Surgical management of urothelial cancer in a cirrhotic patient after partial splenic embolisation

A 50-year-old male patient with known liver cirrhosis due to chronic hepatitis B virus infection was referred to our service for partial splenic embolisation. The patient was diagnosed 1 month earlier with urothelial cancer. The biological assessment revealed severe thrombocytopaenia of 44,000 platelets/mm3. The past medical history showed only viral liver cirrhosis in a compensated state. Given the significant bleeding risk, the multidisciplinary team decided that the patient was not a candidate for surgical nephrectomy, and partial splenic embolisation was proposed as a minimally invasive procedure in an attempt to restore the peripheral blood cell count back to normal. At admission to the gastroenterology department the patient had 50,000 platelets/mm3 and the creatinine level was 1.13 mg% – modification of diet in renal disease (MDRD) = 76 ml/min/1.73 m2. Upper digestive endoscopy revealed oesophageal varices of grade I–II. Computed tomography scan of the abdomen showed marked splenomegaly in addition to cirrhosis-like hepatomegaly, portal hypertension, minimal pelvic ascites, and urothelial left kidney tumour (Figure 1).
The patient gave consent to perform the procedure after being informed of its risks and benefits. The right common femoral artery was accessed, and the initial abdominal aortogram showed the origin of the celiac trunk (Figure 2). Then the splenic artery was catheterised using a 6 Fr catheter (Boston Scientific), and a splenic angiogram showed the spleen vascularisation (Figure 3). The catheter was then advanced through the lower polar splenic artery. Angiography confirmed the location in the distal splenic artery (Figure 4). Partial embolisation of the lower third of the spleen was achieved using haemostatic sponge (Sponjel). Follow-up angiogram showed complete stasis in the embolised segments of the spleen (Figure 5).
Continued follow-up of the patient over a period of 14 days showed gradual improvement of peripheral blood cell count, which returned back to normal levels (platelet count from 44,000 to 156,000 platelets/mm3) (Figure 6). Follow-up abdominal ultrasound performed 2 days after the procedure revealed a hypodense area localised at the inferior spleen pole, corresponding to the splenic infarction that resulted from the previous embolisation and also a hypoechogenic area in the left kidney. The patient was transferred to the urology department 14 days after the procedure, in order to determine the opportunity for...


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