Massive Hematuria Research Articles

Clinical case of successful endovascular correction of an arterio-ureteral fistula

Arterio-ureteral fistulas are a pathological condition characterised by the appearance of a defect between the blood vessels and adjacent distal segments of the ureter. Arterio-ureteral fistulas are relatively rare and potentially life-threatening, since they are associated with a high risk of developing haemorrhagic shock against the background of recurrent massive haematuria.This study describes the successful endovascular treatment of arterio-ureteral fistulas in a 51-year-old female patient. Evisceration of the pelvic organs was performed, followed by uretero-cutaneostomy and colostomy. Ureteral stents were installed to improve the outflow of urine and prevent ureteral stenosis. After stent removal, episodes of recurrent profuse bleeding from uretero-cutaneostomy occurred. On admission, multi-spiral computed tomography with angiography of the iliac arteries was performed. Extravasation of the contrast agent was not detected; however, external compression of the left common iliac artery by the left ureter was identified. After further examination, a balloon-expandable stent-graft was implanted into the left common iliac artery. The postoperative period thereafter was uneventful.This clinical case demonstrates the highly efficient endovascular treatment of the presented pathology and exemplifies the need for an integrated and multidisciplinary approach in the diagnosis and treatment of arterio-ureteral fistulas. Minimally invasive techniques can reduce surgical trauma and quickly isolate pathological blood discharge from the artery into the ureter. The advantages and disadvantages of endovascular technologies in the treatment of the presented pathology are also discussed.Received 16 February 2021. Revised 11 March 2021. Accepted 12 March 2021.Funding: The study did not have sponsorship.Conflict of interest: The authors declare no conflicts of interests.Contribution of the authorsDrafting the article: A.G. Vanyurkin, A.N. KazantsevCritical revision of the article: M.A. Chernyavsky, N.V. Susanin, M.S. MosoyanSurgical treatment: M.A. Chernyavsky, A.G. Vanyurkin, N.V. SusaninFinal approval of the version to be published: M.A. Chernyavsky, M.S. Mosoyan, A.G. Vanyurkin, N.V. Susanin, A.N. Kazantsev

Arterio-Ureteral Fistula: Systematic Review of 445 Patients.

Arterio-ureteral fistula (AUF) is an uncommon diagnosis, but increasingly reported and potentially lethal. This systematic review comprehensively presents risk factors, pathophysiology, location and clinical presentation of AUF aiming to increase clinical awareness of this rare but life-threatening condition, and to put this entity into a contemporary perspective with modern diagnostic tools and treatment strategies. This review was performed according to the PRISMA (Preferred Reporting Items for a Systematic Review and Meta-Analysis of Individual Participant Data) guidelines. A literature search in PubMed® and EMBASE™ was conducted. In addition, retrieved articles were cross-referenced. Data parameters included oncologic, vascular and urological history, diagnostics, treatment, and followup, and were collected using a standard template by 2 independent reviewers. A total of 245 articles with 445 patients and 470 AUFs were included. Most patients had chronic indwelling ureteral stents (80%) and history of pelvic oncology (70%). Hematuria was observed in 99% of the patients, of whom 76% presented with massive hematuria with or without previous episodes of (micro)hematuria. For diagnosis, angiography had a sensitivity of 62%. The most predominant location of AUF was at the common iliac artery ureteral crossing. AUF-specific mortality before 2000 vs after 2000 is 19% vs 7%, coinciding with increasing use of endovascular stents. AUF should be considered in patients with a medical history of vascular surgery, pelvic oncologic surgery, irradiation and/or chronic indwelling ureteral stents presenting with intermittent (micro)hematuria. A multidisciplinary consultation is necessary for diagnosis and treatment. The most sensitive test is angiography and the preferred initial treatment is endovascular.

