Delayed post-laparoscopic partial nephrectomy bleeding rare, tough to predict

Orlando, FL-It is a classic good news-bad news finding. The good news from a recent study is that delayed hemorrhage following laparoscopic partial nephrectomy (LPN) is a rare event, occurring in less than 2% of the patients treated by the procedure at institutions such as the North Shore-Long Island Jewish Medical Center, New Hyde Park, NY. The bad news is that 2% constitutes too few patients to identify any preoperative or perioperative factors that might increase the risks of delayed hemorrhage.

A second valuable finding of the study is that angiography is a reliable tool for determining the origins of hemorrhage. It identified the source of bleeding in all patients who presented with delayed hemorrhage, which the authors defined as bleeding requiring transfusion after discharge from the hospital.

Researchers studied only those patients who required transfusions after discharge, all of whom had uncomplicated hospitalization courses.

Although hemorrhage is a recognized complication of LPN, occurring in up to 10% of patients nationwide, according to the literature, characteristics of delayed hemorrhage are not well described, no doubt owing to its relative infrequency, Seideman explained. She said that a careful literature search turned up no studies similar to the one she presented at the 2008 AUA annual meeting.

The study team reviewed records from 417 LPNs conducted between 1994 and 2007 and found only eight patients who presented with delayed hemorrhage. This was defined as bleeding occurring more than a week following release from the hospital. Indications for intervention upon return were persistent hematuria despite conservative management, requirement for transfusion, and signs or symptoms of hypovolemia.

These eight patients presented with these symptoms between 9 and 29 days (mean, 18 days) postoperatively, and seven of the eight patients presented with gross hematuria.

"One patient presented with clear yellow urine, but constitutional symptoms such as malaise, nausea, and diarrhea, and a systolic blood pressure of 90 [mm Hg] and a pulse of 92. The patient showed a small volume of fluid in the abdomen, was treated conservatively, and responded well to IV fluids. However, the patient re-presented with anemia. Angiographic imaging showed findings consistent with hemoperitoneum," Seideman said.

"Angiography revealed the etiology in all eight patients," she added. "The most common finding was pseudoaneurysm."

She noted that this appeared in six of the eight patients. Imaging also found two instances of arterial extravasation and two areteriovenous fistulas. Four of the eight patients required transfusions in response to symptoms of hypovolemia and clinically significant anemia. These patients had a hematocrit of 23.4%,compared to 32.4% of the patients who did not receive transfusions.

Seideman said all patients were treated successfully with selective angioembolization and that, following the procedure, there were no significant changes in creatinine. She noted that there was one complication: A patient developed a prolonged fever. Computed tomography revealed a ureteral obstruction due to a blood clot and calyceal urinary extravasation that resolved with stent placement.

Although the researchers were unable to identify risk factors for delayed hemorrhage, they were able to get an idea of its incidence. Seideman told Urology Times that patients now are being made aware before their surgery of the risk of delayed hemorrhage.

"We can now tell them that about 2% of our patients will experience delayed hemorrhage," she said. "We also in-form them about the risks of perioperative and postoperative hemorrhage. This doesn't discourage them from undergoing the operation. It appears to make them feel more comfortable when they understand what is going on and what the risks are."

She said the North Shore-Long Island Jewish Medical Center was continuing to study the phenomenon in the hope of identifying factors associated with increased risk of bleeding following LPN.