LAUSR

DOI: 10.1111/iju.15153 Where technically feasible, partial nephrectomy (PN) is increasingly considered the gold standard for localized renal cell carcinomas. The advantage of nephron-sparing surgery is the preservation of renal function; however, this advantage may decrease as the risks associated with surgery increase. Renal artery pseudoaneurysms (RAPs) are a rare type of surgical complication, but they can lead to significant morbidity. Takagi revealed that 15% of patients undergoing open or laparoscopic PN who were screened by contrast-enhanced computed tomography (CECT) had RAP. However, due to the presence of patients with contraindications to contrast agents, early CECT after PN has not been widely accepted. Doppler ultrasonography (DUS), unlike CECT, is a simple, secure, and cost-effective tool. Nevertheless, its diagnostic ability to identify RAP as a screening test has only been evaluated in a small number of patients. Here, we evaluated the diagnostic ability of DUS for the detection of asymptomatic RAP using a relatively large consecutive patient cohort spanning 15 years at a single institution. After approval by our institutional review board, the clinical data of 526 patients who underwent PN and had DUS after surgery at our institution were retrospectively collected. In the current cohort, minimally invasive approaches were applied in 70% of patients. The mean tumor size was 2.9 cm, and the distribution of RENAL nephrometry score 4–6/7–9/10–12 points was 237(45%)/268(51%)/21(4%), respectively. In all cases, antiplatelet and anticoagulant medications were discontinued before surgery. Since May 2009, enoxaparin sodium has been administered in 462 cases (88%) to prevent deep venous thrombosis (DVT) after surgery on postoperative days (PODs) 1–7. The surgeries were performed according to our institutional standardized procedures by numerous urologists. Tumor resection was performed using cold ischemia in open cases, and warm ischemia in laparoscopic and robot-assisted cases. For intraoperative bleeding control, a soft coagulation device has been utilized since April 2013, regardless of surgical approach. For renal reconstruction, the inner suture was placed in all cases, and the outer parenchymal suture was omitted according to the surgeon’s discretion when soft coagulation achieved good hemostasis in cases with low complexity tumors. During renal reconstruction, tissue-sealing sheets were placed on the cut surface. In the current study, DUS was performed on PODs 5–7 as a screening test for RAP. CECT was additionally performed without delay when DUS suggested RAP (Figure 1a) or when the surgeon thought it necessary. As shown in Figure 1a, DUS as a screening test identified four cases of asymptomatic RAP. In the meantime, of the remaining 522 patients, 44 underwent exploratory CECT based on the surgeons’ decisions (in complex cases for the surgeon, where there was a concern about intraoperative vascular manipulation or the possibility of complications other than RAP), and 1 of the 44 was diagnosed with asymptomatic RAP. In the remaining 478 cases without CECT, 1 patient had a symptomatic RAP presenting as a sudden onset of hematuria (Figure 1c) after discharge. As shown in Figure 1d, all six patients with postoperative RAP had undergone PN through an open approach and without the use of soft coagulation. As listed in Figure 1e, five of the six cases of RAP were diagnosed prior to the onset of any hemorrhagic symptoms, while the sixth case was detected by CECT conducted at the onset of hematuria on POD 21. Five of these six patients diagnosed with RAP underwent angioembolization and recovered quickly. The remaining patient refused treatment but his convalescence was uneventful. According to the present findings, the sensitivity and specificity of postoperative DUS for detecting asymptomatic RAP were 67% and 100%, respectively. This suggests that DUS has a limited role as a screening test for postoperative RAP detection. Meanwhile, CECT based