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Angiographic Management of Bleeding Secondary to Genitourinary Tract Surgery
Vol. 113, January Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1975 by The Williams & Wilkins Co.
ANGIOGRAPHIC MANAGEMENT OF BLEEDING SECONDARY TO GENITOURINARY TRACT SURGERY J. CARLISLE SMITH, JR., WALTERS. KERR, CHRISTOS A. ATHANASOULIS, ARTHUR C. WALTMAN, ERNEST J. RING AND STANLEY BAUM* From the Departments of Radiology and the Surgical Service, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
Recently, angiography has played an increasing role in the management of gastrointestinal bleeding. 1-• Angiographic methods also have been applied successfully in the management of patients with massive pelvic hemorrhage secondary to trauma. 5 Bleeding from the genitourinary tract may be equally serious, particularly in patients who are poor operative risks. The same angiographic methods which have been successfully applied to gastrointestinal and pelvic bleeding have been used recently in the management of bleeding from the genitourinary tract. We herein present our experience with 2 cases of postoperative bleeding, 1 following an ilea! loop cutaneous diversion and the other after a prostatic needle biopsy.
ing from the nephrostomy tube as well as the ileal loop. Right nephrectomy was considered although believed inadvisable since the patient would then have a solitary kidney containing calculi. Angiography was undertaken to localize and, possibly, to control the bleeding site. Renal arteriography demonstrated no bleeding from the right kidney. A selective superior mesenteric arteriogram demonstrated contrast extravasation from a distal ilea! artery, contiguous to the ureteroileal anastomosis (fig. 1, A and B). After an infusion of 0.3 units per minute of posterior pituitary extract for 20 minutes into the superior mesenteric artery, a repeat arteriogram demonstrated no further extravasation (fig. 1, C). The catheter was left in place for 72 hours, on gradually decreasing infusion rates of posterior pituitary extract, and was removed when the patient had stabilized clinically. No further therCASE REPORTS apy for bleeding was necessary and the patient was Case 1. C. B., MGH 109 20 86, a 72-year-old discharged from the hospital subsequently. white man with bilateral renal calculi, underwent Comment: Operative intervention in this situacystectomy and ilea! loop diversion for chronic tion would have been extremely hazardous. Angiincapacitating cystitis. Bright red bleeding was ography was successful not only in localizing the noted from the ilea! loop 20 days postoperatively. bleeding site but in achieving permanent hemostaThe hematocrit decreased 4 points, necessitating sis. The blood issuing from the nephrostomy tube transfusion. Renal calculi were suspected as the apparently originated from the ilea! loop anassource of bleeding and a right pyelolithotomy was tomosis and refluxed up the right ureter. performed, with removal of multiple lower pole Case 2. D. W., MGH 037 44 39, a 67-year-old renal calculi and placement of a nephrostomy white man, had complaints of frequency and tube. Postoperatively the patient continued bleed- nocturia. A prostatic nodule was found on physical examination. There was no hematuria. The patient was admitted to the hospital for transperineal Accepted for publication May 31, 1974. Supported in part by United States Public Health prostatic biopsy. Multiple Vim-Silverman needle Service Grant 2R01 AM16026-03. biopsies were obtained from the left lobe of the * Requests for reprints: Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts prostate. The patient's condition was stable upon transfer from the operating room to the recovery 02114. 1 Baum, S., Stein, G. N., Nusbaum, M. and Chait, A.: room. Four hours postoperatively the patient sufSelective arteriography in the diagnosis of hemorrhage in fered a sudden hypotensive episode and the blood the gastrointestinal tract. Radio!. Clin. N. Amer., 7: 131, pressure was unobtainable. On physical examina1969. 2 Rosch, J ., Dotter, C. T. and Antonovic, R.: Selective tion the lower abdomen was tender and tense to vasoconstrictor infusion in the management of arterio- palpation and there was an enlarged abdominal capillary gastrointestinal hemorrhage. Amer. J. Roent- girth. However, the perineum was flat with no gen., 116: 279, 1972. evidence of ecchymosis or scrotal swelling. Com3 Baum, S., Athanasoulis, C. A., Waltman, A. C. and Ring, E. J.: Gastrointestinal hemorrhage: angiographic parison with the pre-biopsy hematocrit revealed a diagnosis and control. In: Advances in Surgery. Edited by decrease from 35 to 26 per cent. After the standard J. D. Hardy and R. M. Zollinger. Chicago: Year Book measures had restored the blood pressure a cystoMedical Publishers, Inc., vol. 7, pp. 149-166, 1973. 'Baum, S. and Nusbaum, M.: The control of gastroin- gram demonstrated a tear-drop bladder with no testinal hemorrhage by selective mesenteric arterial infu- evidence of contrast extravasation. Diagnosis of sion of vasopressin. Radiology, 98: 497, 1971. massive retroperitoneal bleeding was made. Fur5 Margolies, M. N., Ring, E. J., Waltman, A. C., Kerr, ther blood replacement restored the hematocrit to W. S., Jr. and Baum, S.: Arteriography in the management of hemorrhage from pelvic fractures. New Engl. J. 33 per cent and angiography was performed. Since the biopsy was obtained from the left lobe Med., 287: 317, 1972. 89
