Intraluminal hematoma of an ileal conduit causing postrenal acute kidney injury 14 years after radical cystectomy: A case report

Abstract

A 77-year-old man developed gross hematuria and postrenal acute kidney injury 14 years after radical cystectomy with ileal conduit diversion. Computed tomography demonstrated intraluminal hematoma and bilateral hydronephrosis without active extravasation. Angiodysplasia exacerbated by anticoagulant therapy was considered a possible etiology. Ileal conduit decompression improved urine output and renal function, and endoscopy revealed no active bleeding or tumors. Because the patient remained clinically stable, conservative management was successfully performed without invasive intervention. This case highlights that intraluminal hematoma can cause conduit obstruction and postrenal acute kidney injury after urinary diversion.

Highlights

• •Intraluminal hematoma caused ileal conduit obstruction.
• •Hematuria resulted in postrenal acute kidney injury.
• •Angiodysplasia exacerbated by anticoagulation was suspected.
• •Conservative management was successful.
• •Careful evaluation avoided invasive intervention.

1. Introduction

Ileal conduit urinary diversion is widely used after radical cystectomy, but it is associated with early and late complications, including urinary obstruction, fistula formation, conduit stenosis, and parastomal hernia 1, 2, 3. Hematuria and urinary obstruction are clinically important because their delayed recognition may result in acute renal function decline. Common causes of postrenal acute kidney injury after ileal conduit diversion include ureteroenteric anastomotic stricture, stomal stenosis, conduit kinking, or volvulus 4, 5, 6.

Bleeding from an ileal conduit is an uncommon but potentially serious complication. Reported etiologies include tumor recurrence, inflammation, stomal varices, and vascular abnormalities, such as ureteroarterial fistula or arterial pseudoaneurysm.^7,8 In addition, intermittent bleeding from unidentified mucosal or vascular lesions, including angiodysplasia, may complicate diagnosis because imaging studies do not always demonstrate active extravasation.^9,10

In clinical practice, determining the optimal management strategy can be challenging when the bleeding source cannot be definitively identified because hemorrhage may be intermittent and imaging studies may not demonstrate active extravasation. Here, we report a case of postrenal acute kidney injury caused by intraluminal hematoma of an ileal conduit occurring 14 years after radical cystectomy, in which the precise bleeding source remained uncertain, but careful imaging and endoscopic evaluation supported successful conservative management without invasive intervention.

2. Case presentation

A 77-year-old man presented with gross hematuria and decreased urine output from his ileal conduit. He had a history of bladder cancer and had undergone radical cystectomy with ileal conduit urinary diversion 14 years earlier. He also had chronic atrial fibrillation, for which he had been receiving warfarin as anticoagulant therapy. Pathological examination at the time of cystectomy revealed urothelial carcinoma (pT1N0M0, grade 3). The patient was followed at our institution without evidence of recurrence.

Approximately 2 weeks before his presentation, the patient noticed new-onset gross hematuria. He initially visited the emergency department, where contrast-enhanced computed tomography revealed early-phase contrast enhancement surrounding a calcified intraluminal lesion, consistent with intraluminal hematoma (Fig. 1A and B). His symptoms were relatively mild and no hydronephrosis was observed on the initial computed tomography. Therefore, he was discharged home with a plan for outpatient follow-up. However, he returned shortly after because his urine output from the ileal conduit remained markedly decreased. Laboratory evaluation demonstrated acute kidney injury, with the serum creatinine concentration increasing from approximately 0.9 mg/dL to 2.5 mg/dL. At that time, the PT-INR was elevated to 3.13. Urinalysis revealed 1–4 white blood cells per high-power field without pyuria. Computed tomography demonstrated bilateral hydronephrosis and intraluminal hematoma within the ileal conduit, confirming postrenal obstruction (Fig. 1C and D). A retrograde contrast study through the stoma was performed, followed by guidewire-assisted insertion of a 12-Fr nephrostomy catheter into the ileal conduit. Blood clots were evacuated, and no active bleeding was identified. Following catheter placement, urine output increased promptly. Although the serum creatinine concentration increased to 3.0 mg/dL on the morning after admission, urine output remained adequate and hydronephrosis did not worsen. Therefore, the patient was monitored without additional intervention. His renal function gradually improved and returned to near baseline (Fig. 2). Warfarin therapy was temporarily discontinued, and PT-INR gradually decreased to the therapeutic range during follow-up (Fig. 2). The hemoglobin concentration remained stable throughout the clinical course without the need for blood transfusion, endoscopic intervention, or transcatheter arterial embolization (Fig. 2). Two days later, endoscopic evaluation of the ileal conduit was performed. Endoscopic examination revealed intraluminal hematomas adjacent to a calcified lesion, which was located approximately 5 cm from the stoma and distant from the ureteroileal anastomosis (Fig. 3A). Several erythematous areas suspected to represent prior bleeding sites were observed; however, no definite bleeding source or tumorous lesions were identified (Fig. 3B). Urine cytology was also negative for malignant cells.

