Subcapsular renal haematoma after holmium:yttrium-aluminum-garnet laser ureterolithotripsy

A rare complication after ureterorenoscopy lithotripsy: Subcapsular renal hematoma

OBJECTIVE

To evaluate the prevalence, risk factors, clinical manifestations, and outcomes of subcapsular renal hematoma (SRH) following ureterolithotripsy.

PATIENTS AND METHODS

Between January 2014 and December 2023, patients who underwent ureterorenoscopy lithotripsy (URL) at our hospital were retrospectively reviewed. Clinical data including basic information, calculi-related indicators, and perioperative period data were collected. A Student's t-test was used for continuous data, while a Chi-square test or Fisher's exact test was utilized for categorical data.

RESULTS

A total of 2098 patients treated with URL for ureteric stones were included in this study. The incidence of SRH after URL was 0.52% (11 cases). All SRH cases were confirmed by non-contrast computed tomography, with an average patient age of 55.54 years (range 34-84). The mean stone size in patients with SRH was 10.54 cm (range 0.8-1.5). Patients with SRH had a higher proportion of severe hydronephrosis caused by ureteral stones (54.55% vs 26.07%, p = 0.032) and narrow ureters (45.45% vs 8.04%, p < 0.001) compared to those without SRH. Patients with SRH experienced a longer length of stay, with a significant difference between the two groups (11.64 ± 5.05 vs 3.87 ± 8.12, p < 0.001). Nine patients were managed conservatively without further intervention, while embolization was required in one patient and percutaneous drainage was performed in another. All SRH cases resolved completely during a 4-month follow-up.

CONCLUSIONS

The incidence of SRH following URL is low, with severe hydronephrosis and narrow ureters identified as risk factors. Most SRH cases can be successfully managed conservatively, although patients with SRH may experience a significant prolongation of their length of stay.

Japanese survey of perioperative complications and ureteral stricture after ureteroscopy with laser lithotripsy for upper urinary tract stones in multicenter collaborative study

OBJECTIVES

This study aimed to investigate perioperative complications and the details of postoperative ureteral stricture after ureteroscopy with laser lithotripsy (URS-L) for upper urinary tract stones in Japan.

METHODS

Patient data on intra- and postoperative complications after ureteroscopy using URS-L were retrospectively collected from multiple centers in Japan between April 2017 and March 2020 with the cooperation of the Japanese Society of Endourology and Robotics. Data included the number of patients undergoing URS-L, number and type of intra- and postoperative complications, and detailed characteristics of postoperative ureteral stricture.

RESULTS

In total, 14 125 patients underwent URS-L over 3 years at 82 institutions. Annual URS-L numbers gradually increased from 4419 in 2017, to 4760 in 2018, and 4946 in 2019. The total complication rate was 10.5%, which was divided into intra-operative complications in 1.40% and postoperative complications in 9.18%. The annual incidences of intra- and postoperative complications were not significantly different from year to year (p = 0.314 and p = 0.112). Ureteral perforation, ureteral avulsion, and the intra-operative conversion rate were 1.35%, 0.03%, and 0.02%, respectively. Fever >38°C, septic shock, blood transfusion, and postoperative mortality were 7.44%, 0.81%, 0.07%, and 0.04%, respectively. Ureteral stricture occurred in 0.8% of cases. The median length of stricture site was 10.0 mm and the success rate of stricture treatment was 54.6%.

CONCLUSION

Although URS-L utilization has increased in Japan, the annual complication rate has remained steady. Although URS-L is a useful and less invasive procedure, devastating complications can still occur.

The Effect of High- and Low-power Holmium Laser Settings for Transurethral Lithotripsy in the Management of Adults with Ureteral Stone