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Fm. 1. Case 1-72-year-old white man with bleeding from ilea! loop. A, superior mesenteric arteriogram demonstrates extravasation (arrow) from ilea! artery branches, contiguous to ureteroileal anastomosis. B, further accumulation of extravasated contrast (arrows) is seen at bleeding site in late phase of superior mesenteric arteriogram. C, superior mesenteric arteriogram following 20-minute infusion of 0.3 units per minute of vasopressin into superior mesenteric artery demonstrates no further extravasation, indicating control of bleeding.
ANGIOGRAPHIC MANAGEMENT OF BLEEDING
91
FIG. 2. Case 2-67-year-old man with prostatic bleeding following needle biopsy. A, left hypogastric arteriogram demonstrates extravasation (curved arrow) from branches of superior vesical artery (straight arrow), as well as inferior vesical artery (double arrows). Contrast has refluxed from hypogastric artery into external iliac and femoral arteries. B, selective left hypogastric arteriogram following introduction of autologous clot demonstrates no extravasation indicating control of bleeding. Previously identified superior and inferior vesical arteries are now occluded by injected clot. C, selective right hypogastric arteriogram demonstrates same extravasation as identified previously (curved arrow), now supplied by right inferior vesical artery (straight arrow). D, following introduction of autologous clot through catheter no extravasation is identified. Inferior vesical artery has been occluded by injected clot.
92
SMITH AND ASSOCIATES
of the prostate a selective left hypogastric artery injection was initially performed, demonstrating massive contrast extravasation in the region of the prostate from branches of the left vesical arteries (fig. 2, A). The catheter was selectively advanced into the bleeding branch and embolization was carried out with 2 ml. autologous blood clot. A repeat arteriogram showed no further extravasation (fig. 2, B). The right hypogastric artery was studied, demonstrating extravasation in the same area now supplied by the right vesical artery branches (fig. 2, C). Again an autologous blood clot was introduced through the catheter, achieving hemostasis, as confirmed by the post-embolization arteriogram (fig. 2, D). The catheter was removed and the patient was returned to the recovery room. During the next several hours blood replacement requirements diminished and vital signs remained stable. The post-angiographic course was marked by a moderately severe paralytic ileus, secondary to massive retroperitoneal bleeding, as well as a moderate temperature elevation that responded to ampicillin. Final pathologic diagnosis on the prostatic specimen was adenocarcinoma and radiation therapy is currently being planned. Comment: This case illustrates the need for the study of the right and left hypogastric arteries in cases of pelvic bleeding because of the extensive anastomoses between the 2 sides. Rich collateralization from the external iliac and femoral, as well as the inferior mesenteric arteries, suffices to maintain viability of the bladder, despite bilateral occlusion of the vesical arteries. DISCt:SSION
Hemorrhage from the genitourinary tract following ileal loop cutaneous diversion and needle biopsy of the prostate is uncommon. Wendel and Evans reported 2 cases of major pelvic hematoma following transperineal prostatic needle biopsy, which responded to conservative management, although extensive perivesical scarring created serious technical problems at the operation a month later. 6 Their cases represented the first such reported complication in the English literature. Likewise, bleeding from the ilea! loop is rare, occurring in 1.5 per cent of cases in a review of 244 cutaneous diversions. 7 When such bleeding does occur it often subsides on conservative management. However, when hemorrhage continues angiographic methods of localizing and controlling the site of bleeding may be a valuable alternative to an operation. Hemostasis can be achieved angiographically by s e v ; ~ m : : l r e s . Tbe Tntra~arfena"CinfuSIOn oT· a vasoconstricfcir;--pr1rnarily posterior
-·-~- • ----·--•·" ---.v--•- • --'>•·------··-·-
6 Wendel, R. G. and Evans, A. T.: Complications of punch biopsy of the prostate gland. J. Urol., 97: 122, 1967. 7 Harbach, L. B., Hall, R. L .. Cockett, A. T. K., Kaufman, J. J., Martin, D. C., Mims, M. M. and Goodwin, W. E.: Ilea! loop cutaneous urinary diversion: a critical review. J. Urol., 105: 511, 1971.
