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      Common iliac artery aneurysm as a cause of massive hematuria post TURBT. Case report

      case-report

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          Highlights

          • Bleeding after transurethral resection of bladder tumor is usually minimal and resolve spontaneously within days or weeks.

          • Common iliac artery aneurysm is a rare but can cause severe hematuria after cystoscopy with minimal manipulation.

          • Endovascular graft repair is minimally invasive procedure that showed excellent results in treatment of common iliac artery aneurysm.

          Abstract

          Introduction

          Transurethral resection of bladder tumor (TURBT) is an outpatient simple procedure that aims to remove bladder masses. Bleeding post TURBT is usually minimal and resolve completely within days or weeks. Massive bleeding after TURBT for small bladder masses is unusual. In this article we will report a case of unexpected massive hematuria that occurred after simple TURBT.

          Presentation of case

          A 69 patient who presented to our clinic complaining of intermittent painless gross hematuria. Ultrasound showed 1 cm bladder mass for which TURBT was done. On the 3rd post operative day the patient presented to ER complaining of massive hematuria and drop in hemoglobin. CT scan showed large left common iliac artery aneurysm which was managed using Endovascular graft repair (EVAR).

          Discussion

          Common iliac artery aneurysm is rare entity. Usually it is asymptomatic. However if it is large it can compress the perivesical vessels causing engorgement of these vessels that can manifest as massive hematuria after minimal endoscopic manipulation of the bladder.

          Conclusion

          Massive hematuria after simple TURBT is unusual for urologists. If it happens it may indicates iliac aneurysm or vascular malformation.

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          Most cited references7

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          Common iliac artery aneurysm: expansion rate and results of open surgical and endovascular repair.

          To assess expansion rate of common iliac artery aneurysms (CIAAs) and define outcomes after open repair (OR) and endovascular repair (EVAR). Clinical data of 438 patients with 715 CIAAs treated between 1986 and 2005 were retrospectively reviewed. Size, presentations, treatments, and outcomes were recorded. Kaplan-Meier method with log-rank tests and chi2 test were used for analysis. Interventions for 715 CIAAs (median, 4 cm; range, 2-13 cm) were done in 512 men (94%) and 26 women (6%); 152 (35%) had unilateral and 286 (65%) had bilateral CIAAs. Group 1 comprised 377 patients (633 CIAAs) with current or previously repaired abdominal aortic aneurysm (AAA). Group 2 comprised 15 patients (24 CIAAs) with associated internal iliac artery aneurysm (IIAA). Group 3 comprised 46 patients (58 isolated CIAAs). Median expansion rate of 104 CIAAs with at least two imaging studies was 0.29 cm/y; hypertension predicted faster expansion (0.32 vs 0.14 cm/y, P = .01). A total of 175 patients (29%) were symptomatic. The CIAA ruptured in 22 patients (5%, median, 6 cm; range, 3.8-8.5 cm), and the associated AAA ruptured in 20 (4%). Six (27%) ilioiliac or iliocaval fistulas developed. Repairs were elective in 396 patients (90%) and emergencies in 42 (10%). OR was performed in 394 patients (90%) and EVAR in 44 (10%). The groups had similar 30-day mortality: 1% for elective, 27% for emergency repairs (P or=3.5 cm seems justified. Although buttock claudication after EVAR remains a concern, results at 3 years support EVAR as a first-line treatment for most anatomically suitable patients who require CIAA repair. Patients with compressive symptoms or those with AVF should preferentially be treated with OR.
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            Isolated iliac artery aneurysms.

            Isolated aneurysms of the iliac arteries are extremely rare, comprising less than 2% of all aneurysmal disease. These aneurysms are typically seen in older men. Their natural history, although fairly indolent, carries a significant risk of rupture when the aneurysms have attained a large size. Their operative mortality is significantly higher when undertaken as an emergent versus elective procedure, underscoring the importance of early diagnosis and appropriate management. This article reviews the literature with regard to the natural history, diagnostic workup, and treatment of iliac artery aneurysms. For patients undergoing elective repair, preoperative imaging with computed tomography or magnetic resonance is advocated. Repair is recommended for good-risk patients with aneurysms larger than 3.5 cm. A working classification based on aneurysmal anatomy is provided along with an outline of the suggested open and endovascular surgical options. Results of open and endovascular strategies are summarized and follow-up recommendations are proposed.
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              Isolated iliac artery aneurysms.

              The records of 50 patients with isolated iliac artery aneurysms seen between January 1970 and January 1982 were reviewed. Forty-seven were men and three were women. Their ages ranged from 41 to 92 years (mean 69.7 years). Aneurysm diameter ranged from 2 to 20 cm (mean 4.7 cm). Seventeen patients had multiple aneurysms. Sixty-two percent of aneurysms were on the right side. Eighty-nine percent were located in the common iliac artery, 10% in the internal iliac artery, and 1% in the external iliac artery. Twelve patients had symptoms; all presented with sudden pain. Rupture occurred in seven patients; only three patients survived. Twenty-four patients had surgical treatment. Aneurysmorrhaphy with graft interposition was the most common procedure. There were no deaths during elective operation. Nineteen patients who did not undergo operation were followed from 0.25 to 11 years (mean 4.9 years). Enlargement occurred in nine patients and rupture in one. We conclude that the natural history of isolated iliac artery aneurysms is similar to that of other atherosclerotic aneurysms. Elective resection and arterial reconstruction are recommended.
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                Author and article information

                Contributors
                Journal
                Int J Surg Case Rep
                Int J Surg Case Rep
                International Journal of Surgery Case Reports
                Elsevier
                2210-2612
                11 July 2020
                2020
                11 July 2020
                : 73
                : 121-124
                Affiliations
                [a ]Department of Urology, Faculty of Medicine, Hashemite University, 13133, Zarqa, Jordan
                [b ]Department of Urology, Prince Hamzah Hospital, Amman, Jordan
                [c ]Hashemite University, Faculty of Medicine, Zarqa, Jordan
                [d ]Prince Hamzah Hospital, Amman, Jordan
                Author notes
                [* ]Corresponding author at: Department of general and special surgery/Faculty of Medicine, Hashemite University, P.O BOX 330127, Zarqa, 13133, Jordan. dr23hak@ 123456yahoo.com h.alkhatatbeh@ 123456hu.edu.jo
                Article
                S2210-2612(20)30509-5
                10.1016/j.ijscr.2020.06.105
                7365959
                2e82d4be-5454-41b5-9ddf-78cb3503bda3
                © 2020 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 11 May 2020
                : 23 June 2020
                : 25 June 2020
                Categories
                Article

                hematuria,turbt,common iliac artery aneurysm,endovascular graft repair

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