Selective embolization of bleeding renal angiomyolipoma in pregnancy

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Spontaneous rupture of renal angiomyolipoma during pregnancy

A renal angiomyolipoma (AML) is a rare benign tumour of kidney origin. Pregnancy is known to be associated with an increased risk of tumour rupture causing hypovolaemic shock, which is usually managed surgically or through an embolisation procedure. However, having surgery during pregnancy predisposes the mother to a preterm delivery, and the unknown influences of radiation exposure to the fetus make the management of such cases very challenging. A 30-year-old pregnant woman had a sudden onset of gross haematuria at the 20th week of her pregnancy. The MRI showed a 10 cm mass suggestive of AML in the left kidney, with evidence of an intrarenal haematoma. To avoid an iatrogenic preterm delivery and unnecessary fetal exposure to radiation, conservative management was conducted until 34 weeks of gestation, when she came to our hospital reporting of flank pain. An endovascular treatment was performed immediately after an emergency caesarean delivery.

Renal angiomyolipoma and lymphangioleiomyomatosis in pregnancy

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

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

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

Retroperitoneal haemorrhage in renal angiomyolipoma causing hepatic functional decompensation: a case report

Renal angiomyolipomata usually present as incidental findings on routine imaging, but rarely they may give rise to significant haemorrhage. If bleeding occurs, first-line treatment is currently angiography with selective embolisation. Prophylactic embolisation may be considered in some cases, depending on lesion size and patient co-morbidities.

We present a case of retroperitoneal bleeding from a renal angiomyolipoma in a patient with known cirrhosis of the liver, which caused acute deterioration of liver function and consequent hepatic encephalopathy. Selective embolisation of the lesion was performed with a good subsequent outcome. Such functional hepatic decompensation has not previously been reported in this context and we suggest the use of prophylactic embolisation for incidental renal angiomyolipomata, regardless of size, in all patients with chronic liver disease to prevent this potentially life-threatening complication.

Conservative management of a bleeding renal angiomyolipoma in pregnancy

BACKGROUND

Bleeding angiomyolipomas in pregnancy are rare but may be devastating and potentially fatal. In previous cases, most of these lesions have been managed with urgent nephrectomy or embolization. Only one other case report describes treating these lesions through conservative management and vaginal delivery.

CASE

A 32-year-old woman with known bilateral angiomyolipomas presented at 39 weeks of gestation with acute onset left flank pain. The ultrasound result was consistent with a bleeding angiomyolipoma. The patient was otherwise hemodynamically stable and was managed safely in a conservative outpatient approach that consisted of close clinic follow-up, serial hemoglobins, ultrasound studies, and vaginal delivery.

CONCLUSION

Bleeding angiomyolipomas in pregnancy were managed successfully through conservative management and vaginal delivery.

[Influence of pregnancy on renal angiomyolipoma]

The aim is to perform a literature search on the role of pregnancy in the rupture of renal angiomyolipoma. Articles published from 1952 to 2004 in the Medline database were searched using the keywords renal angiomylipoma and pregnancy. Pathologies associated with angiomylipoma (lymphangioleiomyomatosis and Bourneville tuberous sclerosis) were taken into account. Seventy-two cases of association of renal angiomyolipoma and pregnancy were found, out of which 58 presented a haemorrhage. In only 26% of the cases, renal angiomyolipoma had been documented prior to pregnancy. Clinical presentation was similar to cases occurring among non pregnant women: abdominal pains (88%), hypotension or shock (33%) and hematuria (24%). Average size of the rupture was 11,7 cm. Rupture does not occur solely with the first pregnancy but occurred equally during the first, second and third pregnancy. Average gestation age upon occurrence of haemorrhage was 27 weeks with a minimum at ten weeks. Therapeutic strategies at the time of shock or hypotension were total nephrectomy in 79% of the cases, 7% polar nephrectomy, 7% embolisation followed by nephrectomy and 7% abstention. A causal role of pregnancy in the atraumatic rupture of angiomyolipoma is not clearly defined. Nevertheless, many arguments (whether it be abdominal mechanical pressure, hormonal or histological ones) suggest that a pregnancy could increase the risk of renal angiomyolipoma rupture. These patients should have a medical follow-up period at closer intervals during their pregnancy and the postpartum phase.

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

A case is described of a woman 10 weeks pregnant who had severe bleeding, secondary to a renal angiomyolipoma (AML), that was treated with embolization. Subsequent pregnancy was uneventful and she delivered a normal female infant 28 weeks after the procedure. One month after delivery, liquefaction of the AML occurred, which eventually required surgical drainage. We review and discuss AML during pregnancy, its management and post-embolization complications.

Pregnancy and lymphangioleiomyomatosis: anaesthetic management

Lymphangioleiomyomatosis is a rare, progressive cystic pulmonary disease related to tuberous sclerosis complex, affecting almost exclusively females of childbearing age. Progression of the disease is variable but may lead to terminal respiratory failure. As the disease may be oestrogen-dependent, it can arise de novo in pregnancy or established disease may undergo exacerbation. We report on the successful labour and delivery of such a patient and present the results of an internet survey of 30 pregnancies in 15 patients worldwide with lymphangioleiomyomatosis conducted by our patient before delivery.