P.rtuitary extract, ha_l'>J:>.~~12_j;J:!~!:!.lill_fil_fillllLQJ;1J:;h in g~qintestinal hemorrhage, when_ the calib
encour~ed.
However, drug infusions have been unsatisfactory in the control of bleeding from major arteries, since the large caliber of the bleeding vessels often precludes adequate vasoconstriction. Furthermore, pelvic bleeding is often bilateral and would require drug infusion into the left and right hypogastric arteries. In such cases, various mechanical means of obturating a bleeding vessel have been reported, including embolization with gelfoam, muscle or autologous clot. 8 Bookstein and Goldstein rer_e.:otly reported successful c~~trolci(Q.ost-traumatic rei~al hemorr1iage by transcatheter introduction of autologous dot." . . . ---·-··. . §_iEiian:t.iaL.exp.erie=...has...JJ.illlL...he_e_12_1!_<_:<_:_1c1111 u - " lated indicating that embolization with autologous/ /
~~~~~~~1~~~~~~~!11!f~~i:e~:1f~:~!};6I1~r',
pelvi(:_ hemo.r..rhage. Major pelvic ves;el;- can ~ oc~luded without untoward sequela lO and immediate hemostasis can be achieved without the necessity of leaving an indwelling arterial catheter in place. Autologous blood is sterile, readily available and does not represent a foreign body. The catheter sh_o.1lld bwlaced as near aJ,_possible to.i~ lifofilling.£i.te._t.o..ac.cmnpli.s.h_s.eJe ctiy.e_ em boliza tion: Interru_2t_i_g_g the vessel too proximaUy will encourage collat~ra]s to blJ>aSS the site of ocdusion aria conti_!lllJLt.Q.S11ppIY::ih.a1.le.eding_site. ··A,Ii:h;;;:;-gh we recognize the relative rarity of these specific bleeding problems we believe the angiographic methods will have application in managing the more commonly encountered types of bleeding seen following a renal or prostatic operation. SUMMARY
Angiographic methods were applied to control bleeding in 2 patients following genitourinary tract operations. In 1 patient hemorrhage into the prostatic bed after needle biopsy of the prostate was controlled with embolic occlusion of branches of the hypogastric arteries. In the second patient bleeding from the ileum following ileal loop cutaneous diversion was controlled with the infusion of vasopressin into the superior mesenteric artery. Therefore, angiography offers an attractive alternative to an operation in the management of postoperative hemorrhage from the genitourinary tract. 8 Rosch, J., Dotter, C. T. and Brown, M. J.: Selective arterial embolization: a new method for control of acute gastrointestinal bleeding. Radiology, 102: 303, 1972. 9 Bookstein, J. J. and Goldstein, H. M.: Successful management of postbiopsy arteriovenous fistula with selective arterial embolization. Radiology, 109: 5:35, 1973. 10 Binder, S. S. and Mitchell, G. A.: The control of intractable pelvic hemorrhage by ligation of the hypogastric artery. South. Med. ,J., 53: 837, 1960.
