末期腎病患者於逆行性腎盂造影後發生嚴重後腹膜出血：病例報告

鄭苑伶、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

End-Stage Renal Disease Patient Developing Severe Retroperitoneal Hemorrhage After Retrograde Pyelography: A Case Report

Yuan-Ling Cheng, 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

Introduction:

Retrograde pyelogram (RP) is generally regarded as a safe procedure for evaluating upper urinary tract malignancies and hydronephrosis. Although complications from RP are uncommon, the development of severe retroperitoneal hemorrhage following RP is exceedingly rare and is almost unreported in existing medical literature.

Case presentation:

We report the case of a 61-year-old man with a medical history of hypertension, type 2 diabetes mellitus, and end-stage renal disease (ESRD) receiving regular hemodialysis, who developed symptoms concerning for necrotizing fasciitis of the left foot in July 2023. He presented to the emergency department on July 3, 2023, with left foot swelling, erythema, and pain. A lower-limb computed tomography (CT) scan was performed but did not conclusively rule out necrotizing fasciitis. As a result, an urgent fasciotomy was carried out on July 15, followed by surgical debridement on August 2, and additional debridement with delayed primary closure thereafter.

On August 22, 2023, the patient developed hematuria. Urologic evaluation, including abdominal ultrasonography and cystoscopy, was arranged. Cystoscopy on August 24 revealed erythematous changes around the left ureteral orifice. Given the elevated risk of urothelial carcinoma in patients on chronic hemodialysis, bilateral ureteroscopy with retrograde pyelography was performed on August 28. That night, the patient experienced acute hypotension and altered mental status. Laboratory data showed a significant drop in hemoglobin to 5.5 g/dL (baseline: 8.0 g/dL), raising concern for hypovolemic shock. Blood transfusion was initiated, and a central venous catheter was inserted on August 29.

On August 30, the patient reported postprandial lower flank discomfort and persistent severe pain with poor analgesic response. A contrast and non-contrast abdominal CT performed on August 31 demonstrated a renal hematoma in the left kidney, explaining the shock and profound anemia.

Because follow-up abdominal CT on September 2 showed enlargement of the hematoma, interventional radiology was consulted for angiography and potential embolization. Transarterial embolization (TAE) was performed the same day, reducing blood flow to the left anterior superior and anterior inferior renal arterial branches and leading to gradual improvement of the patient’s pain.

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

Discussion:

Most documented cases of retroperitoneal hemorrhage in the literature involve spontaneous, non-traumatic bleeding. Reported etiologies include ruptured angiomyolipoma, renal cell carcinoma, cystic renal diseases, and anticoagulant use. Although perirenal hematomas have been described as uncommon complications of endourological procedures, retroperitoneal bleeding specifically following RP has been only rarely reported, likely reflecting underrecognition or underreporting rather than its actual incidence.

The markedly reduced size of end-stage kidneys inevitably leads to changes in their biomechanical properties, as demonstrated in ultrasound elastography research. Leong et al. showed that patients with CKD exhibit increased renal stiffness relative to healthy controls, suggesting that ESRD kidneys are more vulnerable to injury—even under relatively low intrapelvic pressures, such as those encountered during RP. In our case, the patient’s ESRD likely contributed to increased renal fragility and susceptibility to hemorrhage.

Severe retroperitoneal bleeding after RP is an unusual but potentially life-threatening event. Timely management requires rapid hemodynamic stabilization and early transarterial embolization, in accordance with advanced life-support guidelines.