歐穎倫、蘇忠仁、羅華成、李俊德

三軍總醫院松山分院外科部泌尿外科

Ying-Lun Ou, Chung-Jen Su, Hua-Cheng Lo, Chun-Te Lee

Division of Urology, Department of Surgery, Tri-Service General Hospital Songshan Branch

Taiwan

 

Introduction: Extracorporeal shock wave lithotripsy (ESWL) has been widely used in medical practice since 1980s. Because of its noninvasive approach, it has become one of the main treatment options in patients with renal and/or ureteral calculi. Though it has been considered as a safe modality, there are still uncommon complications such as retroperitoneal hematoma and hematocele of scrotum happened, which may be severe and life-threatening. Only few cases have been reported according to our search, thus, we presented a case with retroperitoneal hematoma and hematocele after ESWL, and discussed the possible risk factor and treatment. 

Case report: A 41-year-old Asian man without past history of systemic disease or coagulopathy, no daily usage of medication. He receive ESWL on 2015/10/05 for the right renal stone.

It was treated with MEDISPEC ECONOLITH 2000 lithotripter, 3000 shocks, were delivered to the stone, with rate 1 per second. He was then discharged from the recovery room. About 8 hours after ESWL, he presented to the emergency department due to severe right flank pain with gross hematuria, treated with pain control, intravenous fluid hydration, and then discharged. He visited GU OPD 2 days later, at which the ecchymosis of the right flank region progressed, estimated 15x12cm in size. Also, the ecchymosis was noted over the penile skin and the bilateral scrotum. The drop of Hb was also noted, from 18.5 g/dL before ESWL to 11.3 g/dL. The CNCT of abdomen was done during the ER, results of one huge perirenal hematoma, right, and the hematoma extended downward along and within the right retroperitoneal space, all long to the right inguinal canal and scrotum.He was then admitted for further monitoring. During the hospital course, we kept conservative treatment, monitored his vital sign which no signs of hemorrhagic shock presented and the area of the ecchymosis did not progress. After days of treatment, he was then discharged under a stable condition. 

During the OPD visiting 3 months later, the abdominal CT with contrast injection was done, revealed the size of the perirenal hematoma shrink and liquefied, and so as the size of the scrotal hematoma.

Discussion :Extracorporeal shock wave lithotripsy (ESWL) has been widely used and considered as a safe modality in patients with renal and/or ureteral calculi. According to our search and review, there are only few cases presented with prominent hematoma and been reported. Few study indicated the incidence of perirenal hematoma range from 1% to 30%. The incidence of perirenal hematoma may be up to 30% if the CT screen been regularly used. The most common signs and symptoms include flank pain, hematuria, and skin bruising. The image modality may be indicated only if the signs and/or symptoms worsen or persisted. Also, initial blood transfusion may be needed if the patient presented with signs of hemorrhagic shock. According to our review, there are few risk factors associated with perirenal hematoma, including obesity, hypertension, old age, diabetes mellitus, coronary artery disease, coagulopathy or anticoagulation medication. Most of the perirenal hematoma can be treated conservatively, the initial blood transfusion may be needed. No surgical intervention been reported, but there was one case report mentioned the usage of percutaneous drainage for the symptomatic perirenal hematoma.