What is the next step in managing a 53-year-old man who is hemodynamically stable but has a significant drop in hemoglobin (from 13 to 10) and a right perinephric hematoma on CT scan, three days after a right Percutaneous Nephrolithotomy (PCNL)?

Management of Post-PCNL Perinephric Hematoma in a Hemodynamically Stable Patient

For a hemodynamically stable patient with a perinephric hematoma and significant hemoglobin drop after PCNL, angiography with potential super-selective angioembolization is the recommended next step in management.

Initial Assessment

• The patient is hemodynamically stable but has experienced a significant hemoglobin drop (from 13 to 10) with evidence of perinephric hematoma on CT scan following PCNL 1
• Hemodynamic stability despite the presence of a hematoma and hemoglobin drop allows for non-operative management as the initial approach 1
• The significant hemoglobin drop (3 g/dL) indicates active or recent bleeding that requires intervention despite current hemodynamic stability 1

Management Algorithm

Step 1: Confirm Hemodynamic Stability

• Ensure ongoing hemodynamic monitoring (heart rate, blood pressure, capillary refill) 1
• Continue to assess for signs of hemodynamic deterioration that would necessitate immediate surgical intervention 1

Step 2: Diagnostic Angiography

• Angiography with potential super-selective angioembolization is indicated in this hemodynamically stable patient with:

  • Significant hemoglobin drop (3 g/dL)
  • Perinephric hematoma on CT scan
  • Recent PCNL (high risk for arterial injury) 1

• CT angiography (CTA) may be performed first as a screening technique to identify potential bleeding sources such as pseudoaneurysms or arteriovenous fistulas 2

Step 3: Angioembolization

• If active bleeding, pseudoaneurysm, or arteriovenous fistula is identified, proceed with super-selective angioembolization 1
• Angioembolization should be performed as selectively as possible to preserve renal function 1
• This approach has a high success rate (63-100%) in controlling bleeding while preserving kidney function 1

Step 4: Post-Procedure Management

• Following angioembolization, the patient should be admitted to a critical care area for monitoring 1
• Continue serial hemoglobin measurements and hemodynamic monitoring 1, 3
• Monitor for complications including persistent fever, ileus, or worsening hematoma 4

Rationale for Angioembolization

• Extended perirenal hematoma is a specific indication for angiography and potential angioembolization 1
• The procedure is minimally invasive compared to surgical exploration and has lower complication rates 1
• Renal dysfunction or renovascular hypertension directly linked to angioembolization for renal injury is rare 1
• Angioembolization has better outcomes in terms of renal function and ICU length of stay compared with nephrectomy 1

Alternative Approaches

• If angiography is negative for active bleeding, conservative management with close monitoring is appropriate 1
• If the patient becomes hemodynamically unstable during management, immediate surgical intervention is indicated 1
• In cases where angioembolization fails, a repeat angioembolization should be considered before proceeding to surgery 1

Important Considerations

• Blind angioembolization is not indicated if angiography is negative for active bleeding 1
• Most perinephric hematomas after PCNL (approximately 30%) do not require intervention, but the significant hemoglobin drop in this case warrants further investigation 4
• The success of angioembolization is linked to the experience of the center, so the procedure should be performed at facilities with appropriate expertise 1