Since there is insufficient evidence to determine the best treatment of transurethral laser lithotripsy (TLL) in ureteral stones, this study compared the effectiveness and safety of TLL using high-power (HP) (100 W) and low-power (LP) (20 W) laser settings. All patients with maximally sized ureteral stones who were planned for transurethral holmium laser lithotripsy were enrolled in this open study. One of the two laser setting groups-LP or HP-was allocated to each alternate patient. Using IBM SPSS Statistics 24, the treatment groups were compared for operating time, intraoperative and postoperative problems (up to 1 year), and rates of stone-free recovery. Welch tests were employed to compare continuous data, whereas Fisher's exact or Chi-square tests were used to assess categorical variables. At P < 0.05, statistical significance was established. A total of 207 individuals were included and preoperative data were comparable between the two groups. The HP group had a considerably greater ablation rate and a significantly shorter procedure duration (42.61 ± 11.74 min) than the LP group (78.56 ± 25.91 min) ( P = 0.025). The Overactive Bladder Symptom Score and International Prostate Symptom Score were considerably higher in the HP group than in the LP group. Treatment effectiveness was considerably impacted by the location of the ureteral stone, according to univariate and multivariate logistic regression models. A HP laser setting of up to 100 W greatly shortens the duration of the process for treating ureteral stones without raising the risk of problems.

Uncommon Complications of Cystoscopy: Presentations of Concurrent Perirenal Hematoma and Candida albicans Sepsis

Subcapsular hematoma (SRH) or perirenal hematoma (PRH) can be seen after trauma, interventional radiological procedures, urological procedures, anticoagulant medications, coagulation disorders, infections, and spontaneously in some patients. Within the urological procedures, PRH can occur after percutaneous nephrolithotomy and extracorporeal shortwave lithotripsy but has only been reported a few times after cystoscopy/ureteroscopy. Here, we present the case of PRH as a complication from cystoscopy with retrograde pyelography in a patient with underlying chronic kidney disease (CKD) and an extensive surgical history for nephrolithiasis. In addition to this, our patient had a further complication of sepsis by Candida albicans, of which the source is proven to be urinary, and it appears that the fungemia was triggered during the procedure as well. The diagnosis was confirmed by abdominal computed tomography (CT), and PRH was proven to resolve with conservative management on repeat imaging months later.

Subcapsular renal haematoma after ureteroscopic lithotripsy: a single-centre, retrospective study in China

OBJECTIVES

To investigate the incidence, predisposing factors, diagnosis and management of subcapsular renal haematoma (SRH) after ureteroscopic lithotripsy (URSL).

DESIGN

Retrospective observational study.

SETTING

Shandong Provincial Hospital, a 4500-bed tertiary hospital in China.

PARTICIPANTS

The data from 1535 consecutive patients treated with URSL (including rigid URSL and flexible URSL) between January 2015 and October 2020 were retrospectively analysed.

MAIN OUTCOME MEASURES

SRH after URSL confirmed via CT. The characteristics, operative data and outcomes of these patients were documented and compared.

RESULTS

Six patients were confirmed to have an SRH after URSL on CT. The total incidence of SRH after URSL was 0.39%. The incidences of SRH after rigid URSL and flexible URSL were 0.38% and 0.41%, respectively. Unendurable ipsilateral flank pain and a significant decrease in haemoglobin after surgery were the typical clinical manifestations of SRH after URSL. There were no significant differences in age, sex, history of diabetes mellitus, preoperative hypertension, body mass index, stone laterality or perfusion pressure (p&gt;0.05). However, SRH was significantly associated with the stone size, stone location, degree of hydronephrosis and operative duration (p&lt;0.01). One patient was managed conservatively without further intervention, percutaneous drainage was performed in four patients and one patient underwent emergency angiography. No patients died of SRH.

CONCLUSIONS

SRH is a rare but potentially serious complication of URSL. Severe hydronephrosis and a thin renal cortex preoperatively and prolonged operative duration are strong predisposing factors for SRH. Laparoscopic ureterolithotomy should be considered as an alternative surgery for patients with severe ureteral tortuosity. SRH is treated based on patients' clinical manifestations. Most patients can be managed with conservative treatment or percutaneous drainage alone.

Subcapsular renal hematoma after ureterorenoscopy

Introduction

Subcapsular renal hematoma after ureterorenoscopy using a holmium yttrium‐aluminum‐garnet laser is a rare complication. We experienced a case of subcapsular hematoma after ureterorenoscopy.

Case presentation

The patient was a 56‐year‐old man with a history of hypertension and coronary vasospastic angina, and he was taking antiplatelet drugs. He had the middle and lower calyx stones measured 36 mm in diameter of the right kidney. We performed ureterorenoscopy, which was completed about 2 h without intraoperative complications. We could not remove the stone completely. After the surgery, the patient developed a fever and complained of right back pain. Computed tomography showed several residual stones formed a stone street, obstructing the stent and resulting in grade 3 hydronephrosis. Furthermore, the right subcapsular renal hematoma infection had detected. Percutaneous hematoma drainage and percutaneous nephrostomy were performed.