The misleading laboratory results: Renal impairment associated with high anti myeloperoxidase titer (anti-MPO) does not always mean ANCA vasculitis

Introduction: Antineutrophil cytoplasmic autoantibodies (ANCAs) are crucial in the pathogenesis of ANCA-associated glomerulonephritis. Although highly specific for this disease, these antibodies can appear in healthy individuals or occur in other settings such as malignance, other inflammatory disease, or drugs. Renal biopsy remains essential for diagnosis and as a prognostic tool. Failing to perform a biopsy risks an incomplete evaluation or misdiagnosis. Clinical case: A 60-year-old male known to have had previous normal kidney function was admitted with generalized pitting edema, nonpruritic erythematous rash, and decreased urine output. He had been recently started on clozapine for depression. Laboratory tests revealed nephrotic syndrome with massive proteinuria (11g/day), hematuria and elevated serum creatinine that reached a maximum of 4.9 mg/dl. The only positive finding was a high titer of myeloperoxidase (MPO) ANCA antibody (111 UI/ml). Clozapine was discontinued, and he was started on conservative management of the nephrotic syndrome. The rash disappeared within one week. Kidney biopsy showed cellular variant focal segmental glomerulosclerosis (FSGS) with mild acute tubular injury. The patient was treated with oral prednisolone with complete remission. Repeat MPO-ANCA was negative after one month. Discussion: We present a challenging case that highlights the importance of kidney biopsy for accurate diagnosis with major impact on treatment and prognosis. This case also underlines the presentation and evolution of FSGS cellular variant, a rare and poorly understood disease. The relationship between skin rash with high MPO titer and the administration of clozapine with clinical remission after its discontinuation favors the hypothesis of drug associated ANCA-vasculitis.

Massive Hematuria in the Heterozygous Sickle Cell Disease: A Report of Two Cases

These were 2 patients with heterozygous SCD with highly abundant macroscopic hematuria. The patients were 23 and 31 and had a clotting total hematuria. They were both anemic with good renal function. Cystoscopy had found bleeding from the left kidney in both patients. Uro-tomodensitometry and diagnostic uretero-renoscopy were without particularity for both patients. Treatment consisted of transfusions, oral rehydration, and hydergine for vaso-occlusive crisis.

Successful endovascular treatment of massive hematuria due to ureteroarterial fistula secondary to ureterocutaneostomy

Successful endovascular treatment of massive hematuria due to ureteroarterial fistula secondary to ureterocutaneostomy

Conservative management of primary malignant melanoma of the bladder: a case report

BackgroundPrimary malignant melanoma (PMM) of the bladder represents a very rare clinic-pathologic entity. Given the rarity of the disease, the best treatment option is not well recognized.Case presentationWe describe a case of neoplasm of the bladder in a 74 years-old Caucasian man presenting with massive hematuria. Based on clinical, instrumental and histological findings a diagnosis of PMM was made. The patient underwent trans urethral resection of bladder tumor plus intravesical Bacillus Calmette–Guérin.ConclusionsTo make a correct diagnosis, clinical history, endoscopic evaluation, histopathological examination and immunohistochemistry, are necessary. Multidisciplinary evaluation is required to discriminate primary from metastatic malignant melanoma.

Rare Surgical Complication of In Vitro Fertilisation Treatment: Bladder Injury During Oocyte Retrieval

Current literature suggests that surgical complications from oocyte retrievals (ORs) are uncommon. Here, we present a rare case of bladder injury during OR and its subsequent management. A 37-year-old nulliparous woman underwent assisted reproductive therapy (ART) for primary infertility secondary to anovulatory cycle. During OR, there was an inadvertent puncture of the bladder, with active intra-bladder bleeding seen on transvaginal ultrasound. Bladder washout followed by continuous drainage was instituted with antibiotic coverage over several days. Bladder integrity ascertained through computer tomography urogram and cystoscopy were unremarkable. She was discharged well and continued with her fertility treatment. Transvaginal OR is associated with few complications. Bladder injury, albeit rare, can present with massive hematuria and hemodynamic instability. Early identification of the injury is key to management with insertion of the indwelling urinary catheter, hemodynamic resuscitation and bladder irrigation. With a urological multi-disciplinary approach, most bladder injuries can be resolved non-invasively. J Med Cases. 2021;12(3):102-106 doi: https://doi.org/10.14740/jmc3632

Advanced cervical cancer in young women: imaging study of late and very late radiation-related side effects after successful treatment by combined radiotherapy

