Renal Hematomas After Ureterolithotripsy: Report of Four Cases

Abstract

Background: Renal hematomas, although relatively rare, are potentially life-threatening complications after ureterolithotripsy.

Case Presentation: We present four cases of renal hematomas that occurred in our department during the past decade (2008–2018). Unstable vital signs, increased inflammatory markers, fever, and flank pain were the commonest postoperative findings. Two patients were treated conservatively and had an uneventful recovery, whereas one patient underwent selective arterial embolization for bleeding control. The fourth patient was diagnosed with contralateral ureteral urothelial tumor and ultimately underwent contralateral radical nephroureterectomy.

Conclusion: Application of safety measures during ureteroscopy may reduce the incidence of perirenal hematomas. Prompt diagnosis is based on a thorough clinical examination in combination with imaging to evaluate the location and extent of the hematoma.

Introduction and Background

Endoscopic treatment of ureteral stones, using semirigid ureteroscope, is an effective therapeutic option with a low complication rate. Subcapsular or perirenal hematomas are unusual after ureteroscopy/ureterolitotripsy (URL), with only two cases thus far reported in detail.^1,2 We herein present our center's experience of subcapsular and/or perirenal hematomas after semirigid URL.

Presentation of Cases

Over a 10-year period (2008–2018), four patients (two males and two females) who underwent scheduled semirigid URL for disintegration of ureteral stones developed subcapsular and/or perirenal hematomas. All patients had preoperatively been diagnosed with hydronephrosis and were stented for relief of obstruction. Operations were performed by one experienced endoscopic surgeon. Preoperative urine cultures were negative in patients 1, 2, and 3, hence these patients received cefoxitine combined with amikacin as antibiotic prophylaxis; in contrast, patient 4 had to be commenced on a different antibiotic regimen that was based on her positive culture. During URL, passive (gravity) infusion was used as the method of irrigation.

Patient 1

A 52-year-old male patient, with a 1.1 cm right ureteral stone causing a Grade 2 hydronephrosis, underwent a scheduled semirigid laser URL, which lasted for 45 minutes and was uneventful. He had a medical history of arterial hypertension and was on antihypertensives. Shortly after he was transferred to the ward, he developed hematuria and persistent acute right lumbar pain not responding to nonsteroidal anti-inflammatory agents. A CT scan, carried out 2 hours later, revealed a subcapsular/perirenal hematoma that was found to increase in size in a repeat CT scan performed 4 days later.

The patient was treated conservatively with bed rest, opioids, and intravenous fluids and antibiotics. He was also transfused with 2 U of red blood cells, as his hemoglobin dropped substantially (from 14.2 to 9 g/dL) over the next days.

The patient was discharged 14 days later with instructions to be followed regularly in clinic, which he did. Serial CT scans revealed progressive dissolution of the hematoma that resolved completely 14 months later (Fig 1A, B).

FIG. 1.

Patient 1. CT scans on the 1st post-URL day (A) and 11 months later (B), demonstrating substantial reduction of the perirenal hematoma of the right kidney. URL, ureterolithotripsy.

Patient 2

A 53-year-old female, with a history of several episodes of left renal colic but otherwise fit and well, was admitted to the department with hydronephrosis. She had had a URL for a 9-mm left ureteral stone 2 months before, during which a 6F Double-J stent was inserted; this was proved impossible to be removed in clinic under local anesthesia. Upon admission, the patient was commenced on prophylactic antibiotics and was scheduled for a semirigid ureteroscopy 48 hours later.

During the procedure, the ureteroscope was advanced parallel to the stent and several lithiasic fragments as well as encrustation of the stent were encountered and disintegrated using the pneumatic lithotripter. Also, a stricture in the upper ureter was found and overcome with great difficulty.

The stent was finally pulled out, nevertheless a few hours later, the patient complained of severe left abdominal pain and developed signs of sepsis, that is, fever (38.5°C), arterial hypotension (70/40 mmHg), tachycardia (HR 108/minute), and metabolic acidosis; consequently, she was commenced on rapid fluid infusion, inotropes, and carbapenem. A large left renal hematoma extending to the paranephric space and displacing the kidney inward was disclosed on an urgent CT scan. Over the next 4 days, the patient remained stable but had to be transfused with 2 U of red blood cells because of drop of hemoglobin to 8 g/dL. She was discharged at the 9th postoperative day with instructions.

Patient 3

A 66-year-old male, with a history of two uneventful left URLs and two sessions of extracorporeal shockwave lithotripsy (SWL) in the past, was admitted to the department for a programmed left URL. Two weeks before the admission, he had been diagnosed with left hydronephrosis apparently because of a small ureteral stone located at the level of the iliac vessels and had a Double-J stent inserted. Also, mild ureterohydronephrosis, extending down to the third part of the ureter, was noticed on the right, however, with no apparent obstructing cause.

During semirigid URL, the left ureteral stone was found to be impacted but was finally disintegrated using a holmium laser. A right ureteroscopy, performed at the same time, revealed a protruding mass in the distal ureter, which was biopsied. The patient, after returning to the ward, developed fever with chills and left lumbar pain. Laboratory studies showed an increase in white blood cells (WBCs) (20,000/mm³) and C-reactive protein (51). Also, the creatinine level was found to constantly increase over the next days (from 2.1 mg% preoperatively to 4.8 mg%).

A CT scan, carried out on the 4th postoperative day, disclosed a subcapsular hematoma of the left kidney, which was dealt with conservatively. The patient remained stable with the laboratory studies improving over the next days, but had his Double-J stent changed on the 8th postoperative day because of persistent hematuria.