Conclusion

Subcapsular renal hematoma after ureterorenoscopy is an uncommon complication but should be kept in mind.

Superselective renal arterial embolization in treatment for severe renal hemorrhage after flexible ureterorenoscopy and laser lithotripsy (FURSL)

OBJECTIVE

Life-threatening renal hemorrhage after flexible ureterorenoscopy and laser lithotripsy (FURSL) is a rare complication. We aim to review our unit's experience with super-selective renal artery embolization as therapeutic options for such patients.

METHODS

From January 2015 to November 2021, total 1125 patients underwent the FURSL procedures in our unit. Patients with life-threatening renal hemorrhage were reviewed and the information of peri-operative, operative and post-operative were recorded.

RESULTS

Of the 1125 patients who underwent FURSL procedure, two patients with life-threatening renal hemorrhage were diagnosis; the age is 67 and 42 years old, respectively. Preoperative imaging examination showed that two patients had upper ureteral stone and renal stone ranging in size from 1.2 to 3.0 cm. Female patient placed the D-J stent for two weeks before FURSL. After the operation, both patients had the massive gross hematuria, significant drop of hemoglobin (Hgb), blood pressure lowering and needed to transfusion. CT scan showed that the male patient had an intrarenal hematoma. All these two were treated by super-selective renal artery embolization and had a successful outcome.

CONCLUSION

Life-threatening renal hemorrhage after FURSL is a rare and severe complication. Super-selective renal artery embolization is a safe and effective method for the treatment of patients with severe renal hemorrhage, preserving healthy renal parenchyma and renal function.

The active guidewire technique versus standard technique as different way to approach ureteral endoscopic stone treatment

BACKGROUND

One of the greatest challenges in semi-rigid ureteroscopies, for both stones and tumors, is the control of endoscopic vision and the maintenance of low intracavitary liquid pressure. We present a comparison between two operative techniques: in the first method an ordinary guide wire (diameter 0.032'') is used for the procedure; in the second one a 5 Fr ureteral catheter replaces the guidewire (we called it "Active guidewire") Methods We compared 50 semirigid ureteroscopies (sURS) performed using the active guidewire with another 50 procedures conducted with a classic guidewire. We evaluated the difference in operating times, quality of endoscopic vision, periprocedural infections rate and stone-free rate.

RESULTS

The use of active guidewire has considerably reduced the standardized operating times per unit stone-volume by about 39%. Vision quality has improved considerably thanks to the continuous flow in-and-out. Consequently, periprocedural infections decreased (3% vs 30%) and the stone-free rate rose from 86% to 92%.

DISCUSSION AND CONCLUSIONS

Employing an "active guidewire" instead of the standard guidewire, the risk of complications related to high pressures and operating time is considerably lower, as well as better treatment quality thanks to the cleaner vision. This technique has proven to be safe as well as easy to apply, and in our belief is to be preferred whenever the ureter accepts without forcing, both the presence of the catheter and the semi-rigid 7 F ureteroscope.

Stone free rate and clinical complications in patients submitted to retrograde intrarenal surgery (RIRS): Our experience in 571 consecutive cases

INTRODUCTION

The purpose of this study is to report the stone free rate (SFR) and clinical complications in patients submitted to retrograde intrarenal surgery (RIRS).

MATERIALS AND METHODS

A total of 571 procedures of upper urinary stones treated using flexible ureteroscopy and holmium laser lithotripsy from January 2014 to February 2020 have been analyzed. Overall SFR was evaluated after 3 months following the procedure by means of a non-contrast computed tomography. Success was considered as stone-free status or ≤ 0.4 cm fragments.

RESULTS

The overall SFR was 92.3% in group 1 (stone size: < 1 cm), 88.3% in group 2 (stone size: > 1 ≤ 2 cm), 56.7% in group 3 (stone size: 2-3 cm) and 69.6% in group 4 (multiple stones). Post-operative complications, according to the Clavien- Dindo (CD) classification system, were recorded in 32 (5.6%) procedures. The major complications recorded were: one case of subcapsular hematoma (SRH) associated with pulmonary embolism two days after the procedure (CD Grade IIIa) treated conservatively and one case of hemorrhagic shock 2 hour with multiple renal bleedings requiring urgent nephrectomy (CD Grade IVA).

