Article Text

Internal iliac artery embolisation for intractable bladder haemorrhage in the peri-operative phase

Abstract

Intractable haemorrhage from the bladder wall during transurethral resection of bladder tumour is uncommon but potentially catastrophic. Internal iliac artery embolisation is a minimally invasive technique, which is now widely practised to stop bleeding from branches of these arteries in situations including pelvic malignancy, obstetric and gynaecological emergencies and trauma. We report its successful use peri-operatively, in an unfit, elderly patient with uncontrolled bleeding.

  • embolisation
  • internal iliac artery
  • transurethral resection of bladder tumour

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Severe haemorrhage from the bladder wall during and following transurethral resection of bladder tumour (TURBT) can be life threatening. Methods of management for uncontrolled bladder bleeding include cystoscopic clot evacuation with cystodiathermy, Helmstein balloon compression,1 irrigation with alum solution,2 and instillation of formalin,3 and may finally culminate in open surgical techniques ranging from simple packing of the bladder to cystectomy and urinary diversion.4 Most patients in this situation are elderly and unfit and therefore unlikely to withstand these latter morbid procedures, especially as they require regional or general anaesthesia. Prolonged hypovolaemia and the associated massive blood transfusions that may be required are also poorly tolerated.

Internal iliac artery embolisation has been successfully used in controlling bladder haemorrhage from terminal pelvic malignancy for over 20 years.5 6 This case report illustrates its added value in the transurethral peri-operative phase.

Case report

A frail 79-year-old man with superficial, high-grade transitional cell carcinoma of the bladder (G3 pT1) kept on regular surveillance for 3 years, was admitted for transurethral resection under general anaesthesia of recurrent bladder tumour. There was no history of recent haematuria and his haemoglobin level was 10.2 g/dl. Clotting profile was normal.

Cystoscopy revealed an extensive tumour recurrence predominantly on the left side and occupying over 70% of the bladder surface area. Resection of the tumour was difficult due to excessive bleeding. After 25 minutes, he became cardiovascularly unstable and was transfused with two units of blood. It was not possible to control the bleeding endoscopically and he was deemed too unfit to undergo an open surgical procedure. Immediate transfer to the radiology suite was organised for bilateral internal iliac artery embolisation. A pelvic arteriogram was performed and the anterior division of the contralateral internal iliac artery supplying branches to the left bladder wall, was identified. This illustrated the significant vasculature supplying the tumour in the left bladder wall (figure 1). Embolisation of the anterior division of the left internal iliac artery was carried out using occlusion coils and repeated on the right side to prevent any collateral circulation (figure 2). Immediate control of the haemorrhage was achieved without complications. His haemoglobin level was 9.7 g/dl following two further units of blood and he made a full recovery. He declined any further surgical intervention, but was well at 3 months with no further haematuria.

Figure 1

Pre-embolisation subtraction arteriogram showing selective contralateral catheterisation of the left internal iliac artery with significant vascular supply to the bladder wall tumour

Figure 2

Post-embolisation subtraction arteriogram showing occlusion coils bilaterally within the anterior divisions of the internal iliac arteries

Discussion

Internal iliac artery embolisation for the palliation of severe bladder haemorrhage in inoperable malignancy results in good initial control in 80–100% of patients. The duration of control is usually life long in these terminal cases.7 Complications arising from the procedure are uncommon and include sepsis, gluteal pain, gait disturbances and, very rarely, bladder necrosis.8

Summary points

  • severe bladder haemorrhage from surgery or pelvic malignancyper se, can be difficult to control and is life threatening

  • internal iliac artery embolisation is a minimally invasive technique which successfully stems intractable haemorrhage in the majority of cases

  • early referral of suitable patients to the radiologist reduces morbidity related to prolonged hypovolaemia and associated blood transfusions and negates the need for more radical open surgical procedures

This case report illustrates the value of the procedure in the acute transurethral peri-operative phase, when haemostasis is proving to be difficult to achieve. Previous reports9 have shown the efficacy of embolisation in the early postoperative period but this was undertaken only after massive blood transfusions had been given for prolonged hypovolaemia, with the attendant risks including consumptive coagulopathy, multi-organ failure, transfusion reactions, and possible blood-borne infections. This case demonstrates that providing there is good liaison between urologist and radiologist, early peri-operative referral of an unfit patient for arterial embolisation results in minimal total blood loss and therefore avoids the morbidity of multiple blood transfusions. It also avoids the use of more invasive techniques to achieve haemostasis.

References

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