Superselective Transarterial Embolization Research Articles

Clinical application of superselective transarterial embolization of renal tumors in zero ischaemia robotic-assisted laparoscopic partial nephrectomy.

To assess the feasibility and safety of zero ischaemia robotic-assisted laparoscopic partial nephrectomy (RALPN) after preoperative superselective transarterial embolization (STE) of T1 renal cancer. We retrospectively analyzed the data of 32 patients who underwent zero ischaemia RALPN after STE and 140 patients who received standard robot-assisted laparoscopic partial nephrectomy (S-RALPN). In addition, we selected 35 patients treated with off-clamp RALPN (O-RALPN) from September 2017 to March 2022 for comparison. STE was performed by the same interventional practitioner, and zero ischaemia laparoscopic partial nephrectomy (LPN) was carried out by experienced surgeon 1-12 hours after STE. The intraoperative data and postoperative complications were recorded. The postoperative renal function, routine urine test, urinary Computed Tomography (CT), and preoperative and postoperative glomerular filtration rate (GFR) data were analyzed. All operations were completed successfully. There were no cases of conversion to opening and no deaths. The renal arterial trunk was not blocked. No blood transfusions were needed. The mean operation time was 91.5 ± 34.28 minutes. The mean blood loss was 58.59 ± 54.11 ml. No recurrence or metastasis occurred. For patients with renal tumors, STE of renal tumors in zero ischaemia RALPN can preserve more renal function, and it provides a safe and feasible surgical method.

Adjunctive endoscopic clip marking enhances non-operative management of massive lower gastrointestinal bleeding.

Massive lower gastrointestinal bleeding (LGB) is common especially in elderly patients. Controversy in the approach to management stems from location of bleeding and morbidity of surgery. Colonic diverticula disease (CD) is the leading cause of painless haematochezia and haemodynamic instability. The use of a novel technique of endoscopic pre-marking (EPM) with radiopaque metal clips to localize is described. EPM guided superselective active transarterial embolization (A-TAE) when active vascular blush was seen. When no active contrast extravasation was seen, EPM also guided prophylactic superselective transarterial embolization (P-TAE). From May 2004 to December 2021, there were 36 patients with massive LGB from diverticular disease encompassing 44 separate bleeding episodes. Spontaneous haemostasis was observed in 18.2% (8/44). The overall success rate in non-operative management was 83.3% (30/36) patients. Three patients proceeded for emergency surgery. Of the 36 patients, six patients had documented EPM followed by TAE due to recurrent bleed in the same episode. A-TAE was performed in two patients. P-TAE was performed in the four patients without active contrast extravasation. Initial haemostasis was successful in five out of six patients. One patient failed embolization and proceeded to emergency surgery. Three months later, one patient encountered late rebleeding and was scheduled for elective colectomy. None of the six developed intestinal infarction from embolization. The 30-day mortality was 0%. A consistent approach to LGB and defined protocol of endoscopic haemostasis, with routine EPM and embolization, has the potential to mitigate the morbidity and mortality in this group of vulnerable patients.

Superselective vesical artery embolisation of bleeding associated with bladder cancer

Superselective vesical artery embolization is used in the control of bleeding due to bladder cancer. However, there are few studies with a small number of patients. The current study aimed to investigate the efficacy, complications, and short-mid-term results of super-selective transarterial embolization in the treatment of persistent hematuria associated with bladder cancer. A retrospective examination was made of 13 patients with bladder cancer-related persistent hematuria who were applied with selective vesical artery embolization in the interventional radiology unit. The patients were evaluated in terms of the success of the treatment, the patients' need for additional interventional procedures, and the complications related to the procedure. Superselective superior vesical artery embolization was applied to a total of 13 patients with a mean age of 78.85±11.76 years and a median follow-up of 181 days. The time without bleeding was determined as a median of 159 days (min: 15, max:1410 days). The short-term clinical success was calculated as 84.6%. In the long-term follow-up of the patients in this study, the clinical success was determined to be 76.9% and no major complications were observed in any patient. Superselective embolization of vesical arteries is an effective and reliable treatment method for bladder cancer-related bleeding with high clinical success rates and low complication rates.