Fig. 1.

Computed tomography findings.

(A) Plain computed tomography obtained at the initial presentation shows a calcified lesion within the ileal conduit (arrow).

(B) Contrast-enhanced computed tomography demonstrates early-phase contrast enhancement surrounding a calcified intraluminal lesion (arrow).

(C) Plain computed tomography obtained at re-presentation reveals bilateral hydronephrosis.

(D) Plain computed tomography at re-presentation shows accumulation of intraluminal hematoma within the ileal conduit (arrowheads). Residual contrast material from the previous contrast-enhanced CT examination is also visible within the conduit.

Fig. 2.

Clinical course of renal function and hemoglobin concentration.

Changes in serum creatinine, PT-INR, and hemoglobin concentrations over time are shown. The horizontal axis represents days after presentation, with Day 0 indicating the day of initial presentation to the emergency department.

Cr, creatinine; Hb, hemoglobin.

Fig. 3.

Endoscopic findings of the ileal conduit.

(A) Endoscopic view of the ileal conduit demonstrates a calcified lesion protruding into the conduit lumen (arrow), with surrounding intraluminal hematomas.

(B) A magnified view of the same area shows clusters of small hematomas.

Follow-up imaging performed several weeks later demonstrated resolution of bilateral hydronephrosis and no evidence of recurrent intraluminal hematoma. The patient remained clinically stable with preserved renal function during subsequent follow-up.

3. Discussion

Bleeding from an ileal conduit is an uncommon complication, but it warrants careful evaluation because it may be associated with underlying vascular abnormalities, including ureteroarterial fistula or arterial pseudoaneurysm.^8,11 Among these, ureteroarterial fistula is particularly important because delayed diagnosis can result in life-threatening hemorrhage. Reported risk factors include prior pelvic surgery, chronic inflammation, radiation therapy, and long-standing urinary diversion.¹²

Contrast-enhanced computed tomography and angiography are commonly used; however, active extravasation is not always detected, particularly in cases of intermittent bleeding.^11,13 Therefore, clinical decision making often relies on a combination of imaging, endoscopic findings, and the clinical course.

Endoscopic hemostasis via an ileal conduit has been reported as a treatment option for conduit-related bleeding.¹⁴ It may be effective when a localized bleeding source is clearly identified within the conduit lumen. However, when vascular abnormalities such as ureteroarterial fistula are suspected, transcatheter arterial embolization or surgical intervention is often required.^15,16 To our knowledge, angiodysplasia has rarely been discussed as a potential bleeding source in ileal conduit patients. However, it is an important cause of small-bowel bleeding in older patients and may present with intermittent hemorrhage without definite active bleeding on imaging or endoscopy.^9,10

In the present case, contrast-enhanced computed tomography demonstrated intraluminal hematoma and enhancement surrounding a calcified lesion, suggesting a possible vascular etiology. However, no definitive findings of recurrence, ureteroarterial fistula or active extravasation were identified. Angiodysplasia was considered a possible explanation for the bleeding because intermittent bleeding may occur without definite active bleeding on imaging or endoscopy, particularly in older patients receiving anticoagulant therapy. The American College of Gastroenterology clinical guideline also notes that anticoagulant therapy may increase the risk of bleeding from small-bowel vascular lesions, including angiodysplasia.⁹ Although local inflammation cannot be completely excluded, there was no evidence of active urinary tract infection, including pyuria. The calcified lesion may have contributed to secondary mucosal irritation or bleeding. However, definitive characterization was not possible because the lesion was not retrieved.

Conservative management was selected because the patient remained hemodynamically stable, hemoglobin levels remained stable, renal function gradually improved after decompression, and neither imaging nor endoscopy demonstrated active bleeding. Nevertheless, close follow-up and readiness for endoscopic hemostasis or transcatheter arterial embolization, if clinically necessary, were considered essential in case of recurrent hemorrhage.

4. Conclusion

Intraluminal hematoma of an ileal conduit should be considered a potential cause of postrenal acute kidney injury in patients with hematuria after urinary diversion. Although the bleeding source may be difficult to identify, angiodysplasia associated with anticoagulant therapy may be a plausible etiology. In stable patients without active bleeding, conservative management may be an appropriate initial approach.

Informed consent

Written informed consent for publication of this case report and accompanying images was obtained from the patient.

Approval of the research protocol

This study was approved by the institutional review board of Kurashiki Central Hospital.

CRediT authorship contribution statement

Kaoru Murakami: Conceptualization, Data curation, Investigation, Writing – original draft. Santa Sugihara: Data curation. Shingo Kitora: Data curation. Tomoki Ohnishi: Data curation. Iori Matsuda: Data curation. Tomoya Okuno: Investigation, Writing – review & editing. Takuro Sunada: Investigation, Writing – review & editing. Noriaki Utsunomiya: Investigation, Writing – review & editing. Akito Terai: Supervision, Writing – review & editing. Koji Inoue: Supervision, Writing – review & editing.

Conflict of interest

The authors declare no conflict of interest.