病例報告：末期腎病變患者於逆行性腎盂造影後之嚴重後腹膜出血

黃君平、陳進利、高建璋、楊明昕、曹智惟、蒙恩、江佩璋

國防醫學院三軍總醫院外科部泌尿外科

Case Report: Severe Retroperitoneal Hemorrhage Following Retrograde Pyelogram in End-Stage Kidney Disease

Chun-Ping Huang, Chin-Li Chen, Chien-Chang Kao, Ming-Hsin Yang, Chih-Wei Tsao, En Meng, Pei-Jhang Chiang

Division of Urology, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114024, Taiwan

Introduction:

Retrograde pyelogram (RP) is a relatively safe method performed for examination of upper urinary tract cancers and hydronephrosis. Among the few cases of complications involving RP, severe retroperitoneal hemorrhage after RP is an exceptionally rare occurrence and remains nearly undocumented in medical literature.

Case presentation:

We present the case of a 61-year-old male with the history of hypertension, type 2 diabetes mellitus, and end-stage renal disease (ESRD) undergoing routine hemodialysis with left foot symptoms suggestive of necrotizing fasciitis in July, 2023. The patient presented to the emergency department on July 3, 2023, with clinical manifestations including edema, erythema, and pain localized to his left foot. A lower extremity computed tomography (CT) scan was performed, which did not definitively exclude the diagnosis of necrotizing fasciitis. Consequently, an urgent fasciotomy was performed on July 15, followed by surgical debridement on August 2, and subsequent surgical intervention for debridement and delayed primary wound closure.

However, on August 22, 2023, hematuria of the patient was noted. A urological consultation was sought, leading to abdominal ultrasonography and cystoscopy. Cystoscopic examination on August 24, revealed erythematous lesions at the left ureteral orifice. Due to the increased predisposition to urothelial carcinoma in hemodialysis recipients, a bilateral ureteroscopy accompanied by retrograde pyelogram was performed on August 28. Following the procedure, on the night of August 28, the patient experienced a sudden decline in blood pressure and altered mentation. Laboratory investigations revealed anemia with a drop in Hb to 5.5 g/dL (baseline level: 8.0 g/dL), leading to suspicion of hypovolemic shock. A blood transfusion was initiated, and a central venous catheter was placed on August 29.

On August 30, the patient complaint postprandial lower flank discomfort and continued to experience severe pain, with analgesic response being suboptimal. Further abdomen CT with and without contrast was performed on August 31, revealing a renal hematoma localized to the left kidney, contributing to the shock and marked anemia.

Due to the enlarged hematoma noted on abdomen CT followed on September 2, consultation with a radiologist specialist for angiography and possible embolization was sought. Intra-arterial embolization (TAE) was performed on September 2, resulting in gradual subsidence of severe pain with decrease blood flow in the left anterior superior and anterior inferior renal arteries.

The patient was discharged on September 9, with outpatient follow-up advised for continued monitoring and management.

Discussion:

Most instances of retroperitoneal hemorrhage recorded in medical literature involve spontaneous, non-traumatic bleeding. These occurrences can be attributed to various causes such as ruptured angiomyolipoma, renal-cell carcinoma, cystic kidney diseases, and anticoagulation therapy. While perirenal hematomas have been reported as rare complications of endourological procedures, retroperitoneal bleeding following RP were rarely described, might be due to under-reporting rather than its true rarity.

The diminished size of end-stage kidneys undoubtedly results in alterations to their structural integrity, a fact supported by findings from ultrasound elastography studies. Leong et al. observed that CKD correlated with increased kidney stiffness compared to healthy individuals, implying that ESRD are more susceptible to injuries, even at relatively low intrapelvic pressures as seen in cases of RP. In our case, ESRD might be the major cause of making the kidneys more fragile and susceptible to bleeding.

Significant retroperitoneal hemorrhage after RP is uncommon and poses a potential life-threatening situation. Immediate management necessitates prompt resuscitation and early TAE, following advanced life-support protocols.