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Renal Arteriovenous Fistula: A Complication of Anatrophic Nephrolithotomy
0022-5347 /83/1304-0754$02.00/0 Vol. 130, October Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1983 by The Williams & Wilkins Co.
RENAL ARTERIOVENOUS FISTULA: A COMPLICATION OF ANATROPHIC NEPHROLITHOTOMY A. O'TAYO LALUDE*
AND
DONALD C. MARTIN
From the Department of Surgery, University of California, Irvine, California
ABSTRACT
We report a case of an arteriovenous fistula following anatrophic nephrolithotomy. The need to consider this possible complication in patients with severe bleeding postoperatively and a prompt investigation with angiography is elaborated. Hematuria generally is accepted as an immediate complication of renal surgery. In their review of 100 consecutive cases of anatrophic nephrolithotomy Boyce and Elkins reported 4 per cent (4 of 100) with postoperative hemorrhage, which was their most common complication. 1 James 2 and Kyriakidis 3 and their associates did not report postoperative hemorrhage as a complication in their respective series. However, Eriksson and Berglund emphasized the need to be alert to severe hematuria after nephrolithotomy, since intrarenal arteriovenous fistula is a possibility. 4 There have been 3 cases reported previously of arteriovenous fistula as a complication of nephrolithotomy. Herein we report the fourth such case.
other episode of hematuria occurred 3 days later, leading to passage of blood clots but the hematocrit was stable at 34 per cent. After a third episode of bleeding 2 days later hematocrit decreased to 18 per cent. Selective renal angiography revealed an intrarenal arteriovenous fistula that communicated with the collecting system (an arteriovenous caliceal fistula) (fig. 2). The left kidney was then re-explored. Under renal hypothermia an arteriovenous fistula sac was resected from the anterior aspect of the kidney where calyrhaphy had been done at the initial operation. The patient did well postoperatively, with excellent serum chemistry, a stable hematocrit and good function of the left kidney on a renogram 6 days later (fig. 3).
CASE REPORT
DISCUSSION
C. G., UCIMC 070-80-87, a 65-year-old woman, was seen at the medical center on March 23, 1979 with a 2-year history of polydipsia, polyuria and nocturia. Medical history included untreated mild hypertension 8 years previously and a review of systems revealed passage of a "kidney stone" 6 years ago. She had arthralgias of the fingers, knees and shoulders with a recent onset of symptoms. Physical examination revealed an obese woman with bilateral costovertebral angle tenderness. Laboratory studies included urinalysis with a pH of 6, specific gravity 1.011, 2+ / 4+ albumin, 2+/4+ heme, and 10 red and 4 white blood cells per high power field with no bacteria. Urine culture yielded no growth. Hematocrit was 43 per cent, white blood count 5,700/cu. mm. and sedimentation rate 18 mm. per hour. Serum calcium was increased to 12.4 (normal up to 10 mg./dl.) with a decreased serum phosphorus of 1.4 (normal up to 2.5 mg./dl.). A chest xray was normal and long bone films showed degenerative joint disease. An excretory urogram (IVP) demonstrated a large staghorn calculus of the left kidney, with prompt and equal function in both relatively small kidneys (fig. 1). The electrocardiogram pattern was within normal limits. A sonogram of the neck did not reveal a parathyroid adenoma and the thyroid gland was normal. Serum parathyroid hormone was 193 pg. eq/ ml. (normal range 163 to 167 ± 2 standard deviations at standard deviation 46) and the 24-hour urinary collection for calcium was 183 mg. per day (normal range 40 to 400 mg. per day). Endocrine and surgical consultants thought that the clinical picture represented primary hyperparathyroidism. On April 26 a right upper parathyroid adenoma was removed. Convalescence was uneventful and left anatrophic nephrolithotomy with intraoperative renal hypothermia was done on May 29. Hematocrit was stable until 3 days postoperatively, when the patient had an episode of hematuria requiring blood transfusion. AnAccepted for publication March 4, 1983. Read at annual meeting of Western Section, American Urological Association, Coronado, California, February 21-25, 1982. * Current address: Division of Urology, Veterans Administration Medical Center, Prescott, Arizona 86313.
