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Original Paper

Urol Int 2013;91:335–339 DOI: 10.1159/000350891

Renal Subcapsular Hemorrhage Complicating Ureterolithotripsy: An Unknown Complication of a Known Day-to-Day Procedure

Hongzhou Meng Shanwen Chen Geming Chen Fuqing Tan Chaojun Wang

Baihua Shen

Department of Urology, The First Affiliated Hospital of Medical College, Zhejiang University, Hangzhou , China

The rate of development of RSH complicating URSL is very low. RSH complicating URSL can occur in patients with un-derlying renal abnormalities. RSH is rarely associated with abrupt hemodynamic instability and usually not lethal. Treatment is selected based on the patient’s hemodynamic state, infection, renal function, and the feasibility of treat-ment modality. Copyright © 2013 S. Karger AG, Basel

Introduction

Transurethral ureteroscopy has undergone an im-pressive development owing to the technical improve-ments of new and smaller urological armamentarium since its clinical introduction in 1980 by Pérez-Castro and Martínez-Piñeiro [1] . Currently, ureteroscopy is a worldwide procedure with a varied number of diagnostic and therapeutic possibilities, including treatment of stones, upper urinary tract tumors, strictures, vascular malformations, placement of difficult ureteral stents, and diagnosis of filling defects or hematuria of unknown or-igin. However, the technique has complications includ-ing bleeding, false passage, ureteral perforation, urino-

Key Words

Renal subcapsular hemorrhage · Ureteroscopic lithotripsy · Percutaneous drain

Abstract

Objective: To report the incidence, risk factors, and treat-ments of renal subcapsular hemorrhage (RSH) complicat-ing ureteroscopic lithotripsy (URSL). Patients and Methods: Data from 1,918 URSLs performed between January 2004 and March 2012 were retrospectively analyzed. Patients’ data included age, sex, relevant medical history, stone side, size, and degree of hydronephrosis. Results: All 8 patients were identified as having an RSH after URSL. There were 2 males and 6 females with a mean age of 45.6 years (range 30–62 years). The patients’ relevant medical histories (renal calculi extracorporeal shock wave lithotripsy, renal opera-tion and hypertension) were statistically different between those who did and did not develop an RSH. Acute onset of flank pain is the most common symptom. Three patients with infective and large hemorrhage were managed by per-cutaneous nephrostomy in 1 and percutaneous subcapsu-lar drainage in 2. Five patients with small and uninfected hemorrhage were managed conservatively. Conclusions:

Received: November 5, 2012 Accepted after revision: March 23, 2013 Published online: July 9, 2013

InternationalisUrologia

Shanwen Chen, MD Department of Urology The First Affiliated Hospital of Medical College, Zhejiang University No. 79 Qing Chun Road, HangZhou, 310003 (China) E-Mail chensw123   @   126.com

© 2013 S. Karger AG, Basel0042–1138/13/0913–0335$38.00/0

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ma, strictures, and ureteral avulsion. In this article, we present 8 patients who developed renal subcapsular hemorrhage (RSH) complicating ureteroscopic litho-tripsy (URSL).

Patients and Methods

After institutional review board approval, we identified 1,918 consecutive patients treated with URSL for ureteric stones between January 2004 and March 2012. In all, 3 surgeons had performed the URSLs. Information was retrospectively reviewed from a data-base that recorded the hospital chart and complications of all pa-tients treated with URSL. Patients’ data included age, sex, relevant medical history, stone side, size, and degree of hydronephrosis. All the radiological examinations were reevaluated.

Stones were detected through ultrasonography, and con-firmed by either noncontrast computed tomography (CT) scan or pyelography. The degree of hydronephrosis or postoperative hematoma was determined on the basis of ultrasonography or CT findings. The stone and hematoma size were measured as the maximum diameter on the radiograph. The degree of hydrone-phrosis was mainly defined by ultrasonography and classified into four groups: no urinary system dilatation; mild dilatation of the renal pelvis; moderate and severe dilatation of the renal pelvis, and calices.

