VOLUME 23 | ISSUE 5 | SEPTEMBER-OCTOBER 2003

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Iatrogenic Renal Pseudoaneurysm after Pyelolithotomy: A Case Report

MS Ansari, MS MCh DNB; D Dodamani, MS; Monish Aron, MS, DNB, MCh, FRCS; Amlesh Seth, MS, DNB, MCh, DNB; Manpreet Gulati, MD; Ashu Seith, MD; Deep N Srivastava, MD

From the Department of Urology and Radiology, All India Institute of Medical Sciences, New Delhi, India

How to cite this article:

M Ansari, D Dodamani, M Aron, A Seth, M Gulati, A Seith, DN Srivastava, Iatrogenic Renal Pseudoaneurysm after Pyelolithotomy: A Case Report. 2003; 23(5): 301-303


Renal artery pseudoaneurysm is rare after pyelolithotomy. The lesion may manifest as haematuria, hypertension, local symptoms or even catastrophic rupture resulting in life-threatening haemorrhage and shock.1-3 When intervention is required, selective or super selective transcatheter embolisation is the treatment of choice.4-6 Surgical exploration is reserved only for a large or refractory pseudoaneurysm because it usually results in partial or total nephrectomy.

Case

Case 1

A 35-year-old female patient presented to the emergency services at our institution with intractable hematuria following a pyelolithotomy for left renal stone seven days previously at a peripheral hospital. She had marked pallor, hypotension and her hemoglobin was only 4 gm/dL. She was resuscitated and 6 units of blood were transfused to stabilize her blood pressure and hemoglobin. After stabilization she was subjected to selective renal angiography, which showed a pseudoaneurysm arising from the inferior segmental branch of the left renal artery (Figure 1). Selective embolisation with a microcoil was performed and the hematuria subsided (Figure 2). She made an uneventful recovery and was doing well at the one-month follow up.

 

Case 2

A 55-year-old male presented with persistent haematuria after pyelolithotomy for a left staghorn calculus. After stabilization, selective renal angiography was performed, which showed a pseudoaneurysm arising from the inferior segmental branch of the left renal artery (Figure 3). Selective embolisation with a microcoil was performed and the hematuria subsided (Figure 4). He made an uneventful recovery and was asymptomatic at the 12-month follow up.

 

Case 3

A 35-year-old man presented with dull aching pain and a mass in the right flank of six months duration. He had undergone right pyelolithotomy elsewhere for a partial staghorn calculus. There was no history of haematuria, hypertension or other urologic disorder. Physical examination revealed a pulsatile and tender mass in the right flank. Routine laboratory investigations were within normal limits. A CT scan of the abdomen showed a large mass (12 x 10 cm) in the upper polar region of the right kidney displacing the kidney inferiorly. Selective right renal angiography revealed a giant aneurysm arising from the posterior division of the right renal artery (Figure 5). Selective embolisation was not possible due to the large size of the aneurysm. The patient was explored via a transperitoneal approach with the intention of carrying out an upper pole partial nephrectomy. On exploration, a large pulsatile mass was seen replacing the upper half of the right kidney. The upper pole of the right kidney was converted into a pseudoaneurysm with a very thick wall. The aneurysm was adherent to the diaphragm superiorly and was lifting the inferior vena cava superomedially going up to the origin of the right renal artery. The right renal artery was controlled at this point. It was not possible to dissect and trace the individual branches of the renal artery due to dense fibrosis and hence a total nephrectomy was performed. The patient made an uneventful recovery and was doing well at the 18-month follow up.

Discussion

A variety of therapeutic options exist for treatment of symptomatic renal calculi, including extracorporeal shock wave lithotripsy (SWL), percutaneous nephrostolithotomy (PCNL) and open pyelolithotomy or nephrolithotomy. Although most renal stones are currently managed either by SWL or PCNL, pyelolithotomy or nephrolithotomy is still performed occasionally when the stone bulk is too large or when there is a lack of facilities or expertise for percutaneous surgery.

