Perinephric Hematoma Research Articles

Giant renal angiomyolipoma with fatal hemorrhage due to a large pseudoaneurysm

We report a case of giant renal angiomyolipoma (AML) with a large pseudoaneurysm causing fatal hemorrhage. A 60-year-old woman presented with right-sided abdominal pain. Sonographic examination revealed a large hyperechoic renal mass. CT examination of the abdomen revealed a 15-cm AML of the right kidney with a large hemorrhagic area within it. Subsequent color Doppler examination revealed a 2.9-cm pseudoaneurysm arising from the upper segmental branch of the right renal artery. The patient, who was about to undergo transcatheter embolization of the pseudoaneurysm, died from cardio-respiratory arrest. The autopsy findings confirmed a large right renal AML containing a thrombosed pseudoaneurysm and a large perinephric hematoma.

Pilot Experience with Transhepatic Percutaneous Renal Cryoablation

Percutaneous renal cryoablation has been shown to be a feasible therapeutic option for small renal tumors. Despite advances in equipment design and imaging capabilities, tumor location can present challenges to the percutaneous approach. We present our pilot experience with transhepatic percutaneous cryoablation of right upper-pole renal tumors. Three patients aged 75 to 87 years with American Society of Anesthesiologists scores of III or IV underwent transhepatic percutaneous cryoablation between November 2005 and February 2006. Tumor size ranged from 2 to 5 cm. Cryoprobe placement was guided by CT imaging, and two freeze-thaw cycles were used. Additionally, 60-second freeze-thaw cycles were used to assist with hemostasis in the transhepatic tract. The procedure was completed percutaneously in all cases with the patient under conscious sedation. The procedure time ranged from 67 to 167 minutes. Postoperative pain was managed with minimal use of nonnarcotic oral medications. Although one patient developed a moderate perinephric hematoma and required a blood transfusion, no hepatic complications were manifest. Local treatment failure was evident in one patient with a 5-cm mass showing enhancement at follow-up imaging. Transhepatic access for percutaneous cryoablation of renal tumors is feasible. Limitations include tumor size, as larger tumors may introduce prohibitive risks.

On-Call Radiology

On-Call Radiology

An unusual complication of silver nitrate therapy for chyluria

Chyluria is a common disorder in the tropics. In our country it is most commonly managed by instillation of silver nitrate. We report a patient who developed severe perinephric hematoma due to pseudoaneurysm of renal artery following silver nitrate instillation. He was managed by angioembolisation followed by drainage of infected perinephric hematoma. We discuss various modalities of treatment of chyluria including complications of silver nitrate therapy.

Safety of kidney biopsy in elderly: a prospective study

Kidney biopsy plays an important role in the diagnosis and management of several renal diseases. There is a general reluctance to perform kidney biopsy in elderly due to fear of complications. There is no prospective head to head trial comparing complications of percutaneous kidney biopsy in elderly versus young. This prospective study was undertaken to know the frequency and type of biopsy related complications in elderly. Biopsy was performed using a spring loaded automatic 16 G biopsy gun. Post-biopsy, patients were confined to bed rest for 24 h. A record of intraprocedural problems and post-procedural complications was kept. A total of 210 native kidney biopsies were done of which 26 were performed in elderly patients (61-78 years). Co-morbid conditions were present in 17 patients, some having more than one, hypertension (11), diabetes mellitus (5), chronic obstructive airway disease (6), interstitial lung disease (2) and coronary artery disease (2). Mean serum creatinine was 5.6 mg/dl (range 0.8-14.1 mg/dl). Pre-biopsy dialysis was given to 10 patients. Adequate tissue for histopathological diagnosis was seen in 24 out of 26 biopsies. In two elderly patients biopsy had to be abandoned though indicated due to inability to hold the breath because of underlying lung and cardiac disease. Clinico-pathologic discorrelation was seen in eight patients. Incidence of gross hematuria was more in elderly than in young (4/26 vs. 7/184 P<0.01). Hematuria subsided within 1-2 days in three, one had persistent hematuria for 1 week. Other complications viz. gross hematuria with need of blood transfusions or hemodynamic compromise (0/26 vs. 4/184), perinephric hematoma (0/26 vs. 1/184) and need of intervention (0/26 vs. 1/184) were not higher in the elderly. We conclude that the standard precautions kidney biopsy in elderly is a safe procedure.

