Cross-sectional imaging of iatrogenic complications after extracorporeal and endourological treatment of urolithiasis

Spontaneous Suburothelial Hemorrhage: The Crucial Role of Radiology in Preventing Unnecessary Interventions

Spontaneous suburothelial hemorrhage (SSH), also known as Antopol Goldman lesion, is a rare condition characterized by spontaneous bleeding into the renal sinus and proximal ureter wall. This case report describes the clinical presentation, imaging findings, and management of SSH in a 20-year-old female initially suspected to have urothelial malignancy. Imaging features of SSH include pre-contrast hyperdensity and non-enhancing thickening of the pelviureteric wall, which can mimic transitional cell carcinoma (TCC) and lead to unnecessary interventions. Radiologists should maintain a high level of suspicion for SSH and be aware of its imaging characteristics to avoid misdiagnosis. Additionally, clinical data, such as bleeding dyscrasia, can aid in the imaging diagnosis. This report provides insights into the diagnosis and management of SSH while offering a comprehensive literature review on its clinical presentation and imaging features. Increased awareness of SSH will facilitate accurate diagnosis and appropriate management, avoiding unnecessary interventions for patients with this benign condition.

Complications after Nephron-sparing Interventions for Renal Tumors: Imaging Findings and Management

The two primary nephron-sparing interventions for treating renal masses such as renal cell carcinoma are surgical partial nephrectomy (PN) and image-guided percutaneous thermal ablation. Nephron-sparing surgery, such as PN, has been the standard of care for treating many localized renal masses. Although uncommon, complications resulting from PN can range from asymptomatic and mild to symptomatic and life-threatening. These complications include vascular injuries such as hematoma, pseudoaneurysm, arteriovenous fistula, and/or renal ischemia; injury to the collecting system causing urinary leak; infection; and tumor recurrence. The incidence of complications after any nephron-sparing surgery depends on many factors, such as the proximity of the tumor to blood vessels or the collecting system, the skill or experience of the surgeon, and patient-specific factors. More recently, image-guided percutaneous renal ablation has emerged as a safe and effective treatment option for small renal tumors, with comparable oncologic outcomes to those of PN and a low incidence of major complications. Radiologists must be familiar with the imaging findings encountered after these surgical and image-guided procedures, especially those indicative of complications. The authors review cross-sectional imaging characteristics of complications after PN and image-guided thermal ablation of kidney tumors and highlight the respective management strategies, ranging from clinical observation to interventions such as angioembolization or repeat surgery. Work of the U.S. Government published under an exclusive license with the RSNA. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available in the Online Learning Center. See the invited commentary by Chung and Raman in this issue.

Suburothelial hemorrhage and intestinal mural hemorrhage secondary to Coumadin use

Both suburothelial hemorrhage and intestinal mural hemorrhage are very rare causes of abdominal pain and gross hematuria. Com-puted tomography (CT) is very valuable in both diagnoses. We present left suburothelial hemorrhage and intestinal mural hemorrhage with CT findings, in a case of Coumadin use for mitral valve replacement.

The antiurolithic activity of Origanum vulgare on rats treated with ethylene glycol and ammonium chloride: Possible pharmaco-biochemical and ultrastructure effects

Background:

Origanum vulgare (OV) Linn is one of the conventional remedies for urolithiasis. Hence, we tested the potential antiurolithic effect of OV active extract, in order to rationalize its medicinal use.

Materials and methods:

The in vivo study was of male Westar rats receiving lithogenic treatment consisting of two 0.75% ethylene glycol injections with a 1 day interval and then in drinking water given for 3 weeks along with ammonium chloride (NH₄Cl) from the 2nd day to the 7th day.

Results:

The active ethanolic extract of OV treatment (20 mg/kg) reversed toxic changes including loss of body weight gain and appetite, raised serum urea and creatinine levels, and raised blood pressure compared to controls.

Conclusions:

The acquired data thus suggested that OV showed antiurolithic effects against renal calcium oxalate crystal deposits by combined mechanisms acting on multiple sites through hypoxaliuric, hypocalciuric, and antioxidant effects.

Perinephric Hematoma Associated with Pyelonephritis Following Ureteral Stent Placement for Ureteral Obstruction Causing Hydronephrosis

BACKGROUND Perinephric hematomas are rare, especially following ureteral stent placement. Etiologies of perinephric hematomas include post-extracorporeal shockwave lithotripsy, Wunderlich syndrome, and renal cell carcinoma, none of which occurred in our patient, who underwent stent replacement. Subcapsular renal hematoma, rather than a perinephric hematoma, can occur following double-J ureteral stent placement. Also, renal parenchymal perforation leading to perinephric hematoma development are complications of double-J ureteral stent placement. Herein, we present a case of a perinephric hematoma following a double-J ureteral stent placement for a ureteral obstruction causing hydronephrosis. CASE REPORT A 43-year-old woman with type 2 diabetes mellitus, hypertension, systemic lupus erythematosus, and recurrent nephrolithiasis presented to our hospital with left flank pain of a 1-day duration. The patient was found to have an obstructive kidney stone causing hydronephrosis. She underwent stent placement and then developed a perinephric hematoma days later. Typically, hematomas are treated conservatively and have spontaneous resolution. The patient received 2 weeks of intravenous antibiotics and 2 more weeks of oral antibiotics, and failed conservative treatment. She re-presented to our hospital 3 days after discharge. Upon the second admission, a perinephric drain was placed. The patient was given another course of antibiotics and was discharged 18 days later. CONCLUSIONS A perinephric hematoma is a rare complication after ureteral stent placement. Perinephric hematoma development can be decreased by controlling blood pressure, treating preoperative urinary tract infections, and shortening operating time during ureteroscopy. It is important to reevaluate potential causes of continued abdominal pain with laboratory testing and repeat imaging.