The endoscopic procedure was performed with the patients in lithotomy position under general anesthesia. A 0.032-inch J tip angiographic guide wire was used for insertion guidance of the rigid 8/9.8-Fr or 6/7.5-Fr ureteroscope (Richard Wolf GmbH, Knittlingen, Germany) without dilating the ureteric orifice under fluoroscopic monitor. Continuous irrigation (Karl Storz GmbH & Co. KG, Tuttlingen, Germany) was used to obtain and sustain a clear operative visual field with insertion of a transurethral 10-Fr catheter to lower the bladder pressure. Stone was visualized in the ureter and was blasted by laser lithotripsy (Coherent Medical Sys-tems, Santa Clara, Calif., USA). The laser energy was applied at 0.8–1.5 J and a pulse rate of 10–15 Hz. Stone fragmentation was completed to achieve a particle size of 2–3 mm. After the proce-dure, an indwelling 6-Fr double J stent was placed according to the patient’s lithotripsy and hydronephrosis, and the double J stent remained in situ for 4 weeks after surgery until patients were stone

free on follow-up radiography. Image protocols were plain ab-dominal film and ultrasonography, which were performed to con-firm RSH formation and to verify stone passage.

Results

Of the 1,918 patients who underwent URSL using a Ho:YAG laser, postoperative RSH occurred in 8 (0.4%) patients, among whom 6 were female and 2 male, with a median (range) age of 45.6 (30–62) years. The mean (range) stone size was 1.4 (0.8–1.8) cm.

Tables 1 and 2 show the clinical features and outcomes of those patients who presented with an RSH after URSL. The patients’ relevant medical histories (renal calculi ex-tracorporeal shock wave lithotripsy, ESWL; renal opera-tion, and hypertension) were statistically different be-tween those who did and did not develop an RSH ( ta-ble  3 ).  The patient’s relevant medical history (diabetes mellitus) was not statistically associated with an increased risk of developing an RSH ( table 3 ). RSH was observed in all patients <24 h after surgery. The median (range) RSH size was 9.6 (5.5–14.1) cm. The median (range) time for presentation of postoperative symptoms was 8.8 (0–18) h. All patients with an RSH presented with severe ipsilateral flank pain accompanied by other symptoms such as fever, gross hematuria, diffuse abdominal pain and even shock. Two patients received a mean (range) of 3 (2–4) units of packed red blood cells upon admission for low hemato-crit level associated with signs of hemodynamic instabil-ity. In 5 of the 8 patients who developed an RSH, the con-dition resolved following conservative treatment with no further intervention (cases 1, 2, 4, 6, 7); 2 were treated with percutaneous subcapsular drain, while one drainage output did not decrease with an average of 300 ml daily (range 150–500 ml; case 5). The creatinine level of the

Table 1. Preoperative characteristics of case studies

CaseNo.

Sex Ageyears

Stoneposition

Past history Hydronephrosis Stonesize, cm

Ureteroscopesize, Fr

Year ofinitial URSL

1 F 50 right hypertension moderate 1.8 8/9.8 20042 M 30 right no moderate 1.7 8/9.8 20053 F 51 right hypertension severe 1.6 8/9.8 20054 F 43 left hypertension moderate 1.0 6/7.5 20055 F 35 left no moderate 1.4 8/9.8 20066 F 47 left renal calculi ESWL severe 1.3 8/9.8 20107 M 62 left hypertension severe 0.8 6/7.5 20118 F 47 left renal operation severe 1.6 6/7.5 2011

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drainage fluid was approximately equal to that of the urine, other than that of the blood. Retropyelogram and contrast-enhanced CT were suggestive of a large persis-tent subcapsular cavity around the left kidney with direct communication with the renal collecting system ( fig. 1 ). A 6-Fr, 26-cm double J stent was inserted in view of ex-travasation. The patients responded to double J stent with lessening drainage output. Subsequently, percutaneous catheter was removed 7 days later.