Acquired arteriovenous fistulas associated with renal biopsies have been reported commonly. 5 Tynes and associates noted that about 25 to 30 per cent of the reported cases occurred with renal biopsies. 6 Large arteriovenous fistulas from renal biopsies, which are immediately symptomatic (flank hematoma and gross hematuria), may require early diagnosis and consideration of surgical repair. 7 Smith and Boyce8 described in detail the surgical approach in anatrophic nephrolithotomy, and the comparative surgical anatomy of the procedure was illustrated by Resnick and associates.9 The surgical incision advocated was about 1 cm.
FIG. 1. IVP demonstrates large staghorn calculus ofleft kidney with good renal function by contrast excretion. 754
RENAL ARTERIOVENOUS FISTULA
755
FIG. 3. Radionuclide scan 6 days after re-exploration of left kidney shows good renal function.
REFERENCES
FIG. 2. Intrarenal arteriovenous fistula seen on selective renal angiography 8 days postoperatively. Note filling of renal vein emptying into inferior vena cava and opacification of some intrarenal arterial branches.
posteromedial to Brodel's white line, where a nephrotomy is made from the apical segment to the basilar segment and between the anteroposterior intersegmental plane. In our case the area of the arteriovenous fistula was in the mid portion of the left renal medulla, where probably an interlobar artery and vein, opened at the time of nephrotomy, were not included in suture-ligation during calyrhaphy. During the initial episode of gross hematuria the blood clot in the juxtaposed arteriovenous vessels might have lysed and a fistulous communication to the pyeloureteral unit could have manifested as severe postopera tive hematuria. Eriksson and Berglund noted 2 other reported cases of intrarenal arteriovenous fistulas and reported 1 of their own cases. 4 They operated on their patient about 4 weeks after nephrolithotomy to repair the fistula. Our patient was reoperated upon 1 week postoperatively. The nephrographic phase of the angiogram showed a mid renal arteriovenous fistula, filling of the renal vein emptying into the inferior vena cava and persistent opacification of multiple intrarenal arterial branches (fig. 2). On the basis of the vascular findings, immediate re-exploration of the left kidney was considered so that subsequent cardiac complication was avoided. The intrarenal arteriovenous fistulas reported in postnephrolithotomy patients, including our case, did not demonstrate bruit or significant cardiovascular symptoms (true of acquired early arteriovenous fistulas). 6 The presence of an intrarenal arteriovenous fistula should be considered as a differential diagnosis, since it has been demonstrated after renal biopsies and after anatrophic nephrolithotomy in cases with persistent hematuria within 1 to 4 weeks postoperatively. We recommend angiographic investigation in a post-nephrolithotomy patient with gross postoperative hematuria and a continuing decrease in hematocrit despite blood transfusion. The early recognition of this secondary hemorrhage will increase the chances of salvaging the affected kidney.