Radical combined radiotherapy (RT) is a standard treatment for advanced cervical cancer. The aim of our study was to identify morphological late (≥6 months) and very late (≥5 years) radiation-related comorbidities on computed tomography (CT), positron emission tomography/computerized tomography (PET/CT) or magnetic resonance imaging (MRI) scans in young females who survived ≥5 years since RT and were considered as successfully treated. Secondly, we studied a rate of clinically silent radiation-related toxicities apparent on imaging scans that might influenced on future well-being of survived females. Thirdly, we analyzed reasons why patients underwent imaging scans. We included 41 subjects aged under 50 years (mean 41.8±7.2 years, median 41 years), who survived ≥5 years since RT, with at least one available imaging scan ≥3 years since RT. The mean time between RT and the last available scan was 12.3±7.9 years (median 9 years); the mean time of clinical follow-up was 15.4±7.1 years (median 14 years). Fourteen (34.1%) females underwent the first imaging scan in emergency situation and 27 (65.9%) patients due to variable chronic complaints. Grade III-V radiation-related comorbidities occurred in 19 (46.3%) females including one case of death due to radiation-induced osteosarcoma. In 14 of 19 patients, comorbidities were multiple. Four (9.8%) females suffered from life-threatening complications (grade IV): one from an uretero-arterial fistula with massive hematuria and 3 from bowel perforations. Eleven (26.8%) subjects suffered from bowel strictures with ileus development, they underwent mean 1.7±0.8 surgery (median 1.5). The mean time since RT to the first surgery for intestinal complications was 5.4±6.0 years (median 3 years), to the second 12.0±9.6 years (median 11.5 years) and to the third surgery 9.0±4.2 years (median 9 years). Late fistulas formations (vesico-recto-vaginal) were seen in 6 (14.6%) patients. Bone complications were diagnosed in 9 (22.0%) of treated females, one case of osteosarcoma included, 4 of 9 bone complications were clinically silent. In 5 (12.2%) subjects, toxicities grade III-IV first time manifested >5 years since RT, majority of them were multiple. The bowel perforation and fistulas formations were the earliest manifested grade III-IV toxicities, with median time 3 years since RT, the bone complications were the latest manifested with median time 16 years since RT. Our study is not able to bring information about the incidence of late and very late radiation related comorbidities, according to International Federation of Gynecology and Obstetrics (FIGO) recommendations patients are clinically followed only for 5 years and imaging cross-sectional scans are not recommended. However, our study shows that if females successfully treated for advanced cervical cancer report abdominal/pelvic clinical problems, it is highly probable their imaging scans will reveal late radiation related side-effects that may affect the rest of their life. It puts forward question whether females after radical RT should been regularly followed by cross-sectional imaging methods.

Renal arteriovenous malformation in a 14-year old girl with gross hematuria

Renal arteriovenous malformation (AVM) is a rare cause of gross hematuria in children and adolescents that may present so acute and severe hematuria, leading to significant anemia in patients. We present a 14-year old girl with acute massive gross hematuria with no history of trauma or coagulation defect. Although AVM not common, it should be included in the differential diagnosis of gross hematuria in children and adolescents.

Arterioureteral fistula: overview of clinical characteristics, endovascular management, and outcomes

Background Arterioureteral fistula (AUF) is a condition resulting from the pathologic connection between the ureter and the artery. Despite the low incidence, it can lead to devastating clinical consequences due to massive hematuria with a considerable mortality rate. Material and methods From January 2009 to December 2018, eight patients with AUF from two tertiary referral centers were included. Clinical data including presenting symptoms, previous pelvic surgery or radiotherapy, indwelling ureteral stents, primary vascular pathology, angiographic findings, type of treatment, survival, and recurrence were analyzed. Results All eight patients (six women, mean age 62.4 ± 14.5 years) presented with macroscopic hematuria and were successfully treated by endovascular management. One patient developed AUF due to an underlying iliac artery aneurysm, and the rest were due to secondary causes. Six patients had a history of an indwelling ureteral stent for a median of 5.5 months (1–84 months). All of the patients were successfully treated by endovascular management. For the median follow up of 987 days, three patients had recurrence of hematuria in a mean of 6.3 months, two patients were treated by surgery, while one was treated by endovascular treatment. Conclusion AUF should be confirmed through a purposeful iliac angiogram or ureterography when suspected based on a relevant history or CT findings. AUF can be successfully treated by endovascular management. The surgical option should be considered in cases of recurrence. Abbreviations AUF: arterioureteral fistula; CIA: common iliac artery; DJ: double J; EIA: external iliac artery; IIA: internal iliac artery; NBCA: N-butyl cyanoacrylate; PCN: percutaneous nephrostomy