Multidisciplinary management of juvenile nasopharyngeal angiofibroma

BackgroundJuvenile nasopharyngeal angiofibroma (JNA) is a rare benign, but the locally aggressive, vascular tumor that occurs almost exclusively in young men. Although this tumor accounts for only about 0.5% of head and neck tumors, it is by far the most common benign nasopharyngeal neoplasm. It is presented typically with epistaxis, obstructive symptoms, and chronic otomastoiditis. The examination of this tumor reveals pale reddish-blue mass. The tumor is seen on imaging as vividly augmenting soft-tissue mass centered on the sphenopalatine foramen. The treatment of choice is usually surgical resection; either open or endoscopic. Pre-operative embolization is usually done to help with hemostasis. We aim to address the efficiency and the safety of endovascular modality in JNA.MethodsIn the period between January 2012 to December 2017, 20 male patients with age ranging from 6 to 20 years were referred to the Endovascular Unit, at Departments of Neurosurgery in Sohag, Alexandria, and Tanta University Hospitals with JNF. Preoperative trans-arterial embolization was done, followed by endoscopic surgical resection by our ENT surgeons. All patients were subjected to clinical and radiological Imaging evaluation pre embolization, post embolization, and post endoscopic resection. All patients had clinical and radiological follow-ups for at least 1 year.Results20 male patients with JNA underwent preoperative super-selective trans-arterial embolization. The average age at presentation was 13 years. All patients underwent successful embolization with total obliteration of vascular blush of the tumor in 15 patients, and near-total obliteration of blush in 5 patients. The dramatic effect of preoperative embolization was observed on limiting intraoperative blood loss (average 200 ml) and decreasing the time of surgery (average 2.5 h). There was no permanent morbidity or mortality related to either embolization or endoscopic resection in all patients.ConclusionsTrans-arterial embolization is strongly recommended in patients with JNA, it offers a good assist to the surgeon, reduces blood loss, decreases the amount of transfusion, improves the degree of resection, reduces operative time, and decreases the incidence of recurrence.

Bleeding after prostatectomy: endovascular management.

To evaluate role of interventional radiology (IR) in post-surgical haemorrhagic complications of prostatectomy. A retrospective study was performed. From April 2015 to January 2018, 10 patients referred to IR Department for haemorrhagic complications post radical prostatectomy (RP). All patients (mean age: 68.5 years; range, 58-85 years) were successfully treated with superselective trans-arterial embolization. We evaluated technical and clinical success and post procedural complications. Technical and clinical success was 100% (10/10) and no major complications were identified. No complications related to the endovascular procedures occurred. No recurrences during follow-up (8-20 months) were observed. Among minor complications, only 20% (2/10) developed mild post embolization syndrome. The endovascular management of significant haemorrhage after prostatectomy is safe and long-term effective, with no major ischaemic events associated to embolization.

Long-term renal function following zero ischemia partial nephrectomy.

Partial nephrectomy (PN), also known as nephron sparing surgery, is considered as the first-line treatment in small renal masses, especially in T1/2 tumors, and is applied as a standard treatment in advanced centers. The main expected outcomes from an ideal PN are surgical margin negativity, minimal impairment in renal function, and any surgical complications. Many authors have defined PN techniques as “zero ischemia partial nephrectomy”, where surgery is performed without clamping the main renal artery in order to protect the renal parenchyma from ischemic injury. Various PN techniques employed by surgeons include: selective or segmental renal artery clamping technique; off-clamp, clampless, or unclamped technique; preoperative superselective transarterial tumor embolization technique; sequential/modified sequential preplaced suture renorrhaphy technique, radio frequency ablation-assisted technique, and combination of these techniques. The common goal of all these techniques is to provide zero ischemia without hilar clamping. This systematic review focuses on the long-term functional outcomes of PNs performed by zero ischemia techniques.