1. Boyce, W. H. and Elkins, I. B.: Reconstruetive renal surgery following anatrophic nephrolithotomy: followup of 100 consecutive cases. J. Urol., 111: 307, 1974. 2. James, R., Novick, A. C., Straffon, R. A. and Stewart, B. H.: Anatrophic nephrolithotomy for removal of staghorn or branched renal calculi. Urology, 15: 108, 1980. 3. Kyriakidis, A., Karidis, G., Papacharalambous, A. and Yannopoulos, P.: Surgical management of renal staghorn calculi by selective hypothermic perfusion. Eur. Urol., 5: 173, 1979. 4. Eriksson, I. and Berglund, G.: lntrarenal arteriovenous fistula after nephrolithotomy. Surgical treatment with salvage of the kidney. Scand. J. Urol. Nephrol., 8: 73, 1974. 5. Leiter, E., Gribetz, D. and Cohen, S.: Arteriovenous fistula after percutaneous needle biopsy-surgical repair with preservation of renal function. New Engl. J. Med., 287: 971, 1972. 6. Tynes, W. V., Devine, C. J., Jr., Devine, P. C. and Poutasse, E. F.: Surgical treatment of renal arteriovenous fistulas: report of 5 cases. J. Urol., 103: 692, 1970. 7. Javadpour, N., Dellon, A. L., Vermess, N. V. and Klippel, J. H.: lntrarenal arteriovenous fistula. Early surgical repair with preservation of renal parenchyma. Urology, 1: 457, 1973. 8. Smith, M. J. V. and Boyce, W. H.: Anatrophic nephrotomy and plastic calyrhaphy. J. Urol., 99: 521, 1968. 9. Resnick, M. I., Pounds, D. M. and Boyce, W. H.: Surgical anatomy of the human kidney and its applications. Urology, 17: 367, 1981. EDITORIAL COMMENTS The authors are to be commended for presenting a technique for the diagnosis of postoperative arteriovenous fistula, which should encourage conservative reconstructive surgery rather than nephrectomy. W.H.C.
We have just completed a review of 848 consecutive nephrolithotomies for stones, all of which required occlusion of the renal artery and local hypothermia was used. Extensive reconstructive surgery of the kidney was necessary in 533 cases, with an average renal artery clamp time of 2.65 hours. The incidence of postoperative blood loss of 500 cc or more occurred in 6.8 per cent of the complicated procedures. Of the patients with postoperative hemorrhage 3 had small arteriovenous fistulas immediately postoperatively, the hemorrhage becoming apparent in 6 to 12 days postoperatively. Hemorrhage from these fistulas usually is delayed postoperatively and is severe, persistent and intractable. In my opinion such bleeding is the indication for angiography and for immediate surgical exploration and repair, rather than any measures at temporization. All 3 of our patients were so treated successfully and precise localization of the fistula was accomplished by use of the Doppler ultrasound equipment.
THE JOURNAL OF UROLOGY
Copyright© 1983 by The Williams & Wilkins Co.
RENAL ARTERIOVENOUS FISTULA: A COMPLICATION OF ANATROPHIC NEPHROLITHOTOMY A. O'TAYO LALUDE*
AND
DONALD C. MARTIN
From the Department of Surgery, University of California, Irvine, California
ABSTRACT
We report a case of an arteriovenous fistula following anatrophic nephrolithotomy. The need to consider this possible complication in patients with severe bleeding postoperatively and a prompt investigation with angiography is elaborated. Hematuria generally is accepted as an immediate complication of renal surgery. In their review of 100 consecutive cases of anatrophic nephrolithotomy Boyce and Elkins reported 4 per cent (4 of 100) with postoperative hemorrhage, which was their most common complication. 1 James 2 and Kyriakidis 3 and their associates did not report postoperative hemorrhage as a complication in their respective series. However, Eriksson and Berglund emphasized the need to be alert to severe hematuria after nephrolithotomy, since intrarenal arteriovenous fistula is a possibility. 4 There have been 3 cases reported previously of arteriovenous fistula as a complication of nephrolithotomy. Herein we report the fourth such case.
other episode of hematuria occurred 3 days later, leading to passage of blood clots but the hematocrit was stable at 34 per cent. After a third episode of bleeding 2 days later hematocrit decreased to 18 per cent. Selective renal angiography revealed an intrarenal arteriovenous fistula that communicated with the collecting system (an arteriovenous caliceal fistula) (fig. 2). The left kidney was then re-explored. Under renal hypothermia an arteriovenous fistula sac was resected from the anterior aspect of the kidney where calyrhaphy had been done at the initial operation. The patient did well postoperatively, with excellent serum chemistry, a stable hematocrit and good function of the left kidney on a renogram 6 days later (fig. 3).