Bladder Artery Embolization for Massive Hematuria Treatment in a Patient With Ataxia-Telangiectasia Acute Lymphoblastic Leukemia

Ataxia-telangiectasia (AT) is a hereditary recessive autosomal disorder following a course of progressive cerebellar ataxia, and oculocutaneous telangiectasia. Disease-specific telangiectasias are generally localized in the oculocutaneous region, while telangiectasias located within the bladder are rarely seen in patients with AT. The patient who had been followed-up with a diagnosis of AT since the age of 3 years was later diagnosed with acute lymphoblastic leukemia at the age of 8 years. The patient developed hematuria approximately in the 29th month of treatment. The cystoscopy revealed regions of extensive hemorrhagic telangiectasis, which was interpreted as the bladder involvement of AT. The case presented here underwent several cycles of intravesical steroid and tranexamic acid treatments and intravesical cauterization procedures, but the patient was unresponsive to all medical treatment approaches. The patient was consequently evaluated by an interventional radiology unit for a selective arterial embolization. The patient's hematuria resolved after embolization. Bladder wall telangiectasia may, on rare occasions, develop in patients with AT, and can result in life-threatening hemorrhages. We also suggest that a selective arterial embolectomy can be safely carried out in pediatric patients with treatment-resistant intravesical bleeding.

Akut Myeloid Lösemi Hastasında Transkateter Embolizasyon Gerektiren Masif Hematüri

Akut Myeloid Lösemi Hastasında Transkateter Embolizasyon Gerektiren Masif Hematüri

Massive hematuria due to an autogenous saphenous vein graft and urinary bladder fistula in an extra-anatomic iliofemoral bypass: a case report

IntroductionGross hematuria caused by rupture of an artery in the urinary tract is a rare but potentially fatal condition. Iliac artery aneurysms, pelvic surgery with radiation, vascular reconstructive surgery, surgery for stenosis of the ureteropelvic junction, and transplantation are reported to be associated with this condition. In the vascular reconstructive surgery group, the most common etiology is rupture of the degenerated artery or synthetic graft in the ureter.Case presentationWe present a case of rupture of the small anastomotic pseudoaneurysm at the proximal anastomosis of a right iliofemoral autogenous vein extra-anatomic graft in the urinary bladder. To our knowledge, this is the first report of a rupture of an autogenous vein graft in the urinary bladder. Our patient, a 24-year-old Albanian farmer, was admitted to the emergency department in severe hemorrhagic shock induced by exsanguinating hematuria. He underwent immediate surgery, during which direct sutures to the bladder were placed and the saphenous graft was replaced with a synthetic one. The patient recovered completely, was free of hematuria, and showed no signs of pathological communication between the urinary and arterial tracts on postoperative cystoscopy and computed tomographic angiography during 2 years of follow-up.ConclusionThe incidence of artery-to-urinary tract fistulas is growing due to the increasing use of urologic and vascular surgery, pelvic oncologic surgery, and radiation therapy. In addition to fistulas involving a degenerated artery and ureter or synthetic grafts and ureter, they can also involve an autogenous vein graft and the urinary bladder. In our patient, the fistula was a result of erosion of the bladder from a pseudoaneurysm at the proximal anastomosis of an autogenous vein iliofemoral bypass in an extra-anatomic position. Open surgery remains the best treatment option, although there is increasing evidence of successful endovascular treatment.

Triple-balloon-assisted n-butyl-2-cyanoacrylate embolization of a cirsoid renal arteriovenous malformation.

We report a patient with a cirsoid renal arteriovenous malformation (AVM) causing massive hematuria that was successfully embolized by n-butyl-2-cyanoacrylate under triple-balloon occlusion. Proximal balloons were placed in the renal artery and vein for flow control, and a coaxial microballoon was placed in a feeding artery of the AVM to control the delivery of n-butyl-2-cyanoacrylate. Under triple-balloon occlusion, n-butyl-2-cyanoacrylate embolization achieved complete occlusion of the AVM with no procedure-related complications, such as renal infarction. This triple-balloon-assisted technique enabled us to control blood flow and the delivery of n-butyl-2-cyanoacrylate, allowing complete occlusion of the AVM. This approach may prevent proximal embolization and distal migration of n-butyl-2-cyanoacrylate.

