and in another patient, additional 0.018-inch microcoils were used to completely occlude the injured artery. Technical success was achieved in all patients. The volume of the resulting renal infarction was estimated less than 5% of the renal volume. No other procedure-related complications occurred.

Conclusion:

The MVP is a safe and effective device allowing superselective renal artery embolization. Therefore, we recommend the MVP as a valuable embolic in superselective renal artery embolization. Additionally, a single device is sufficient in most cases, potentially reducing the cost, duration, and radiation exposure of the procedure.

Renal Artery Embolization Before Radical Nephrectomy for Complex Renal Tumour: Which are the True Advantages?

Introduction

Renal artery embolization is performed before radical nephrectomy (RN) for renal mass in order to induce preoperative infarction and to facilitate surgical intervention through decrease of intraoperative bleeding. Moreover, in metastatic renal cancer it seems to stimulate tumour-specific antibodies, even if no established benefits in clinical response or survival have been reported. The role of preoperative renal artery embolization (PRAE) in management of renal masses has been often debated and its real benefits are still unclear. Nevertheless, in huge and complex renal masses, which are often characterized by a high and anarchic blood supply and rapid local invasion, radical nephrectomy can be challenging even for skilled surgeons. The aim of this prospective randomized study was to evaluate the effectiveness and safety of PRAE in complex masses by comparing perioperative outcomes of RN with and without PRAE.

Materials and methods

From December 2015 to May 2018 we enrolled prospectively 64 patients who underwent RN for localized (T2a-b) or locally advanced (T3 and T4) or advanced (N+, M+) renal cancers. Patients were divided in two groups. The first group included 30 patients who underwent PRAE; in the second group we enrolled 34 patients who did not undergo RN without PRAE. Perioperative outcomes in terms of operative time, blood loss, transfusion rate and length of hospitalization were evaluated. Statistical analysis was performed using GraphPad Prism 6.0 software.

Results

Median blood loss was 250 ml (50-500) and 400 ml (50-1000) in the first and second group, respectively, with a statistically significant difference (p=0.0066). Median surgical time was 200 min (90-390) and 240 min (130-390) in PRAE and No-PRAE group (p=0.06), respectively. No major complications occurred after embolization. Overall complication rate in Group 1 and 2 was 46.7% (14/30) and 50% (17/34), respectively (p=0.34). No major complications occurred in both groups. The mean follow up was 21,5 months.

Conclusions

Our results prove PRAE to be a safe procedure with low complications rate. To our experience, PRAE seems to be a useful tool in surgical management of a large mass and advanced disease.

Failure of initial superselective renal arterial embolization in the treatment of renal hemorrhage after percutaneous nephrolithotomy: A respective analysis of risk factors

Superselective renal arterial embolization (SRAE) is a well-established method for the treatment of severe hemorrhage following percutaneous nephrolithotomy (PCNL). However, there remains a significant rate of failures requiring repeat SRAE or nephrectomy. To identify risk factors for initial treatment failure of SRAE, the data of patients who had undergone SRAE for severe bleeding due to PCNL between August 2005 and June 2016 were retrospectively analyzed. A total of 98 patients required SRAE for bleeding control following PCNL. Renal arteriography revealed pseudoaneurysm in 65 patients, arteriovenous fistula in 6 patients, and a combination of both in 11 patients. Free extravasation was observed in 11 patients; 8 of these patients exhibited coexisting pseudoaneurysm. Vascular aberration/tortuosity was identified in 10 patients. A total of 17 patients (17.3%) experienced initial treatment failure and underwent repeat SRAE. Multivariate analysis identified percutaneous tract size, number of bleeding sites and vascular aberration/tortuosity as significant predictors of initial treatment failure. The results from the present study suggested that repeated SRAE is preferred for patients who have experienced initial treatment failure with recurrent hemorrhage following PCNL. Large tract size, multiple bleeding sites and renal vascular aberration/tortuosity were significantly associated with increased risk of initial treatment failure of SRAE. These data may assist interventional radiologists in the planning and execution of SRAE in the treatment of PCNL.