Evolution of Technique from Minimally Ischemic to Pure Off-Clamp Partial Nephrectomy: 15-Year Learning Curve and Outcomes of 1083 Patients

Introduction and Objective: There is a growing interest in surgical techniques aimed at minimizing ischemia during partial nephrectomy (PN). The aim of this video is to report surgical tips, perioperative, functional, and oncologic outcomes of first 1083 patients treated with laparoscopic or robotic minimally ischemic1,2 or pure off-clamp (Off-C) PN treated between 2002 and 2015 in a high-volume center. Materials and Methods: Patients were placed in an extended flank position and a four-port or five-port access was performed for laparoscopic or robotic approach, respectively. Hilar vessels were not clamped in any case; pure or hybrid tumor enucleation was the resection technique used. The first case shows a robotic PN with the “sutureless technique” for more exophytic masses, which can also be performed with a laparoscopic approach.3 The second video shows a 4 cm left mesorenal tumor treated with laparoscopic PN after superselective transarterial embolization.4–6 This original technique, first used in 2003, at the beginning of the learning curve, has been no longer used since 2010. The third video shows a robotic PN in a right solitary kidney, affected by a 4.3 cm tumor involving the medial aspect of the upper pole. Small arterial feeders identified or transected during the enucleation of the tumor were selectively coagulated. Two suction devices were used simultaneously to maintain a bloodless surgical field. A point-specific hemostasis was performed before starting a sliding clip renorrhaphy. Results: Overall complication rate was 15.7% with a transfusion rate of 7.8%. Only 4.25% of complications were severe with a Clavien grade equal to or greater than 3. Five-year local recurrence-free survival and cancer-specific survival rates were 98.1% and 98%, respectively. The 5-year risk of severe renal function (RF) deterioration (chronic kidney disease (CKD) stage 4) was 0%, 0.9%, 7.5%, and 10.7% for patients with stages 1, 2, 3A, and 3B CKD, respectively. At multivariable analysis, baseline RF (p = 0.001) and postoperative RF decrease ≥10% (p = 0.048) independently predicted a new onset stage 4 or 5 CKD. Conclusions: Off-C PN is a challenging surgical procedure. At the beginning of learning curve, a stepwise adoption of pure Off-C approach is mandatory and preparing hilar vessels for intermediate and high nephrometry score renal tumors is recommended. Oncologic outcomes were comparable with on-clamp PN series and excellent functional outcomes of our series support Off-C as a first line treatment option in high-volume tertiary referral centers. No competing financial interests exist. Runtime of video: 5 mins 5 secs Presented at the World Congress of Endourology in Cape Town, South Africa, November 2016.

Superselective Transarterial Embolization for Lower Gastrointestinal Bleeding: An Analysis of its Effectiveness and Safety

Background: Superselective transarterial embolization (TAE) is the most commonly used treatment for lower gastrointestinal (LGI) bleeding when endoscopic management is impossible or fails. Its effectiveness and safety are increased using advanced techniques, instruments, and embolic materials. Objectives: To evaluate the outcome and safety of TAE for LGI bleeding and to analyze various influencing factors, including embolic material, embolization site, and anticoagulant or antiplatelet medication. Patients and Methods: Fifty-two patients who underwent superselective TAE for LGI bleeding between 2003 and 2011 were included, and their clinical and imaging information were retrospectively reviewed. Outcome and safety measures, including technical and clinical success, early and delayed rebleeding, and complications, were evaluated. Logistic regression analysis was used to determine whether the clinical success rate was associated with specific variables. Results: Technical and clinical success was achieved in 52 (100%) and 43 (83%) patients, respectively. The prior embolization site was the point of rebleeding in five of the nine patients with early rebleeding. Delayed rebleeding was documented in four patients, including two patients with angiodysplasia. Logistic regression analysis showed that embolization site, embolic material, and anticoagulant or antiplatelet medication were not statistically significant factors affecting the clinical success rate of TAE for LGI bleeding. A major complication, ischemic colitis, occurred in one patient. Conclusion: Superselective TAE for LGI bleeding has a high success and low complication rate. There are no statistical correlations between the clinical success rate and several variables, including embolic material, embolization site, and anticoagulant or antiplatelet medication.

