
==== Front
J Surg Case Rep
J Surg Case Rep
jscr
Journal of Surgical Case Reports
2042-8812
Oxford University Press

10.1093/jscr/rjae594
rjae594
Case Report
AcademicSubjects/MED00910
jscrep/0170
Renal artery pseudoaneurysm presenting in a single functioning kidney with prior partial nephrectomy following flexible ureterorenoscopy: a case report
Asi Tariq Department of Urology, Main Campus, Al-Quds University, Jerusalem 20002, Palestine

Khamashta Natalie Faculty of Medicine, Main Campus, Al-Quds University, Jerusalem 20002, Palestine

Dalal Ahmad Faculty of Medicine, Main Campus, Al-Quds University, Jerusalem 20002, Palestine

Corresponding author. Department of Urology, Main Campus, Al-Quds University, Jerusalem 20002, Palestine. E-mail: tarikasi07@gmail.com
9 2024
17 9 2024
17 9 2024
2024 9 rjae59426 6 2024
07 9 2024
Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2024.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

Abstract

Renal artery pseudoaneurysm (RAP) formation following flexible ureterorenoscopy (FURS) with laser lithotripsy is rare. Previous kidney surgery places patients at an increased risk due to potential vascular injury associated with renal intervention. In our case, a 62-year-old man with a single functioning right kidney and a history of right partial nephrectomy presented 10 days following FURS with holmium laser lithotripsy, complaining of gross hematuria. Attempted conservative management failed. Renal arteriography was done, which revealed a RAP that was managed with selective angioembolization. RAP following FURS can be serious if not managed properly. Most cases present with late gross hematuria. RAP can usually be demonstrated on renal arteriography. Selective angioembolization is the definitive treatment.

FURS
flexible ureteroscopy
renal artery pseudoaneurysm
holmium laser lithotripsy
==== Body
pmcIntroduction

Flexible ureterorenoscopy (FURS) with laser lithotripsy is considered the first choice for the management of kidney stones ≤2 cm [1]. It is a minimally invasive treatment modality with a relatively low complication rate [2]. Renal artery pseudoaneurysm (RAP) has been rarely reported after uncomplicated FURS with laser lithotripsy [3]. We herein report a case of RAP developed after uncomplicated FURS and Holmium laser lithotripsy in a single functioning kidney. It was managed with selective angioembolization.

Case report

A 62-year-old man presented to the urology clinic complaining of recurrent right flank pain and an ultrasound report of a right kidney stone. Patient had a history of left open pyelolithotomy performed twice due to left kidney stone, which led to left atrophic kidney. He had a history of right open partial nephrectomy due to renal mass highly suspicious of renal cell carcinoma on CT done 4 years ago. He had a medical history of type 2 diabetes mellitus, hypertension, dyslipidemia, and stage I chronic kidney disease (CKD). A new noncontrast CT showed left atrophic kidney and right huge kidney stone of 4.5 × 4 cm in the posterior part of the upper calyx (Fig. 1). Patient was offered percutaneous nephrolithotomy (PCNL), but he refused due to the fear of possible bleeding complications. He preferred multiple session flexible ureteroscopy with holmium laser lithotripsy. The patient was pre-stented 2 weeks before the first session.

Figure 1 (A) Preoperative non-contrast CT scan showing a renal stone measuring 4.5*4 cm. (B) Postoperative non-contrast CT scan. The arrow points to the area from which the pseudoaneurysm most-likely originated postoperatively.

The ureteral access sheath was placed under fluoroscopy guidance. After that, a disposable flexible ureteroscope was introduced. The stone was identified and disintegrated with a low-energy holmium laser machine (30 W) in dusting mode. Total procedure time was 60 min. A double J stent was inserted, and the first session ended uneventfully.