THE JOURNAL OF UROLOGY
Copyright © 1975 by The Williams & Wilkins Co.
ANGIOGRAPHIC MANAGEMENT OF BLEEDING SECONDARY TO GENITOURINARY TRACT SURGERY J. CARLISLE SMITH, JR., WALTERS. KERR, CHRISTOS A. ATHANASOULIS, ARTHUR C. WALTMAN, ERNEST J. RING AND STANLEY BAUM* From the Departments of Radiology and the Surgical Service, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
Recently, angiography has played an increasing role in the management of gastrointestinal bleeding. 1-• Angiographic methods also have been applied successfully in the management of patients with massive pelvic hemorrhage secondary to trauma. 5 Bleeding from the genitourinary tract may be equally serious, particularly in patients who are poor operative risks. The same angiographic methods which have been successfully applied to gastrointestinal and pelvic bleeding have been used recently in the management of bleeding from the genitourinary tract. We herein present our experience with 2 cases of postoperative bleeding, 1 following an ilea! loop cutaneous diversion and the other after a prostatic needle biopsy.
ing from the nephrostomy tube as well as the ileal loop. Right nephrectomy was considered although believed inadvisable since the patient would then have a solitary kidney containing calculi. Angiography was undertaken to localize and, possibly, to control the bleeding site. Renal arteriography demonstrated no bleeding from the right kidney. A selective superior mesenteric arteriogram demonstrated contrast extravasation from a distal ilea! artery, contiguous to the ureteroileal anastomosis (fig. 1, A and B). After an infusion of 0.3 units per minute of posterior pituitary extract for 20 minutes into the superior mesenteric artery, a repeat arteriogram demonstrated no further extravasation (fig. 1, C). The catheter was left in place for 72 hours, on gradually decreasing infusion rates of posterior pituitary extract, and was removed when the patient had stabilized clinically. No further therCASE REPORTS apy for bleeding was necessary and the patient was Case 1. C. B., MGH 109 20 86, a 72-year-old discharged from the hospital subsequently. white man with bilateral renal calculi, underwent Comment: Operative intervention in this situacystectomy and ilea! loop diversion for chronic tion would have been extremely hazardous. Angiincapacitating cystitis. Bright red bleeding was ography was successful not only in localizing the noted from the ilea! loop 20 days postoperatively. bleeding site but in achieving permanent hemostaThe hematocrit decreased 4 points, necessitating sis. The blood issuing from the nephrostomy tube transfusion. Renal calculi were suspected as the apparently originated from the ilea! loop anassource of bleeding and a right pyelolithotomy was tomosis and refluxed up the right ureter. performed, with removal of multiple lower pole Case 2. D. W., MGH 037 44 39, a 67-year-old renal calculi and placement of a nephrostomy white man, had complaints of frequency and tube. Postoperatively the patient continued bleed- nocturia. A prostatic nodule was found on physical examination. There was no hematuria. The patient was admitted to the hospital for transperineal Accepted for publication May 31, 1974. Supported in part by United States Public Health prostatic biopsy. Multiple Vim-Silverman needle Service Grant 2R01 AM16026-03. biopsies were obtained from the left lobe of the * Requests for reprints: Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts prostate. The patient's condition was stable upon transfer from the operating room to the recovery 02114. 1 Baum, S., Stein, G. N., Nusbaum, M. and Chait, A.: room. Four hours postoperatively the patient sufSelective arteriography in the diagnosis of hemorrhage in fered a sudden hypotensive episode and the blood the gastrointestinal tract. Radio!. Clin. N. Amer., 7: 131, pressure was unobtainable. On physical examina1969. 2 Rosch, J ., Dotter, C. T. and Antonovic, R.: Selective tion the lower abdomen was tender and tense to vasoconstrictor infusion in the management of arterio- palpation and there was an enlarged abdominal capillary gastrointestinal hemorrhage. Amer. J. Roent- girth. However, the perineum was flat with no gen., 116: 279, 1972. evidence of ecchymosis or scrotal swelling. Com3 Baum, S., Athanasoulis, C. A., Waltman, A. C. and Ring, E. J.: Gastrointestinal hemorrhage: angiographic parison with the pre-biopsy hematocrit revealed a diagnosis and control. In: Advances in Surgery. Edited by decrease from 35 to 26 per cent. After the standard J. D. Hardy and R. M. Zollinger. Chicago: Year Book measures had restored the blood pressure a cystoMedical Publishers, Inc., vol. 7, pp. 149-166, 1973. 'Baum, S. and Nusbaum, M.: The control of gastroin- gram demonstrated a tear-drop bladder with no testinal hemorrhage by selective mesenteric arterial infu- evidence of contrast extravasation. Diagnosis of sion of vasopressin. Radiology, 98: 497, 1971. massive retroperitoneal bleeding was made. Fur5 Margolies, M. N., Ring, E. J., Waltman, A. C., Kerr, ther blood replacement restored the hematocrit to W. S., Jr. and Baum, S.: Arteriography in the management of hemorrhage from pelvic fractures. New Engl. J. 33 per cent and angiography was performed. Since the biopsy was obtained from the left lobe Med., 287: 317, 1972. 89
