0022-5347/79/1213-0360$02. 00/0 Vol. 121, March
THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
Printed in U.S.A.
MASSIVE RENAL ANGIOMYOLIPOMA: PREOPERATIVE INFARCTION BY BALLOON CATHETER ANTHONY A. EASON, EUGENE V. CATTOLICA*
AND
TERENCE W. MCGRATH
From the Departments of Urology and Radiology, Kaiser-Permanente Medical Center, Oakland and the Department of Urology, University of California, San Francisco, California
ABSTRACT
A case of a renal angiomyolipoma supplied by 2 renal arteries is reported. Preoperative, percutaneous transluminal infarction by a balloon catheter facilitated surgical removal of this massive neoplasm. In the series reported by Marberger and Georgi balloon occlusion of the renal artery facilitated nephrectomy in 70 per cent of malignant renal neoplasms. Herein we report on the successful use of this technique for the management of a benign but massive renal neoplasm. CASE REPORT
A 45-year-old woman complained of left upper quadrant pain 6 months in duration. Physical examination showed a slightly tender, hard, fixed abdominal mass that occupied the left upper quadrant and extended into the left lower quadrant. Laboratory data included a hematocrit value of 29.4 per cent and a normal urinalysis. Excretory urography (NP) demonstrated a large mass in the lower portion of the left kidney (fig. 1). Abdominal aortography showed 2 left renal arteries (fig. 2, A) and multiple tumor vessels within the kidney. Injection of the lower renal vessel showed a 6.5 cm. in diameter cavity adjacent to the renal pelvis, interpreted as a pseudoaneurysm (fig. 2, B). Injection of the superior mesenteric artery revealed parasitization of the branches of this vessel by the tumor. The selective venogram was normal, as well as the chest x-ray, upper gastrointestinal series, barium enema, and liver-spleen and bone scans. Because of the large pseudoaneurysm and the large size of the tumor preoperative infarction of the tumor was done. The short lower renal artery, with backflow of contrast material into the aorta on the selective study, precluded the choice of infarction with particulate materials because of the possibility of peripheral embolization. Therefore, the superior and inferior renal arteries were occluded using a 70 cm. long, 4.8F, flow-directed balloon cathetert with the distal 1.5 cm. angled 30 degrees. This was introduced through a 5F catheter introducer using the Seldinger transfemoral technique. Immediate aortography using the opposite femoral arterial approach demonstrated a lack of blood supply to the tumor (fig. 3). The balloon catheters were left in place overnight to infarct the tumor. The patient required 2 narcotic injections during the night. At operation the next morning the catheters in the right groin were prepared and draped separately to allow intraoperative manipulation without contaminating the operative field. Through a left thoracoabdominal approach the descending colon was easily mobilized medially without any apparent parasitic vessels encountered. The left inferior renal artery was identified and mobilized, and an arterial clamp was placed around the vessel but not secured. The balloon catheter Accepted for publication June 30, 1978. * Requests for reprints: Department of Urology, Kaiser-Permanente Medical Center, 280 W. MacArthur Blvd., Oakland, California 94611. t Cook, Inc., Bloomington, Indiana. 360
Fm. 1. IVP shows large left kidney with distortion of collecting structures.
was deflated and retracted into the aorta and the artery was clamped immediately. When the artery was divided an intraluminal clot was noted. Because of the occluding arterial balloon catheter in the remaining superior renal artery the left renal vein was safely identified, secured and divided. Division of the superior renal artery after removal of the occluding balloon catheter was facilitated greatly by the previous division of the overlying vein. After vascular control of the tumor mobilization from its attachments to the pancreas, lienorenal ligament and diaphragm was accomplished and the tumor was removed. Blood loss for this procedure was minimal. The catheters were removed from the femoral artery immediately after closure.
361
MASSIVE RENAL ANGIOMYOLIPOMA
FIG. 2. A, abdominal aortogram shows 2 left renal arteries and tumor vessels. B, left lower renal arteriogram reveals large pseudoaneurysm overlying renal pelvis.