CASE REPORT
DISCUSSION
C. G., UCIMC 070-80-87, a 65-year-old woman, was seen at the medical center on March 23, 1979 with a 2-year history of polydipsia, polyuria and nocturia. Medical history included untreated mild hypertension 8 years previously and a review of systems revealed passage of a "kidney stone" 6 years ago. She had arthralgias of the fingers, knees and shoulders with a recent onset of symptoms. Physical examination revealed an obese woman with bilateral costovertebral angle tenderness. Laboratory studies included urinalysis with a pH of 6, specific gravity 1.011, 2+ / 4+ albumin, 2+/4+ heme, and 10 red and 4 white blood cells per high power field with no bacteria. Urine culture yielded no growth. Hematocrit was 43 per cent, white blood count 5,700/cu. mm. and sedimentation rate 18 mm. per hour. Serum calcium was increased to 12.4 (normal up to 10 mg./dl.) with a decreased serum phosphorus of 1.4 (normal up to 2.5 mg./dl.). A chest xray was normal and long bone films showed degenerative joint disease. An excretory urogram (IVP) demonstrated a large staghorn calculus of the left kidney, with prompt and equal function in both relatively small kidneys (fig. 1). The electrocardiogram pattern was within normal limits. A sonogram of the neck did not reveal a parathyroid adenoma and the thyroid gland was normal. Serum parathyroid hormone was 193 pg. eq/ ml. (normal range 163 to 167 ± 2 standard deviations at standard deviation 46) and the 24-hour urinary collection for calcium was 183 mg. per day (normal range 40 to 400 mg. per day). Endocrine and surgical consultants thought that the clinical picture represented primary hyperparathyroidism. On April 26 a right upper parathyroid adenoma was removed. Convalescence was uneventful and left anatrophic nephrolithotomy with intraoperative renal hypothermia was done on May 29. Hematocrit was stable until 3 days postoperatively, when the patient had an episode of hematuria requiring blood transfusion. AnAccepted for publication March 4, 1983. Read at annual meeting of Western Section, American Urological Association, Coronado, California, February 21-25, 1982. * Current address: Division of Urology, Veterans Administration Medical Center, Prescott, Arizona 86313.
Acquired arteriovenous fistulas associated with renal biopsies have been reported commonly. 5 Tynes and associates noted that about 25 to 30 per cent of the reported cases occurred with renal biopsies. 6 Large arteriovenous fistulas from renal biopsies, which are immediately symptomatic (flank hematoma and gross hematuria), may require early diagnosis and consideration of surgical repair. 7 Smith and Boyce8 described in detail the surgical approach in anatrophic nephrolithotomy, and the comparative surgical anatomy of the procedure was illustrated by Resnick and associates.9 The surgical incision advocated was about 1 cm.
FIG. 1. IVP demonstrates large staghorn calculus ofleft kidney with good renal function by contrast excretion. 754
RENAL ARTERIOVENOUS FISTULA
755
FIG. 3. Radionuclide scan 6 days after re-exploration of left kidney shows good renal function.
REFERENCES
FIG. 2. Intrarenal arteriovenous fistula seen on selective renal angiography 8 days postoperatively. Note filling of renal vein emptying into inferior vena cava and opacification of some intrarenal arterial branches.
