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Massive haemorrhage post-extracorporeal shockwave lithotripsy resulting in nephrectomy: a case report At our institution, approximately 700 people receive extracorporeal shockwave lithotripsy (ESWL) annually. Considered a relatively safe procedure, complications do occur. Some of the reported complications include those relating to the passage of stone fragments, infection and the potential for damage to neighbouring structures, specifically cardiovascular, gastrointestinal structures and the unborn foetus.1,2 A 53-year-old male underwent ESWL for a 17-mm right mid-zone renal calculus. He was an otherwise well gentleman with no past history of renal calculi. His co-morbidities were significant only for a history of chronic back pain. He had no prior history of renal calculi. His regular medications at the time of treatment were oxycontin, pregabalin and diazepam. He was not taking any oral anticoagulant medication. The patient in question had presented to the emergency department 3 weeks prior to his ESWL treatment with severe right-sided abdominal pain and two computer tomography (CT) proven renal tract calculi – an 8-mm ureteric calculus causing moderate rightsided hydronephrosis and a 17-mm renal calculus in the inferior calyx treated with cystoscopy and stent insertion. Three weeks later, the patient re-presented for his scheduled ESWL treatment. He underwent a routine procedure receiving 3000
shocks at 80% power. Post-procedure, the patient was noted to be in considerable pain. A CT abdomen/pelvis was completed that evening demonstrating a right-sided perinephric haematoma with active contrast extravasation and pseudoaneurysm (Fig. 1). The patient then underwent digital subtraction angiography embolization later that evening revealing four segmental bleeding vessels. Following the embolization, the patient continued to have significant back pain. The pain was such that repeat CT abdominal angiogram was performed demonstrating ongoing active bleeding at the lateral interpolar region of the right kidney. Further digital subtraction angiography was completed with embolization of multiple branches of the right renal artery (Fig. 2). There had been a considerable decrease in the patient’s haemoglobin, which dropped as low as 62 g/L over this time and was transfused. After the second embolization procedure, it was felt that the patient’s condition had stabilized and he was discharged from intensive care unit to the urology ward. Over the subsequent 24-h period, the patient became increasingly haemodynamically unstable, requiring a further four units of packed red blood cells. At this point, given that multiple attempts at embolization had failed to successfully stem the ongoing haemorrhage, the decision was made to perform an
Fig. 1. CT KUB performed post-ESWL procedure demonstrating a large right subscapsular haematoma.
Fig. 2. Demonstrates multiple attempts at coil embolization of the bleeding renal vessels.
© 2014 Royal Australasian College of Surgeons
ANZ J Surg •• (2014) ••–••
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Another case report describes a 79-year-old female who died 23 h post-ESWL because of the rupture of a small vein in the perirenal adipose capsule, without evidence of damage to the larger renal vessels.10 This patient had undergone ESWL 11 years prior without complication. Established risk factors for bleeding post-ESWL include hypertension, coagulopathies, diabetes, old age, coronary artery disease and obesity,3–6 none of which were present in our patient.
Fig. 3. Right renal specimen post-nephrectomy demonstrating a large laceration of lower interpolar region.
open right nephrectomy. After planned preoperative right renal artery embolization, the patient was taken immediately to the theatre and underwent an open right nephrectomy without complication. Macroscopic specimen evaluation post nephrectomy demonstrated a large laceration at the lower interpolar region (Fig. 3). Renal haemorrhage is considered to be the most common acute, potentially fatal complication. One study found seven cases of severe haematoma out of 4815 ESWL cases between the years 1992–2007 (