3:54 PMAbstract No. 383 - Clinical predictors of pain after transarterial embolization of hepatocellular carcinoma

Transarterial embolization (TAE) of HCC, while effective, can cause post-embolization syndrome with potentially severe pain. Some centers routinely admit patients overnight in case of severe pain requiring intravenous narcotic pain medications. However, in patients without significant pain, the overnight admission may be costly and unnecessary. The purpose of this study is to determine whether baseline patient and procedure characteristics are predictive of post-embolization pain. Retrospective review of our procedural database was undertaken for all patients undergoing TAE for HCC. For the purpose of assessing lobar embolization, only right lobe TAE was analyzed. In total, analysis was performed on 198 patients with HCC (149 males, 49 females, mean age 61.7 years) undergoing either right lobar TAE (n=113) or superselective TAE within the right lobe (n=85). All patients were empirically admitted for at least one night with a patient controlled analgesia pump. The amount of narcotics administered was determined. Hydrocodone dosing was converted to fentanyl equivalence for the purpose of comparison. Factors such as phrenic artery embolization, chronic narcotic use, tumor burden, subcapsular tumor location, prior cholecystectomy, particle size, and tumor hypervascularity were assessed. Post-TAE admission for more than one night for pain control was more common in patients undergoing lobar TAE than superselective TAE (16% vs 5%, p=0.01). Lobar TAE was also associated with higher narcotic utilization (p=0.01). Substantial narcotic utilization was less common in patients with prior cholecystectomy (20% versus 58%, p=0.002). The only factor correlated with nausea was high narcotic utilization. The only factor predictive of a maximum 10/10 reported pain score was tumor burden (p=0.02). Chronic narcotic use was not associated with any metric. Several factors correlated significantly with narcotic usage and hospital stay after TAE, including superselective versus lobar TAE, prior cholecystectomy, and tumor burden. These factors may be helpful as selection criteria for anticipating which patients are most likely to benefit from empiric admission after TAE.

Combination of Superselective Arterial Embolization and Radiofrequency Ablation for the Treatment of a Giant Renal Angiomyolipoma Complicated with Caval Thrombus.

This is a case of a 78-year-old male patient with multiple angiomyolipomas of a solitary right kidney. The largest of these tumors (maximum diameter: 13.4 cm) caused significant extrinsic compression of the inferior vena cava complicated by thrombosis of this vessel. Treatment of thrombosis with anticoagulants had been ineffective and the patient had experienced a bleeding episode from the largest right renal angiomyolipoma, which had been treated by transarterial embolization in another institution, 4 months prior to our intervention. Our approach included superselective transarterial embolization of the dominant, right kidney angiomyolipoma with hydrogel microspheres, which was combined, 20 days later, with ultrasonographically guided radiofrequency ablation. Both interventions were uneventful. Computed tomography 2 months after ablation showed a 53% reduction in tumor volume, reduced space-occupying effect on inferior vena cava, and resolution of caval thrombus. Nine months after intervention the patient has had no recurrence of thrombosis or hemorrhage and no tumor regrowth has been observed. The combination of superselective transarterial embolization and radiofrequency ablation seems to be a feasible, safe, and efficient treatment of large renal angiomyolipomas.

Efficacy of automated tumor-feeder detection software using cone-beam computed tomography technology in transarterial embolization through extrahepatic collateral vessels for malignant hepatic tumors.

We evaluated the performance of automated tumor-feeder detection (AFD) software using cone-beam computed tomography technology in identifying tumor-feeders of extrahepatic collaterals. AFD was prospectively used in superselective transarterial chemoembolization (TACE) or embolization (TAE) of extrahepatic collaterals for 29 hepatocellular carcinomas and one liver metastasis (mean tumor diameter ± standard deviation, 28 ± 15.6 mm) in 25 patients. The detectability of extrahepatic tumor-feeders with non-selective digital subtraction angiography (DSA) and AFD was evaluated and compared using a χ(2) -test. Tumor response of target lesions in each patient at 2-3 months after treatment was evaluated using the modified Response Evaluation Criteria in Solid Tumors. Complications were also evaluated. Of 46 tumor-feeders, non-selective DSA and AFD could identify 26 and 44, respectively (P < 0.001). Regarding the origin of tumor-feeders, both non-selective DSA and AFD could identify 14 of 15, six of seven and two of two tumor-feeders of the right inferior phrenic, omental and right renal capsular artery, respectively. In the cystic and left gastric or right colic artery, AFD could identify 13 of 13 and nine of nine tumor-feeders but non-selective DSA could identify only three of 13 and one of nine, respectively (P < 0.001). Complete response was obtained in 15 patients, partial response in six, stable disease in three and progressive disease in one. No severe complications developed except for right pleural effusion after embolization of the right inferior phrenic artery. AFD has a sufficient ability to identify extrahepatic tumor-feeders and may improve the safety and local effects of TACE/TAE of extrahepatic collaterals.

