Recurrent Hematuria: An endovascular treatment

Clinical History

A seventy year old male patient presented to the emergency department with complaints of blood tinged urine associated mild dull aching pain which was acute in onset. Patient also gives a past history of nephrectomy.

Imaging Findings

On ultrasound evaluation, the right kidney was not visualized, and left kidney showed multiple heteroechoic lesions. The patient gives a history of similar complaints in the past. CT scan showed about 5-6 enhancing lesion, with contrast extravasation which was not well localized to a specific lesion on CT. The largest lesion measures about 4.9x4 cm in the upper pole, the other lesions measured about 2.5-3.8 cm. On Angiography the suspicious lesion showing bleeding was seen in the upper pole and lower poles. One vial of 300-500 micron PVA particles was injected. Check angiogram was acquired. The patient showed clinical improvement with no complaints of hematuria. There was no further drop in Hb value (Pre procedure 7.4 gm % and post-procedure 7 gm %) and also further improvement in Hb of 9 gm% at one week with transfusion. Pre-procedure creatinine was 1.9 mg/dl, and post-procedure creatinine was 3 mg/dl.

Discussion

Renal Cell Carcinoma (RCC) is the most common renal malignant tumor and accounts for about 2-3% of renal lesions in adult. Histopathologically clear cell carcinoma are the most common variant. Patients commonly presents with palpable mass, flank pain and hematuria. These symptoms are usually seen in an advanced condition. Some genetic conditions shows higher preponderance which includes Von Hippel Lindau, hereditary papillary renal cancer and rarely tuberous sclerosis. These lesions are usually encapsulated and can be either solid, cystic or both. RCC is most common in male presenting between the age group of 50-70yrs. Five year survival period is 90% for localized and 10% for advanced disease [1]. Surgical resection is the treatment of choice in localized disease with ablation in advanced condition. Renal artery embolisation was first popularised by Almgård [2]. Various indications for embolisation includes preoperative treatment, palliation and treatment for angiomyolipoma. Various embolic agents have been used including gelfoam, glue, PVA particles, embosphere and coils. Studies have shown promising results in palliative setting [3]. Post embolic syndrome is well manageable with supportive treatment.

‘Written informed patient consent for publication has been obtained.’

Differential Diagnosis List

Final Diagnosis

Renal Cell Carcinoma

URL:	https://eurorad.org/case/16200
DOI:	10.1594/EURORAD/CASE.16200
ISSN:	1563-4086