Computed tomography-guided, resistance-based, percutaneous radiofrequency ablation of renal malignancies under conscious sedation at two years of follow-up

Objectives To evaluate the use of computed tomography-guided, resistance-based, percutaneous radiofrequency ablation of renal malignancies using conscious sedation. Methods Twenty-three patients with a mean age of 74 years underwent 27 PRFA treatments, using only conscious sedation, for enhancing renal masses, with a mean renal mass of 2.69 cm. All patients had multiple medical comorbidities that precluded standard operative management. Patients were followed up postoperatively at 3-month intervals with renal function studies and enhanced imaging. Successful ablation was defined as a lack of enhancement or resolution of the renal mass. Results Of the 23 patients, 16 (80%) had successful ablation with a single treatment, 4 had initial failure, and 3 were lost to follow-up. Of the 4 patients with initial failure, 2 underwent reablation successfully, 1 patient elected watchful waiting, and 1 patient died of metastatic renal cell carcinoma. The overall cancer-free survival rate was 90% (18 of 20 patients) at a mean follow-up of 24 months. The exclusion of 2 patients who underwent four sessions for renal masses greater than 4 cm improved the survival rate to 94% (17 of 18). No statistically significant difference was found between the preoperative and postoperative serum creatinine levels ( P = 0.46), even in the patients with a preoperative creatinine level greater than 1.5 ( P = 0.51). Our only complication was a single perinephric hematoma that resolved spontaneously. Conclusions We have demonstrated promising oncologic results for computed tomography-guided percutaneous radiofrequency ablation of tumors in select patients with small renal masses. The procedure was well tolerated under conscious sedation. None of the patients demonstrated significant changes in renal function.

Technique of percutaneous, CT-guided radiofrequency ablation of small renal lesions under conscious sedation

RESULTS: From July 2001 to July 2005 we ablated 27 tumors in 23 patients with a mean follow-up of 24 months. The mean patient age was 74 years with a mode ASA score of 3. The mean renal mass size was 2.71 cm. The mean preoperative serum creatinine was 1.34, and the mean postoperative serum creatinine was 1.46, yielding a change which was not statistically different(p 0.46). Follow-up imaging revealed a 70%(16/23)initial success rate and a 17%(4/23)initial failure rate. Two of these failures underwent successful repeat ablation, 1 is on watchful waiting and 1 patient was a true failure. Our only complication was a large perinephric hematoma which resolved spontaneously.

Does side matter? Review comparing right versus left‐sided laparoscopic adrenalectomy

Objective: There is concern about the limitation in right‐sided tumour due to the more demanding surgical technique. We aimed to compare right versus left laparoscopic adrenalectomy in terms of operative outcome.Methods: This is a review of medical records from 1999 to 2003 in a district hospital. Patients’ records were retrieved from the computer system under procedure name of adrenalectomy (ICD code 07.22). Primary outcome measures included complication and mortality. Other outcome measures included operation time, blood loss and length of stay.Results: Thirty‐two consecutive cases (left = 18 vs right = 14) of laparoscopic adrenalectomy were performed from 1999 to 2003. The median age of patients was 45 years. Twenty‐four of them were Conn’s Syndrome (left 14 vs right 10). Median size of tumour was 2 cm (range 0.5–5 cm, left = 2 cm vs right = 1.7 cm; P = 0.87; Mann–Whitney U‐test). One left‐sided tumour was complicated with perinephric haematoma requiring needle aspiration. There was no operative mortality in both groups. There was no difference in operation time (median time; left = 127 min vs right = 120 min; P = 0.91). There were two conversions (right = 1 vs left = 1) due to bleeding and unclear anatomy. The majority of them had minimal blood loss with none above 200 mL. All patients resumed full diet and were ambulatory within 2 days after the operation. There was no difference in hospital stay (right 4.5 days vs left 5 days; P = 0.28 Mann–Whitney U‐test). There was no significant difference between the outcomes of left and right‐sided tumour.Conclusions: There is no difference in clinical outcomes between left and right laparoscopic adrenalectomy.