 

Renovascular injury is a recognized complication of percutaneous procedures. The reported incidence of pseudoaneurysm formation is 0.6% to 1% following PCNL and 2% to 3.4% following percutaneous needle biopsy of a renal allograft.7 The incidence of vascular complications in open surgical procedures like pyelolithotomy and nephrolithotomy has been reported as 0.1% to 0.3 %. Arteriovenous fistulae and pseudoaneurysms of the renal artery are formed and maintained by high-pressure leak from a lacerated artery. It is easy to picture laceration of arterial branches during a percutaneous transparenchymal procedure. During pyelolithotomy such injuries can occur during dissection in the Gil Vernet plane or during blind manipulations with a Randall forceps within calyces or at the infundibular neck. The leak is transmitted into a low resistance system as found around the pelvis, calyces or into the surrounding connective tissue. Small sized pseudoaneurysms with little bleeding can be managed expectantly.7,8 Selective embolisation is the best treatment for pseudoaneurysms, which remain symptomatic in terms of bleeding, hypertension or pain.9,10The advantages of this mode of treatment are that it is well tolerated, relatively safe and allows maximal preservation of functioning renal tissue. 10

 

A significant vascular lesion (large pseudoaneurysm or arteriovenous malformation) may not be amenable to embolisation and require nephrectomy or partial nephrectomy.11,12 Surgical excision of a renal artery aneurysm is recommended for the treatment of haematuria, hypertension, and local symptoms or to prevent aneurismal rupture.13 Elective surgical management with a simplified technique involving ligation of the neck of the aneurysm is also successful.14 Small sized aneurysms involving a short segment of the renal artery can be managed by resection and primary closure with or without patch angioplasty.14 Bench surgery with extracorporeal aneuresmectomy with vascular reconstruction and auto transplantation has also been done in patients with intrarenal aneurysm involving multiple arterial branches. Currently, total or partial nephrectomy is reserved for patients with renal infarction, severe ischaemic renal atrophy or particularly complex intrarenal aneurysm.15 In the third case nephrectomy was necessitated as dissection and mobilization of the pseudoaneurysm was not possible due to its dense adhesions in the renal hilum that precluded dissection of the branches of the renal artery.

 

This report is of interest as it presents two different manifestations of post-pyelolithotomy renal pseudoaneurysms requiring different treatments. Selective renal angiography is most helpful in the diagnosis and offers therapy by super selective angioembolisation. Such embolisation is most feasible and effective in small lesions. Surgical intervention in advised in cases of large aneurysms not amenable to selective embolisation. The problem, however, is best prevented by careful dissection in the vicinity of the renal sinus and gentle manipulations during the performance of a pyelolithotomy.

References

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2. Gordon RL, Verstandig AG, Perlberg S. Repeated subselective renal embolisation following pyelithotomy:angiographic salvage of a kidney. J Urol. 1984 Feb; 13(2):324-326.

3. Andersson I. Renal artery lesions after pyelolithotomy: a potential cause of renovascular hypertension. Acta Radiol Diagn (Stockh). 1976 Sep; 17(5B):685-695.

4. Endovascular treatment of traumatic and iatrogenic intrarenal arterial lesions by microcoil embolisation. Ann Radiol (Paris). 1996; 39(6):234-239.

5. Konishi T, Kokuho M, Narita M, Kataoka A, Arai Y, Okada Y, Tomoyoshi T. Renal pseudoaneurysm successfully treated by superselective embolisation as a complication of percutaneous nephrolilothotomy: report of a case. Hinyokika Kiyo. 1991 Oct; 37(10):1299-1302.

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8. Clark RE, McNamara TO, Paluhinskas AJ. Intrarenal mycotic aneurysms detected angiographically. Br J Radiol. 1972: 45,67.

9. Patterson, David E and Joseph W. Segura et.al. The etiology and treatment of delayed bleeding following percutaneous lithotripsy. J Urol. 1985; 133:447-451.

10. Mundth E.D, Dailing RC, Alvarado R. Surgical management of mycotic aneurysm and complication of infection in vascular reconstructive surgery. S Afr Med. 1969; 43:870-873.

11. Du Perez HM. Two unusual intrarenal vascular lesions treated by conservative surgery. S Afr Med. 1969; 43:870-873.

12. Patterson DE and Joseph W. Segura, Andrew J. Leroy et.al. The etiology and treatment of delayed bleeding following percutaneous lithotripsy. J Urol. 1985; 133:447-451.

13. Ortenberg J, Novick AC, Straffon RA, et.al. Surgical treatment of renal artery aneurysm. Brit J Urol. 1983; 55:341.

14. Novick AC. Management of intrarenal branch arterial lesions with extracorporeal microvascular reconstruction & autotransplantation. J Urol. 1981; 126:150.

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