case_images: PMC10587595_01
case_images: (A) Ureteroscopic lithotripsy preoperative abdominal CT showed a right upper ureteral stone (red arrow), about 0.5 cm in diameter (July 24, 2022). (B) Ureteroscopic lithotripsy preoperative abdominal CT showed no significant abnormality in the morphology, size and density of both kidneys, and clear perinephric space in both kidneys. The red arrow shows mild dilatation of the right renal pelvis (July 24, 2022). (C) The patient was transferred to our department for the first abdominal CT. The images showed no significant abnormalities in both kidneys and bilateral ureters (September 15, 2022, day 12 of admission).
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case_images: PMC10587595_01_fmed-10-1173386-g001.jpg
case_images: fig1
case_images: One month before admission, he underwent a holmium laser lithotripsy and right double J-tube placement in a local hospital for right upper ureteral calculi and hydronephrosis (Figures 1A,B). Other laboratory results, including blood potassium, blood glucose, coagulation, liver function, and CRP levels were within normal limits. After transfer to our department, a computed tomography (CT) of the abdomen showed no significant abnormalities in both kidneys and bilateral ureters (Figure 1C). Other laboratory tests: WBC 8.83 x 109/L, N 0.77, HB 97 g/L, PLT 373 x 109/L, Cre 336 mumol/L, creatinine clearance 50.97 mL/min/1.73 m2, urine WBC 19/muL, urine RBC 14168/muL, PT 13.90 s, APTT 29.90 s,
case_images: (A) CT of both kidneys. The right kidney is increased in size, heterogeneous in density, with multiple flaky hyperdense shadows, and clear perirenal space in both kidneys. The red arrow shows a hematoma in the lower pole of the right kidney (September 19, 2022, day 16 of admission). (B) Angiography of the right renal artery. Red arrows show active extravasation of multiple subsegmental arteries supplying the lower pole. White arrow indicates pseudoaneurysm formation (September 19, 2022, day 16 of admission). (C) CT of both kidneys. The right kidney is increased in size, heterogeneous in density, with multiple patchy hyperdense shadows, and clear perirenal space in both kidneys. The red arrow shows a hematoma in the upper pole of the right kidney (September 22, 2022, day 19 of admission). (D) Digital subtraction angiography of the right renal artery. Red arrow indicates active extravasation of the subsegmental artery supplying the superior pole (September 22, 2022, day 19 of admission).
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case_images: PMC10587595_01_fmed-10-1173386-g002.jpg
case_images: fig2
case_images: Fib 3.95 g/L. Four days later, the patient presented with significant gross hematuria with difficulty in urination, and a repeat abdominal CT showed multiple hemorrhages and hypodense lesions in the right kidney (Figure 2A), and the bladder was filled with a blood clot. With the patient's and family's consent, selective right renal artery embolization was performed immediately (Seldinger method, puncture of right femoral artery), and intraoperative angiography revealed multiple hemorrhages and pseudoaneurysm formation in the lower pole of the right kidney (Figure 2B), and the lower pole of the right renal artery was embolized using 2 platinum spring coils and 350 mum gelatin sponge particles. APTT 29.70 s, Fib 4.05 g/L. Abdominal CT showed hemorrhage and pneumatization in the right kidney and blood in the bladder, and it was considered that there was still active bleeding in the right kidney (Figure 2C). Intraoperative contrast reveals multiple hemorrhagic spots in the upper pole of the right kidney (Figure 2D), and the same was embolized using 2 platinum spring coils and 350 mum gelatin sponge particles in the upper pole artery of the right kidney.
case_images: (A) CT of both kidneys. The left kidney is increased in size, heterogeneous in density, with multiple patchy hyperdense shadows and a few flocculent hyperdense shadows seen in the perirenal space of the left kidney. The red arrow indicates a hematoma in the lower pole of the left kidney (September 27, 2022, day 5 of transfer to ICU). (B) Digital subtraction angiography of the left renal artery. The red arrow shows suspicious active extravasation of the subsegmental artery supplying the lower pole (October 18, 2022, day 26 of transfer to ICU).
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case_images: fig3
case_images: A repeat abdominal CT showed bleeding in both kidneys, with additional bleeding in the left kidney (Figure 3A). With the consent of the patient's family, a left renal arteriogram was attempted on the patient (Seldinge method, puncture of the left femoral artery), a suspicious bleeding point in the left inferior pole artery was found intraoperatively (Figure 3B), therefore, 350 mum gelatin sponge particles were used to embolize this vessel.
case_images: Timeline from the first surgery to discharge. All of these events occurred in 2022.
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case_images: PMC10587595_01_fmed-10-1173386-g004.jpg
case_images: fig4
case_images: The timeline from the first surgery to discharge is presented in Figure 4.