Totally bloodless percutaneous renal surgery

We evaluated the feasibility of intraoperative transarterial balloon occlusion of renal artery as a novel technique to reduce blood loss in high-risk patients undergoing complex percutaneous renal surgery (PRS).

Four patients (staghorn calculi: n=2, renal pelvis TCC: n=1, ureteropelvic junction obstruction: n=1) underwent transfemoral arteriography prior to PRS. The renal artery was identified and an occluding balloon was inflated in the main renal artery. The kidney was intermittently allowed to perfuse with heparinized saline. Percutaneous renal access was obtained under fluoroscopic guidance by the urologist. Multiple tracts were established as needed to perform the procedure. The arterial occluding balloon was taken down at the completion of PRS and renal angiography repeated through the established angiographic catheter to identify any vascular injury.

Subjective improved visualization was attributed to decreased bleeding. Blood loss was less than 500 cc. Post-PRS intraoperative angiography revealed no active bleeding vessels requiring embolization. Two of the four patients presented with delayed renal hemorrhage over 10 days later requiring angiography and selective embolization with cessation of bleeding. All vascular abnormalities identified on repeat angiogram were not present on immediate post-PRS angiography.

Intraoperative balloon occlusion of renal artery is feasible and safe in patients undergoing complex PRS. Vascular control improves intraoperative endoscopic visibility while reducing intraoperative blood loss in patients at high risk for bleeding. However, these patients can still be at risk for delayed hemorrhage as iatrogenic vascular abnormalities, which can cause bleeding, can take time to develop and not be evident immediately post PRS.