Dergiler / Türk Üroloji Dergisi/Turkish Journal of Urology / 2008 / Cilt: 34 - Sayı: 4
Perkütan nefrolitotomi sonrası böbrek anjiyografisi gerektiren hastalar
- Sayfa
- 431–435
- DOI
- —
Özet
Perkütan nefrolitotomi ameliyatı günümüzde böbrek taşlarının tedavisinde açık cerrahinin yerini almıştır. Perkütan nefrolitotominin en ciddi istenmeyen yan etkisi kanamadır. Bu çalışmada perkütan nefrolitotomi ameliyatı sonrası masif kanama nedeni ile böbrek anjiyografisi ve/veya selektif embolizasyon uygulanan olgular gözden geçirildi. Kliniğimizde Ekim 2003 ve Temmuz 2008 tarihleri arasında uygulanan 656 perkütan nefrolitotomi ameliyatının sonuçları geriye dönük olarak incelendi. Bu hastalardan kanaması basit uygulamalar ile kontrol altına alınamayan ve böbrek anjiyografisi ve/veya embolizasyon uygulanmasını gerektiren hastalar çalışmaya alındı. 656 perkütan nefrolitotomi uygulamasından, 6’sında (%0,9) kanamanın nedenin saptanması için böbrek anjiyografisi yapıldı. Hastaların 5’i erkek, 1’i bayandı. Hastaların ortalama yaşı 43,8 yıl (14-69 yıl) idi. Böbrek anjiyografisi sonunda 3 hastada arteriyovenöz fistül, 2 hastada psödoanevrizma tespit edildi, 1 hastada ise herhangi bir lezyona rastlanmadı. Tespit edilen lezyonlara süper selektif embolizasyon uygulandı. 4 hastada kanama tamamen durdurulurken, 1 hastada 2. kez böbrek anjiyografisi ve embolizasyon yapılmasına gerek duyuldu. Bu hastaya yapılan 2. böbrek anjiyografik embolizasyon işlemi de başarısız oldu ve bunun üzerine bu hastaya açık nefrektomi ameliyatı uygulandı. Perkütan nefrolitotomi sonrası ciddi kanama oranı yaklaşık %1’dir ve bunların büyük çoğunluğu süper selektif embolizasyon ile kontrol altına almak mümkündür. Ancak seyrekte olsa açık cerrahi girişim gereksinimi olabilmektedir.
Abstract
Introduction: Percutaneous nephrolithotomy is the procedure of choice for treating large and complex renal calculi. One of the most worrisome complications of this procedure is severe bleeding. In most cases bleeding is in venous origin and conservative treatment choices are usually enough to control bleeding. Arterial bleedings are not generally responded to conservative treatment measures and super selective embolization is required to control arterial bleeding. Following percutaneous nephrolithotomy in less than 1% of cases renal angiographic embolization is required. In the present study we report our experience with severe bleeding that required renal angiography and/or embolization following percutaneous nephrolithomy. Materials and Methods: A total of 656 percutaneous nephrolithotomy operations were done in our clinic between October 2003 and June 2008. Patients, with serious blood loss and whose did not respond to conservative bleeding treatment techniques, underwent renal angiography. During angiography if source of bleeding such as arteriovenous fistula or pseudoaneurysm were detected, concominant super selective embolization of the lesion was performed. For embolization of the vascular lesions metallic coils were used. Results: Of the 656 patients, 6 (0.9%) (5 men and 1 woman) required renal angiography and/or embolization. The mean age of these patients was 43.8 years (range 14 to 69). The mean time from discharge to readmission to the hospital with severe hematuria and hemoglobin drop was 5.6 days (range 1 to 10 days). The mean drop in hemoglobin level was 4.6 mg/dl (range 2.5 to 7 mg/dl). The mean stone size of the patients was 591.6 mm2 (range 300 to 1200 mm2). Two patients (2/6, 33%) had history of previous ipsilateral open stone surgery. One patient had history of known hypertension controlled with medication. During first renal angiography we observed arteriovenous fistula in 3 patients, pseudoaneurysm in 1 patient, and no lesion in 2 patients. In 3 of 4 patients (75%), successful super selective embolization of the vascular lesions was achieved. In 1 patient (25%) hematuria and hemoglobin drop was recurred and he underwent repeat angiography and embolization. Repeat embolization was not also successful and subsequently he underwent open nephrectomy with flank incision. Patients with no vascular lesions during first renal angiography were closely observed. In 1 of these patients hematuria did not recurred. But the other patient was readmitted to emergency room with severe hematuria, underwent second renal angiography. Second renal angiography revealed pseuodoaneursym. He underwent concominant super selective embolization of the lesion and the result was successful in that patient. Conclusion: Arterial hemorrhage following percutaneous nephrolithotomy is rare. But it is a life threatening complication. Renal angiography and super selective embolization of the lesion is the first choice of treatment. With the aid of renal angiography and super selective embolization most of the arterial bleedings following percutaneous nephrolithotomy can be managed successfully but rarely nephrectomy may be required.