ENDOUROLOGY & LAPAROSCOPY

Renal artery pseudoaneurysm following laparoscopic partial nephrectomy
Shapiro EY, Hakimi AA, Hyams ES, Cynamon J, Stifelman M, Ghavamian R
Department of Urology, Montefiore Medical Center, Bainbridge, Bronx, New York.
Urology. 2009 [Epub ahead of print]

• Objectives: To present our experience with the management of renal artery pseudoaneurysms following laparoscopic partial nephrectomy (LPN).
• Methods: Our bi-institutional LPN database of 259 patients from July 2001 to April 2008 was queried for patients diagnosed with a postoperative renal artery pseudoaneurysm. Demographic data, perioperative course, complications, and follow-up studies in identified subjects were analyzed. Postembolization success was defined as symptomatic relief, resolution of hematuria, and a stable hematocrit and serum creatinine.
• Results: We identified 6 patients (2.3%) who were diagnosed with a renal artery pseudoaneurysm after LPN. The mean age of our cohort was 61.2 years (49-76), mean operative time was 208 minutes (140-265), and mean estimated blood loss was 408 mL (50-800). Patients presented at a mean of 12.6 days (5-23) after the initial surgery. Five patients had gross hematuria and a decreased hematocrit, with 1 patient presenting with clinical symptoms of hypovolemia. The sixth patient was incidentally diagnosed. The diagnosis of a renal artery pseudoaneurysm was confirmed in all cases by angiography. Selective angioembolization was successfully performed in all patients. At a median follow-up of 8.3 months all patients (100%) remained without any evidence of recurrence.
• Conclusions: Although pseudoaneuryms are a rare postoperative complication of LPN, they are potentially life-threatening. Early identification and proper management can help reduce the potential morbidity associated with pseudoaneurysms. Our experience demonstrates the feasibility and supports the use of selective angioembolization as an excellent first-line option for patients who present with this form of delayed bleeding.

• Editorial Comment
  The authors should be congratulated for reviewing their experience of pseudoaneurysms following laparoscopic partial nephrectomy (LPN). In contrast to case reports describing this particular complication post LPN, this manuscript reviewed the incidence of pseudoaneurysms post LPN in a series of LPN. From a total of 259 LPNs performed in 81 months the authors identified 6 patients (2.3%) who were diagnosed with a renal artery pseudoaneurysm after LPN. The majority of patients presented with gross hematuria and a decreased hematocrit, with 1 patient presenting with clinical symptoms of hypovolemia. One patient was incidentally diagnosed. Their diagnosis was confirmed in all cases by angiography. Selective angioembolization was successfully performed in all patients. At a median follow-up of 8.3 months, all patients (100%) remained without any evidence of recurrence. Their conclusion was that pseudoaneurysms are a rare postoperative complication of LPN, but they are potentially life threatening. Early identification and proper management can help reduce the potential morbidity associated with pseudoaneurysms and selective angioembolization is an excellent first-line of treatment of patients who present with this form of delayed bleeding. It would be beneficial if we could predict the patients that would develop this type of complication, i.e.; localization of the tumor, size, anatomical characteristics, etc., so we could foresee and prevent the occurrence of postoperative bleeding due to a pseudo-aneurysm.

Dr. Fernando J. Kim
Chief of Urology, Denver Health Med. Ctr.
Associate Professor, Univ. Colorado Health Sci. Ctr.
Denver, Colorado, USA
E-mail: fernando.kim@dhha.org