A 59-year-old female patient who presented with flank pain and spot hematuria was referred to our hospital. US revealed some wide lacunar areas in he right kiney and a thin cortex. Three-dimensional computed tomography (3D-CT) revealed a giant right renal arteriovenous malformation (AVM). My question is what is the best treatment?
It˜s not an ease case but i would think in doing embolization first and than open surgery after reducing AVM.You have any others pictures?
I need more images to better assess renal vascularization (number, location and diameter of renal artery and vein). Than lap nephrectomy
I do agree, Than after angio study you can plan your better acess ,also embolizaton with coils and onix could help you in shrink the AVM.
Hello dear Colleagues, finally I had the 3D reconstruction of the case. Here you can find some details. I'm not sure that a lap approach could be safe enough .... anyway it depends on the personal skills
The 3D reconstruction showed that you will need both, the urologist and interventional radiologist or Vascular Surgeon working in a multidisciplinary team to determine whether a less invasive percutaneous approach first is necessary and may be in two weeks , surgery. The embolization could be done with microespheres to the distal circulation in a superseletive vascular access . Coils /onix could help you to decrease the MAV.
Good idea to embolize the artery and wait few weeks. After that I would perform a laparoscopic exploration. If the MAV is included in the Gerota's, the procedure may results as a standard radical nephrectomy. The artery seems to be unique and long enought to allow a GIA passage. My concern is the approache in case of a lap procedure: transperitoneal would more safe for a better access to major vessels, but maybe dangerous for the mobilization of the lower pole of the kidney. Retro peritoneal would be preferable for a direct access to the renal artery but taff in case of vascular complication. A multidisciplinary team in the OR is mandatory
I think that`s convencional transperitoneal access will be better ,that`s a rude MAV,than it is not in ease surgery. Do not forget that you can do embolization 2 or tree times before surgery.
Suggest coil occlude the proximal renal artery as there does appear to be an arterial aneurysm as part of the abnormality on CT and then wait 24 hours and operate. During the open surgery gain proximal control of the renal artery first if at all possible. NB there may be inflammation around the kidney secondary to this pathology so it is not straightforward to go straight to open surgery (unless you have very experienced operators).
Hello Dear Colleagues!
I'm happy to had received all these comments. I've planned an open nephectomy and we did this surgery safely (no blood tranfusions), quickly, directly togheter with vascular surgeon. The patient came back home four days after surgery, without impairement of renal function. I liked a lap approach but the prudence and the principle of the safety won!
Dear Luca Cindolo,
Nice work !
Congratulations !
Best regards,
Paulo Ocke Reis
single renal artery seen by angiography, make the surgery easier to be done, I agree with transperitoneal Approach.
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