title: Subcapsular hematoma after ureteroscopy and laser lithotripsy.
abstract: OBJECTIVE
  Renal hematoma after ureteroscopic lithotripsy (URSL) using holmium:yttrium-aluminum-garnet (Ho:YAG) laser is a rare complication. We aimed to review our center's experience of post-URSL subcapsular hematoma.
  
  
  METHODS
  From 2007 to 2012, 1114 URSLs using 7.5F semi-rigid ureteroscopes were performed. Patients with post-URSL symptomatic renal hematoma were reviewed. Perioperative information on patients' preoperative morbidity, renal function, stone characteristics, and degree of hydronephrosis were reviewed. Operative information, postoperative presentation of symptoms, changes in blood parameters, CT findings, and subsequent management were documented.
  
  
  RESULTS
  Post-URSL subcapsular hematoma was diagnosed in 4 of 1114 (0.36%) patients, who ranged in age from 43 to 63 years. Preoperative imaging showed that all four patients had obstructing proximal ureteral stones ranging in size from 0.7 to 2.1 cm, and three of them had thin renal cortices. Pressure bags were not used, and Double-J ureteral stents were inserted in all cases. All four patients had the triad of loin pain, fever, and significant hemoglobin drop necessitating transfusion. Three patients presented within 2 days of URSL, and one patient presented on day 20. One patient was treated conservatively and recovered with bed rest and antibiotics. Urgent angiography was performed on one patient in view of a significant drop in hemoglobin, but no embolization was needed. One patient underwent ultrasonography-guided drainage of the hematoma, and another had an emergency open clot evacuation because of significant compression on the kidney by the hematoma. Follow-up CT scans confirmed the resolution of the hematoma in all cases.
  
  
  CONCLUSIONS
  Post-URSL subcapsular hematoma is a rare but potentially serious complication. A high index of suspicion is needed when patients present with significant loin pain and fever after URSL for obstructing proximal ureteral stones with thin renal cortices. The management of post-URSL subcapsular hematomas needs to be customized for each patient.
authors.affiliation: Department of Surgery, Princess Margaret Hospital, Hong Kong.
authors.forename: Peter Ka-Fung
authors.initials: PK
authors.lastname: Chiu
authors.forename: Chun-Ki
authors.initials: CK
authors.lastname: Chan
authors.forename: Wai-kit
authors.initials: WK
authors.lastname: Ma
authors.forename: Kim-Chung
authors.initials: KC
authors.lastname: To
authors.forename: Fu-Keung
authors.initials: FK
authors.lastname: Cheung
authors.forename: Ming-kwong
authors.initials: MK
authors.lastname: Yiu
mesh_terms: D000328:Adult; D005260:Female; D005334:Fever / Q000209:etiology; D006406:Hematoma / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D006801:Humans; D007674:Kidney Diseases / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D053844:Lasers, Solid-State / Q000009:adverse effects; D017602:Lithotripsy, Laser / Q000009:adverse effects* / Q000295:instrumentation; D008297:Male; D008875:Middle Aged; D010149:Postoperative Pain / Q000209:etiology; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014514:Ureteral Calculi / Q000175:diagnosis / Q000601:surgery*; D014517:Ureteral Obstruction / Q000175:diagnosis / Q000601:surgery*; D020709:Ureteroscopes / Q000009:adverse effects; D018666:Ureteroscopy / Q000009:adverse effects* / Q000295:instrumentation