CONCLUSIONS

The RIRS is an effective and safe procedure with a high SFR significantly correlated with the stone size; at the same time, RIRS could be characterized by severe clinical complications that require rapid diagnosis and prompt treatment.

Page kidney post ureteroscopy: a case report

Renal injury after surgical intervention is not uncommon in current urological practice with most complication would be anticipated in high risk patient. Subcapsular renal hematoma is not known complication post some urological interventions such as extracorporeal shockwave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL) and trauma. Few cases of subcapsular hematomas are reported as a complication post ureteroscopy in the literature. Clinical spectrum varies from spontaneous resolution through acute renal failure secondary to Page kidney. Page kidney is the external compression of a kidney usually caused by a subcapsular hematoma associated with high blood pressure and occasional renal failure. It is named after Dr. Irvin Page who first demonstrated in 1939 that applying external compression on the renal parenchyma could cause hypertension. Various management options are mentioned in literature and depend upon the severity and presentation. Percutaneous drainage is an option for the management of subcapsular hematoma in hemodynamically stable patient.

Clinical Comparison of Super Pulse Thulium Fiber Laser and High-Power Holmium Laser for Ureteral Stone Management

Purpose: To evaluate the efficacy of new super pulse thulium fiber laser (SP TFL) and compare it with holmium laser for ureterolithotripsy. Patients and Methods: A total of 174 patients with solitary ureteral calculi were enrolled in 2016 to 2018. Stone sizes ranged between 0.6 and 2.4 cm. The SP TFL FiberLase U2 and 120H Ho:YAG laser with fibers diameters of 400 and 365 μm, respectively, were used. The laser settings were 1 J × 10 Hz = 10 W for both devices. All patients were randomized into two groups. The age, stone size, location, and density were comparable in both groups. The evaluated parameters were operation time, endoscopic view quality, retropulsion grade, stone-free rate, and complication rate. Results: The total operation time and lasering time were longer in the Ho:YAG group (24.7 ± 0.7 minutes vs 32.4 ± 0.7 minutes, p = 0.05), and postoperative stenting was necessary in one vs four cases, respectively. At 30 days of follow-up, no residual stones were observed in the SP TFL group (vs five cases of Ho:YAG). Conclusion: SP TFL technology was associated with excellent efficacy/safety ratio. The SP TFL may be considered as a viable alternative to Ho:YAG laser stone management.

Huge perinephric hematoma after ureteroscopy and pneumatic lithotripsy for ureteral stone; A life-threatening rare complication: Case report and review of literature

INTRODUCTION

Ureteroscopy with pneumatic lithotripsy is a relatively safe procedure for the management of the ureteral stone disease. However; subcapsular hematoma and even huge perinephric hematoma are potentially serious events that may complicate this procedure and must be kept in mind.

CASE PRESENTATION

We present a case of huge perinephric hematoma post ureteroscopy and pneumatic lithotripsy for an impacted ureteral stone.

CONCLUSION

The occurrence of such a rare complication in a relatively safe procedure must be taken into consideration especially while dealing with patients with long-standing obstruction and thin renal cortex. Furthermore, the risk of bleeding should be included in risk-benefit counselling before ureteroscopic lithotripsy.

Stone fragments migration into subcapsular renal hematoma post flexible ureterorenoscopy (unique presentation)

This is a case report of 45-year-old female patient who presented with right flank pain. Abdominopelvic CT scan showed right renal pelvis stone measuring 20 mm. Right flexible ureterorenoscopy with holmium laser was performed in our institute. Postoperatively, she was febrile and pale. Immediate Abdominopelvic CT scan was obtained which revealed a large right subcapular hematoma. Conservative management was maintained for a week. Two months later, repeated Abdominopelvic CT scan showed regression of right subcapsular renal hematoma with stone fragments migration into the perinephric space as a first presentation in the world.