Benefits and shortcomings of superselective transarterial embolization of renal tumors before zero ischemia laparoscopic partial nephrectomy

AimsTo report feasibility, safety and effectiveness of “zero-ischemia” laparoscopic partial nephrectomy (LPN) following preoperative superselective transarterial embolization (STE) for clinical T1 renal tumors. MethodsWe retrospectively reviewed perioperative data of 23 consecutive patients, who underwent STE prior LPN between March 2010 and November 2012 for incidental clinical T1 renal mass. STE was performed by two experienced radiologists the day before surgery. Surgical procedures were performed in extended flank position, transperitoneally, by a single surgeon. ResultsMean patients age was 68 years (range 56–74), mean tumor size was 3.5 cm (range 2.2–6.3 cm). STE was successfully completed in 16 patients 12–15 h before surgery. In 4 cases STE failed to provide a complete occlusion of all feeding arteries, while in 3 cases the ischemic area was larger than expected.LPN was successfully completed in all patients but one where open conversion was necessary; a “zero-ischemia” approach was performed in 19/23 patients (82.6%) while hilar clamp was necessary in 4 cases, with a mean warm-ischemia time of 14.8 min (range 5–22).Mean operative time was 123 min (range 115–130) and mean intraoperative blood loss was 250 mL (range 20–450).No patient experienced postoperative acute renal failure and no patient developed new onset IV stage chronic kidney disease at 1-yr follow-up. ConclusionsSTE is a viable option to perform “zero-ischemia” LPN at beginning of learning curve; however, hilar clamp was necessary to achieve a relatively blood-less field in 17.4% of cases.

8:18 AM; Abstract No. 148 - Superselective trans-arterial embolization in a translational rat model of hepatocellular carcinoma

Recent advances in the molecular biology of hepatocellular carcinoma (HCC) have identified new therapeutic targets that may potentiate the effects of transarterial embolization (TAE). Development of these new therapies requires a pre-clinical model that recapitulates the human disease and allows minimally invasive TAE that mimics the protocol used in patients. We describe a minimally invasive, superselective TAE in a translational rat model of HCC.

Intra‐Arterial Treatment for Massive Subcutaneous Hemorrhage in Hemodialysis Patients

The incidence of acute massive hemorrhage in hemodialysis (HD) patients is thought to be higher than in healthy individuals, and a large, expanding subcutaneous hematoma can result in necrosis of the overlying skin. We evaluated the efficacy of intra-arterial treatment for acute massive subcutaneous hemorrhage in HD patients. Seven HD patients with subcutaneous hemorrhage following minor blunt trauma were treated using superselective transarterial embolization, between July 2005 and October 2012. After examining the site of the hemorrhage using contrast-enhanced computed tomography (CT), embolizations were performed using microcoils, gelatin sponges, or N-butyl cyanoacrylate. Hematoma evacuation or skin grafting was performed as needed. Four men and three women with a mean age of 70 years (range, 63-82 years) comprised the study population. Sites of bleeding were as follows: lower leg (N = 3), upper leg (N = 1), buttock (N = 1), precordia (N = 1), and forearm (N = 1). Blood transfusions were administered to five cases. All patients were successfully salvaged using transarterial embolization. Six patients underwent hematoma evacuation after transarterial embolization, and two patients underwent split-thickness skin grafting for skin necrosis. We established a treatment strategy for HD patients with acute subcutaneous hemorrhage. Immediate confirmation of the site and the degree of bleeding with contrast-enhanced CT and early treatment using the transarterial embolization and as needed, hematoma evacuation are effective for preventing skin necrosis in HD patients with acute subcutaneous hemorrhage.

