with Cystoscopy Hematuria by mikeholy



                                                                                                                                                                                                                         Case                             Report

L   #{149}                                       .     .    .   .   ..      .,.   ;                         .           .             .     :                   #{149}    #{149}     :                          ,

        Selective                           Renal Embolization                                                              for Hematuria:                                                                    Coordination
       with Cystoscopy
        Douglas          A. Swartz,1           Garey       L. McLeIIan,2                 Dale       Mitchum,3               and     Frederick                  Vines2

           A case of selective segmental         renal arterial embolization         for                                      cells and hypotonic fluids. When these measures failed, aminocaproic
       clinically significant    renal hematuria     due to sickle cell nephrop-                                              acid (Lederle, Pearl River, NY) was administered without success. An
       athy is presented.       The patient was heterozygous            for the sickle                                        artenogram      was performed, but no lesion was identified.      Two more
                                                                                                                              units    of packed red blood cells were subsequently         required for a
       cell trait and had significant       anemia caused by the hematuria.
                                                                                                                              symptomatic anemia.
       The hematuria         was refractory    to conservative       measures.       No
                                                                                                                                    Segmental                 infarction                  was          necessary               because               of   the       continued
       lesion was identifiable         on angiography.         The technique          by                                      bleeding   and transfusion   requirement.      After induction of general
       which we identified        the bleeding    segment      in order to coordi-                                            endotracheal anesthetic, the patient was positioned to allow simul-
       nate embolization        has not been previously       reported.      The renal                                        taneous   access to the right femoral   artery    and perineum. The pres-
       segment       to be infarcted    was selected      by cystoscopic         obser-                                       ence of bloody right ureteral efflux was confirmed by cystoscopy. An
       vation      of the cessation      of blood flow from the ipsilateral                                                   open-tip,             5-French               ureteral                  catheter           (Cook,           Inc.,       Bloomington,                 IN)
       ureteral orifice during temporary           occlusion     of the segmental                                             was         endoscopically                      placed               retrograde             into       the     renal        pelvis       to allow
       renal branches       with a transcatheter      angiography        balloon. The                                         irrigation    of the pyelocaliceal system with saline.
       suspected       renal segment     was then infarcted      by using Gelfoam                                                   A 6.5-French guiding catheter    from a Wholey                                                          occlusion              coaxial        set
                                                                                                                              (Cook,         Inc.)        was introduced                           into the right renal artery. Superselective
       particles and a single embolization          coil. Fourteen months after
                                                                                                                              placement                  of the catheter                           was facilitated   by use of an injectable,
       infarction,     the patient remains normotensive            and free of he-
                                                                                                                              steerable              guide-wire                    system             (C. R. Bard, Inc., Biller/ca,                                 MA). The
       maturia.                                                                                                               injectable             guidewire                had             an     outer          diameter          of 0.038            in. (0.097            cm)
                                                                                                                              and         permitted            replacement                           of the mandril                   with a steerable,                      J-tip
                                                                                                                              guidewire              (0.01     6-in.          [0.041               cm],      outer       diameter)            [1].
       Case Report
                                                                                                                                 A selective injection reconfirmed normal renal vasculature without
           A 28-year-old woman was hospitalized for painless gross hema-                                                      the presence of malformations.     After positioning the 6.5-French guid-
       turia and anemia. The onset followed the birth of her last child, 13                                                   ing     catheter            in the         selected                    segmental             artery,          the      3-French           Wholey
       months before admission. The frequency of hematuria increased; 7                                                       occlusion             balloon          catheter                  was         placed         through           the      guiding          catheter.
       months         before   admission,      hematuria        had      been       occurring      daily.       An IV         The         balloon            was         inflated,                  and       contrast            mater/al            was        injected           to
       pyelogram,          abdominal        CT, and renal sonogram                    were normal. Bloody                     confirm           occlusion.               Immediately                       after       occlusion,            1 0 ml of saline was
       efflux was        observed      from the right      ureteral       orifice      dunng cystoscopy.                      gently irrigated through the ureteral catheter until the efflux cleared.
       A right retrograde ureterogram was normal.                                                                             The ureteral efflux was then observed for hematuria over a period                                                                                 of
           On admission, the hematocrit   was 21 %. Hemoglobin    electropho-                                                 5 mm.             The        sequence                      of        ureteral          irrigation            and       observation              was
       resis showed    67% hemoglobin A and 29% hemoglobin S. Conserv-                                                        repeated              as     each          of        the        five        segmental              renal      arteries            was      serially
       ative therapy included the infusion of four units of packed red blood                                                  Occluded.               Clear        right            ureteral              efflux        was       observed                only      when          the

