RECURRENT BLEEDING FROM INTERCOSTAL ARTERIAL PSEUDOANEURYSM AFTER RETROPERITONEAL LAPAROSCOPIC RADICAL NEPHRECTOMY R. BLUEBOND-LANGNER, P. A. PINTO, F. J. KIM, T. HSU, AND T. W. JARRETT ABSTRACT We report a case of a 59-year-old man with recurrent bleeding after retroperitoneal laparoscopic nephrec- tomy. Computed tomography and Doppler ultrasonography confirmed an intercostal artery pseudoaneu- rysm as the source. Angiography 1 month later demonstrated resolution after conservative management. UROLOGY 60: 1111i–1111ii, 2002. © 2002, Elsevier Science Inc. A 59-year-old man with renal failure who re- ceived hemodialysis presented with gross he- maturia. Computed tomography (CT) of the abdo- men and pelvis with intravenous contrast showed a 3-cm enhancing lesion in the right kidney. He un- derwent retroperitoneal laparoscopic radical ne- phrectomy. The pathologic examination revealed Fuhrman grade II renal cell carcinoma. A CT scan on postoperative day 3 because of a decreasing hematocrit demonstrated a hematoma in the nephrectomy bed. The patient received 2 U of packed red blood cells and was discharged home on postoperative day 6. After hemodialysis, on postoperative day 17, the patient presented with acute flank pain. Angiography of the aorta with attention to the proximal segments was negative. He was transfused a total of 3 U of packed red blood cells and discharged on hospital day 7. The patient subsequently had recurrent episodes of flank pain and decreasing hematocrit. A CT scan 3 months postoperatively showed a decrease in the prior retroperitoneal hematoma and, surprisingly, a new collection in the posterior abdominal wall suspicious for an intercostal arterial pseudoaneu- rysm (Fig. 1A). Doppler ultrasonography showed a biphasic vascular structure, confirming the diag- nosis (Fig. 1B). His bleeding stopped, and elective angiography with embolization was scheduled. Follow-up studies, however, showed complete res- olution of the pseudoaneurysm (Fig. 2). At 8 months, CT demonstrated resolution of the hema- toma and the absence of the pseudoaneurysm. COMMENT A pseudoaneurysm is a collection of blood out- side the vessel lumen that communicates with the flowing blood. 1 Unlike a true aneurysm, which contains all three elements of the vessel wall, a pseudoaneurysm lining includes only the tunica intima and media. Many result from trauma, sur- gery, catheterization, or venipuncture. The diagnosis can be made with CT scan, Doppler ultrasonogra- phy, or angiography. Often, no intervention is re- quired; however, embolization is a practical option to stop significant bleeding and prevent further ep- isodes. 2 To our knowledge, intercostal artery pseudoan- eurysm as a complication of laparoscopic nephrec- tomy has not been reported. Three trocars were placed in the anterior, mid, and posterior axillary lines. Retroperitoneal access was initially obtained through a 1.5-cm incision at the tip of the 12th rib. It is likely the injury occurred at this site. A prior case of an intercostal artery pseudoaneurysm after percutaneous transhepatic cholangiography 2 was recognized and treated with early transarterial em- bolization rather than observation. Our patient presented with recurrent bleeding because of a pseudoaneurysm of an intercostal ar- tery. The initial diagnosis was missed on early an- From the James Buchanan Brady Urological Institute, Johns Hop- kins Medical Institutions, Baltimore, Maryland Address for correspondence: Thomas W. Jarrett, M.D., Divi- sion of Endourology, James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Jefferson Building, Suite 161, Baltimore, MD 21287 Submitted: May 3, 2002, accepted (with revisions): August 8, 2002 CASE REPORT © 2002, ELSEVIER SCIENCE INC. 0090-4295/02/$22.00 ALL RIGHTS RESERVED PII S0090-4295(02)01998-2 1111i