Risk factors and clinical management of hemorrhage after open partial nephrectomy

Objective To identify the risk factors for hemorrhage after open partial nephrectomy (OPN) for renal tumor,and to discuss the clinical management.Methods From May 2008 to October 2011,362 consecutive patients who underwent OPN in Renji Hospital were analyzed in this study.Sex,age,body mass index,ASA score,hypertension,diabetes mellitus,coronary artery disease/congestive heart failure,multifocality,malignant vs benign pathology and preoperative aspects and dimensions used for anatomical classification (PADUA) score were tested and significant variables entered in a multivariate model associated with hemorrhagic complications (blood loss requiring blood transfusion).The clinical management of hemorrhage after OPN was reviewed.Results Fifteen patients with bleeding received blood transfusion in the 362 cases.On muhivariate analysis,PADUA score (P＜0.001) and multifocal tumors (P=0.004) were independent risk factors associated with hemorrhagic complications.Among 15 bleeding patients,11 received conservative therapy; other 4 needed superselective percutaneous transarterial embolization (TAE).Bleeding was finally controlled in all the 15 patients.Conclusions High PADUA score and multifocal tumors could be identified as risk factors for hemorrhage after OPN.The management was relying on TAE as an effective and safe treatment for bleeding after OPN. Key words: Nephron-sparing surgery ; Hemorrhage ; Risk factor

Efficacy of Intra‐Arterial Treatment for Massive Gastrointestinal Bleeding in Hemodialysis Patients

The incidence of acute nonvariceal massive gastrointestinal bleeding (GIB) is higher in hemodialysis (HD) patients than in healthy individuals, and this is often a life-threatening event. We evaluated the efficacy of intra-arterial treatment for GIB in HD patients. Between January 2006 and June 2012, eight HD patients with GIB were treated with superselective transarterial embolization. Of the eight cases, one was duodenal bleeding, two were jejunal bleeding, one was ileocecum bleeding, two were ascending colonic bleeding, and two were sigmoid colonic bleeding. After examining the site of bleeding by endoscopy or contrast-enhanced computed tomography (CT), embolizations with microcoils, gelatin sponges, or N-butyl cyanoacrylate were performed through interventional radiology (IVR). In all cases, blood transfusions were frequently administered. Six of the eight patients with GIB were successfully salvaged by transarterial embolization. In one case, duodenal bleeding was refractory to endoscopic treatment. Embolization was performed twice in this case; however, the patient died of an aneurysm rupture at the embolization site 24 days after the embolizations. In another case, massive jejunal bleeding and disseminated intravascular coagulation were identified at the time of the first examination, and the patient died of multiorgan failure 26 days after the embolization. On the basis of our experience, we established an effective treatment strategy for HD patients with acute nonvariceal massive GIB, by immediately identifying the exact site and degree of bleeding using contrast-enhanced computed tomography and performing early treatment with transarterial embolization.

A Case of a Gastric Submucosal Tumor Treated With Combined Therapy Using Superselective TAE and Endoscopic Local Resection

The case was a 76-year-old female, who was noted to have a gastric submucosal tumor 25 mm in size located at the lesser curvature of the gastric body. Computed tomography revealed that the tumor was located near the coronary loop between the left and right gastric arteries. On the day before endoscopic local resection, abdominal angiography was performed and it revealed that the tumor was supplied by the left and right gastric arteries. Superselective transarterial embolization of the left and right gastric arteries around the tumor was performed to prevent accidental bleeding during the endoscopic procedure. Endoscopic local resection using full-thickness resection and submucosal dissection techniques was performed under general anesthesia. The tumor was completely resected without accidental bleeding. A gastric wall defect was closed using metallic clips and loop snares. Histologic examination revealed that the tumor was a low-risk gastrointestinal stromal tumor. We suggest that the combined therapy using superselective transarterial embolization and endoscopic local resection is an optional safe method for the treatment of gastric submucosal tumors.