Convalescence was uneventful and the patient was discharged from the hospital 11 days later. The pathologic specimen measured 28 x 16 x 9 cm. and weighed 1.74 kg. Microscopic examination of the tumor revealed a classic angiomyolipoma. DISCUSSION
Moorhead and associates have reported successful, nonoperative management of an angiomyolipoma with selective arterial embolization. 2 Because of neovascularity and the parasitization of the branches of the superior mesenteric artery by the tumor our preoperative diagnosis was a giant renal cell carcinoma. Parasitic lumbar arterial blood supply of a renal angiomyolipoma has been reported by Hyman and associates,~ although the superior mesenteric artery was parasitized in our patient. There are several advantages of preoperative balloon occlusion of the arterial supply. Division of the renal vein before surgical ligation of the renal artery is technically easier. However, to prevent vascular engorgement of the kidney surgical ligation of the renal artery before division of the vein usually is mandated. The preoperative balloon occlusion obviates this maneuver. Additionally, the blood flow within the renal vein is reduced markedly, with proportional collapse of the main renal vein and any tumor vessels. Surgical division of the vein before operative mobilization of the tumor disallows tumor cell embolization to the general circulation. Cleavage planes are better defined and dissected by the edema consequent to renal infarction. This advantage of facilitating
FIG. 3. Abdominal aortogram shows occluding renal artery catheters. Note lack ofblood supply to kidney distal to balloons (arrows).
the operation obtains independent of whether the tumor is malignant. Other than the morbidity common to all transfemoral arterial catheterizations, the morbidity of pain secondary to renal infarction is related to the delay between infarction and surgical extirpation. In our patient this pain was controlled easily. Our lack of operative complications using preoperative infarction of the tumor by 2 occlusive balloon catheters leads us to recommend the technique for resection of any large renal neoplasm, benign or malignant. REFERENCES
1. Ma:rberger, M. and Georgi, M.: Balloon occlusion of the renal artery in tumor nephrectomy. J. Urol., 114: 360, 1975. 2. Moorhead, J. D., Fritzsche, P. and Hadley, H. L.: Management of hemorrhage secondary to renal angiomyolipoma with selective arterial embolization. J. Urol., 117: 122, 1977. 3. Hyman, R. A., Bluestone, P., Waldbaum, R. S., Naidich, J.B. and Susin, M.: Parasitic lumbar arterial blood supply in renal angiomyolipoma. Urology, 8: 629, 1976.
THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
Printed in U.S.A.
MASSIVE RENAL ANGIOMYOLIPOMA: PREOPERATIVE INFARCTION BY BALLOON CATHETER ANTHONY A. EASON, EUGENE V. CATTOLICA*
AND
TERENCE W. MCGRATH
From the Departments of Urology and Radiology, Kaiser-Permanente Medical Center, Oakland and the Department of Urology, University of California, San Francisco, California
ABSTRACT
A case of a renal angiomyolipoma supplied by 2 renal arteries is reported. Preoperative, percutaneous transluminal infarction by a balloon catheter facilitated surgical removal of this massive neoplasm. In the series reported by Marberger and Georgi balloon occlusion of the renal artery facilitated nephrectomy in 70 per cent of malignant renal neoplasms. Herein we report on the successful use of this technique for the management of a benign but massive renal neoplasm. CASE REPORT
A 45-year-old woman complained of left upper quadrant pain 6 months in duration. Physical examination showed a slightly tender, hard, fixed abdominal mass that occupied the left upper quadrant and extended into the left lower quadrant. Laboratory data included a hematocrit value of 29.4 per cent and a normal urinalysis. Excretory urography (NP) demonstrated a large mass in the lower portion of the left kidney (fig. 1). Abdominal aortography showed 2 left renal arteries (fig. 2, A) and multiple tumor vessels within the kidney. Injection of the lower renal vessel showed a 6.5 cm. in diameter cavity adjacent to the renal pelvis, interpreted as a pseudoaneurysm (fig. 2, B). Injection of the superior mesenteric artery revealed parasitization of the branches of this vessel by the tumor. The selective venogram was normal, as well as the chest x-ray, upper gastrointestinal series, barium enema, and liver-spleen and bone scans. Because of the large pseudoaneurysm and the large size of the tumor preoperative infarction of the tumor was done. The short lower renal artery, with backflow of contrast material into the aorta on the selective study, precluded the choice of infarction with particulate materials because of the possibility of peripheral embolization. Therefore, the superior and inferior renal arteries were occluded using a 70 cm. long, 4.8F, flow-directed balloon cathetert with the distal 1.5 cm. angled 30 degrees. This was introduced through a 5F catheter introducer using the Seldinger transfemoral technique. Immediate aortography using the opposite femoral arterial approach demonstrated a lack of blood supply to the tumor (fig. 3). The balloon catheters were left in place overnight to infarct the tumor. The patient required 2 narcotic injections during the night. At operation the next morning the catheters in the right groin were prepared and draped separately to allow intraoperative manipulation without contaminating the operative field. Through a left thoracoabdominal approach the descending colon was easily mobilized medially without any apparent parasitic vessels encountered. The left inferior renal artery was identified and mobilized, and an arterial clamp was placed around the vessel but not secured. The balloon catheter Accepted for publication June 30, 1978. * Requests for reprints: Department of Urology, Kaiser-Permanente Medical Center, 280 W. MacArthur Blvd., Oakland, California 94611. t Cook, Inc., Bloomington, Indiana. 360
Fm. 1. IVP shows large left kidney with distortion of collecting structures.