Subcapsular renal hematoma after retrograde ureterorenoscopic lithotripsy: our experience

BACKGROUND

Ureterorenoscopy is the current standard treatment for ureteral and kidney stones, also stones greater than 2 cm can be removed. Complications linked to infectious processes or ureteral damage are the most frequently reported. Subcapsular renal hematoma is an extremely rare complication following this procedure.

METHODS

We report the retrospective experience of two urological referral units for stones disease by analyzing incidence, risk factors and management of subcapsular renal hematoma.

RESULTS

Between May 2011 and December 2017, 2497 consecutive ureteroscopies for urolithiasis were performed by 8 skilled endourologists. A subcapsular renal hematoma was diagnosed in four cases (0.12%). Symptoms appeared few hours after intervention in two patients and after 14 postoperative days in the remaining two. In all cases CT scan revealed a subcapsular renal hematoma without signs of active bleeding. Conservative treatment was successful. Two patients required blood transfusion. One patient developed renal hypotrophy.

CONCLUSIONS

Subcapsular renal hematoma represents a rare but potentially serious complication after ureterorenoscopic lithotripsy. Its real incidence and etiology still need to be clarified. The elevated intrarenal pressures play an important role. Persistent hematuria, flank pain and hemoglobin drop should guide prompt investigation to reach an early diagnosis. In most cases a conservative management is sufficient.

Perirenal Hematoma After Ureteroscopy: A Systematic Review

INTRODUCTION

With the broadening indications of ureteroscopy (URS) for complex stones and high-risk patients, more URS is being performed and hence there is an increasing risk of major potentially life-threatening complications. We wanted to define the incidence, predisposing factors, management, and long-term sequelae for post-URS perirenal hematoma (PRH).

MATERIAL AND METHODS

We conducted a systematic review of literature according to Cochrane and preferred reporting items for systematic reviews and meta-analysis guidelines for all studies reporting on post-URS PRH from 1980 to September 2016. A literature search was conducted through PubMed, EMBASE, CINAHL, and Cochrane Library for all English language articles.

RESULTS

Based on a literature search of 210 articles, seven studies (8929 patients) met the inclusion criteria with an incidence of post-URS PRH reported as 0.45% (40 patients, range: 0.15%-8.9% per study) with a mean age of 53 years and a mean stone size of 1.7 cm. The predisposing factors were moderate-severe hydronephrosis, thin renal cortex, prolonged operative duration, hypertension, and preoperative urinary tract infection (UTI). The management strategy varied from conservative management with blood transfusion and antibiotics (n = 22, 55%) to percutaneous drainage (n = 11, 27.5%). Surgical intervention was needed in seven (17.5%) patients. Two of these were emergency angiography of which one proceeded to open nephrectomy. Open surgery with clot removal was done in three patients, nephrostomy for severe hydronephrosis in one patient, and surgery to correct malpositioned stent in one patient. There was one mortality reported, wherein a patient who had postangiography nephrectomy died of multiple organ failure after the intervention.

CONCLUSION

URS related PRH is a rare, but potentially life threatening complication with a small risk of renal loss. Although most cases may be managed conservatively, incidence of PRH can be minimized by control of blood pressure, treatment of preoperative UTI, and reduction in intrarenal pressures and operative time duration.

Subcapsular Renal-Infected Hematoma After Retrograde Intrarenal Surgery: A Rare but Serious Complication

We report a case of a 53-year-old woman affected by a left kidney stone and persistent positive urinary culture treated by retrograde intrarenal surgery. During postoperative day 1, she developed a sudden back pain associated with a decrease in hemoglobin. CT scan showed a subcapsular hematoma giving the impression of partial compression of kidney and upper urinary tract. For that reason, in the first instance, a Double-J ureteral stent was installed. Unfortunately, an open surgical drainage was necessary because a secondary infection of the hematoma was evident during the following days.

Large subcapsular hematoma following ureteroscopic laser lithotripsy of renal calculi in a spina bifida patient: lessons we learn

Introduction

Paraplegic patients are at greater risk of developing complications following ureteroscopic lithotripsy because of urine infection associated with neuropathic bladder, difficulties in access due to altered anatomy of urinary bladder and urethra, spinal curvature, spasticity, and contractures. We report the occurrence of large subcapsular hematoma following ureteroscopy and discuss lessons we learn from this case.