             Received August 17, 1 987; accepted      after revision September       16, 1987.
             I Department of Surgery,   Division of (kology,    University  Hospital, 655 W. 8th St., Jacksonville,                                      FL 32209.             Address                reprint       requests         to D. A. Swartz.
             2 Department of Radiology,    University Hospital, Jacksonville,     FL 32209.
             3   Department    of Surgery, t.kiiversity Hospital, Jacksonville,                 FL 32209.
       AJR 150:325-326,             February 1988 o361-803x/88/1502-0325                         C American        Roentgen         Ray Society
326                                                                           SWARTZ       ET AL.                                                               AJR:150,     February    1988

single middle segmental artery was occluded. The occlusion            was                  embolization     or segmental       resection   has been localization         of
repeated    after 30 mm to confirm the findings.                                           the bleeding      renal segment.         In most cases of sickle cell
    Gelfoam particles (Upjohn, Kalamazoo, Ml) were embolized into                          nephropathy      with gross hematuria,        no focal lesion is apparent
the single middle segmental renal artery. After significantly decreasing
                                                                                           on the renal arteriogram.            Percutaneous        nephroscopy        and
renal flow to this segmental artery, an occluding spring embolus (3
                                                                                           retrograde    ureteroscopy      could potentially      locate the bleeding.
mm in diameter, 4 cm long) (Cook, Inc.) was placed in the artery. A
                                                                                           Hematuria    associated     with the routine trauma of nephroscopy
pull-back arterial injection confirmed complete occlusion.
    After surgery, the patient had transient right flank pain. Her blood                   and ureteroscopy        makes visualization       of a bleeding site diffi-
pressure remained normal. The hematocrit remained stable, and the                          cult. Coordination        of embolization         with     nephroscopy        or
urine was clear. A renal scan showed middle segmental infarction                           ureteroscopy      may also be a problem. This report describes                 a
and normal perfusion of the remaining parenchyma. Fourteen months                          technique    by which the bleeding renal segment                can be iden-
after infarction, the patient is normotensive and has had no hematuria.                    tified to allow segmental          renal embolization.         Simultaneous
                                                                                           cystoscopic     observation     of the change in the involved ureter
                                                                                           efflux from bloody to clear during temporary                occlusion    of the
                                                                                           segmental     renal arteries allows identification           of the involved
    Sickle cell trait occurs in approximately             8% of blacks. Sickle
cell hemoglobinopathy              accounts      for one-third         of cases of
gross hematuria          in blacks [2]. The mechanism                is not known
but probably         involves      papillary    necrosis       due to ischemia              1 . Sos TA, Cohn DJ, Srur D, Wengrover                   SI, Saddikni S. A new open-ended
                                                                                                 guide   wire/catheter.      Radiology     1985;154:817-818
caused by red blood cell sickling.
                                                                                            2.   Schaeffer AJ, DelGreco F. Other renal diseases of urologic significance.
    Conservative       measures        such as hypotonic          fluid hydration,               In: Walsh c, Gnttes RF, Per/mutter                    AD, Stamey        TA, eds. Cambell’s
sodium bicarbonate,            mannitol,     and loop diuretics        were initially            urology. Philadelphia:        Saunders,      1986:2342-2360
used [3, 4]. Aminocaproic                 acid, a urokinase          inhibitor,   has       3.   Knochel JP. Hematuna           in sickle cell trait: the effect of intravenous admin-
                                                                                                 istration of distilled water, urinary alkalinization,            and diuresis. Arch Intern
been reported         effective    in hematuria      associated         with hemo-
                                                                                                 Med 1969;123:160-165
globin S [5]. Hematuria             can be recurrent           and refractory        to     4.   Marynick       SP, Ramsey EJ, Knochel JP. The effect of bicarbonate                        and
standard      methods         of therapy.      Nephrectomy          is sometimes                 distilled water on sickle cell trait hematuria                and in vitro studies      on the
necessary,       despite the risk of development                 of hematuna          in         interaction      of osmolality and PH on erythrocyte                  sickling trait. J Urol
the contralateral        kidney [6]. Limited segmental                nephrectomy                1977:113:793-797
                                                                                            5.   Immugul MA, Stevenson T. The use of epsilon-amino                        caproic acid in the
has also been reported              as successful        after identification        of
                                                                                                 control     of hematuria         associated       with     hemoglobinopathies.         J Urol
the bleeding segment             by open nephroscopy            [71.                             1965;93:100-1         11
    Whenever        possible,      conservative       surgical        management            6.   Mostofi FK, vorder Bruegge             CF. Diggs LW. Lesions in kidneys removed
should be attempted.             The disease can be bilateral,               and pa-             for unilateral      hematuria      in sickle    cell disease.      Arch Pathol Lab Med
tients who have undergone                nephrectomy         for hematuria      may
                                                                                            7.   Douglas LL, Pawaroo J. conservative                    surgery   for refractory    sickle cell
have future bleeds from the remaining                 kidney [81. Segmental                      hematufla.      J Urol 1978:120:385-386
renal arterial embolization           is an ideal surgical alternative            be-       8. Lund HG, CordonnierJJ,              Forbes KA. Gross hematur/a in sickle cell disease.
cause     of the reduced         morbidity.     The problem          with applying               J Urol 1954:71           :11-18

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