Rapid Communication: First Clinical Experience with Doli S 220F-XP Extracorporeal Lithotripter for Urinary Lithiasis

To assess the initial results of the Dornier Doli S 220F-XP extracorporeal lithotripter for the management of solitary urinary calculi. We prospectively examined the outcome of shockwave lithotripsy (SWL) in the first 140 patients with solitary renal and ureteral lithiasis treated by one urologist with the new power Doli S lithotripter. Ninety-one patients (group A) had renal stones, and 49 patients (group B) had ureteral stones. Data were collected with respect to stone size, location, and fragmentation. In group A, clinical success was documented in 77 patients (84%) at 1 month after lithotripsy. Three months after lithotripsy, 69 patients (75.2%) were stone free and 8 (8.8%) had fragments <4 mm. In group B, 41 patients (83%) achieved clinical success 1 month after lithotripsy. Thirty-eight patients (77%) were stone free 3 months after treatment, and 3 (6%) had fragments <4 mm. Seven patients (7%) in group A and three patients (6%) in group B required re-treatment. The overall efficiency quotient was 67%. No patient developed a perinephric hematoma. Ninety-four percent of the patients reported mild pain during lithotripsy. The majority (91%) mentioned that they were satisfied with this treatment modality for urinary lithiasis (mean visual analog scale satisfaction score 8). The Doli S 220 F-XP is a safe and effective device for managing calculi throughout the urinary tract.

Ultrasonography for Acute Blunt Renal Trauma: Does it Help?

The role of ultrasonography in diagnosing blunt renal trauma is uncertain because it is much less sensitive in detecting parenchymal organ injuries. Indirect evidence such as perinephric haematoma may be easier to identify by ultrasonography and it is highly suggestive of underlying renal parenchymal injury. A patient with significant renal injuries diagnosed by bedside ultrasonography is reported and the role of ultrasonography in renal trauma is discussed.

Initial Experience of Radiofrequency Ablation of Renal Tumor

Purpose: We wanted to report the our early experience with performing nephron-sparing radiofrequency ablation (RFA) of renal tumor. Materials and Methods: Three percutaneous RFAs were performed under combined computed tomography (CT) and ultrasonogram guided, and two intraoperative ultrasonograpy-guided laparoscopic RFAs were performed since June 2004. The treatment indications were localized, small (<4cm), solid renal masses in elderly patients and also the same type masses in the patients with comorbid conditions. The follow-up studies included physical examination, CBC, serum creatinine, urine analysis and kidney CT, and these were performed at day 1, 1 week, 1 month, 3 months, 6 months and 1 year after ablation, and then semi-annually thereafter. The mean follow-up duration was 8.8 months (range: 5-12 months). Results: All five patients underwent successful RFA without any serious events. One patient had a mild perinephric hematoma and another patients had mild gross hematuria postoperatively. With a mean follow-up of 8.8 months, none of the patients showed any residual tumor on follow-up contrast-enhanced CT after the final tumor ablation. Complete tumor ablation was achieved after a single treatment session in 80% of the patients and in 20% of patients after the subsequent ablation sessions. Conclusions: Percutaneous or laparoscopic RFA is a promising nephronsparing treatment for selected patients with small renal mass. Contrastenhanced CT performed immediately after ablation is a reliable method to exclude residual viable tumor. The ultimate role for this modality will continue to evolve and this warrants further studies. (Korean J Urol 2006; 47:244-251) ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ

