Patient population

This retrospective study enrolled consecutive patients in the Department of Urology, Urology and Nephrology Centre, Mansoura University, Mansoura, Egypt between January 2006 to June 2018. The series of patients included both local patients as well as those referred from other hospitals for immediate intervention. The inclusion criteria were as follows: (1) those patients with an indication for RAE; (2) patients with recurrent attacks of haematuria; (3 patients with a significant haemoglobin reduction. The exclusion criteria were as follows: (1) patients with non-significant renal haemorrhage; (2) patients that refused to be included in the study. The indications for RAE were classified into four main categories as follows (1) post-traumatic; (2) iatrogenic; (3) renal tumours; (4) unknown (spontaneous). Post-traumatic included both blunt and penetrating trauma. Iatrogenic included post-percutaneous nephrolithotomy (PCNL), percutaneous nephrostomy (PCN) and renal biopsy. Renal tumours included angiomyolipoma (AML) and renal cell carcinoma (RCC), both before radical surgery and as a palliative therapy. Unknown (spontaneous) cases were those that presented with significant haematuria or concealed renal bleeding with no identifiable cause (trauma, iatrogenic or tumours).

Basic laboratory, physical examinations and imaging investigations were undertaken as standard throughout the medical history. Abdominal ultrasound and Doppler ultrasound were used as the initial imaging tools using a Philips iU22 xMatrix-DS ultrasound system (Philips Healthcare, Best, the Netherlands) and Acuson-sequoia 512 (Acuson, Mountain View, CA, USA). Non-contrast computed tomography (CT) imaging was used to detect the actual size of the intrarenal or perinephric haematoma and to detect any other associated abdominal organ injury. CT angiography was performed after intravenous (i.v.) administration of 1–2 ml/kg of non-ionic contrast media (Omnipaque™ 350 mg/ml, Schering, Berlin, Germany; Optiray 320 mg/ml, USP; Iodixanol 270 ml/kg; Visipaque, GE Healthcare, Amersham, England and Ultravist, Bayer Healthcare, Berlin, Germany) using a 64-multislice helical CT scanner (Brilliance, Philips, The Netherlands) (Philips Healthcare); light-speed plus scanner (General Electric, Milwaukee, Wis). When the administration of contrast media was contraindicated, or in cases of compromised renal function, magnetic resonance angiography (MRA) was undertaken using two MRI machines; 1.5-T MRI (SIGNA Horizon, General Electric Medical Systems, Milwaukee, WIS), and 3 Tesla MRI scanner (Phillips, Ingenia 3 T, Best, The Netherlands) after using gadolinium enhanced MRA with i.v. administration of 0.2 mmol/kg of Gadolinium; DOTAREM@ 0.5 mmol/ml (Guerbet, Princeton, NJ, USA), Gadodiamide (Omniscan 0.5 mmol/mL Gd-DTPA-BMA, Gadopentetate dimeglumine (0.2 mmol/kg of Magnevist; Schering Health Care, USA).

In terms of patient management, this was initially conservative in stable patients that presented with haematuria. Conservative patient management included bed rest, serial recording of vital signs and haemoglobin levels, i.v. fluid administration and blood transfusion (if required). RAE was the next step if conservative management failed. Emergency RAE was performed for those that presented with severe renal bleeding and shock.

The study protocol was approved by the Institutional Review Board of Mansoura University, Mansoura, Egypt (no. R/18.04.218). This observational study has followed the STROBE guidelines for reporting observational studies [19]. All personal data were anonymized. All patients were counselled and provided written or verbal consent to treatment.

Angiographic technique

Vascular access was obtained via femoral artery puncture while the patient was in the supine position and under local anaesthesia. In all patients, the renal artery was selectively catheterized using a 5F cobra head catheter (Cordis, Santa Clara, CA USA) using the Seildinger technique. Non-ionic contrast media (Omnipaque™ 350 mg/ml. Schering, Berlin, Germany; Optiray 320 mg/ml, USP; Iodixanol 270 ml/kg, iopromide 300 mg/ml and Visipaque, GE Healthcare, Amersham, England) was used for arteriography in all patients.

In selective angiography, manual injection was used to administer a dose of 8–10 ml of contrast media in each injection. Digital subtraction angiography was carried out using a Toshiba Medical Angiography System (Toshiba, Tokyo, Japan) and Philips biplane flat-detector angiography system (Philips Healthcare, Best, the Netherlands) with a standard DSA program. The runs were finished after the renal vein was clearly visualized and then the same amount of saline as contrast media was administered. Sub-selective catheterization of the injured vessel was then performed using either the standard catheter or a microcatheter. Microcoils, sized 3–5 mm in diameter and 4–9 mm in length (Pushable platinum coils; Boston Scientific, Marlborough, MA, USA), were frequently used. Other materials, such as alcohol and gel foam, were also used. Post-embolization, selective angiography was undertaken while the catheter was in the main renal artery to assess for arterial occlusion by manual injection of contrast media (8–10 ml of contrast media in each injection). All patients were treated by 3 intervention uroradiologists (TD, TM and HF), with 30, 25 and 10 years of experience, respectively.

Clinical outcome

For the purposes of statistical analyses, patients that were enrolled for RAE were classified into two groups; group (A) included patients that had positive findings on angiography regardless of whether the final outcome succeeded or failed; and group (B) included patients with negative renal catheter angiography findings that were subsequently denied RAE procedures.

Statistical analyses

All statistical analyses were performed using IBM SPSS Statistics for Windows, version 21 (IBM Corp., Armonk, NY, USA). For univariate analysis, frequency and percentage were used to express nominal and ordinal variables. Mean ± SD was used to express continuous variables with normally distributed data. Median and range were used for continuous data that were not normally distributed. For bivariate analysis, χ2-test was used for nominal variables. Paired sample t test was used for normally distributed continuous data. A P value < 0.05 was considered statistically significant.

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