CASE 10180 Published on 05.07.2012

Imaging findings of Renal Haematoma after Extracorporeal Shock Wave Lithotripsy (ESWL).

Section

Uroradiology & genital male imaging

Case Type

Clinical Cases

Authors

S.Chawla [1] J. C. Belfield [2]

1. Department of Radiology, University Hospital Aintree, Liverpool, UK.
2. Department of Radiology, Royal Liverpool University Hospital, Liverpool, UK.
Email:sumitachawla@doctors.org.uk

Patient

73 years, male

Categories

Area of Interest Kidney ; Imaging Technique CT, Ultrasound

Procedure Diagnostic procedure ; Special Focus Haemorrhage, Calcifications / Calculi, Acute ;

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Clinical History

A patient presented to our institution with a two-day history of left flank pain after extra shock wave lithotripsy treatment for left-sided renal calculi. He was clinically stable but was admitted for further investigations. He denied the presence of haematuria and his initial haemoglobin was 10.7g/dl.

Imaging Findings

An initial abdominal X-ray was performed, which demonstrated renal calculi in the lower pole of the left kidney and a left JJ stent in situ. Subsequently the patient had an ultrasound, which showed a mixed echogenic mass seen around the left kidney.

The patient deteriorated with dizzy episodes and worsening left flank pain and his blood pressure dropped to 90/65. He went on to have an unenhanced Computed Tomography examination. This showed a high attenuation mass with Hounsfield Unit (HU) 68, anterior to the left kidney tracking from the pancreatic tail to the pelvic brim with significant fat stranding, consistent with a retroperitoneal haematoma. A further area of high attenuation was seen around the outer cortex of the left kidney, consistent with haemorrhage. Bilateral renal calculi and left JJ stent were also noted.

In view of the clinical and imaging findings the patient was treated conservatively and he responded well.

Discussion

Extracorporeal shock wave lithotripsy (ESWL) was introduced in 1980 by Chaussy et al. [1-3] It has since revolutionized the management of urolithiasis by providing an alternative to surgical treatment. The therapeutic use of ESWL became widespread in 1984. [3-7]

There is a reported complication rate of 3-7%, which is mainly due to compressive and tensile force of shock waves directed at soft tissue and cavitation effect on cell integrity. [3, 5, 8]
Most complications are related to the passage of stone fragments, including flank pain, haematuria and ureteric obstruction.

Predisposing factors include hypertension, diabetes mellitus, obesity, increased age, coronary artery disease, small kidney, coagulopathy, use of anticoagulants and increased shock wave number. [2, 4]

The incidence of clinically significant haematoma formation after ESWL is reported in less than 1% of the cases in the literature. [1, 5, 7, 9] Most haematomas secondary to lithotripsy are initially subcapsular, but may extend to the perirenal or retroperitoneal space due to rupture of the renal capsule.

The key to a successful diagnosis of haematoma is an accurate assessment of the extent of renal injury by US, CT or MRI examination. [4, 7, 8] A CT should be performed to assess for haemorrhage when persistent, unexplained pain occurs following ESWL.

Treatment of patients with sub-capsular haematoma is usually conservative. However, transfusion should be immediately started for cases in which signs of hypovolemic shock are observed or where the haemoglobin level is severely decreased. [10, 11]
Embolization or surgical treatment should be considered for cases that do not respond to transfusion and supportive care, including watchful waiting or percutaneous drainage of the blood collection.

Repeat ESWL is not contraindicated but should be postponed for a few weeks after the acute episode. Long-term prognosis is good without adverse effects on blood pressure or renal function. [2, 5, 9] Death may be caused by haemorrhagic shock due to massive renal or retroperitoneal haematoma.

The late complication of a nonoperative approach is the Page Kidney. The term “Page Kidney” refers to the occurrence of hypertension secondary to renal compression associated with a perinephric or sub capsular haematoma, first described by Page in 1939. At present, there are no definitive management options for treatment of Page Kidney. [7, 9, 10]

Renal haematoma post-ESWL is a rare complication, which can often be managed with a nonoperative approach, as the majority of renal parenchymal injuries will be absorbed without surgical exploration. [3, 5, 10]

Differential Diagnosis List

Renal Haematoma after Extracorporeal Shock Wave Lithotripsy.

None

Nil

Final Diagnosis

Renal Haematoma after Extracorporeal Shock Wave Lithotripsy.

References

[1] Kaude JV, Williams CM, Millner MR, Scott KN, Finlayson B. (1985) Renal morphology and function immediately after extracorporeal shock-wave lithotripsy. Amer J Roentgen 145(2):305-313.

[2] Alcover J, Rousaud A, Ruiz Marcellan Fj, Serrallach N, Serrate R. (1992) . Efectos adversos de las ondas de choque. Tema monográfico del LVII Congreso Nacional de Urología Ene Ediciones S.A. Cap. 3: Aspectos técnicos de la LEOC: 33. Cap 5: Efectos biológicos de las ondas de choque: 51-56.

[3] Collado Serra A, Huguet Pérez J, Monreal García de Vicuña F, Rousaud Barón A, Izquierdo de la Torre F, Vicente Rodríguez J. (1999) Renal hematoma as a complication of extracorporeal shock wave lithotripsy. Scand J Urol Nephrol 33(3):171-175

[4] Torrecilla Ortiz C, Matías López JJ, Contreras García J, Aguiló Luciá F, Camps Lloveras N, Riera Canals L. (1997) Renal hematoma after shockwave extracorporeal lithotripsy. Actas Urol Esp 21(8):752-757.

[5] Dhar NB, Thornton J, Karafa MT, Streem SB. (2004) A multivariate analysis of risk factors associated with subcapsular hematoma formation following electromagnetic shock wave lithotripsy. J Urol 172(6 Pt 1):2271-2274.

[6] Krishnamurthi V, Streem SB (1995) Long-term radiographic and functional outcome of extracorporeal shock wave lithotripsy induced perirenal hematomas. J Urol 154(5):1673-1675.

[7] Marini F, Martino F, Alfano V, Valente R. (1989) Computerized tomography and magnetic resonance imaging after ESWL. Arch Esp Urol 42(8):823-824.

[8] Tuteja AK, Pulliam JP, Lehman TH, Elzinga LW. (1997) Anuric renal failure from massive bilateral renal hematoma following extracorporeal shock wave lithotripsy. Urology 50(4):606-608.

[9] Hsin CY, Jung TS, Wen JW. (2008) Spontaneous bilateral subcapsular hematoma of the kidneys: a case report. J Taiwan Urol Assoc 19:228–31.

[10] Héctor Pastor Navarro, Pedro Carrión López, Jesús Martínez Ruiz, José Mª Pastor Guzmán, Mariano Martínez Martín, Julio A. Virseda Rodríguez (2009) Renal hematoma after extracorporeal shock-wave lithotripsy (ESWL). UROLÓGICAS ESPAÑOLAS 33(3):296-303

[11] Liang-Chung huang, Meng-Chia Chen, Che-Wei hsu (2010) Subcapsular Hematoma of Kidney with Rupture into the Perirenal Space After Extracorporeal Shock Wave Lithotripsy:. J Emerg Crit Care Med Vol. 21, No. 4

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