Complications after percutaneous radiofrequency ablation of renal tumors

ObjectivesTo evaluate our experience with percutaneous radiofrequency ablation (pRFA) to determine common characteristics of patients with complications, to elucidate possible relative contraindications to therapy. MethodsMedical records of all patients undergoing pRFA were reviewed for demographic data, medical and surgical history, indication, tumor characteristics, and treatment information (complications and management). The group of patients with complications was analyzed for common characteristics. ResultsFrom January 2000 to September 2003, 24 patients (mean age 61 years, 5:1 male/female) with 32 renal tumors were treated with pRFA. Indications for pRFA included prior renal surgery and/or chronic renal insufficiency, significant medical disease, patient choice, von Hippel-Lindau disease, and treatment of a metastasis. Average pretreatment tumor size was 2.4 cm (range 0.5–8.6 cm). Of the 5 patients experiencing complications from pRFA treatment, 2 developed perinephric hematomas, 1 had a persistent urinoma and proximal ureteral stricture, and 2 had colonic injuries. Among patients with complications, 3 of 5 had undergone prior partial nephrectomy on the pRFA-treated kidney. Two of four patients treated for multiple tumors and 57% of patients (4 of 7) with anteriorly located tumors experienced complications. ConclusionsEarly experience with pRFA for renal tumor seems promising, but patient selection criteria are evolving. On the basis of our limited experience, we recommend caution when using renal pRFA in patients with prior partial nephrectomy, multiple tumors treated in the same setting, and tumors located anteriorly or centrally. Further clinical experience will help establish guidelines for the use of this powerful technology in the management of renal tumors.

Does Pretransplant Obesity Affect the Outcome in Kidney Transplant Recipients?

The effect of obesity on renal transplant outcome remains unclear due to conflicting published studies. The purpose of this study was to assess whether obesity affects the outcome in renal transplant patients. Methods We retrospectively analyzed 33 obese (BMI >30; mean = 34.1 ± 3.68; group I) and 35 nonobese (BMI ≤ 30; mean = 23.6 ± 3.18; group II) renal transplants performed at our center between March 1999 to December 2002. These two groups were well matched with respect to age, sex, donor source, hypertension, diabetes, ischemic heart disease, hyperlipidemia, native kidney disease (PCKD, 6 vs 4; diabetic, 5 vs 4; glomerulonephritis, 6 vs 7; FSGS, 2 vs 2 and IgA, 2 vs 7), HLA mismatch and immunosuppressants medications (Neoral, 21 vs 25; tacrolimus, 11 vs 10; Cellcept, 28 vs 31; Prednisone, 33 vs 35; ATG, 7 vs 8; Basiliximab, 14 vs 13 and Rapamycin, 5 vs 2, groups I and II, respectively). Follow-up was from 7 months to 4.4 years. Results Significant differences were noted in operating time, wound infection, perinephric hematoma, lymphocele, and number of hospital days. There were no significant differences between the two groups in the incidence of wound dehiscence, deep vein thrombosis, pulmonary embolism, atelectasis, urine leak, delayed graft function, acute rejection rate, and the following posttransplant variables: diabetes mellitus, myocardial infarction, hyperlipidemia, hypertension, and incisional hernia. We conclude that obesity significantly increases operating time, wound complications, and hospitalizations.

Spontaneous renal rupture in patients on chronic hemodialysis

Background: Because of high incidence of acquired renal cyst and renal malignancy, it is suggested that spontaneous renal rupture more frequently occurs in patients receiving long‐term hemodialysis than in the general population. This study was performed to evaluate the clinical characteristics of spontaneous renal rupture in hemodialysis patients. Methods: This retrospective study enrolled 12 hemodialysis patients who developed spontaneous renal rupture. We investigated primary renal disease, duration of dialysis, clinical symptoms and signs, radiologic findings, treatment modalities, and histologic findings. Result: The mean age of the patients was 54 ± 10 years old and the number of male was 9. Primary renal disease consisted of autosomal dominant polycystic kidney disease (PCKD)(n = 5), chronic glomerulonephritis (n = 2), diabetic nephropathy (n = 1), hypertensive nephropathy (n = 1), unknown cause (n = 3). Presenting symptoms and signs were sudden onset of flank pain in 9 patients and gross hematuria with mild flank pain in 3 patients. Mean duration from initiation of hemodialysis to development of spontaneous renal rupture was 53 ± 36 months. Abdominal computed tomography showed subcapsular or perinephric hematoma in all patients. Of the 7 non‐PCKD patients, 6 patients had multiple acquired renal cysts. Surgical exploration was undertaken in 9 patients. Pathologic examination demonstrated small sized renal cell carcinoma in 2 of 9 patients. Three patients were only treated with conservative management including blood transfusion. All 12 patients recovered without recurrence. Conclusion: This study demonstrated that genetic or acquired renal cyst was an important cause of spontaneous renal rupture in hemodialysis patients and presenting manifestations were sudden onset of flank pain and gross hematuria.

