LARGE PERIRENAL HEMATOMA AFTER EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY E ANDREW KNORR, M.D. JEFFREY R. WOODSIDE, M.D. From the Division of Urology, University of New Mexico School of Medicine, Albuquerque, New Mexico

LCT-- We report a case of a large perirenal hematoma following extracorporeal shock-wave (ESWL) that resulted in compromised renal blood flow and function and necessitated drainage. Caution is advised and close follow-up recommended in patients who have " "n-containing compounds, are elderly, have hypertension, or exhibit a significant drop in rit following ESWL.

is a well-recognized eomrporeal shock-wave litho~t are small and asymptolreat to renal function. We whom a large perirenal hefollowing ESWL which 'unction and required open lr weeks postoperative. Case Report white man with a of idiopathic calcium ght flank pain. An in?) demonstrated three md left kidneys. The idney was in a midcax 20 ram. There was truetion, and the paVL. The preoperative ,artial thromboplastin t count were normal 18 percent. zave lithotripsy of the erformed after placeeral stent. A total of :ed at 22 kV. Severe stoperatively, neeessiaage for an additional Jped to 29 percent on ttment. It was later had been taking two Ileeding time was ele-

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vated. He was discharged taking ferrous sulfate and was instructed to discontinue aspirin. Lithotripsy of the left renal calculi was scheduled in six weeks. The patient was seen at the referring institution one week after ESWL complaining of malaise, flank pain, and shortness of breath. He had been passing some gravel, The hematocrit remained 29 percent. Ferrous sulfate was continued, and he returned three weeks later. An IVP showed a delayed right nephrogram and no excretion of dye thirty-five minutes later (Fig. 1A). A renogram demonstrated poor blood flow to the right kidney (Fig. 1B). Ultrasound examination of the right kidney showed a large perirenal hematoma and the suggestion of parenchymal compression (Fig. IC). Blood pressure at the time of admission was 155/95 mm Hg. Surgical drainage of the perirenal hematoma was performed and approximately 450 mL of clot were evacuated. Measurement of the pressure within the Gerota fascia prior to its incision was 49 mm Hg. On postoperative day I a renogram showed improved blood flow to the right kidney (Fig. 1D). An IVP four weeks later showed a prompt nephrogram and excretion of contrast material at five minutes (Fig. 1E). Comment Perirenal and subcapsular hematomas are well-recognized complications of ESWL. In the

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FICURE 1. (A) IVP one month after ESWL shows delayed Junction oJ right kidney, indwel stent and stone fragments in lower pole collecting system. (B) Preoperative renogram demonstr, blood flow in right kidney. (C) Right renal ultrasound shows large perirenal hematoma and parenehymal compression. (D) Benogram one day after surgical drainage oj hematoma dem( improvement in right renal blood flow. (E) IVP four weeks after surgery shows prompt furJ kidney and excretion of contrast material. original series by Chaussy et al. ~ subcapsular h e m a t o m a s occurred in 6 of 945 patients (0.6%) ,echo had received a total of 1,068 treatments. 'Two patients required blood transfusion. The United States Cooperative Study and the Methodist Hospital of Indiana each reported low incidences of perirenal bleeding, 0.2 percent and 0.4 percent, respectively: '3 These were eharaeterized as "the most significant 152

clinical event directly attrib~ waves. ''a Forty percent of th quired transfusion, but only than 2 units of blood. Similai several of these patients were £c vated bleeding times from aspJ When the acute effects of sh( kidneys are carefully studied, a cidenee of renal bleeding is des~ . . . . . .

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Eects of E S W L with exitative radionuclide re., resonance imaging. In ,f 38 treated kidneys exlar hemorrhage (24 %) renal cyst (5 %). Dif• incidence of perirenal ,qates to several factors. le patient immediately etic resonance imaging ive test for detecting rest, Chaussy et al.1 studan IVP and renogram ttment, at which time aorrhages may have retmber of shoeks in the exceeded that reported ~he Methodist Hospital g the FDA trials an xal ultrasound were obrs after ESWL. Three ; obtained; and if residsent, an exeretory uroMRI is more sensitive •etory urography in de~.eding and only larger uld be detected by the ged bleeding, as in our nissed b y renal ultrasotours after ESWL. m of canine kidneys afcortical and medullary eys after forty-eight to tree fourths of canine rirenal hemorrhage afttrarenal and perirenal ad to be related to the ~toperative perinephric :hodist Hospital of In:ion could be found bee weight of the patient, ne disease, stone size, y of previous renal surthe kidney, number of 'eament, or abnormal tes. ~ There was, howLhypertension and adnee of hypertension in tic hematoma was 67 tl 7 pereent in the overaypertensive patients in ~veloped were in poor liastolic blood pressures . . . . . . . . . ~. ~ n i f i c a n t risk was con-

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ferred by both advanced age and hypertension; 7 of 9 patients over fifty years of age with a hematoma were hypertensive, and all patients over sixty years with a hematoma had hypertension. Consonant with these findings, our patient was sixty-seven years old and admission blood pressure was 155/95 m m Hg. Outpatient lithotripsy has become increasingly popular. I m m e d i a t e complications of ESWL are often treated by admission to the treatment facility or referral hospital. Interestingly, the Indiana series found that the majoriVy of patients with perinephric hematoma had a renal pelvic stone (53 % ), usually I cm or less in diameter, and received 1,000 or less shock waves. 6 Such stones are considered those most amenable to outpatient lithotripsy. Long-term patient follow-up after ESWL is conducted by either the treatment facility or referring physician. Failure to follow these.patients closely or failure by the patient to return for evaluation, especially those at increased risk, can result in eomplieations that threaten renal funetion. Certainly the most common is silent renal obstruction. 7 Also at risk for significant perirenal h e m a t o m a are those who are elderly and hypertensive or who show a significant drop in hematoerit after ESWL. These patients should undergo a renal ultrasound twenty-four hours after ESWL and again within the next month. Abnormalities can be further investigated, if necessary, using MRI or CT scanning. Patients taking aspirin-containing compounds should be instructed to stop these medications two weeks prior to ESWL. 6431 Fannin, Suite 6.018 Texas Medical Center Houston, Texas 77030 (DR. WOODSIDE) References 1, Chaussy C, et ah Extraeorporeal shock-wave lithotripsy (ESWL) for treatment of urolithiasis, Urology (Special Issue) 23: 59 (1984). 2. Drach GW, et ah Report of the United States cooperative study of extracorporeal shock wave llthotripsy, J Urol 135:1127 (1986L 3. Lingeman JE, et ah Extracorporeal shock wave lithotripsy: the Methodist Hospital of Indiana experience, J Urol t35:1184

(1986).

4. Kaude ]V, et ah Renal morphology and function immediately after extraeorporeal shock wave lithotripsy, AJR 145:305

(1985).

5. Newman R, et ah Pathologic effects of ESWL on canine renal tissue, Urology 2 9 : i 9 4 (1987). 6. Newman DM, et ah ExtracorporeaI shock-wave lithotripsy, Urol Clin North Am 14:63 (1987). 7. Hardy MR, and MeLeod DG: Silent renal obstruction with severe functional loss after extracorporeal shock wave lithotripsy: a report of 2 cases° J Urol 137:91 (1987).

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Large perirenal hematoma after extracorporeal shock-wave lithotripsy.

We report a case of a large perirenal hematoma following extracorporeal shock-wave lithotripsy (ESWL) that resulted in compromised renal blood flow an...
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