What are the management options for a patient with hematuria after ureteral stent placement?

Management of Hematuria After Ureteral Stent Placement

Severity Assessment and Initial Approach

Mild hematuria after ureteral stent placement is expected and benign in approximately 50% of patients, requiring only observation, while persistent or massive bleeding demands urgent evaluation for life-threatening vascular injury. 1

Distinguish Between Mild and Severe Hematuria

• Mild hematuria (pink-tinged urine, clearing with hydration) is clinically asymptomatic and common after stent placement, occurring in roughly half of patients 1
• Persistent or massive hematuria (bright red blood, clots, hemodynamic instability) requires immediate intervention as it may indicate clinically significant bleeding into the collecting system or retroperitoneum 1
• Thrombocytopenia increases bleeding risk and should be checked if hematuria is more than minimal 1

Critical Life-Threatening Diagnosis: Ureteroarterial Fistula

In patients with long-term indwelling ureteral stents who develop gross hematuria—especially women with prior pelvic surgery or radiation—ureteroarterial fistula must be immediately suspected as this represents a urological emergency with mortality rates of 7-23%. 2, 3

High-Risk Features for Ureteroarterial Fistula

• History of pelvic surgery (particularly gynecologic procedures like Wertheim-Meigs operation) 2, 4, 3
• Prior pelvic radiation therapy 2, 3
• Long-term or chronic ureteral stenting 2, 3
• High-pressure balloon dilation during stent placement 2
• Female gender (all reported cases in one series) 3

Diagnostic Approach for Suspected Vascular Injury

• Do NOT remove the stent if massive bleeding occurs during stent change—the stent may be tamponading the fistula 5
• CT angiography has poor diagnostic accuracy and often delays diagnosis, leading to over-treatment 3
• Angiography is the gold standard diagnostic tool and should be performed urgently when ureteroarterial fistula is suspected 1, 5, 3
• Look for pseudoaneurysms, arteriovenous fistulas, or frank contrast extravasation on angiography 1

Management of Ureteroarterial Fistula

• Endovascular stent graft placement is the preferred first-line treatment as it is minimally invasive, corrects the bleeding source, and preserves distal blood flow 5, 6, 3
• Transcatheter embolization can be used for vascular injuries but may require extra-anatomic vascular reconstruction 1, 5
• Surgical options include nephroureterectomy, ureteral reconstruction with bypass surgery and ureter ligation, or nephrostomy tube placement 5, 2
• Endovascular treatment has shown good outcomes with no mortality in recent series 3

Management of Non-Life-Threatening Hematuria

Conservative Management for Mild Hematuria

• Initial observation is appropriate for mild, self-limited hematuria without hemodynamic compromise 1
• Ensure adequate hydration to prevent clot formation
• Monitor hemoglobin if bleeding persists beyond 24-48 hours

When to Escalate Care

• Persistent bleeding beyond 48-72 hours should prompt arteriographic evaluation even if not massive 1
• Hemorrhage requiring transfusion occurs in approximately 4% of patients after percutaneous nephrostomy alone 1
• Rising creatinine, severe flank pain, or anuria indicate obstruction requiring immediate urologic consultation 7, 8

Stent-Related Interventions

• Stent migration (occurs in ~5% of cases) can cause bleeding and requires cystoscopic repositioning or replacement 7, 8
• Plain radiography or ultrasound can confirm stent position 7, 8
• If stent removal is considered due to persistent symptoms, ensure the original indication for placement has resolved 7, 8

Critical Pitfalls to Avoid

• Never dismiss gross hematuria in patients with long-term stents—assume ureteroarterial fistula until proven otherwise, particularly in women with surgical/radiation history 2, 3
• Do not rely on CT scan alone for diagnosis of vascular injury; proceed directly to angiography if clinical suspicion is high 3
• Avoid removing a stent during active massive bleeding as it may worsen hemorrhage from an underlying fistula 5
• Do not delay urologic and interventional radiology consultation when persistent or severe hematuria is present 1, 7