A case of subacute-onset myelodysplastic syndrome with infection mimicking thrombotic thrombocytopenic purpura: a case report with literature review

BackgroundSchistocytosis, which is often observed in thrombotic thrombocytopenic purpura (TTP) patients, is a rare complication in myelodysplastic syndrome (MDS) patients.Case presentationWe report on a 59-year-old man with progressive anemia and thrombocytopenia. Schistocytes were observed in his peripheral blood; consciousness disturbance, renal insufficiency, and fever were subsequently observed, fulfilling the classic pentad of TTP. He also showed massive hematuria, headache, chest pain, and abdominal pain, and brain magnetic resonance imaging scan demonstrated small infarctions. Cefmetazole was not effective, and there was no focus of infection. Disseminated intravascular coagulation (DIC) score was low at that time. We suspected TTP, and therapeutic plasma exchange was initiated. Simultaneously, antibiotic was changed to piperacillin/tazobactam. After the initiation of those treatments, his general condition improved. ADAMTS13 activity did not decrease significantly; therefore, we stopped the therapeutic plasma exchange. His D-dimer level increased and antithrombin level decreased. Heparin treatment was initiated; however, anemia and thrombocytopenia persisted. Bone marrow examinations revealed dyspoiesis in all cell lines, and a complex karyotype indicated a high risk of MDS. His TTP-like condition relapsed; again, piperacillin/tazobactam was effective. Enterococcus faecalis and Haemophilus influenzae were detected in urine culture later. Infection and/or DIC superimposed on MDS might be involved in the pathophysiology of this case.ConclusionsIt should be noted that subacute-onset of MDS with infection can mimic TTP.

Uretero-iliac artery fistula: a challenge diagnosis for a life-threatening condition: monocentric experience and review of the literature.

Uretero-iliac artery fistulae (UIAF) are the consequence of chronic inflammatory events that create a fibrous and poorly vascularized uretero-vascular adhesion. They often occur in patients with a history of surgery, pelvic radiotherapy, and chronic ureteral stenting. The presentation is usually massive gross hematuria with acute anemia unto to hemorrhagic shock, representing a life-threatening condition. High mortality rate is reported (7-23%). We present four cases in three patients, treated in our Institution from 2013 to 2018, and reviewed the published literature. UIAF was defined as the ratified presence of an abnormal communication between the ureter and any artery. In all patients, the UIAF was initially evaluated by contrast-enhanced computed tomography (CT) angiography. The management strategy was defined individually based on the specific risk profile of each patient. In all cases, ureteral-iliac artery fistula occurred in female patients with previous surgery or radiation and with presence of indwelling ureteral stent. In every case the hematuria was massive and life-threatening. Diagnosis was delayed because of the poor diagnostic accuracy of CT scan, leading to over-treatment. Angiography resulted the best diagnostic tool. The endovascular treatment proved good outcomes in terms of early complications, with no case of mortality. In case of gross hematuria during ureteral stent change in female patients with history of previous pelvic surgery and radiation, UIAF must be suspected and immediately treated, since it represents a urological emergency. Angiography can be useful to confirm the diagnosis and endovascular treatment with vascular endoprosthesis is the best therapeutic option.

Evaluation of urologic emergency cases applying to emergency service

Introduction: Urological emergencies constitute a significant proportion of patients presenting to emergency services. In this study demographic data, clinical diagnosis and treatment options of urological emergency cases referred to Malatya Training and Research Hospital Emergency Service were evaluated retrospectively. Materials and Methods: 18658, which were evaluated as urological emergency from 717624 patients who applied for Malatya Training and Research Hospital Emergency Service between March 2017 and March 2018 for any reason, were evaluated retrospectively. Demographic characteristics, such as age and gender of the patients, and medical treatments applied o clinics were evaluated. Findings: 47.2% of the patients were male (mean age: 43.7), 52.8% were female (mean age: 39.9), 6.7% were children, 11.3% were 70 years or above. The number of patients who were diagnosed with genitourinary system infection was 8549. There were 4536 patients with acute renal colic, 67 patients with massive macroscopic hematuria. When 74 cases with genitourinary system trauma were evaluated, minor and major renal injuries were seen most frequently. 73 of the patients were surgically operated. A total of 5 (0.02%) patients with two major renal traumas, 2 Fournier gangrene and 1 gunshot injury to the scrotum region were referred to the secondary center after the first visit to the emergency center. Conclusion: Urological emergencies that are frequently encountered in the emergency department should be evaluated quickly by the emergency physician and should be referred to a urology specialist. Having a detailed knowledge of the urological experience of the urologist and assessing the patient quickly and making the necessary intervention in the shortest time can be lifesaving.