One patient (case 8) presented with chills during laser lithotripsy, which was given up at once; subsequently, the patient developed high fever and severe pain in the left flank with severe tenderness. Ultrasonography was sug-gestive of an 11.1 × 7.0 × 3.9 cm sized RSH and severe hydronephrosis, confirmed by a CT scan. After failed conservative management, RSH was managed by percu-taneous nephrostomy in view of extravasation. Postpro-cedure pain and fever were relieved. Follow-up ultraso-

nography (on the 6th day) showed reduced hemorrhage of the size up to 8.6 × 5.2 × 2.5 cm. A second laser litho-tripsy was performed under ureteroscopy 3 month later. All patients had normal creatinine levels perioperatively. During 6 months of follow-up, the RSH resolved in all patients. Hydronephrosis disappeared or improved in all patients.

Discussion

In the last 20 years, ureteroscopy has become an out-standing tool in the diagnosis and treatment of different ureteral problems. Today, it is increasingly used in the management of the common ureteral stones, and such frequent indication has made ureteroscopy become a worldwide technique, with the expected appearance of multiple types of complications (9–20%), some of them severe, including ureteral perforation or avulsion, bleed-ing, and urinary tract infection [2–4] .

Traditionally, the term RSH has been described as a complication after ESWL, trauma, infection, obstruction, renal angiographic procedures. RSH occurs spontane-ously in patients with malignancies and in patients on anticoagulation. With the advent of endourology, that term has also been used in ureteroscopy. Although an in-frequent event in the endoscopic management of ureteral calculi, with only two published reports [5, 6] , RSH is a potential serious complication that should always be tak-en into account when performing such procedures.

Table 2. Postoperative results of case studies

CaseNo.

Operation duration, min

Presentation,clinical signs

Symptom presentationafter surgery, h

DecreasedHb, g/dl1

CRPmg/l

RSH size,cm

Trans-fusion

Management Outcome/resolutionof hemorrhage/follow-up, months

1 39 flank pain 18 25 12 6.5 × 5.6 × 2.2 no conservative resolution/5/652 51 flank pain 12 12 10 5.5 × 3.6 × 1.2 no conservative resolution/4/693 62 flank pain,

fever 6 32 267 14.1 × 5.3 × 4.6 yes percutaneous

drain resolution/2/72

4 42 flank pain 15 10 8 5.5 × 3.6 × 0.8 no conservative resolution/2/485 46 flank pain,

fever5 21 207 12.5 × 5.7 × 4.2 no percutaneous

drain resolution/3/60

6 54 flank pain, low fever, shock

8 50 121 10.5 × 6.6 × 6.2 yes conservative resolution/6/12

7 38 flank pain 6 15 23 10.8 × 5.5 × 5.2 no conservative resolution/2/608 30 flank pain,

fever0 8 238 11.1 × 7.0 × 3.9 no percutaneous

nephrostomyresolution/4/6

1 The decreased value of preoperative hemoglobin and postoperative hemoglobin.

Table 3. Comparison of relevant medical histories with and with-out RSH after URSL

Medical history Without RSH (n = 1,910)

With RSH(n = 8)

p

Renal calculi ESWL 78 (4.1%) 2 (12.5%) 0.003Renal operation 56 (2.9%) 2 (12.5%) <0.001Hypertension 380 (19.9%) 4 (50%) 0.034Diabetes mellitus 83 (4.3%) 0 0.547

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The incidence of RSHs after URSL in the present series was 0.4%, significantly higher than in those reported in the review by Blute et al. [3] , significantly lower than in those reported in the review by Bai et al. [6] . A possible explanation could be the fact that Bai et al. [6] systemati-

cally inserted a double J stent, and so did we mostly. Some patients have continuous flank pain after placement of a double J stent, and not only during voiding. This could explain the higher incidence of technical investigations and detection of hematoma in our population and in that of Bai et al. [6] .

Subcapsular hemorrhage in previous enumerated eti-ologies is due to trauma to renal vessels or renal paren-chyma [7, 8] . In our patients, there was no obvious trau-ma to the pelvicalyceal system or renal parenchyma. The most probable etiology of hematoma is as follows: Sud-denly increased intrarenal pressure leads to forniceal rup-ture or trauma to the pelvicalyceal system during guide wire manipulation. After URSL, ureteric recanalization induces the sudden expansion and rupture of the com-pressed parenchyma and/or capsular vessels. Blood and fluid accumulate in the subcapsular area of the kidney. The renal capsule then gradually separates from the pa-renchyma, and thus the hematoma is formed [7, 9] . An-other probable etiology of hemorrhage can be explained by injury due to guidewire access during ureteroscopy [5, 10] .

