During recent years whole medicine is moving to minimally invasive medicine, with goals to preserve patients’ healthy tissues, reduce pain, have less complications and shorten hospital [1]. Partial nephrectomy is one of the examples of minimally invasive surgery, often performed laparoscopic and used for treating well-contained renal tumours [2].

The increased number of performed partial nephrectomies means higher number of iatrogenic vascular complications [3]. These complications often form specifically in kidneys due to highly vascularized renal parenchyma. Most frequent vascular complications are arteriovenous fistula and pseudoaneurysm, with latter being more common. Other possible causes of vascular complications occurrence include abdominal injuries and congenital defects [4].

Most common clinical presentation of iatrogenic vascular complication is hematuria. Some patients may also report lumbar pain, general fatigue and weakness. If macrohematuria is present patients may develop hemodynamic disorders, therefore these patients should be evaluated quickly and precisely.

According to algorithms, ultrasound imaging is in the first place for evaluation of suspected postoperative and trauma induced iatrogenic vascular complications. However, specialists and machinery needed for this evaluation may be not always available. Second best option is computed tomography with contrast enhancement. This method is used frequently due to its objectivity, precision and availability. Finally, patients can be referred for angiography with a possibility of simultaneous embolization of iatrogenic vascular complications. This paper discusses a case of a patient diagnosed with a renal pseudoaneurysm after a partial nephrectomy, who was treated with endovascular embolization in the Department of Radiology and Nuclear Medicine.

A 52 year old woman arrived at a hospital for a routine health check-up. Abdominal ultrasound revealed a 4.5 cm diameter lesion in the right kidney. Patient was directed to perform a contrast-enhanced computed tomography (CT), which was performed to specify the nature of the formation. CT found 49 mm x 34 mm cyst in the middle-lower portion of right kidney with septum and contrast accumulation (Figure 1), it was classified as Bosniak III and partial nephrectomy was chosen as a main choice of treatment.

Figure 1. Figure 1. A contrast-enhanced Computed Tomography of abdomen was performed (a 49 mm x 34 mm cyst in the middle-lower portion of right kidney with septum and contrast accumulation was found (white arrow)

Partial resection of the lower lobe of right kidney was performed. Before surgery blood creatinine was 83 µmoL/L and estimated glomerular filtration rate (eGFR) was 73 mL/min/1.73 m2. During operation, a 45 mm size capsule deforming lesion of the right kidney was visualised and removed from the patient. Hystologic diagnosis revealed the lesion to be renal chromophobic carcinoma (G1, according to Paner modified chromophobic carcinoma scheme), pT1a (35 mm, kidney limited lesion). Carcinoma structures were 0,1 mm distance from parenchyma resection borders, confirming that radical resection of the tumor was achieved. Five days after partial nephrectomy patient was feeling satisfactorily, was urinating normally and did not mention any pain in the lumbar region. Renal function was normal, creatinine was 86 µmoL/L and eGFR was 70 mL/min/1.73 m2.

After 11 days from operation patient noticed red urine and started to feel pain in lower right abdomen. In the emergency department, patient’s examination found right hydronephrosis due to blood clot and hemathoma and hematuria with urine bladder tamponade. Laboratory tests revealed anemia (hemoglobin was 0.86 g/dL) and renal function deterioration (creatinine increased till 100 µmoL/L and eGFR was 58 mL/min/1.73 m2).

Cause of hematuria had to be determined, therefore urgent contrast enhanced computed tomography was performed (Figure 2) – contrast extravazation was found on the lower third of the right kidney (area of surgery), along with subcapsular hemathoma. Right hydroureteronephrosis and fluid in pelvis were observed. Blood clots and a small amount of contrast in the bladder were seen.

Figure 2. Figure 2. Contrast extravazation was found on the lower third of the right kidney (white arrow), subcapsular he-mathoma (grey arrow)

Figure 3. Figure 3. Blood in bladder (grey area in bladder), small amount of contrast in the bladder (bladder is full, with catheter inside it)

Patient was admitted to interventional radiology departament for embolization of the bleeding vessel int resected part, before it drainage and lavage of urinary bladde was perfomed and hemotransfusion started.

Right femoral artery was punctuated under local anesthetic. Inferior segmental artery was selectively catheterized and pseudoaneurysm was visualized. A microcatheter was inserted into segmental branch (Figure 4).

Figure 4. Figure 4. Renal pseudoaneurysm catheterized andvisualized using contrast solution

Figure 5. Figure 5. Pseudoaneurysm embolized using 3 coils

Pseudoaneurysm was embolized with two 8 mm x 20 cm coils, an additional coil of 12 mm x 30 cm (Figure 5).

Control angiography with contrast was performed. Pseudoaneurysm was completely occluded and no longer visible (Figure 6). No extravasation was found.

After embolization, creatinine decreased till 83 µmoL/L and eGFR was 73 mL/min/1.73 m2. Pseudoaneurysm was no longer visible, as well as small segmental branches. Vascularization of renal parenchyma is reduced.

Contrast enhanced computed tomography was performed on patient as a check-up after pseudoaneurysm embolization. Scarring tissues near the lower lobe of resected right kidney and ~3 milimetres size hyperdensive lesion were found. Renal collectoric systems were not spread out. No signs of recidyves/progression of renal cell carcinoma were found.

Figure 6. Figure 6. Control angiography after embolization (pseudoaneurysm is no longer visible; small segmental branches in renal parenchyma are not visible)

Surgical procedures in highly vascularized renal parenchyma sometimes can cause iatrogenic vascular complications to form, such as pseudoaneurysms. Although incidence of these complications is low, around 1%, clinical presentation of these patients can be quite severe – hematuria, lumbar pain, dizziness, weakness. Prompt and precise diagnostics and treatment are essential. Selective microcoil embolization is a safe and effective kidney-preserving procedure for treating iatrogenic vascular complications. Embolization leads to a significant loss of renal parenchymal volume, but not to a loss of renal function.