A repeat CT scan 3 days later showed a substantial reduction of the hematoma. Histology of the tissue obtained from the right ureter returned as T3N0M0 urothelial carcinoma and the patient consequently underwent a right radical nephroureterectomy on the 14th post-URL day. His postoperative course was uneventful and he was discharged 12 days later with a stable creatinine level (2.5–2.7 mg%).

Patient 4

A 53-year-old woman was admitted to the department for a scheduled right URL. She had a 6-month history of recurrent right renal colic because of three ureteral calculi for which she had undergone two SWL sessions. A month before, and shortly after her last SWL, she had been admitted to the department with fever and Grade 3 hydronephrosis, which were dealt with insertion of Double-J stent and antibiotics. A CT urography performed at that time showed the patient to have three ureteral stones on the right (one 1.3 cm just below the pelviureteral junction and two 0.8 and 0.6 cm at the lower ureter).

A semirigid URL was carried out after the patient had received a 5-day course of piperacillin+tazobactam, based on the results of urine cultures. Both lower ureteral stones were completely disintegrated using the pneumatic lithotripter; however, the upper ureteral stone was only partially smashed. After 2 days, fever up to 38°C, elevated C-reactive protein (CRP), and drop in the hematocrit value were noticed and the patient was transfused with 2 U of red blood cells; also, as Pseudomonas aeruginosa and Enterococcus faecalis were isolated from urine, vancomycin was added in the treatment protocol.

A CT scan disclosed bilateral pleural effusions and a large subcapsular/perinephric hematoma on the right, which was decided to be treated conservatively. Nonetheless, 4 days later, the hematoma was found to be slightly increased on a repeat CT scan; also, severe hematuria with clots was noticed and the patient underwent an urgent renal angiography during which three bleeding vessels were occluded by embolization. Despite this, substantial hematuria remained and a repeat angiography was carried out with embolization of another two vessels (Fig. 2A, B).

FIG. 2.

(A,B) Patient 4. Angiography (12th post-URL day) with embolization of bleeding vessels.

Over the next days, the patient remained stable and, despite having a transient elevation in WBC and CRP that were dealt with appropriately, she was discharged home with instructions to be regularly followed up in clinic. A renal scintigraphy dimercaptosuccinic acid carried out 4 months later showed substantial ipsilateral loss of renal function (19% vs 81%).

Discussion

Renal and/or perirenal hematomas may rarely complicate URL and are scarcely reported in the literature^1,2; in a systematic review and meta-analysis, the incidence of post-URL perirenal hematomas, in a cohort of 8929 patients with a mean age of 53 years and a mean stone size of 1.7 cm, was found to be 0.45%.³ Etiology is uncertain, nonetheless trauma to the pelvicaliceal system during manipulation of safety guidewire or forniceal rupture because of increased intrarenal pressure has been reported to facilitate hematoma formation.^1,4

Whitehurst et al. suggested moderate to severe hydronephrosis, hypertension, prolonged operation, preoperative urinary tract infection (UTI), and thin kidney cortex to be potential predisposing factors; in contrast, evidence for body mass index was conflicting.³ SWL and renal operation have also been reported as predisposing factors.⁴

Formation of hematomas with the use of the pneumatic lithotripter has scarcely been described.^1,2 Consequently, safety measures for prevention of this uncommon complication would include effective preoperative treatment of UTIs, control of hypertension, intraoperative monitoring of the guidewire tip, avoidance of sudden increases and maintenance of a constant decreased intrarenal pressure during the procedure, and placement of a Double-J stent after ureteroscopy.^3,4 Lowering the pressure can be achieved by minimal irrigation and/or regular cessation of the operation to open the tap for pressure relief.⁴

In our series, none of the patients was overweight or obese and only one had a history of hypertension; in addition, apart from the female patient with the encrustated stent, they were already stented and hence their hydronephrosis had been resolved. Gravity infusion was used in all cases to keep intrarenal pressure low during the procedures. Operative time was slightly prolonged (90 minutes) only in patient 4, because of the encountered difficulties in totally disintegrating all three stones on the right. This female patient was the only one to ultimately experience compromization of the right renal unit function. Pneumatic lithotripter was used in two of our patients.

Management of subcapsular/perirenal hematomas is mainly conservative; however, a substantial number of cases may have to undergo additional percutaneous or surgical procedures.

In the meta-analysis of Whitehurst et al., 55% of patients were treated conservatively, whereas 27.5% underwent percutaneous drainage of the hematoma and a further 17.5% was subjected to some form of surgical intervention (angiography, surgical clot removal, nephrostomy, surgical correction of malpositioned stent, and nephrectomy). In this meta-analysis, there was one death reported.³ Three of our patients were treated conservatively with bed rest, intravenous fluids, and antibiotics, and had a favorable outcome. In contrast, angiography and selective embolization of bleeding vessels were necessary in one patient to control intractable hematuria.

Conclusion

Renal hematomas, although rare, should be considered a severe and sometimes life-threatening complication after URL. Application of safety measures during the operation may reduce the incidence of the event. Prompt diagnosis is based on a thorough clinical examination in combination with imaging to evaluate the location and extent of the hematoma. Most cases can be managed conservatively, with only a few cases necessitating some form of surgical intervention.

Abbreviations Used

CRP

C-reactive protein

CT

computed tomography

SWL

extracorporeal shockwave lithotripsy

URL

ureterolithotripsy

UTI

urinary tract infection

WBC

white blood cell

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received.

Cite this article as: Mitsogiannis IC, Kostakopoulos NA, Lazarou L, Deliveliotis K, Karagiotis T, Deliveliotis C (2020) Renal hematomas after ureterolithotripsy: Report of four cases, Journal of Endourology Case Reports 6:1, 26–29, DOI: 10.1089/cren.2019.0103.