How to manage post-operative bleeding after a left Ureteroscopic Retrograde Stone Lithotripsy (URSL) procedure for renal stones?

Management of Post-Operative Bleeding After Left URSL for Renal Stones

For post-operative bleeding after ureteroscopic retrograde stone lithotripsy (URSL), immediate assessment of bleeding severity followed by appropriate interventions is essential, with ureteroscopy being the preferred first-line treatment in patients with bleeding complications.

Initial Assessment and Management

Immediate Evaluation

• Assess hemodynamic stability (blood pressure, heart rate)
• Evaluate the severity of bleeding (hematuria characteristics - mild, moderate, severe)
• Monitor for signs of hypovolemic shock
• Check hemoglobin/hematocrit levels to quantify blood loss 1

First-Line Interventions

1. For mild hematuria (common and expected):

   • Conservative management with hydration
   • Mild hematuria is present in approximately 50% of patients after urological procedures and typically resolves spontaneously 2
   • Monitor for clot formation that could lead to obstruction

2. For moderate bleeding with stable vital signs:

   • Ensure adequate ureteral stent patency (if placed during URSL)
   • Maintain hydration to prevent clot formation
   • Bed rest to minimize physical activity
   • Analgesics for pain control
   • Monitor hemoglobin levels

3. For severe bleeding with hemodynamic instability:

   • Immediate fluid resuscitation
   • Consider blood transfusion if hemoglobin drops significantly
   • Apply direct pressure with gauze for 3-5 minutes to allow natural hemostasis 1
   • Maintain systolic blood pressure of 80-100 mmHg until bleeding is controlled 1

Management Based on Bleeding Source

Intraluminal Bleeding

• If bleeding is from the ureter or collecting system:
  • Ensure proper ureteral stent placement for tamponade effect
  • Consider upsizing the stent if bleeding persists
  • Maintain adequate hydration to prevent clot formation

Subcapsular Renal Hematoma

• Rare but serious complication of URSL (reported in case studies) 3
• Presents with significant loin pain, fever, and sometimes hemoglobin drop
• Diagnosis confirmed by CT scan
• Management options:
  1. Conservative treatment for small, stable hematomas:
     • Bed rest, antibiotics, hemostasis, and analgesia 3
  2. Ultrasonography-guided drainage for larger or symptomatic hematomas 3

Arterial Bleeding

• For persistent significant bleeding suggesting arterial injury:
  • Angiography and selective embolization is the treatment of choice 4
  • Angiographic findings may include arteriovenous fistula, pseudoaneurysm, or lacerated renal vessels 4

Risk Factors and Prevention

Identified Risk Factors for Post-URSL Complications

• Longer operative duration (>90 minutes significantly increases risk) 5
• Lower hospital procedural volume 5
• Thin renal cortices 3
• Obstructing ureteral stones 3

Prevention Strategies

• Use of safety guidewire during the procedure (recommended by AUA guidelines) 2
• Limiting operative duration when possible 5
• Careful technique, especially with laser lithotripsy
• Appropriate stent placement post-procedure when indicated

Special Considerations

Anticoagulation Management

• For patients on anticoagulants with severe bleeding:
  • Consult with the prescribing physician regarding temporary discontinuation
  • Resume anticoagulation as soon as hemostasis is achieved 1
  • URS is considered first-line therapy in patients with bleeding diatheses or who require continuous anticoagulation/antiplatelet therapy 2

Infection Prevention

• Monitor for signs of infection or sepsis
• Consider prophylactic antibiotics if not already administered
• If purulent drainage is observed, obtain cultures and provide appropriate antibiotic coverage 2

When to Escalate Care

Indications for Angiography and Embolization

• Persistent bleeding despite conservative measures
• Hemodynamic instability despite fluid resuscitation
• Significant drop in hemoglobin requiring multiple blood transfusions
• Sudden hemorrhage occurring more than 7 days postoperatively 4

Indications for Surgical Intervention

• Failed embolization
• Expanding retroperitoneal hematoma
• Refractory hemodynamic instability

By following this algorithmic approach to post-URSL bleeding management, clinicians can effectively address this complication while minimizing morbidity and mortality.