was deflated and retracted into the aorta and the artery was clamped immediately. When the artery was divided an intraluminal clot was noted. Because of the occluding arterial balloon catheter in the remaining superior renal artery the left renal vein was safely identified, secured and divided. Division of the superior renal artery after removal of the occluding balloon catheter was facilitated greatly by the previous division of the overlying vein. After vascular control of the tumor mobilization from its attachments to the pancreas, lienorenal ligament and diaphragm was accomplished and the tumor was removed. Blood loss for this procedure was minimal. The catheters were removed from the femoral artery immediately after closure.
361
MASSIVE RENAL ANGIOMYOLIPOMA
FIG. 2. A, abdominal aortogram shows 2 left renal arteries and tumor vessels. B, left lower renal arteriogram reveals large pseudoaneurysm overlying renal pelvis.
Convalescence was uneventful and the patient was discharged from the hospital 11 days later. The pathologic specimen measured 28 x 16 x 9 cm. and weighed 1.74 kg. Microscopic examination of the tumor revealed a classic angiomyolipoma. DISCUSSION
Moorhead and associates have reported successful, nonoperative management of an angiomyolipoma with selective arterial embolization. 2 Because of neovascularity and the parasitization of the branches of the superior mesenteric artery by the tumor our preoperative diagnosis was a giant renal cell carcinoma. Parasitic lumbar arterial blood supply of a renal angiomyolipoma has been reported by Hyman and associates,~ although the superior mesenteric artery was parasitized in our patient. There are several advantages of preoperative balloon occlusion of the arterial supply. Division of the renal vein before surgical ligation of the renal artery is technically easier. However, to prevent vascular engorgement of the kidney surgical ligation of the renal artery before division of the vein usually is mandated. The preoperative balloon occlusion obviates this maneuver. Additionally, the blood flow within the renal vein is reduced markedly, with proportional collapse of the main renal vein and any tumor vessels. Surgical division of the vein before operative mobilization of the tumor disallows tumor cell embolization to the general circulation. Cleavage planes are better defined and dissected by the edema consequent to renal infarction. This advantage of facilitating
FIG. 3. Abdominal aortogram shows occluding renal artery catheters. Note lack ofblood supply to kidney distal to balloons (arrows).
the operation obtains independent of whether the tumor is malignant. Other than the morbidity common to all transfemoral arterial catheterizations, the morbidity of pain secondary to renal infarction is related to the delay between infarction and surgical extirpation. In our patient this pain was controlled easily. Our lack of operative complications using preoperative infarction of the tumor by 2 occlusive balloon catheters leads us to recommend the technique for resection of any large renal neoplasm, benign or malignant. REFERENCES
1. Ma:rberger, M. and Georgi, M.: Balloon occlusion of the renal artery in tumor nephrectomy. J. Urol., 114: 360, 1975. 2. Moorhead, J. D., Fritzsche, P. and Hadley, H. L.: Management of hemorrhage secondary to renal angiomyolipoma with selective arterial embolization. J. Urol., 117: 122, 1977. 3. Hyman, R. A., Bluestone, P., Waldbaum, R. S., Naidich, J.B. and Susin, M.: Parasitic lumbar arterial blood supply in renal angiomyolipoma. Urology, 8: 629, 1976.