Functional Recovery After Partial Nephrectomy: Effects of Volume Loss and Ischemic Injury

We used what is to our knowledge a new method to estimate volume loss after partial nephrectomy to assess the relative contributions of ischemic injury and volume loss on functional outcomes. We analyzed the records of 301 consecutive patients who underwent conventional partial nephrectomy between 2007 and 2010 with available data to meet inclusion criteria. Percent functional volume preservation was measured at a median of 1.4 years after surgery. Modification of diet in renal disease-2 estimated glomerular filtration rate was measured preoperatively and perioperatively, and a median of 1.2 years postoperatively. Statistical analysis was done to study associations. Hypothermia or warm ischemia 25 minutes or less was applied in 75% of cases. Median percent functional volume preservation was 91% (range 38%-107%). Percent glomerular filtration rate preservation at nadir and late time points was 77% and 90% of preoperative glomerular filtration rate, respectively. On multivariate analysis percent functional volume preservation and warm ischemia time were associated with nadir glomerular filtration rate while only percent functional volume preservation was associated with late glomerular filtration rate (each p <0.001). Late percent glomerular filtration rate preservation and percent functional volume preservation were directly associated (p <0.001). Recovery of function to 90% or greater of percent functional volume preservation predicted levels was observed in 86% of patients. In patients with de novo postoperative stage 3 or greater chronic kidney disease, percent functional volume preservation and Charlson score were associated with late percent glomerular filtration rate preservation. Warm ischemia time was not associated with late functional glomerular filtration rate decreases in patients considered high risk for ischemic injury. In this cohort volume loss and not ischemia time was the primary determinant of ultimate renal function after partial nephrectomy. Technical modifications aimed at minimizing volume loss during partial nephrectomy while still achieving negative margins may result in improved functional outcomes.

Superselective Embolization of the Inferior Vesical Artery for the Treatment of Intractable Hematuria from Pelvic Malignancy: Case Report

Massive intractable hematuria in the urinary bladder remains a bothersome-and sometimes life-threatening-problem in clinical practice. Regardless of the cause, initial treatment is conservative. However, in some cases, hematuria is not controlled with such conservative management (1). Since Hald and Mygind first reported the use of transarterial embolization to control massive intractable hematuria, several studies regarding transarterial embolization of the internal iliac artery (IIA) for control of massive bladder hemorrhage have been reported (210). We present two cases of intractable hematuria that were successfully managed by superselective transarterial embolization of the inferior vesical artery using 350 to 500 μm polyvinyl alcohol (PVA) particles (Contour; Boston Scientific, CA, USA) without evidence of complication.

Zero Ischemia Laparoscopic Partial Nephrectomy After Superselective Transarterial Tumor Embolization for Tumors with Moderate Nephrometry Score: Long-Term Results of a Single-Center Experience

To describe a 7-year experience with zero-ischemia laparoscopic partial nephrectomy (LPN) after superselective transarterial tumor embolization (STE) and to report oncologic and functional results of the first 210 consecutive patients. Between August 2003 and January 2010, 210 consecutive patients with nephrometry scores ≥ 6 underwent STE and LPN. Angiographic and surgical procedures were performed consequently. The follow-up schedule included serum creatinine levels at 3-month intervals and technetium 99m Tc diethylenetetramine pentacetic acid renal scintigraphy 3 months and 1 year postoperatively, CT scan and chest radiography together with abdominal ultrasonography alternatively performed at 6-month intervals in cases of renal-cell carcinoma (RCC), and abdominal ultrasonography 6 months postoperatively and yearly thereafter in cases of benign tumors. Median tumor size was 4.2 cm(range 2.5-6.5 cm). Median operative time was 62 minutes (35-220 min), median blood loss was 150 mL (20-800 mL), and median hospital stay was 3 days (2-12 d). In one patient, radical nephrectomy (RN) was necessary because of an unexpected total intraparenchymal growth of the tumor. Postoperative complications included urinary fistulas successfully managed with a Double-J stent placement (n=4); hematoma (n=6, 1 managed with percutaneous drainage), delayed hematuria successfully managed with pseudoaneurysm embolization (n=2). At a median follow-up of 46 months, one patient underwent RN for locally recurrent RCC and one patient died of cancer. At 3-month and 1-year follow-up, the median increase of serum creatinine levels was 0.3 mg/dL and 0.24 mg/dL, respectively, and the median decrease of split renal function was 9% and 5%, respectively. STE allowed us to perform a zero-ischemia LPN for tumors with moderate nephrometry score and provided excellent functional results with low complications rate and adequate oncologic results. STE significantly simplifies LPN and combines the advantages of excellent bleeding control without any ischemia and thus without time thresholds within which to perform tumor excision.