Managing post-traumatic gunshot thoraco-abdominal bleeding by intervention embolisation: A case report

We report an interesting life-threating case of post-traumatic severe bleeding in the thoraco-abdominal region. The patient was initially treated by open surgery, which failed to control bleeding in the intrahepatic and sub-diaphragmatic regions of the liver with associated haematoma collection. As bleeding continued, on the 2nd post-operative day, the patient underwent super-selective embolisation of the bleeding vessels to cease serious bleeding. The pre-embolisation arterial feeders with active bleeding and post-embolisation images by computed tomography subtraction angiography showed complete cessation of haemorrhage. Torrential haemorrhage in the thoraco-abdominal regions can be successfully managed by trained interventional radiologists in highly specialised centres.

'Step Up' approach to the application of REBOA technology in a rural

Our group has developed a ‘Step Up’ approach to the application of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in a rural trauma system. This incorporates viewing REBOA as a spectrum of technology. Examples of REBOA technology use to improve outcomes and provision of our system’s clinical practice guideline for the Step-Up application of REBOA technology in the care of trauma patients are presented.

Renal arteriovenous fistula after renal biopsy: a case report and literature review

Acquired renal arteriovenous fistulas (AVF) are rare conditions in which an anomalous connection arises between the arterial and venous systems. Renal AVFs can be classified into three main groups: idiopathic, congenital, and acquired, the last of which are the most common. Incidence has been increasing, due to the growing number of renal biopsies. Although the renal biopsy procedure is relatively safe nowadays, one possible complication is formation of an AVF in the renal vascular territory. Treatment of renal AVF is widely discussed in the literature and a variety of treatment methods can be employed. We report a case of arteriovenous fistula after renal biopsy that was successfully treated with endovascular coil embolization.

Pediatric blunt renal trauma practice management guidelines: Collaboration between the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society

BACKGROUND

Injury to the kidney from either blunt or penetrating trauma is the most common urinary tract injury. Children are at higher risk of renal injury from blunt trauma than adults, but no pediatric renal trauma guidelines have been established. The authors reviewed the literature to guide clinicians in the appropriate methods of management of pediatric renal trauma.

METHODS

Grading of Recommendations Assessment, Development and Evaluation methodology was used to aid with the development of these evidence-based practice management guidelines. A systematic review of the literature including citations published between 1990 and 2016 was performed. Fifty-one articles were used to inform the statements presented in the guidelines. When possible, a meta-analysis with forest plots was created, and the evidence was graded.

RESULTS

When comparing nonoperative management versus operative management in hemodynamically stable pediatric patient with blunt renal trauma, evidence suggests that there is a reduced rate of renal loss and blood transfusion in patients managed nonoperatively. We found that in pediatric patients with high-grade American Association for the Surgery of Trauma grade III-V (AAST III-V) renal injuries and ongoing bleeding or delayed bleeding, angioembolization has a decreased rate of renal loss compared with surgical intervention. We found the rate of posttraumatic renal hypertension to be 4.2%.

CONCLUSION

Based on the completed meta-analyses and Grading of Recommendations Assessment, Development and Evaluation profile, we are making the following recommendations: (1) In pediatric patients with blunt renal trauma of all grades, we strongly recommend nonoperative management versus operative management in hemodynamically stable patients. (2) In hemodynamically stable pediatric patients with high-grade (AAST grade III-V) renal injuries, we strongly recommend angioembolization versus surgical intervention for ongoing or delayed bleeding. (3) In pediatric patients with renal trauma, we strongly recommend routine blood pressure checks to diagnose hypertension. This review of the literature reveals limitations and the need for additional research on diagnosis and management of pediatric renal trauma.

LEVEL OF EVIDENCE

Guidelines study, level III.

Simultaneous Ureteral and Renal Foreign Bodies

Clinical presentation of patients with foreign bodies is highly variable. We received a 55-year-old female patient with fever and right flank pain. She was treated previously for kidney stones by percutaneous nephrolithtomy with partial resolution, requiring renal embolization during this procedure because of bleeding. CT evidenced metallic density images localized in kidney and ureter, associated with kidney stones located in lower calix. Semirigid ureteroscopy and retrograde intrarenal surgery were performed, revealing the presence of foreign bodies in both localizations and lower calix stones. Complete removal of foreign bodies and stones was performed. Foreign bodies were found to be embolization coils applied in the previous procedure.

