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.