Complicaciones quirúrgicas post-trasplante renal. Estudio en 185 casos

ObjectiveTo analyze the incidence of surgical complications its diagnosis and treatment after renal transplantation. MethodsA retrospective study measuring the incidence of surgical complications and reviewing its diagnosis and treatment in 185 renal single transplants. Results185 transplants, 27% had surgical complications. Only one patient lost the graft due to surgical complications and there was no associated mortality. Cold ischemia time 20 hours. Double J stenting in 19%, under surgeon’s opinion. Vascular complications 3,2% (all of them renal artery stenosis). Urological complications 6,4%. Perinephric haematoma 7%. Lymphocele 4,9%. Peritoneum related complications 4%. Other 4%. The diagnosis was clinical and radiological in most of cases. 14% needed any kind of intervention. ConclusionsOur results are similar to those reported in other recent series. Only one surgical team involved and the same technique for vascular and vesico-ureteric anastomosis probably makes lower our complications rate. Early postoperative abdominal ultrasonography contributes to the diagnosis of surgical complications. The initial treatment approach is the endoscopic-conservative one, with exceptions.

Relative Adrenal Insufficiency: Case Examples &amp; Review

A 21 year old morbidly obese man s/p motor vehicle crash presented to the E.R. with a SBP 70, P 128, RR 20 and complaining of chest pain and pelvic pain. Physical examination revealed crepitus along the right chest wall and a right chest tube was placed (with a minimal air leak). A dislocated right shoulder and an abdominal wall contusion with diffuse pelvic tenderness was also noted. Blood work revealed a Hct 40 with ABG’s of 7.29/42/151. Further studies (after following initial ATLS protocol) included a CXR (showing a small Right-sided PTX with Chest Tube in position), multiple rib fxs; Bilateral rami fractures on pelvic film; negative C-spine series; a normal Cystogram; and an abdominal C.T. demonstrating a left perinephric hematoma and pelvic hematoma.

A MULTIVARIATE ANALYSIS OF RISK FACTORS ASSOCIATED WITH SUBCAPSULAR HEMATOMA FORMATION FOLLOWING ELECTROMAGNETIC SHOCK WAVE LITHOTRIPSY

Subcapsular or perinephric hematoma is one of the most frequent and potentially serious complications of extracorporeal shock wave lithotripsy (SWL). We determined the incidence of and risk factors for renal hematomas following electromagnetic shock wave lithotripsy. Between February 1999 and August 2003, 570 SWL treatments were performed using a Modulith SLX electromagnetic lithotriptor (Storz, St. Louis, Missouri). A total of 415 of these treatments in 317 patients were performed for stones in the renal pelvis or calices and these treatment episodes represent the study group reported. Treatment episodes were reviewed from a prospective institutional review board approved registry and analyzed for patient age, gender, body mass index, mean arterial pressure at induction, stone location, total number of shock waves and peak shock wave intensity. Following these 415 episodes subcapsular or perinephric hematomas developed in 17 patients for an overall incidence of 4.1%. The probability of hematoma after shock wave lithotripsy increased significantly as patient age at treatment increased, such that the probability of hematoma was estimated to be 1.67 times greater for each 10-year incremental increase in patient age. None of the other variables analyzed were significantly related to the incidence of hematoma formation at the 0.05 level. The incidence of renal hematoma formation following electromagnetic SWL for renal calculus was 4.1%. The probability of hematoma increased significantly with increasing patient age but it was not associated with increasing mean arterial pressure at treatment. These findings are in contrast to previous reports of hematoma associated with electrohydraulic SWL. These differences may be a consequence of the smaller focal zone and higher peak pressure associated with Storz Modulith electromagnetic SWL and, just as importantly, a consequence of the difference in the manner in which blood pressure was defined.