Early and late adverse renal effects after potentially nephrotoxic treatment for childhood cancer

BACKGROUND

Improvements in diagnostics and treatment for paediatric malignancies resulted in a major increase in survival. However, childhood cancer survivors (CCS) are at risk of developing adverse effects caused by multimodal treatment for their malignancy. Nephrotoxicity is a known side effect of several treatments, including cisplatin, carboplatin, ifosfamide, radiotherapy and nephrectomy, and can cause glomerular filtration rate (GFR) impairment, proteinuria, tubulopathy, and hypertension. Evidence about the long-term effects of these treatments on renal function remains inconclusive. It is important to know the risk of, and risk factors for, early and late adverse renal effects, so that ultimately treatment and screening protocols can be adjusted. This review is an update of a previously published Cochrane Review.

OBJECTIVES

To evaluate existing evidence on the effects of potentially nephrotoxic treatment modalities on the prevalence of renal dysfunction in survivors treated for childhood cancer with a median or mean survival of at least one year after cessation of treatment, where possible in comparison with the general population or CCS treated without potentially nephrotoxic treatment. In addition, to evaluate evidence on associated risk factors, such as follow-up duration, age at time of diagnosis and treatment combinations, as well as the effect of doses.

SEARCH METHODS

On 31 March 2017 we searched the following electronic databases: CENTRAL, MEDLINE and Embase. In addition, we screened reference lists of relevant studies and we searched the congress proceedings of the International Society of Pediatric Oncology (SIOP) and The American Society of Pediatric Hematology/Oncology (ASPHO) from 2010 to 2016/2017.

SELECTION CRITERIA

Except for case reports, case series and studies including fewer than 20 participants, we included studies with all study designs that reported on renal function (one year or longer after cessation of treatment), in CCS treated before the age of 21 years with cisplatin, carboplatin, ifosfamide, radiation involving the kidney region, a nephrectomy, or a combination of two or more of these treatments. When not all treatment modalities were described or the study group of interest was unclear, a study was not eligible for the evaluation of prevalence. We still included it for the assessment of risk factors if it had performed a multivariable analysis.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, 'Risk of bias' assessment and data extraction using standardised data collection forms. We performed analyses according to the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Apart from the remaining 37 studies included from the original review, the search resulted in the inclusion of 24 new studies. In total, we included 61 studies; 46 for prevalence, six for both prevalence and risk factors, and nine not meeting the inclusion criteria, but assessing risk factors. The 52 studies evaluating the prevalence of renal dysfunction included 13,327 participants of interest, of whom at least 4499 underwent renal function testing. The prevalence of adverse renal effects ranged from 0% to 84%. This variation may be due to diversity of included malignancies, received treatments, reported outcome measures, follow-up duration and the methodological quality of available evidence.Seven out of 52 studies, including 244 participants, reported the prevalence of chronic kidney disease, which ranged from 2.4% to 32%.Of these 52 studies, 36 studied a decreased (estimated) GFR, including at least 432 CCS, and found it was present in 0% to 73.7% of participants. One eligible study reported an increased risk of glomerular dysfunction after concomitant treatment with aminoglycosides and vancomycin in CCS receiving total body irradiation (TBI). Four non-eligible studies assessing a total cohort of CCS, found nephrectomy and (high-dose (HD)) ifosfamide as risk factors for decreased GFR. The majority also reported cisplatin as a risk factor. In addition, two non-eligible studies showed an association of a longer follow-up period with glomerular dysfunction.Twenty-two out of 52 studies, including 851 participants, studied proteinuria, which was present in 3.5% to 84% of participants. Risk factors, analysed by three non-eligible studies, included HD cisplatin, (HD) ifosfamide, TBI, and a combination of nephrectomy and abdominal radiotherapy. However, studies were contradictory and incomparable.Eleven out of 52 studies assessed hypophosphataemia or tubular phosphate reabsorption (TPR), or both. Prevalence ranged between 0% and 36.8% for hypophosphataemia in 287 participants, and from 0% to 62.5% for impaired TPR in 246 participants. One non-eligible study investigated risk factors for hypophosphataemia, but could not find any association.Four out of 52 studies, including 128 CCS, assessed the prevalence of hypomagnesaemia, which ranged between 13.2% and 28.6%. Both non-eligible studies investigating risk factors identified cisplatin as a risk factor. Carboplatin, nephrectomy and follow-up time were other reported risk factors.The prevalence of hypertension ranged from 0% to 50% in 2464 participants (30/52 studies). Risk factors reported by one eligible study were older age at screening and abdominal radiotherapy. A non-eligible study also found long follow-up time as risk factor. Three non-eligible studies showed that a higher body mass index increased the risk of hypertension. Treatment-related risk factors were abdominal radiotherapy and TBI, but studies were inconsistent.Because of the profound heterogeneity of the studies, it was not possible to perform meta-analyses. Risk of bias was present in all studies.

