An uncommon case of antegrade stent causing serious persistent haematuria

Graphical abstract

Highlights

• •Severe haematuria following PCN and antegrade stent insertion.
• •The severe bleeding recorded in this case could not have been attributed to the stent.
• •CT renal angiogram organised early to exclude and renal vascular injury following PCN and antegrade stent insertion.
• •CT renal angiogram revealed stent was in the nephrostomy tract.
• •Change of stent settled haematuria.

Abstract

Introduction

Transient minor bleeding after nephrostomy tube placement is very common, occurring in up to 95% of cases. Often this is due to small vessel or venous bleeding. Severe post procedure bleeding requiring transfusion or other intervention is RARE.

Presentation of case

A case of a 79 year old man, who had antegrade stent insertion for 10 mm left upper ureteric stone. He was alright for up to one week but developed severe haemturia requiring three way catheter. Catheter was blocking regularly and needed to go to theatre for bladder washout. No source of bleeding was found in bladder. CT renal angiogram revealed his stent has migrated into the nephrostomy tract. He was taken to theatre and had his stent changed. His haematuria settled.

Discussion

The severe bleeding recorded in this case could not have been attributed to the stent, though the initial bleeding following the procedure has settled it seemed likely to blame vascular injury following PCN as the cause of bleeding. Subsequent CT scan was able to point at the right source of bleeding.

Conclusion

All possibilities should be considered when presented with a case severe bleeding following antegrade stent insertion.

1. Case presentation

A 79 year old gentleman, who presented as an emergency with urosepsis and abnormal renal function, suggestive of acute kidney injury. Initial USS KUB showed left side moderate hydronephrosis and subsequent CT KUB was arranged which revealed 10 mm left upper ureteric stone with moderate hydronephrosis. Initial attempt for retrograde stent failed, at this point discovered to have two large bladder stones. Subsequently, went on to have nephrostomy and antegrade stent insertion. Treated with IV antibiotics and fluids, he made good recovery with renal function back to normal. His nephrostomy tube was removed after satisfactory nephrostogram and his urine was clear of any bleeding.

His discharge was delayed as he developed chest symptoms suggestive of COPD. While this was being treated, he developed frank haematuria about a week later. Initially, thought to be due to sepsis as WBC and CRP were rising and renal function worsening. IV antibiotics and fluids were started and also three way catheter put in place for irrigation. Despite these measures, the bleeding continued catheter getting blocked inspite of frequent bladder washouts. He needed transfusion of three units of blood.

He was taken to theatre and lots of clots were washed out and no bleeding sources in the bladder were identified. Due to the large amount of bleeding found, it is thought that there is a possibility of renal vascular injury. A CT renal angiogram was arranged with a view to proceed to emobolization should source of bleeding is identified. CT scan showed abornmally positioned stent, with the tip having passed through the previous nephrostomy tract, abutting the outer cortex of the kidney.

He was taken to theatre and had his stent removed and a new stent put in place under fluoroscopy. His bleeding settled overnight and his catheter was subsequently removed. Inflammatory markers and renal function returned to normal and was discharged with further plans to treat ureteric and bladder stones.

2. Discussion

Percutaneous nephrostomy (PCN) and antegrade stent insertion in urological emergencies can be life saving and allows time for planning of treatment at a later date under controlled situation. Relief of urinary obstruction represents the most common indication for PCN placement representing 85–90% of patients in several large series [1]. In one large series, 26% of all nephrostomy tubes were placed because of calculus disease and 61% due to malignancy [2]. Other reasons for PCN include: diagnostic testing, access for therapeutic interventions, and urinary diversion.

Most of the time they usually go quite well, with little patient complications. Most series report combined major and minor complication rates of PCN placement of ∼10% with a mortality rate of 0.05–0.3% [1,3]. The major complications can be divided into three types, injury to adjacent structures, severe bleeding, or severe infection/sepsis.

Transient minor bleeding after nephrostomy tube placement is very common, occurring in up to 95% of cases. Often this is due to small vessel or venous bleeding. Severe post procedure bleeding requiring transfusion or other intervention is reported to occur in 1–4% of patients [1]. This can take the form of hematuria or retroperitoneal bleeding. Persistent gross hematuria more than 3–5 days after PCN placement may indicate severe arterial injury requiring treatment.

The treatment of suspected arterial injury consists of a renal angiogram followed by subselective coil embolization of disrupted vascular branches. Venous bleeding can also be the source. This can sometimes be treated by tamponade with a larger diameter nephrostomy tube or balloon catheter.

The severe bleeding recorded in this case could not have been attributed to the stent, though the initial bleeding following the procedure has settled it seemed likely to blame vascular injury following PCN as the cause of bleeding. Subsequent CT scan was able to point at the right source of bleeding.

3. Conclusion

I have reported an uncommon case of ureteric stent mimicking renal vascular complication following a percutaneous nephrostomy. It is recognised that serious complications from PCN are rare, when they occur should be recognised early and proper investigations and management put in place.