(.0
0
r,,
s::
~ :I:
z>
0
> r,, r,, 0
(")
~
r,,
Fm. 1. Case 1-72-year-old white man with bleeding from ilea! loop. A, superior mesenteric arteriogram demonstrates extravasation (arrow) from ilea! artery branches, contiguous to ureteroileal anastomosis. B, further accumulation of extravasated contrast (arrows) is seen at bleeding site in late phase of superior mesenteric arteriogram. C, superior mesenteric arteriogram following 20-minute infusion of 0.3 units per minute of vasopressin into superior mesenteric artery demonstrates no further extravasation, indicating control of bleeding.
ANGIOGRAPHIC MANAGEMENT OF BLEEDING
91
FIG. 2. Case 2-67-year-old man with prostatic bleeding following needle biopsy. A, left hypogastric arteriogram demonstrates extravasation (curved arrow) from branches of superior vesical artery (straight arrow), as well as inferior vesical artery (double arrows). Contrast has refluxed from hypogastric artery into external iliac and femoral arteries. B, selective left hypogastric arteriogram following introduction of autologous clot demonstrates no extravasation indicating control of bleeding. Previously identified superior and inferior vesical arteries are now occluded by injected clot. C, selective right hypogastric arteriogram demonstrates same extravasation as identified previously (curved arrow), now supplied by right inferior vesical artery (straight arrow). D, following introduction of autologous clot through catheter no extravasation is identified. Inferior vesical artery has been occluded by injected clot.
92
SMITH AND ASSOCIATES
of the prostate a selective left hypogastric artery injection was initially performed, demonstrating massive contrast extravasation in the region of the prostate from branches of the left vesical arteries (fig. 2, A). The catheter was selectively advanced into the bleeding branch and embolization was carried out with 2 ml. autologous blood clot. A repeat arteriogram showed no further extravasation (fig. 2, B). The right hypogastric artery was studied, demonstrating extravasation in the same area now supplied by the right vesical artery branches (fig. 2, C). Again an autologous blood clot was introduced through the catheter, achieving hemostasis, as confirmed by the post-embolization arteriogram (fig. 2, D). The catheter was removed and the patient was returned to the recovery room. During the next several hours blood replacement requirements diminished and vital signs remained stable. The post-angiographic course was marked by a moderately severe paralytic ileus, secondary to massive retroperitoneal bleeding, as well as a moderate temperature elevation that responded to ampicillin. Final pathologic diagnosis on the prostatic specimen was adenocarcinoma and radiation therapy is currently being planned. Comment: This case illustrates the need for the study of the right and left hypogastric arteries in cases of pelvic bleeding because of the extensive anastomoses between the 2 sides. Rich collateralization from the external iliac and femoral, as well as the inferior mesenteric arteries, suffices to maintain viability of the bladder, despite bilateral occlusion of the vesical arteries. DISCt:SSION
Hemorrhage from the genitourinary tract following ileal loop cutaneous diversion and needle biopsy of the prostate is uncommon. Wendel and Evans reported 2 cases of major pelvic hematoma following transperineal prostatic needle biopsy, which responded to conservative management, although extensive perivesical scarring created serious technical problems at the operation a month later. 6 Their cases represented the first such reported complication in the English literature. Likewise, bleeding from the ilea! loop is rare, occurring in 1.5 per cent of cases in a review of 244 cutaneous diversions. 7 When such bleeding does occur it often subsides on conservative management. However, when hemorrhage continues angiographic methods of localizing and controlling the site of bleeding may be a valuable alternative to an operation. Hemostasis can be achieved angiographically by s e v ; ~ m : : l r e s . Tbe Tntra~arfena"CinfuSIOn oT· a vasoconstricfcir;--pr1rnarily posterior
-·-~- • ----·--•·" ---.v--•- • --'>•·------··-·-
6 Wendel, R. G. and Evans, A. T.: Complications of punch biopsy of the prostate gland. J. Urol., 97: 122, 1967. 7 Harbach, L. B., Hall, R. L .. Cockett, A. T. K., Kaufman, J. J., Martin, D. C., Mims, M. M. and Goodwin, W. E.: Ilea! loop cutaneous urinary diversion: a critical review. J. Urol., 105: 511, 1971.
