Post-PCNL Renal Artery Pseudoanurysm

CASE REPORT Post-PCNL Renal Artery Pseudoanurysm Safdar Shah1, Abeer Fatima2, Muhammad Danial Ali Shah3, Wajid Ali1, Irfan Ahmed Gorya1 and Fawad Nasrullah4 ABSTRACT A renal artery pseudoaneurysm is a rare but important complication that can occur after renal trauma, renal biopsy, percutaneous nephrostomy, percutaneous nephrolithotomy (PCNL), and partial nephrectomy. The incidence of this potentially life-threatening complication is less than 1%, but is likely to increase with the increasing popularity of endoscopic renal procedures. We present a case of a 30-year female who underwent right PCNL for a right renal pelvic stone. Two weeks later, she presented with massive hematuria. Renal angiography revealed psuedoanurysm of interlobar artery which was successfully treated with coil embolization. Key Words: Hematuria. Pseudoaneurysm. Renal stone. INTRODUCTION Since its introduction in 1976,1 percutaneous nephrolitholtomy (PCNL) has become the gold standard treatment for renal stones requiring surgery. In addition to other complications, hemorrhage is its most common complication.1 Hemorrhage may be venous or arterial. Venous bleed is usually treated conservatively while the arterial bleed requires special attention, as it may be due to postoperative renal artery pseudoanurysm, arterio-venous or arterio-calyceal fistula. Renal artery pseudoanurysm is a rare complication that occurs after renal trauma, renal biopsy, percutaneous nephrostomy, PCNL and partial nephrectomy,2,3 and deserves meticulous care and treatment. Diagnosis and treatment of renal arterial pseudoaneurysm is made by renal angiography and arterial embolization, respectively.4,5 CASE REPORT A 30-year female presented to us with complaint of right flank pain for 6 months. On examination, her abdomen was soft. Right flank was non-tender with no visceromegaly. Her laboratory investigations were within normal range. Ultrasonography showed right renal stone of 3 cm with mild hydronephrosis. The left kidney was normal. X-ray kidney ureter bladder (KUB) showed radiopaque right renal pelvic stone (Figure 1). She underwent right PCNL. The stone was approached from the lower pole. Complete fragmentation of the stone was done and nephrostomy was placed. The 1 2 3 4 Department of Urology, KEMU/Mayo Hospital, Lahore. Student, Allama Iqbal Medical College, Lahore. Student, King Edward Medical University, Lahore. Department of Urology, Postgraduate Medical Institute, Lahore. Correspondence: Prof. Safdar Shah, Head, Department of Urology, Hemodialysis and Renal Transplantation, KEMU/ Mayo Hospital, Lahore. E-mail: [email protected] Received: April 28, 2016; Accepted: October 30, 2017. 238 patient was discharged on the 3rd postoperative day after the removal of nephrostomy. At 13th day of discharge, patient presented with the high grade fever along with gross hematuria. Prophylactic intravenous antibiotics were commenced initially and later, according to the sensitivity report, blood was transfused. Her bladder wash was done and blood clots were evacuated. She was discharged on the 5th day. After 10 days, she presented with the complaint of urinary retention and history of gross hematuria for 3 days. Perurethra catheterization and bladder wash were done with evacuation of clots. Blood was also transfused. Her cystoscopy was done which revealed a large organised clot, which was evacuated too. At night, she again developed massive hematuria. Exploration of the right kidney was planned and done, once the patient's condition was optimized. Operative finding was a healthy kidney with clots in the renal pelvis, which were evacuated but no incidence of active bleeding. Wound was closed after placement of nephrostomy tube. The next day, she again developed gross hematuria alongwith bleeding in the nephrostomy tube. Her renal CT angiogram was carried out which showed a psuedoanurysm of interlobar branch of right renal artery. The following day, her renal angiography with subsequent selective angioembolization was done with the coil (Figures 2 and 3). She was kept under observation for 4 days and finally discharged. DISCUSSION Renal calculi are nowadays treated with minimal access surgery, like PCNL and retrograde intrarenal surgery (RIRS). The stone-free rate for calculi > 2 cm is found to be 71% and 37% for PCNL and RIRS, respectively.1 There are various reports in literature related to a safety margin of PCNL, but some unique complications of the procedure still remain dreadful.1 The rate of venous hemorrhage, which needs blood transfusion, is 7.3%; Journal of the College of Physicians and Surgeons Pakistan 2018, Vol. 28 (3): 238-239 Post-PCNL renal artery pseudoanurysm Figure 1: Plain X-ray kidney, ureter and bladder (KUB) showing stone in right kidney. Figure 2: Renal CT angiogram showing aneurysm of interlobar branch of right renal artery. but arterial complications have a wide spectrum.1 The most challenging issue in these complications is how to diagnose these conditions because CT-guided contrast studies are helpful in nearly arterial phase and there is difficulty in performing the selective angiography. MRI is also helpful but it has its limitations. The only modality, which is useful both for diagnostic as well as therapeutic intervention, is the selective renal angiography.6-8 Transarterial embolization (TAE) by direct percutaneous method is a preferred method of intervention, which involves coil embolization of the content of pseudoaneurysm under fluoroscopic control. The use of TAE technique has disadvantage of arterial injury, and hemorrhage during intervention leading to nephrectomy. In the present case, we had intraarterial occlusion by coil and were successful.9 This method is useful and supported by many studies.2,9,10 Post-PCNL hematuria may present with a potentially lifethreatening condition having an underlying etiology of renal artery psuedoanurysm or renal arterio-venous fistula. Embolization of the injured vessel is an effective, and relatively easy procedure in experienced hands, with high rate of success and immediate benefits, thus saving the patient from morbidity and mortality. REFERENCES 1. Hakan Ozturk International pseudoaneurysm after percutaneous nephrolithotomy at solitary kidney. Nephrourol Mon 2014; 6: e1937. Figure 3: CT angiogram showing coil lodged at right interlobar vessel with complete occlusion. 2. Massulo-Aguiar MF, Campos CM, Rodrigues-Netto N Jr. Intrarenal pseudoaneurysm after percutaneous nephrolithotomy. Angiotomographic assessment and endovascular management. Int Braz J Urol 2006; 32:4. 3. Mukesh Kumar Vijay, Preeti Vijay, Ranjit Kumar Das, Anup Kumar Kundu. Renal artery pseudoaneurysm following percutaneous nephrolithotomy. Saudi J Kidney Dis Transpl 2011; 11:347-8. 4. Kervancioglu S, Gelebek Yilmaz F, Erturhan S. Endovascular management of vascular complications after percutaenous nephrolithotomy. Vasa 2014; 43:459-64. 5. Jinga V, Dorobat B, Youssef S, Radavoi GD. Transarterial embolization of renal vascular lesions after percutaneous nephrolithotomy Chirurgia (Bucur) 2013; 108:521-9. 6. 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