Refractory thrombocytopenia in SLE patient with massive thigh hematoma and hematuria successfully treated with Rituximab: Case Report

Background: Systemic Lupus Erythematosus is a multisystemic inflammatory disease with broad clinical presentation, 9.5% to 44.5% of patients with SLE have thrombocytopenia complication of different grades. No significant increase in risk of hemorrhage was found in patients with SLE with moderate thrombocytopenia, while those with severe thrombocytopenia frequently developed bleeding, which is associated with the activity of the disease and potentially life-threatening condition, if left untreated. Case presentation: We report a case of 35-year-old SLE male patient, presented with sudden painful large non-traumatic ecchymotic lesion on the right thigh extending to calf with macroscopic hematuria. At presentation, platelets count was 50 x 109/L with hemoglobin dropping from 10.3 to 6.9 g/dl. Anticardiolipin antibody and Antiphospholipid antibody were absent. Other factors including infection and visceral involvement were excluded. MRI of the thigh showed huge intramuscular hematoma extending to calf. Satisfactory control was partially achieved with platelet transfusion, pulse steroid, cellcept, IVIG (intravenous immunoglobulins) and consequently Rituximab. Our case describes refractory thrombocytopenia not responding to multiple agents including high dose steroids, cellcept, platelet transfusion, IVIG (intravenous immunoglobulins) and cyklokapron; however, it achieved its complete remission with Rituximab. Bleeding is not usual presentation with moderate thrombocytopenia in SLE patients and presumably played a role in prognosis. Conclusion: Our case report has demonstrated the efficacy of treating refractory thrombocytopenia resistant to steroids due to Systemic Lupus Erythematosus in whom other reasonable options have been exhausted.

Renal arteriovenous malformations: diagnosis and treatment

Renal arteriovenous fistula is a comparatively rare malformation that accounts for < 1% of all arteriovenous fistulas malformations. Renal ANM are devided into congenital or acquired, traumatic and nontraumatic, that can cause massive hematuria, pain, retroperitoneal hemorrhage, and heart failure. Non-invasive imaging modalities, including US, MDCT and MRI, are widely used to diagnose this payhology, but the gold standard for the diagnosis of renal AVM remains angiography. The advantage of angiography in comparison with other methods is the possibility of simultaneous treatment of such patients. The treatment of renal AVM can include endovascular dissociation of the arteriovenous fistula or an open operation, including the using of ex vivo techniques. The choice of method of the treatment is based on the general patient status and the characteristics of renal arteriovenous malformation.

Microwave ablation combined with transcatheter arterial chemoembolization is effective for treating unresectable hepatoblastoma in infants and children

The present study is to evaluate the feasibility and efficacy of microwave ablation (MWA) combined with transcatheter arterial chemoembolization (TACE) in the treatment for unresectable hepatoblastoma in infants and children. A total of 17 patients with PRETEXT stage III and IV hepatoblastoma that was unresectable by conventional resection were included in the present study. The patients were treated with TACE, MWA, and chemotherapy. All cases were diagnosed by computed tomography (CT) and liver tumor biopsy before TACE procedure. All patients received 2 courses of TACE and 1 to 2 times of MWA. Finally, several cycles of chemotherapy were arranged. Among the 17 patients, 14 were alive and had normal alpha-fetoprotein (AFP) levels. The other 3 patients died from tumor progression. The follow-up periods ranged from 10 to 68 months. Complete ablation was achieved in the 14 patients (14/17, 82.35%). Most patients were well tolerated during the whole course except for 1 patient with pneumonedema after TACE and another 1 with biloma after MWA. No marked chemotherapeutic agent-induced toxicity occurred. After chemotherapy or TACE, transient blood indicators and symptoms were observed as follows: myelosuppression, abnormal liver function, gross hematuria, fever, and abdominal pain. Transient symptoms after MWA were fever, abdominal pain, and massive gross hematuria. The present study demonstrates that MWA combined with TACE is a safe and effective method for treating unresectable hepatoblastoma in infants and children with controllable side effects.