Underlying renal abnormalities or a systemic disease, such as hydronephrosis, perirenal infection, diabetes, hy-pertension or lymphoma, may also facilitate the forma-tion of an RSH. Bansal et al. [5] reported RSH after ure-terorenoscopy in patients with a medical history of dia-betes mellitus on insulin. The results of the present study showed that these medical histories are significantly as-sociated with the development of an RSH: renal calculi ESWL, renal operation and hypertension. In addition, all patients presented with moderate or severe hydrone-phrosis. A renal condition with hydronephrosis is prone to hemorrhage due to the lack of elastic tissue. In a hydro-nephrotic kidney, increased intrapelvic pressure causes kinking, stretching and/or obstruction of the major ves-sels [11] . The atherosclerosis of the vasculature caused by hypertension is associated with loss of tensile strength of the vascular walls. This makes the vessel walls more vul-nerable to the trauma of high intrarenal pressure as in our cases 1, 3, 4, 7.

To prevent this uncommon complication, we suggest that surgeons should monitor the tip of the guidewire dur-ing ureteroscopy, avoid suddenly increased and decreased intrarenal pressure during manipulation, minimize exces-sive intrarenal pressure during manipulation, avoid ex-tracting or removing stone fragments, and place a double J stent in the ureter after ureteroscopy. There are several measures to lower the pressure: the use of a minimal amount of irrigation by adjusting the tap; the use of 6/7.5-

Fig. 1. Retropyelogram and contrast-enhanced CT suggestive of a large persistent subcapsular cavity around the left kidney with di-rect communication with the renal collecting system (black arrow).

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Fr ureteroscope; relieving the pressure regularly by stop-ping the flow and opening the tap or even the removal of the ureteroscope, and the insertion of a transurethral 10-Fr catheter to lower the bladder pressure during surgery, es-pecially in cases where operation is expected to be long. Long operation might intraoperatively aggravate the inner pressure of the pelvicalyceal system, which contributes to RSH formation. Preoperative anti-infection treatment and nephrostomy, as necessary, are additional precautions.

Treatment is selected based on the patient’s hemody-namic state, infection, renal function, and the feasibility of treatment modality. Our experience suggests that non-surgical care is a reasonable first option in patients with RSH. Invasive measures can be withheld unless the fluid continues to extend or uncontrolled infection is present. Small, uninfected hemorrhage (cases 1, 2, 4, 6, 7) is usu-ally managed conservatively for rapid and spontaneous resolution. Conservative management includes antibiot-ics, control of pain with monitoring of vital signs, serum creatinine and Hb values [7] . RSH is rarely associated with abrupt hemodynamic instability and usually not le-thal because these fluid collections are limited in the sub-capsular space. Transfusion should be immediately start-ed in cases in which signs of hypovolemic shock are ob-served or where the hemoglobin level is severely decreased (our cases 3, 6). In order to prevent kidney function im-pairment and potential secondary hypertension, percuta-neous drainage was offered when deemed necessary ow-ing to progression of symptoms, large or infective hemor-

rhage, and shortened the time to resolution (our case 3, 5, 8) [7, 11, 12] . All patients responded well to our treat-ment, and CT showed complete absorption of the RSH at 6 months’ follow-up. As most RSHs will ultimately heal spontaneously, we preferentially advocate conservative management.

Conclusion

The rate of RSH complicating URSL is very low. RSH complicating URSL can occur in patients with underlying renal abnormalities. RSH is rarely associated with abrupt hemodynamic instability and usually not lethal. Most pa-tients who present with an RSH after URSL can be treated conservatively with no intervention or with a drain only. Treatment is selected based on the patient’s hemodynam-ic state, infection, renal function and the feasibility of treatment modality.

Acknowledgements

This work was supported by the National Key Clinical Special-ty Construction Project of China.

Disclosure Statement

The authors declare that they have no relevant financial interests.

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