AUTHORS' CONCLUSIONS

The prevalence of adverse renal effects after treatment with cisplatin, carboplatin, ifosfamide, radiation therapy involving the kidney region, nephrectomy, or any combination of these, ranged from 0% to 84% depending on the study population, received treatment combination, reported outcome measure, follow-up duration and methodological quality. With currently available evidence, it was not possible to draw solid conclusions regarding the prevalence of, and treatment-related risk factors for, specific adverse renal effects. Future studies should focus on adequate study designs and reporting, including large prospective cohort studies with adequate control groups when possible. In addition, these studies should deploy multivariable risk factor analyses to correct for possible confounding. Next to research concerning known nephrotoxic therapies, exploring nephrotoxicity after new therapeutic agents is advised for future studies. Until more evidence becomes available, CCS should preferably be enrolled into long-term follow-up programmes to monitor their renal function and blood pressure.

The Clinical Application of New Generation Super-Mini Percutaneous Nephrolithotomy in the Treatment of ≥20 mm Renal Stones

Purpose: To evaluate the safety and efficacy of new generation super-mini percutaneous nephrolithotomy (New-SMP) in the treatment of ≥20 mm renal stones. Methods: We retrospectively analyzed the New-SMP procedures (14F) performed in the cases with ≥20 mm renal stones between April 1, 2016 and July 1, 2018. The cases with ipsilateral Double-J stent and/or nephrostomy tube preoperatively, ipsilateral ureteral stone, uncorrected coagulopathy, active urinary tract infection, congenital abnormalities, and urinary diversion were excluded. Results: Of totally 188 included cases, 8 (4.3%) were children (≤14 years) and 180 (95.7%) were adults. The cases had a mean age of 47.14 ± 15.13 years, a mean stone size of 31.57 ± 9.8 mm, and a mean S.T.O.N.E score of 7.02 ± 0.73. The New-SMP took a median operative time of 35 minutes (range 6-127). A total of 173 (92%) cases received single-access-tract procedure. The drop in hematocrit was 14.62 ± 8.36 g/L after the procedure. The serum white blood cells (WBCs) increased to 2.58 ± 2.89 × 10⁹/L. The mean hospital stay was 2.4 ± 1.5 days. New-SMP had a stone-free rate of 84% within 48 hours and 91.5% at 3 months postoperatively. Five (2.7%) cases required auxiliary procedures. The tubeless rate was 87.2%, including 44.1% cases with total tubeless, 41.5% cases with Double-J stent, and 1.6% cases with ureteral catheter. Totally 9.6% cases got fever (>38°C), 1.0% cases had urosepsis, and no cases developed shock. In addition, no transfusion and arterial embolization were required. Conclusions: New-SMP could be a safe and efficacious approach for the management of ≥20 mm renal stones. The novel modified technique and system may extend the indication of SMP to large renal stones. Further clinical studies and direct comparisons between New-SMP and other available modalities of percutaneous nephrolithotomy are required.