P.rtuitary extract, ha_l'>J:>.~~12_j;J:!~!:!.lill_fil_fillllLQJ;1J:;h in g~qintestinal hemorrhage, when_ the calib
encour~ed.
However, drug infusions have been unsatisfactory in the control of bleeding from major arteries, since the large caliber of the bleeding vessels often precludes adequate vasoconstriction. Furthermore, pelvic bleeding is often bilateral and would require drug infusion into the left and right hypogastric arteries. In such cases, various mechanical means of obturating a bleeding vessel have been reported, including embolization with gelfoam, muscle or autologous clot. 8 Bookstein and Goldstein rer_e.:otly reported successful c~~trolci(Q.ost-traumatic rei~al hemorr1iage by transcatheter introduction of autologous dot." . . . ---·-··. . §_iEiian:t.iaL.exp.erie=...has...JJ.illlL...he_e_12_1!_<_:<_:_1c1111 u - " lated indicating that embolization with autologous/ /
~~~~~~~1~~~~~~~!11!f~~i:e~:1f~:~!};6I1~r',
pelvi(:_ hemo.r..rhage. Major pelvic ves;el;- can ~ oc~luded without untoward sequela lO and immediate hemostasis can be achieved without the necessity of leaving an indwelling arterial catheter in place. Autologous blood is sterile, readily available and does not represent a foreign body. The catheter sh_o.1lld bwlaced as near aJ,_possible to.i~ lifofilling.£i.te._t.o..ac.cmnpli.s.h_s.eJe ctiy.e_ em boliza tion: Interru_2t_i_g_g the vessel too proximaUy will encourage collat~ra]s to blJ>aSS the site of ocdusion aria conti_!lllJLt.Q.S11ppIY::ih.a1.le.eding_site. ··A,Ii:h;;;:;-gh we recognize the relative rarity of these specific bleeding problems we believe the angiographic methods will have application in managing the more commonly encountered types of bleeding seen following a renal or prostatic operation. SUMMARY
Angiographic methods were applied to control bleeding in 2 patients following genitourinary tract operations. In 1 patient hemorrhage into the prostatic bed after needle biopsy of the prostate was controlled with embolic occlusion of branches of the hypogastric arteries. In the second patient bleeding from the ileum following ileal loop cutaneous diversion was controlled with the infusion of vasopressin into the superior mesenteric artery. Therefore, angiography offers an attractive alternative to an operation in the management of postoperative hemorrhage from the genitourinary tract. 8 Rosch, J., Dotter, C. T. and Brown, M. J.: Selective arterial embolization: a new method for control of acute gastrointestinal bleeding. Radiology, 102: 303, 1972. 9 Bookstein, J. J. and Goldstein, H. M.: Successful management of postbiopsy arteriovenous fistula with selective arterial embolization. Radiology, 109: 5:35, 1973. 10 Binder, S. S. and Mitchell, G. A.: The control of intractable pelvic hemorrhage by ligation of the hypogastric artery. South. Med. ,J., 53: 837, 1960.