Managing Complications Following Nephron-Sparing Procedures for Renal Masses

Life-threatening arteriovenous fistula after percutaneous nephrostomy: A case report

INTRODUCTION

Arteriovenous fistula (AVF) is a rare but serious complication following percutaneous nephrostomy. While more commonly observed after nephrolithotomy, it can also occur with prolonged nephrostomy placement or complicated procedures. Early diagnosis and management are critical for preventing life-threatening complications.

CASE PRESENTATION

A 59-year-old female with recurrent bilateral urolithiasis, right heart failure, poorly controlled type 2 diabetes, and chronic kidney disease presented with right flank pain, fever, and fatigue. She had previously undergone right double-J stent placement but was lost to follow-up. A CT scan revealed hydronephrosis, a calcified stent, and a 22 mm pelvic stone, leading to the performance of a percutaneous nephrostomy. The patient developed an embolic stroke three days later and subsequently presented with hematuria, hypotension, and significant anemia. CT angiography confirmed an AVF with active bleeding, which was successfully treated with embolization.

DISCUSSION

Post-nephrostomy AVFs are rare, with risk factors including prolonged nephrostomy, diabetes, and complex renal stones. Early detection using Doppler ultrasound or CT angiography is crucial, and selective embolization remains the treatment of choice with a high success rate.

CONCLUSION

Post-nephrostomy AVF is a rare but potentially fatal complication requiring rapid diagnosis and intervention. Early suspicion, timely imaging, and selective embolization are key to successful management.

Complications after Nephron-sparing Interventions for Renal Tumors: Imaging Findings and Management

The two primary nephron-sparing interventions for treating renal masses such as renal cell carcinoma are surgical partial nephrectomy (PN) and image-guided percutaneous thermal ablation. Nephron-sparing surgery, such as PN, has been the standard of care for treating many localized renal masses. Although uncommon, complications resulting from PN can range from asymptomatic and mild to symptomatic and life-threatening. These complications include vascular injuries such as hematoma, pseudoaneurysm, arteriovenous fistula, and/or renal ischemia; injury to the collecting system causing urinary leak; infection; and tumor recurrence. The incidence of complications after any nephron-sparing surgery depends on many factors, such as the proximity of the tumor to blood vessels or the collecting system, the skill or experience of the surgeon, and patient-specific factors. More recently, image-guided percutaneous renal ablation has emerged as a safe and effective treatment option for small renal tumors, with comparable oncologic outcomes to those of PN and a low incidence of major complications. Radiologists must be familiar with the imaging findings encountered after these surgical and image-guided procedures, especially those indicative of complications. The authors review cross-sectional imaging characteristics of complications after PN and image-guided thermal ablation of kidney tumors and highlight the respective management strategies, ranging from clinical observation to interventions such as angioembolization or repeat surgery. Work of the U.S. Government published under an exclusive license with the RSNA. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available in the Online Learning Center. See the invited commentary by Chung and Raman in this issue.

Renal artery embolization for iatrogenic renal vascular injuries management: 5 years' experience

OBJECTIVE

Evaluate the efficacy and safety of renal artery embolization (RAE) for iatrogenic renal vascular injuries (IRVI) management at Fondazione Policlinico Universitario "A. Gemelli" IRCCS, in the last 5 years.

METHODS

Retrospective analysis of all RAE procedures performed from January 2013 to December 2017. Patients-related (age, sex, vascular variants, hemoglobin and serum creatinine), IRVI-related (type and vascular level of IRVI, presence and extension of hematoma), management-related (temporal interval between diagnostic imaging and RAE) and procedure-related (embolic materials, technical success, clinical success and complications) parameters were evaluated.

RESULTS

28 RAE procedures performed on 28 patients (21 males; 7 females) were included. 19/28 patients had pseudoaneurysm, 7/28 active bleeding and 1/28 arteriovenous fistula; 4/28 patients had a combination of 2 IRVI.The extent of perirenal hematoma showed correlation with the cause of IRVI (p = 0.028).Technical success was achieved in all patients whereas clinical success in 25/28 (89.3%), with 3 patients requiring re-treatment. Minor complications were observed during 2/28 (7.1%) endovascular procedures. No major complications occurred. A longer procedural time was observed in patients with lower pre-procedural levels of hemoglobin (p = 0.016).No differences were found in mean serum creatinine (p = 0.23) before and immediately after treatment, while values of creatinine at 1 week from the procedure were significantly lower (p = 0.04).

CONCLUSION

RAE is safe and effective for the management of iatrogenic IRVI showing high technical and clinical success rate and low complication rate.

ADVANCES IN KNOWLEDGE

Low pre-procedural hemoglobin levels increase procedural duration time. Glue alone or in combination with other materials is as safe as coils.

Percutaneous image-guided renal ablations: Current evidences for long-term oncologic efficacy

The rise in incidentally discovered small renal neoplasms has focused attention on nephron-sparing treatment strategies including partial nephrectomy and percutaneous ablation as well as active surveillance. As all treatment modality, renal ablation has matured technically. Radiofrequency ablation, microwave ablation or cryoablation are now performed in many institutions under imaging guidance. The long-term results allow them to be now recommended as a therapeutic option whatever the patients' condition if complete ablation can reliably be achieved.

A systematic management algorithm for perioperative complications after robotic assisted partial nephrectomy

Nephron-sparing surgery (NSS) is the treatment of choice for T1 renal cell carcinoma (RCC). Since the first robotic assisted partial nephrectomy (RAPN) was performed in 2004, NSS is being implemented with increasing frequency. RAPN will likely become the gold standard procedure for T1 RCC due to improved dexterity, enhanced visualization, shorter learning curve, quicker recovery time, and shortened warm ischemic time. Although RAPN appears to be the preferred treatment for select renal tumours, there are notable complications in up to 35% of cases. While complications associated with RAPN are well-described, there is a lack of literature describing appropriate management strategies. Herein, we review complications associated with RAPN and design an appropriate systematic management algorithm.

[Percutaneous renal ablation: Pre-, per-, post-interventional evaluation modalities and adapted management]

OBJECTIVES

Ablative treatment (AT) rise is foreseen, validation of steps to insure good proceedings is needed. By looking over the process of the patient, this study evaluates the requirements and choices needed in every step of the management.

METHODS

We searched MEDLINE^®, Embase^®, using (MeSH) words and we looked for all the studies. Investigators graded the strength of evidence in terms of methodology, language and relevance.

RESULTS

Explanations of AT proposal rather than partial nephrectomy or surveillance have to be discussed in a consultation shared by urologist and interventional radiologist. Per-procedure choices depend on predictable ballistic difficulties. High volume, proximity of the hilum or of a risky organ are in favor of general anesthesia, cryotherapy and computed tomography/magnetic resonance imaging (CT/MRI). Percutaneous approach should be privileged, as it seems as effective as the laparoscopic approach. Early and delayed complications have to be treated both by urologist and radiologist. Surveillance by CT/MRI insure of the lack of contrast-enhanced in the treated area. Patients and tumors criteria, in case of incomplete treatment or recurrence, are the key of the appropriate treatment: surgery, second session of AT, surveillance.

CONCLUSION

AT treatments require patient's comprehension, excellent coordination of the partnership between urologist and radiologist and relevant choices during intervention.