Ten days after discharge, the patient presented to the emergency department (ED) due to gross hematuria. Patient was hemodynamically stable with a hemoglobin drop from 12 on discharge to 10.7 at the ED. Foley’s catheter was applied, and continuous irrigation was performed, which showed persistent gross hematuria. Contrast-enhanced CT was able to identify a faint contrast extravasation at the posterior surface of the kidney, which was reported to be suspicious of vascular complications. Conservative management with blood product transfusion and antifibrinolytic agents was decided. Hematuria subsided 3 days later, and the patient was discharged the following day with a hemoglobin of 11.9.

Eight days after discharge, he presented to the ED complaining of gross massive hematuria. He went into cardiac arrest, and cardiopulmonary resuscitation (CPR) was performed. His hemoglobin had dropped from 11.9 on the day of previous discharge to 6.8. He was later stabilized and started on blood transfusion and was put under close observation until he became hemodynamically stable. He underwent emergent renal arteriography, which showed RAP, and selective angioembolization was done (Fig. 2). Hematuria subsided after 2 days, and the patient was discharged. After 3 months, the patient was well and still in stage I CKD.

Figure 2 (A) Pseudoaneurysm seen on renal angiography. (B) The pseudoaneurysm following angioembolization.

Discussion

The miniaturization of equipment accompanied with the development and advancement in laser technology has facilitated the usage of FURS in the treatment of variable sizes of kidney stones [7]. With its lower vascular complication rate compared to percutaneous nephrolithotomy, it is gaining more popularity despite being an expensive treatment modality [8].

One of the rare vascular complications is RAP, which occurs after focal rupture of the renal artery wall or its branches. This will lead to the formation of a localized hematoma surrounded by a thin fibrin wall, which upon rupturing, will result in massive bleeding [3]. There are few case reports regarding RAP after FURS with laser lithotripsy (Table 1) [3–6]. Commonly, it presents with late massive hematuria, which can be life-threatening if left untreated [9]. In our case, the patient presented with gross hematuria after 10 days of his FURS procedure. Contrast-enhanced CT is beneficial in the diagnosis, but definitive conclusions and interventions are best made using renal arteriography. In our patient, contrast-enhanced CT showed contrast extravasation with high suspicion of RAP. Renal arteriography confirmed the diagnosis of the pseudoaneurysm.

Table 1 Cases reported in the literature of RAP following flexible ureteroscopy and holmium laser lithotripsy.

Case	Sex	Age	Type of intervention	Comorbidities	History of prior renal surgery	Onset of complications	
Durner et al. (2015) [4]	M	56	FURS + holmiumYAG laser	Mitral heart valve replacement	None	N/A	
Bashar & Hammad (2019) [5]	M	79	FURS + holmium laser	DM + HTN + stage 4 CKD + valvular heart disease	Previous ESWL and FURS with Holmium laser lithotripsy	4 days later	
Deng et al. (2022) [3]	M	29	FURS + holmium laser	Diabetes for 2 years	None	28 days later	
Yin et al. (2023) [6]	M	53	FURS + holmium laser	None	Open bilateral nephrolithotomy (33 years ago) + bilateral inguinal hernia repair (1 month ago)	8 days later	
CKD, chronic kidney disease; DM, diabetes mellitus; ESWL, Extracorporeal shock wave lithotripsy; FURS, flexible ureterorenoscopy; HTN, hypertension; NSTEMI, nonST elevation myocardial infarction; N/A, not available.

The formation of RAP after FURS is caused by multiple factors and not attributed to a single cause. The factors include direct renal damage, increased intrarenal pressure, prolonged operation time, high laser energy, and lastly, previous kidney surgery [9]. The type of the laser, whether holmium or thulium laser, probably does not affect the possibility of RAP formation, as there are case reports related to RAP formation after FURS with thulium laser technology [9]. Our patient had a history of open partial nephrectomy due to kidney mass in the posterior surface. Renal arteriography demonstrated the RAP to be in the posterior branches of the renal artery, which is highly suggestive that previous surgery led to alteration in the intrarenal anatomical course of the vasculature and thinner renal parenchyma in the operation site, which increased the risk of intrarenal vascular damage even with an unintentional mucosal low-energy laser insult. Therefore, urologists could be very careful when deciding and doing FURS with laser lithotripsy in patients with previous kidney surgery.

