title: Delayed haemorrhage after laparoscopic partial nephrectomy: frequency and angiographic findings.
abstract: OBJECTIVE
  • To determine the frequency of delayed postoperative haemorrhage requiring selective angioembolization (SAE) after laparoscopic partial nephrectomy (LPN). • To describe the clinical presentation and characterize the angiographic findings encountered in this setting.
  
  
  METHODS
  • Prospective data from 640 LPNs performed between August 1993 and May 2009 were retrospectively analyzed, from which patients with delayed postoperative haemorrhage (defined as 'gross haematuria ≥ 7 days postoperatively that persists for more than 24 h') and requiring SAE were identified. • Clinicopathological, preoperative and perioperative factors were reviewed. • Selective catheterization and angiography of the renal artery was performed for persistent gross haematuria and for haemodynamic instability associated with a significant drop in haematocrit level. • Arteries feeding the bleeding site were identified and embolized with endovascular coils.
  
  
  RESULTS
  • Patients presented with delayed haemorrhage between 7 and 30 days after surgery. SAE was required in 13 patients (2%) for delayed postoperative bleeding. • Of the 640 LPNs, 68 (10.6%) were performed without hilar occlusion ('off-clamp') of whom one (1.5%) had a delayed haemorrhage, which was successfully embolized. • For patients with and without delayed haemorrhage after LPN, the mean tumour size was 2.7 cm and 3.3 cm (P= 0.31), the mean warm ischaemia time was 28.2 min and 14.3 min (P < 0.001), and the mean estimated blood loss 403.8 mL and 308.2 mL (P= 0.26), respectively. • Percutaneous angiography showed renal artery pseudoaneurysm in 10 patients and arterial contrast extravasation in three patients, two of whom also had an arteriovenous fistula. • Following embolization, creatinine levels remained stable in all patients.
  
  
  CONCLUSIONS
  • Clinically significant delayed postoperative bleeding after LPN occurs in a small percentage of patients. • Angiography will accurately make the diagnosis of RAP or AVF and SAE is safe and effective procedure that allows for preservation of renal function.
authors.affiliation: The Arthur Smith Institute for Urology, North Shore-Long Island Jewish Health System, New Hyde Park, NY, USA.
authors.forename: Sylvia
authors.initials: S
authors.lastname: Montag
authors.forename: Soroush
authors.initials: S
authors.lastname: Rais-Bahrami
authors.forename: Casey A
authors.initials: CA
authors.lastname: Seideman
authors.forename: Ardeshir R
authors.initials: AR
authors.lastname: Rastinehad
authors.forename: Manish A
authors.initials: MA
authors.lastname: Vira
authors.forename: Louis R
authors.initials: LR
authors.lastname: Kavoussi
authors.forename: Lee
authors.initials: L
authors.lastname: Richstone
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017541:Aneurysm, False / Q000150:complications / Q000000981:diagnostic imaging / Q000628:therapy*; D001159:Arterio-Arterial Fistula / Q000150:complications / Q000000981:diagnostic imaging / Q000628:therapy*; D004621:Embolization, Therapeutic / Q000379:methods*; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000601:surgery; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000009:adverse effects* / Q000379:methods; D019106:Postoperative Hemorrhage / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D011859:Radiography; D012077:Renal Artery / Q000000981:diagnostic imaging*; D016896:Treatment Outcome; D055815:Young Adult