Pseudoaneurysm secondary to transvesical prostatectomy.

Pseudoaneurysms associated with the internal pudendal artery is rare and may occur as a complication of prostatic surgery or or pelvic trauma. We present images of the first case in literature of an isolated pseudoaneurysm secondary to transvesical prostatic adenomectomy, which was successfully treated by transarterial coil embolization. This complication can be difficult to diagnose, manage, and cause significant postoperative bleeding. Management requires as a multidisciplinary approach.

INTRODUCTION

Pseudoaneurysms and arteriovenous fistulas (AVF) associated with the internal pudendal artery are unusual.[123] We report the first case of recurrent haematuria in postoperative period caused by internal pudendal artery pseudoaneurysm with AVF secondary to transvesical prostatic adenomectomy (TPA).

CASE REPORT

A 64-year-old male patient underwent TPA for a 155mL prostate. There were no intraoperative complications. On the 5th postoperative day, after removal of the foley catheter, the patient presented recurrent episodes of gross hematuria with a bladder full of clots and anemia that required blood transfusion. Cystoscopy for clot evacuation showed a haematoma caused by arterial bleeding from the left side of the prostatic fossa. The patient underwent computed tomography (CT), which revealed a 2.2 × 1.5 cm hypervascular lesion matching the density of the adjacent iliac vessels on the left side of the residual prostate gland [Figure 1]. The patient was referred to our interventional radiology unit for selective arteriography. A 4 French (Fr) angiographic catheter was inserted via the left femoral artery and left internal iliac arteriography showed a pseudoaneurysm approximately 2 cm in size with venous filling during the early arterial phase, located at the distal portion of the left internal pudendal artery suggesting an AVF [Figure 2a]. The left internal pudendal artery was catheterized super selectively with a 2.7 Fr microcatheter and embolization was carried out using two micro coils 3 mm × 40 mm [Figure 2b]. After the procedure, the patient had no hematuria and was discharged after 3 days. At 6 months follow-up he had no hematuria, infection or ischemic complications.

Figure 1

Pelvic computed tomography sagittal image with contrast shows a 2.2 cm × 1.5 cm hypervascular component matching the density of the adjacent iliac vessels (yellow arrow) near the left residual prostate gland

Figure 2

(a) Selective left internal iliac artery injection revealed a pseudoaneurysm (yellow arrow) associated with arteriovenous fistulas (venous filling in the early arterial phase); (b) The left internal pudendal artery was catheterized (2.7 French microcatheter) and embolized with microcoils (yellow arrow)

DISCUSSION

A pseudoaneurysm is a single layer of fibrous tissue shaped like a sac containing a turbulent blood flow.[4] Arterial pseudoaneurysms are formed after disruption in the vascular wall continuity and may be caused by trauma, inflammation, cancers, and iatrogenic causes. The main iatrogenic causes are access for endovascular procedures, surgical procedures, and biopsies. The major complications of pseudoaneurysms are rupture, embolization of a thrombus, infection, pain, and compression of adjacent structures.[5] We identified 6 published cases in the literature describing the management of this rare complication after radical prostatectomy or transurethral resection of the prostate.[145] Most of these cases present as late haematuria. The initial diagnosis is frequently made by CT. However, angiography is the reference standard for diagnosis and has the advantage of allowing simultanneosu therapeutic intervention.[5]

This case report confirms that trans-arterial embolization is an efficient way of managing postoperative bleeding due to prostatic surgery, preventing further surgical exploration.[4]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.