Selective arterial embolization for severe refractory hematuria of the urinary tract: a useful intervention to keep in mind

Abstract

Introduction and objective: Refractory hematuria is a challenge in the urological practice. Reasons for bleeding are bladder tumors, radiation cystitis, prostate cancer, kidney cancer, among others. Most patients have an advanced age, many comorbidities and are in palliative care due to advanced malignancies. In such patients an aggressive surgical treatment is not feasible and might be the last option of treatment. Selective arterial embolization has been described as part of the treatment of refractory hematuria, being a less invasive procedure with acceptable results in the long term follow up. Our aim is to report our experience with selective embolization as a treatment for severe refractory hematuria of the urinary tract, its success rate and side effects. Methods: Medical charts of patients that underwent selective arterial embolization as the treatment of any cause of refractroy hematuria between 2013 and 2021 in our institution were reviewed; 21 patients were identified. Standard selective arterial embolization was made by the vascular surgery division. Success was defined as the need of additional procedures after embolization. A descriptive analysis was performed, and all data was analyzed using the R software version 3.6.3. Results: A total of 21 patients underwent selective arterial embolization for refractory hematuria between 2013 and 2021. The mean age was 71.3 years old and 76.2% of patients were male. Most patients, 47.6% had advanced prostate cancer, 14.3% had advanced bladder cancer, 28.6% of patients had radiation cystitis and 9.5% had advanced renal cell carcinoma. Patients underwent embolization in a mean period of 23.6 days after admission. The rate of complications after embolization was 4.7% corresponding to one patient who had a Clavien Dindo II complication. Hematuria didn’t resolve in 61.9% of patients and 52.3% needed additional procedures, 27.2% required cystectomy due to failed embolization. The mean time to cystectomy was 29.6 days. Patients who underwent cystectomy were characterized to have radiation cystitis, prostate and bladder cancer corresponding to 4.7% respectively. The success rate of embolization was 52.3% and no post embolization syndrome was noted. Conclusion: Selective arterial embolization remains a minimally invasive option for refractory hematuria, with low rate of complications and should be part of the treatment algorithm of refractory hematuria before aggressive surgical treatment, but with a high rate of patients requiring further treatments, in up to 52.3% of cases.