Case report

A 48-year-old male patient with spina bifida underwent ureteroscopy with laser lithotripsy and ureteric stenting for left ureteric stone and staghorn calculus with hydronephrosis; laser lithotripsy was repeated after 3 months; both procedures were performed by a senior urologist and did not result in any complications. Ureteroscopic laser lithotripsy was performed 5 months later by a urological trainee; it was difficult to negotiate the scope as vision became poor because of bleeding (as a result of the procedure). Postoperatively, hematuria persisted; temperature was 39°C. Cefuroxime was given intravenously followed by gentamicin for 5 days; hematuria subsided gradually; he was discharged home. Ten days later, this patient developed temperature, the urine culture grew Pseudomonas aeruginosa, and ciprofloxacin was given orally. Computed tomography (CT) of the urinary tract, performed 4 weeks after ureteroscopy, revealed a 9×7 cm subcapsular collection on the left kidney compressing underlying parenchyma. Percutaneous drainage was not feasible because of severe curvature of spine. Isotope renogram revealed deterioration in left renal function from 30% to 17%. Follow-up CT revealed reduction in the size of subcapsular hematoma, no hydronephrosis, and several residual calculi.

Conclusion

Risk of subcapsular hematoma following ureteroscopic lithotripsy can be reduced by avoiding prolonged endoscopy and performing ureteroscopy under low pressure. When a paraplegic patient develops features of infection after ureteroscopy, renal imaging should be carried out promptly. Extended perioperative medical care is required for spinal cord injury patients because of their propensity to develop sepsis. Antibiotics should be prescribed on the basis of recent urine microbiology results. Spinal cord injury patients should be treated by senior, experienced doctors and cared for in a spinal injuries unit in order to minimize complications.

Subcapsular renal hematoma after ureteroscopy with holmium:yttrium-aluminum-garnet laser lithotripsy

Subcapsular renal hematoma (SRH) after ureteroscopic lithotripsy (URSL) using holmium:yttrium-aluminum-garnet (Ho:YAG) laser to treat ureteric stones is a rare complication. We aimed to review our unit's experience of post-URSL subcapsular renal hematoma. From 2006 to 2012, 2059 URSLs using F9.5 rigid ureteroscope were performed in our unit. Patients with post-URSL symptomatic renal hematoma were reviewed. Perioperative information on patients' renal function, stone characteristics, and degree of renal hydronephrosis were reviewed. Operative data, postoperative information such as clinical manifestation, changes in blood parameters, CT findings, and subsequent treatment were documented. Of the 2059 patients treated with URSL and Ho:YAG laser, three patients were diagnosed as subcapsular renal hematoma after surgery; the age is 57, 61, and 63 years old, respectively. Preoperative imaging examination showed that two patients and one patient had obstructing middle and proximal ureteral stones ranging in size from 0.8 to 1.6 cm, and three patients had thin renal cortices. The double-J ureteral stents were inserted in all cases regularly. All three subcapsular renal hematoma patients had the loin pain of the operation side and fever, and one patient had significant hemoglobin drop (from 111 to 61 g/L) who need to transfusion. Two patients presented within 24 h of URSL, and one patient presented on day 10. One patient was treated conservatively for 3 weeks and recovered with bed rest, antibiotics, hemostasis, and analgesia with no intervention or drain. The other two patients underwent ultrasonography-guided drainage of the hematoma. Two-month follow-up CT scans or ultrasonography confirmed the resolution of the hematoma in all three cases. Renal subcapsular hematoma after URSL is a rare and one of serious complications. Subcapsular renal hematoma should be considered when patients have the symptoms of significant loin pain after URSL for obstructing ureteral stones with thin renal cortices. The treatment of post-URSL renal subcapsular hematomas needs to be customized for each patient.

Lumbar artery branch injury secondary to ureteroscopic manipulation

Iatrogenic vascular injury in ureteroscopy is relatively uncommon and typically presents as a subcapsular hematoma. We report the case of an injury to a branch of the lumbar artery secondary to ureteral trauma during ureteroscopy. In the immediate postoperative period, the patient became hypotensive and tachycardic, prompting a workup that revealed an active hemorrhage. The patient then underwent subsequent angiogram and successful coil embolization.