Does pain severity predict stone characteristics or outcomes in emergency department patients with acute renal colic?

OBJECTIVES

After initial emergency department (ED) management of acute renal colic, recurrent or ongoing severe pain is the usual pathway to ED revisits, hospitalizations and rescue interventions. If index visit pain severity is associated with stone size or with subsequent failure of conservative management, then it might be useful in identifying patients who would benefit from early definitive imaging or intervention. Our objectives were to determine whether pain severity correlates with stone size, and to evaluate its utility in predicting important outcomes.

METHODS

We used administrative data and structured chart review to study all ED patients with CT proven renal colic at six hospitals in two cities over one-year. Triage nurses recorded arrival numeric rating scale (NRS) pain scores. We excluded patients with missing pain assessments and stratified eligible patients into severe (NRS 8-10) and less-severe pain groups. Stone parameters were abstracted from imaging reports, while hospitalizations and interventions were identified in hospital databases. We determined the classification accuracy of pain severity for stones >5mm and used multivariable regression to determine the association of pain severity with 60-day treatment failure, defined by hospitalization or rescue intervention.

RESULTS

We studied 2206 patients, 68% male, with a mean age of 49 years. Severe pain was 52.0% sensitive and 45.3% specific for larger stones >5mm. After multivariable adjustment, we found a weak negative association (adjusted OR =0.96) between pain severity and stone width. For each unit of increasing pain, the odds of a larger stone fell by 4%. Index visit pain severity was not associated with the need for hospitalization or rescue intervention within 60-days.

CONCLUSIONS

Pain severity is not helpful in predicting stone size or renal colic outcomes. More severe pain does not indicate a larger stone or a worse prognosis.

Impact of Implementing Contrast-Enhanced Ultrasound for Antegrade Nephrostogram After Percutaneous Nephrolithotomy

OBJECTIVES

To report results from a quality improvement (QI) project evaluating diagnostic performance, hospital resource use, and patient response data for postoperative contrast-enhanced ultrasound (CEUS) antegrade nephrostogram after percutaneous nephrolithotomy.

METHODS

For this Health Insurance Portability and Accountability Act-compliant, Institutional Review Board-approved study, QI data were deidentified and analyzed. On the first postoperative day after percutaneous nephrolithotomy, patients underwent both CEUS and fluoroscopic antegrade nephrostogram. For CEUS, 1.0 mL of Lumason (sulfur hexafluoride lipid type A microspheres; Bracco Diagnostics, Inc, Monroe Township, NJ) was injected via an indwelling nephrostomy tube, with ureteral patency confirmed by identifying intravesical ultrasound (US) contrast. Diagnostic performance for ureteral patency and contrast extravasation was calculated (with fluoroscopy as the reference standard). The examination time, room time, physician time, hospital costs, and patient response data were compared. The mean, standard deviation, 95% confidence interval, differences in mean, and 95% confidence interval of differences were calculated.

RESULTS

Eighty-one examinations were performed in 73 patients during the QI period. The sensitivity and specificity of CEUS for ureteral patency were 96% and 57%, respectively. There was no significant difference in time metrics between modalities, and the cost analysis showed lower direct and indirect costs for CEUS. Patient responses revealed lower levels of comfort for CEUS relative to fluoroscopy, without significant differences in reported pain or effort levels.

CONCLUSIONS

Contrast-enhanced US showed very high sensitivity for ureteral patency; the relatively low specificity may have resulted from false-negative results in fluoroscopy. The hospital costs and resource use of CEUS compared favorably to fluoroscopy. Contrast-enhanced US also offers inherent advantages, including portability and lack of ionizing radiation.

Complications of percutaneous nephrolithotomy: classification, management, and prevention

PURPOSE OF REVIEW

Percutaneous nephrolithotomy (PCNL) provides the highest stone-free rate after one session and low morbidity rates in cases of large or multiple renal calculi. The classification, management, and prevention of complications of PCNL are reviewed.

RECENT FINDINGS

PCNL is a well tolerated and very effective procedure for the management of renal stones. Specific complications limit the surgical outcome of PCNL whereas the majority of the complications are resolving with conservative or minimally invasive management. Experience with the technique is important for minimizing complications. There is an ongoing effort to classify the complications and to achieve a consensus in reporting the complications and surgical outcome of the procedure.

SUMMARY

The knowledge of risk factors, complications, and their management is important for every endourologist. Establishing of a PCNL-specific classification system for reporting outcomes and complications could set the basis for further improvement of the PCNL technique and outcomes.