Selective angioembolization is considered a definitive treatment modality because it is minimally invasive with little harm to kidney function [10]. Open repair is the choice when angioembolization fails or if the patient is hemodynamically unstable. Conservative management of RAPs with blood products, transfusions, and antifibrinolytic agents was reported in a few cases with trauma-related RAPs and was enough to control the situation [11]. Despite the possibility of conservative management of RAPs, intervention could be more appropriate because it is hard to predict the outcome. As in our case, conservative management failed and could lead to fatal consequences.

Renal pseudoaneurysm is a rare and unusual complication after FURS with laser lithotripsy. It presents with late gross massive hematuria, which could be life-threatening if not recognized or suspected. Good selection of cases, minimizing operation time, maintaining a normal intrarenal pressure, avoiding direct laser contact with mucosa, and using low energy are the main preventing modalities.

Conflict of interest statement

None declared.

Funding

No external funding was provided.
==== Refs
References

1. Türk C , PetříkA, SaricaK, et al.  EAU guidelines on interventional treatment for Urolithiasis. Eur Urol  2016;69 :475–82.10.1016/j.eururo.2015.07.041.26344917
2. Baş O , TuygunC, DedeO, et al.  Factors affecting complication rates of retrograde flexible ureterorenoscopy: analysis of 1571 procedures-a single-center experience. World J Urol  2017;35 :819–26.10.1007/s00345-016-1930-3.27604373
3. Deng XX , ZhangW, FuD, et al.  Renal pseudoaneurysms after flexible ureteroscopy and holmium laser lithotripsy: a case report. Front Surg  2022;9 :896548.10.3389/fsurg.2022.896548.36034371
4. Durner L , El HowairisMEF, BuchholzN. Renal pseudoaneurysm after flexible ureterorenoscopy - an unusual complication. Urol Int  2017;99 :484–6.10.1159/000441042.26595208
5. Bashar A , HammadFT. Intrarenal arteriovenous malformation following flexible ureterorenoscopy and holmium laser stone fragmentation: report of a case. BMC Urol  2019;19 :20.10.1186/s12894-019-0447-7.30902085
6. Yin C , ChenF, JiangJ, et al.  Renal pseudoaneurysm after holmium laser lithotripsy with flexible ureteroscopy: an unusual case report and literature review. J Int Med Res  2023;51 :030006052311627.10.1177/03000605231162784.
7. Hyams ES , MunverR, BirdVG, et al.  Flexible ureterorenoscopy and holmium laser lithotripsy for the management of renal stone burdens that measure 2 to 3 cm: a multi-institutional experience. J Endourol  2010;24 :1583–8.10.1089/end.2009.0629.20629566
8. Doizi S , TraxerO. Flexible ureteroscopy: technique, tips and tricks. Urolithiasis  2018;46 :47–58.10.1007/s00240-017-1030-x.29222575
9. Al Barajraji M , CoscarellaM, HolzS, et al.  Occult renal artery pseudoaneurysm causing persistent hematuria after flexible thulium fibered laser lithotripsy: a case report and literature review of rare but potentially fatal complication. Radiol Case Rep  2023;18 :3525–8.10.1016/j.radcr.2023.07.030.37547792
10. Monteiro A , WaisanenKM, ErmolovichEV, et al.  Case - renal artery pseudoaneurysm: a life-threatening occurrence following thulium laser lithotripsy. Can Urol Assoc J  2022;16 :E298–300.10.5489/cuaj.7548.34941489
11. Yamaçake KGR , LuconM, LuconAM, et al.  Renal artery pseudoaneurysm after blunt renal trauma: report on three cases and review of the literature. Sao Paulo Med J Rev Paul Med  2013;131 :356–62.10.1590/1516-3180.2013.1315488.