Guide Wire Perforation Leading to Fatal Perirenal Hemorrhage from Transcortical Collaterals after Renal Artery Stent Placement

After successful renal artery angioplasty and stent placement, a patient in a fully anticoagulated state developed hypotension and flank pain. Review of the intraprocedural angiogram demonstrated transcortical position of the guide wire. Computed tomography of the abdomen revealed a large perinephric hematoma. Although only a single renal artery branch was accessed with the guide wire during stent placement, subsequent emergent angiography revealed extravasation from multiple capsular branches. Renal artery embolization failed to control the hemorrhage. The patient's course rapidly deteriorated and he ultimately died. The unique angiographic finding and proposed mechanism of this fatal complication are described and discussed.

DOES PRETRANSPLANT OBESITY AFFECT THE OUTCOME IN KIDNEY TRANSPLANT RECIPIENTS?

P361 Aims: The effect of obesity on renal transplant outcome remains unclear due to conflicting published studies. The purpose of this study was to assess whether obesity affects the outcome in renal transplant patients. Methods: We retrospectively analyzed 33 obese (BMI >30; Mean = 34.1±3.68; Group I) and 35 non-obese (BMI ≤ 30; Mean= 23.6 ± 3.18; Group II) renal transplants performed at our centre between March 1999 to December 2002. These two groups were well matched with respect to age, sex, donor source, hypertension, diabetes, ischemic heart disease, hyperlipidemia, native kidney disease (PCKD, 6 vs. 4; Diabetic, 5 vs. 4; Glomerulonephritis, 6 vs. 7; FSGS, 2 vs. 2 and IgA, 2 vs. 7), HLA mismatch and immunosuppressants medications (Neoral, 21 vs. 25; tacrolimus, 11 vs. 10; Cellcept, 28 vs. 31; Prednisone, 33 vs. 35; ATG, 7 vs. 8; Basiliximab, 14 vs. 13 and Rapamycin, 5 vs. 2, Group I and II respectively). Follow up was from 7 months to 4.4 years. Results: Significant differences were noted in operating time, wound infection, perinephric hematoma, lymphocele and number of hospital days as shown in Table. There were no significant difference between the 2 groups in the incidence of wound dehiscence, deep vein thrombosis, pulmonary embolism, atelectasis, urine leak, delayed graft function, acute rejection rate, and the following post-transplant variables: diabetes mellitus, myocardial infarction, hyperlipidemia, hypertension and incisional hernia.FigureConclusions: We conclude that obesity significantly increases operating time, wound complications and hospitalizations.

Urological and Surgical Complications in 362 Consecutive Living Related Donor Kidney Transplantations

Objective: The aim of this study is to review retrospectively the surgical and urological complications encountered in 362 cases of living related donor kidney transplantations (LRDTs). Material and Methods: Between 1983 and 2002, 362 consecutive LRDTs were performed at our institution. The urological and surgical complications were determined in these cases. Results: Overall, urological and surgical complications were encountered in 57 (15.7%) of the renal transplants. Of the 362 patients, urological complications were detected in 29 of them (8.01%), including 5 urinary fistula (with 1 distal ureteral necrosis), 2 ureteric stenosis, 1 renal calculi, 8 symptomatic vesicoureteral reflux and 13 lymphocele requiring intervention. Vascular complications were developed in 5 patients such as renal vein thrombus in 1 and renal arterial stenosis in 4 cases. Wound infection was detected in 6 patients. Fourteen patients underwent surgical explorations due to perinephric hematoma during the early postoperative period. Renal allograft rupture due to accelerated rejection was developed in 2 cases. A lower segmental arterial injury occurred in 1 patient during the operation. Conclusion: LRDT is an important treatment alternative for patients with end-stage renal disease. Many complications may occur after renal transplantations. Our rate of complications is within the range of the current literature. After a modification of our surgical technique, as not dissecting the external iliac artery, the number of lymphoceles has decreased dramatically and with using ureteric stents, we detected a significant decrease in urinary complication rates.