Radiologically Guided Renal Artery Embolization with an Amplatzer Vascular Plug as a Rescue Therapy for Refractory Nephrotic Syndrome in AL-Amyloidosis

Nephrotic syndrome is common in immunoglobulin light-chain (AL) amyloidosis and successful therapy may pose a challenge. We report the case of a 63-year-old patient with severe nephrotic syndrome due to primary renal AL-amyloidosis with well-preserved renal function at first presentation. Therapy with high dose steroids, loop diuretics, and ACE-inhibitors did not affect his proteinuria and he was seriously disabled because of symptomatic orthostatic hypotension and anasarca. With the patient's informed consent, medical nephrectomy was tried with nonsteroidal-anti-inflammatory drugs (NSAIDs), cyclosporine, and aminoglycosides, with significant deterioration of his renal function, but without relevant effect on his proteinuria. Despite adequate anticoagulation life threatening thrombotic and bleeding complications occurred. Total renal ablation was finally achieved using an Amplatzer vascular plug Typ IV (AVP 4) with a self-expanding Nitinol mesh design, which was placed in both main renal arteries in the same intervention. The patient became completely anuric, protein loss stopped, and serum albumin slowly rose to normal levels. The patient's clinical condition dramatically improved and he regained his full mobility at the price of a lifelong renal replacement therapy. To our knowledge, this is the first reported usage of such a vascular occluder in the setting of refractory nephrotic syndrome with normal kidney function at the time of first presentation.

Renal Arteries Embolization in Unresectable Clear Cell Renal Carcinoma: First Time Experience at Haji Adam Malik Hospital

OBJECTIVE

To report a case of renal arterial embolisation (RAE) in unresectable renal tumour before nephrectomy.

CASE REPORT

On presentation, the clinical features of this patient, including medical history, signs and symptoms, imaging examinations were recorded. After diagnosis and initial treatment, the result and histopathological examination were performed and discussed. We performed RAE in the unresectable renal tumour in the 28-year-old male that was complaining a palpable pain right flank mass and intermittent hematuria that had been observed five months earlier. A month after RAE, the tumour shrinks and become resectable. The parameter used was tumour volume, propulsion and component, with subjective value VAS, hematuria symptom and Quality Of Life Score EORTC-QLQ C30. The next step we performed nephrectomy with histopathology results in Clear Cell Renal Carcinoma (CCRC).

CONCLUSION

RAE is an effective therapeutic and adjuvant tool because it facilitates the dissection of unresectable large renal tumours and tumours with extensive involvement around the renal hilum; it leading to lower overall morbidity. However, the lack of randomised prospective studies is the primary reason that RAE is not used often before surgery.

Treatment options and outcomes for caval thrombectomy and resection for renal cell carcinoma

OBJECTIVE

Advanced renal cell carcinoma (RCC) has a significant predisposition to vascular invasion. Tumor vascular invasion and thrombus are found in the renal vein and the inferior vena cava (IVC) in up to 10% to 25% of patients. This study reviewed the current status of radical nephrectomy with IVC thrombectomy for advanced RCC.

METHODS

A two-level search strategy of the literature (MEDLINE, PubMed, The Cochrane Library, and Google Scholar) for relevant articles listed between January 2000 and December 2015 was performed. The review was confined to patients with primary RCC associated with vascular invasion.

RESULTS

Untreated RCC with intravascular thrombus has a median survival of 5 months. Surgical exposure and intervention are tailored to the level of tumor thrombus. The 30-day mortality for radical nephrectomy with IVC thrombectomy is low (1.5%-10%), and the complication rates have been reported to be 18%, 20%, 26%, and 47% for IVC tumor thrombus level I, II, III, and IV disease, respectively. Disease-specific survival ranges from 40% to 60% at 5 years after nephrectomy and removal of the intravascular tumor.

CONCLUSIONS

Radical nephrectomy with IVC thrombectomy is an effective cancer control operation that can be safely performed with acceptable mortality and morbidity. Preoperative imaging coupled with perioperative surgical management of the IVC is critical to procedural success and patient outcomes.

Benign Neoplasm of Kidney: Angiomyolipoma

Angiomyolipoma is one of the renal benign neoplasms. The most of the angiomyolipomas are asymptomatic and found incidentally with ultrasound. They are more prevalent in patients with tuberous sclerosis. It is very important to make differential diagnosis from other renal neoplasm such as renal cell carcinoma. Growth rate is higher among pregnant women suggest that the hormones may play a role in the stimulation of angiomyolipoma. The most common serious presentation is rupture and hemorrhage, and sometimes it can lead to shock. Adequate diagnosis, treatment, and follow-up are very important in the face of renal angiomyolipoma.