Thoughts on diagnosis and treatment of catheter - Related refractory upper urinary tract Bleeding:A case report

Abstract

We present an extremely rare case of refractory upper urinary tract bleeding related to a single "J" tube, unreported globally. A patient with high - grade invasive urothelial carcinoma had LRC + bilateral uretero - cutaneous ostomy, then bleeding unresponsive to transfusion and RAE. Recovery came after tube removal, with no hematuria in 2 - month follow - up.

Keywords: Hemorrhage of renal pelvic mucosa; Renal artery embolization; Renal hemorrhage; Self-limiting disease.

Fig. 1

a. The non - enhanced computed tomography (NCCT) of the patient before the operation showed that the bilateral renal capsules were intact, and there was no obvious bleeding or hydronephrosis in the bilateral renal pelves. b. Multiple nodular high - density shadows (CT value: 43 - 70Hu) were visible in the bilateral renal pelves and calyces, which were mostly considered as renal pelvic hematomas with partial organization (indicated by red arrows). c. Multiple tubular and nodular high - density shadows were present in the bilateral renal pelves and calyces (indicated by red and blue arrows). Considering the CT values of the stones, co - existence of old and new bleeding was suspected. There was infection around the renal pelvis and ureter, and thickening of the tube wall was visible, which might be due to chronic inflammation (indicated by blue arrows).

Fig. 2

a. No obvious bleeding points were observed during the right renal artery angiography. b. No obvious bleeding points were detected during the left renal artery angiography.

Fig. 3

a. One month after the operation, the patient underwent CT urography (CTU), which showed that the bilateral single "J" tubes were in the correct positions and their positions were stable, indicating normal placement within the urinary tract. b. The CT scan two months after the operation showed that the bilateral single "J" tubes were located in the renal pelves, with obvious signs of unobstructed drainage. This was a positive sign of the patient's postoperative recovery. c. The subsequent CT re - examination after the change in the patient's condition showed obvious thickening of the ureteral wall. This morphological change was accompanied by obvious signs of chronic inflammation, as indicated by the blue arrows. These changes might be related to the patient's persistent urinary system condition. d. The enhanced CT image showed obvious thickening and congestion of the bilateral renal pelves and ureteral walls. These were typical manifestations of chronic inflammation, as indicated by the blue arrows. In addition, the organized old hematomas in the renal pelves, as indicated by the red arrows, further revealed the patient's internal pathological state. e. On the coronal plane of the three - dimensional CT scan, it could be observed that the upper end of the single "J" tube had shifted and was now located in the upper segment of the ureter. Meanwhile, the ureteral wall was obviously thickened, as indicated by the red arrows. This shift and thickening might have an impact on the patient's urinary function and subsequent treatment.

Fig. 4

a. The trend graph of Hb levels before and after the removal of the single "J" stent. b. The trend graph of PLT levels before and after the removal of the single "J" stent. c. The trend graph of serum creatinine (SCr) levels before and after renal artery embolization (RAE).