輸尿管鏡碎石術併發腎臟假性動脈瘤-常規手術的罕見併發症

李一宏、林益聖、歐宴泉、許兆畬、童敏哲

童綜合醫院外科部泌尿科

Ureteroscopic Lithotripsy Related Renal Pseudoaneurysm- A Rare Complication After A Common Operation

Yi-Hong Li, Yi-Sheng Lin, Yen-Chuan Ou, Chao-Yu Shu, Min-Che Tung

Division of Urology, Department of Surgery,

Tungs' Taichung MetroHarborHospital, Taichung, Taiwan

Introduction:

Ureteroscopic lithotripsy(URSL) is a common treatment for ureteral stone. Compared with fewer studies reported renal pseudoaneurysm after flexible ureteroscopy, we share the case developed after rigid ureteroscopy. The patient presented with gross hematuria and intolerable left flank pain after receiving left URSL. Contrast computed tomography(CT) demonstrated one renal pseudoaneurysm at upper renal cortex and another at lower cortex. Management with transcatheter arterial embolization(TAE) with microcoils were performed and he got symptoms relief. We present the first case of renal pseudoaneurysm after URSL

Case presentation: The 57-year-old male has a past medical history of hypertension, chronic kidney disease and gout. There was no known coagulopathy or anticoagulant medication used. He ever received extracorporeal shock wave lithotripsy(ESWL) for left renal stone 6 months earlier before this episode. Due to intermittent left flank pain, he received ureteroscopic lithotripsy and JJ ureteral stent for symptomatic left ureteral stone in other medical intuition. The procedure was performed under spinal anesthesia. However, massive bleeding after severe cough was noted during the procedure and JJ ureteral stent was performed for ureteral protection. Due to refractory left flank pain, gross hematuria and severe anemia(lowest hemoglobin: 6.8) he was transferred to our emergency department where physical examination revealed left flank ecchymosis(Fig. 1) and knocking tenderness. Lab examination showed relative anemia with baseline hemoglobin 14-15 and decreasing to 12.7 but platelet within normal range as 270000. Mild aPTT prolonged as 36.4s(normal range:24-34.9s) but PT within normal range as 11.4s(normal range:8-12s). Urine analysis showed numerous RBC under high power fields. Under the suspicion of active bleeding of retroperitoneum, computer tomography was arranged. The study showed one contrast extravasation over the upper renal cortex in artery phase about 1.8cm(Fig. 2. A) and another over lower renal cortex about 0.8cm(Fig. 2. C; the circled one with higher hounsfield unit was renal stone) but both without size or attenuation increasing in delayed phase(Fig. 2. B, arrow; 2. D, arrow). Symptomatic pseudoaneurysm with active bleeding was suspected and transcatheter arterial embolization was performed immediately. A 1.5 cm pseudoaneurysm was found at the terminal branch of the left upper renal artery(Fig. 3. A) and another one within 0.4cm at the terminal branch of the left lower renal artery(Fig. 3. C). There was no more contrast extravasation after the procedure. Following, the patient received blood clot and left ureteral stent removal with cystoscopy due to hemostasis status. The intraoperative blood loss was about 100mL. A 3-way foley was inserted and he received continuous bladder irrigation for 5 days. He tolerated well after foley removal without recurrent hematuria or acute urinary retention. Decreased hemoglobin level with nadir to 10.8 but recovered to 14.3 after component therapy and hemostasis was achieved. The patient was discharged on postoperative day 8.

Conclusions:

Although renal pseudoaneurysm after ureteroscopic lithotripsy is a rare complication, clinicians should keep in mind the red flag signs as refractory hematuria and flank pain. Since preoperative arterial-phase contrast CT is not recommended as a routine practice, patients who have risk factors like poor control hypertension, pregnancy or history of renal pseudoaneurysm should be paid more attention.