posteromedial to Brodel's white line, where a nephrotomy is made from the apical segment to the basilar segment and between the anteroposterior intersegmental plane. In our case the area of the arteriovenous fistula was in the mid portion of the left renal medulla, where probably an interlobar artery and vein, opened at the time of nephrotomy, were not included in suture-ligation during calyrhaphy. During the initial episode of gross hematuria the blood clot in the juxtaposed arteriovenous vessels might have lysed and a fistulous communication to the pyeloureteral unit could have manifested as severe postopera tive hematuria. Eriksson and Berglund noted 2 other reported cases of intrarenal arteriovenous fistulas and reported 1 of their own cases. 4 They operated on their patient about 4 weeks after nephrolithotomy to repair the fistula. Our patient was reoperated upon 1 week postoperatively. The nephrographic phase of the angiogram showed a mid renal arteriovenous fistula, filling of the renal vein emptying into the inferior vena cava and persistent opacification of multiple intrarenal arterial branches (fig. 2). On the basis of the vascular findings, immediate re-exploration of the left kidney was considered so that subsequent cardiac complication was avoided. The intrarenal arteriovenous fistulas reported in postnephrolithotomy patients, including our case, did not demonstrate bruit or significant cardiovascular symptoms (true of acquired early arteriovenous fistulas). 6 The presence of an intrarenal arteriovenous fistula should be considered as a differential diagnosis, since it has been demonstrated after renal biopsies and after anatrophic nephrolithotomy in cases with persistent hematuria within 1 to 4 weeks postoperatively. We recommend angiographic investigation in a post-nephrolithotomy patient with gross postoperative hematuria and a continuing decrease in hematocrit despite blood transfusion. The early recognition of this secondary hemorrhage will increase the chances of salvaging the affected kidney.
1. Boyce, W. H. and Elkins, I. B.: Reconstruetive renal surgery following anatrophic nephrolithotomy: followup of 100 consecutive cases. J. Urol., 111: 307, 1974. 2. James, R., Novick, A. C., Straffon, R. A. and Stewart, B. H.: Anatrophic nephrolithotomy for removal of staghorn or branched renal calculi. Urology, 15: 108, 1980. 3. Kyriakidis, A., Karidis, G., Papacharalambous, A. and Yannopoulos, P.: Surgical management of renal staghorn calculi by selective hypothermic perfusion. Eur. Urol., 5: 173, 1979. 4. Eriksson, I. and Berglund, G.: lntrarenal arteriovenous fistula after nephrolithotomy. Surgical treatment with salvage of the kidney. Scand. J. Urol. Nephrol., 8: 73, 1974. 5. Leiter, E., Gribetz, D. and Cohen, S.: Arteriovenous fistula after percutaneous needle biopsy-surgical repair with preservation of renal function. New Engl. J. Med., 287: 971, 1972. 6. Tynes, W. V., Devine, C. J., Jr., Devine, P. C. and Poutasse, E. F.: Surgical treatment of renal arteriovenous fistulas: report of 5 cases. J. Urol., 103: 692, 1970. 7. Javadpour, N., Dellon, A. L., Vermess, N. V. and Klippel, J. H.: lntrarenal arteriovenous fistula. Early surgical repair with preservation of renal parenchyma. Urology, 1: 457, 1973. 8. Smith, M. J. V. and Boyce, W. H.: Anatrophic nephrotomy and plastic calyrhaphy. J. Urol., 99: 521, 1968. 9. Resnick, M. I., Pounds, D. M. and Boyce, W. H.: Surgical anatomy of the human kidney and its applications. Urology, 17: 367, 1981. EDITORIAL COMMENTS The authors are to be commended for presenting a technique for the diagnosis of postoperative arteriovenous fistula, which should encourage conservative reconstructive surgery rather than nephrectomy. W.H.C.
We have just completed a review of 848 consecutive nephrolithotomies for stones, all of which required occlusion of the renal artery and local hypothermia was used. Extensive reconstructive surgery of the kidney was necessary in 533 cases, with an average renal artery clamp time of 2.65 hours. The incidence of postoperative blood loss of 500 cc or more occurred in 6.8 per cent of the complicated procedures. Of the patients with postoperative hemorrhage 3 had small arteriovenous fistulas immediately postoperatively, the hemorrhage becoming apparent in 6 to 12 days postoperatively. Hemorrhage from these fistulas usually is delayed postoperatively and is severe, persistent and intractable. In my opinion such bleeding is the indication for angiography and for immediate surgical exploration and repair, rather than any measures at temporization. All 3 of our patients were so treated successfully and precise localization of the fistula was accomplished by use of the Doppler ultrasound equipment.