Rare complication after ureteroscopy and laser lithotripsy: giant subcapsular renal hematoma
Ureteroscopy has undergone a dramatic evolution over the last two decades Nonetheless, ureteroscopy is still the most common cause of ureteral injury. The improvements in instrumentation and technique have resulted in a reduced incidence of serious complications. The subcapsular haematoma was observed in case of larger stones, or more severe ipsilateral hydronephrosis, longer operation duration (> 1 hour ), and higher perfusion pressure of hydraulic irrigation. Giant subcapsular hematoma after ureteroscopic laser lithotripsy (URSL) is a rare but potentially serious post-operative complication. We performed the review of complications in the last 10 years. A similar case was observed about 15 years ago when they used instrument to larger caliber (14.5 Ch).
Methods and results
Between 2004 and 2013, we retrospectively evaluated 1685 URSL who had undergone diagnostic or therapeutic ureteroscopy for lithotripsy (96%), asymptomatic hematuria (3%), migrated or calcified ureteral stent (1%). All procedures were performed using 8 Fr semi-rigid ureteroscopes. Perioperative information on patients' preoperative morbidity, renal function, stone characteristics, and degree of hydronephrosis were reviewed. The preoperative work-up was perfomed with ultrasound, URO-TC and in selected cases renal scintigraphy. The postoperative presentation of symptoms and changes in blood parameters led to practice kidney ultrasound, CT , and subsequent management. In our review early post-operative complications were encountered in 15 -17 % of cases : including transient hematuria (6%), fever (from 2 to 4% if stent preoperative) sepsis (1.0%), renal colic (2%) and transitory vesicoureteral reflux (4%), especially in cases with indwelling double-J. Mostly, complications were managed conservatively, using ureteral stenting and antibiotic therapy. In 3 cases patients developed a subcapsular renal haematoma (0.18 %) In 2 cases the haematoma was < 4 cm; in 1 case (the present) the haematoma was giant.
The case reported in view had a postoperative particular ; in the first day the patient showed only a non significant hematuria associated with lower back pain. At 48 hours was manifested a hemorrhagic shock with fall of Hb (7 g) and need urgent of transfusion : the TC showed the giant hematoma with polar arterial source active. Was given immediately embolization and the patient was stabilized by the dynamic point of view . Followed the formation of a significant pleural effusion with secondary pulmonary atelectasis and a critical clinical condition for at least 2 weeks. The pleural effusion underwent successful percutaneous drainage . The renal hematoma is reabsorbed in 4 months, but residual renal function , already compromised before the procedure (severe hydronephrosis) , appears modest . Given the clinical experience, also in the light of literature data the most effective preventive means may be the preliminary drainage of the kidney through a nephrostomy minimum , so as to avoid the creation of high pressures in a urinary tract already under tension.
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