Subcapsular hematoma after ureteroscopy and laser lithotripsy

BACKGROUND AND PURPOSE

Renal hematoma after ureteroscopic lithotripsy (URSL) using holmium:yttrium-aluminum-garnet (Ho:YAG) laser is a rare complication. We aimed to review our center's experience of post-URSL subcapsular hematoma.

PATIENTS AND METHODS

From 2007 to 2012, 1114 URSLs using 7.5F semi-rigid ureteroscopes were performed. Patients with post-URSL symptomatic renal hematoma were reviewed. Perioperative information on patients' preoperative morbidity, renal function, stone characteristics, and degree of hydronephrosis were reviewed. Operative information, postoperative presentation of symptoms, changes in blood parameters, CT findings, and subsequent management were documented.

RESULTS

Post-URSL subcapsular hematoma was diagnosed in 4 of 1114 (0.36%) patients, who ranged in age from 43 to 63 years. Preoperative imaging showed that all four patients had obstructing proximal ureteral stones ranging in size from 0.7 to 2.1 cm, and three of them had thin renal cortices. Pressure bags were not used, and Double-J ureteral stents were inserted in all cases. All four patients had the triad of loin pain, fever, and significant hemoglobin drop necessitating transfusion. Three patients presented within 2 days of URSL, and one patient presented on day 20. One patient was treated conservatively and recovered with bed rest and antibiotics. Urgent angiography was performed on one patient in view of a significant drop in hemoglobin, but no embolization was needed. One patient underwent ultrasonography-guided drainage of the hematoma, and another had an emergency open clot evacuation because of significant compression on the kidney by the hematoma. Follow-up CT scans confirmed the resolution of the hematoma in all cases.

CONCLUSIONS

Post-URSL subcapsular hematoma is a rare but potentially serious complication. A high index of suspicion is needed when patients present with significant loin pain and fever after URSL for obstructing proximal ureteral stones with thin renal cortices. The management of post-URSL subcapsular hematomas needs to be customized for each patient.

Renal subcapsular hemorrhage complicating ureterolithotripsy: an unknown complication of a known day-to-day procedure

OBJECTIVE

To report the incidence, risk factors, and treatments of renal subcapsular hemorrhage (RSH) complicating ureteroscopic lithotripsy (URSL).

PATIENTS AND METHODS

Data from 1,918 URSLs performed between January 2004 and March 2012 were retrospectively analyzed. Patients' data included age, sex, relevant medical history, stone side, size, and degree of hydronephrosis.

RESULTS

All 8 patients were identified as having an RSH after URSL. There were 2 males and 6 females with a mean age of 45.6 years (range 30-62 years). The patients' relevant medical histories (renal calculi extracorporeal shock wave lithotripsy, renal operation and hypertension) were statistically different between those who did and did not develop an RSH. Acute onset of flank pain is the most common symptom. Three patients with infective and large hemorrhage were managed by percutaneous nephrostomy in 1 and percutaneous subcapsular drainage in 2. Five patients with small and uninfected hemorrhage were managed conservatively.

CONCLUSIONS

The rate of development of RSH complicating URSL is very low. RSH complicating URSL can occur in patients with underlying renal abnormalities. RSH is rarely associated with abrupt hemodynamic instability and usually not lethal. Treatment is selected based on the patient's hemodynamic state, infection, renal function, and the feasibility of treatment modality.

Intracorporeal laser lithotripsy

Objectives

To review the current literature on intracorporeal laser lithotripsy.

Methods

We searched PubMed for relevant reports up to January 2012, using the keywords ‘laser’, ‘lithotripsy’ and ‘intracorporeal’.

Results

We studied 125 relevant reports of studies with various levels of evidence. Efficient lithotripsy depends on the laser variables (wavelength, pulse duration and pulse energy) and the physical properties of the stones (optical, mechanical and chemical). The most efficient laser for stones in all locations and of all mineral compositions is the holmium yttrium–aluminium–garnet laser (Ho:YAG). The frequency-doubled double-pulse Nd:YAG laser functions through the generation of a plasma bubble. New laser systems, such as the erbium:YAG and the thulium laser, are under evaluation. Laser protection systems have also been developed for the novel digital flexible ureteroscopes. Although complications are rare, a high relevant clinical suspicion is necessary.

Conclusions

Laser lithotripsy technology is continuously developing, while the Ho:YAG laser remains the reference standard for intracorporeal lithotripsy.