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.

1 Introduction

Refractory upper urinary tract bleeding associated with a single “J” tube needs to be carefully differentiated from spontaneous renal hemorrhage (SRH) and idiopathic submucosal bleeding of the renal pelvis (AGL). Clinically, once these two rare diseases are excluded in cases of refractory upper urinary tract bleeding, this condition should be the top consideration.

2 Case report

The patient was a 71 – year – old male who underwent laparoscopic radical cystectomy (LRC) plus bilateral uretero – cutaneous ostomy on April 11, 2023. After the surgery, the patient regularly returned to the hospital for the replacement of the single “J” tube. On February 13, 2024, bright – red bloody urine emerged immediately after the replacement of the single “J” tube. Subsequently, hematuria recurred repeatedly and became more severe each time after the replacement of the single “J” tube.

By comparing the CT images before and after the change in the patient’s condition, it was observed that hematomas were present in the bilateral renal pelves on the CT scans ( Fig. 1 a and b). Through comparing the CT values of the hematomas, it was revealed that there had been a long – term co – existence of organized old hematomas and fresh bleeding in the patient’s renal pelvis ( Fig. 1 c), indicating persistent bleeding in the renal pelvis.

On October 31, 2024, the patient was admitted to the hospital due to “hemorrhagic shock” and received a total of 27.5U of blood transfusion and 7U of intermittent platelet transfusion. Regrettably, after three multidisciplinary team (MDT) consultations, no improvement was noted in the intervention measures. Subsequently, a flexible ureteroscopy was conducted. However, due to severe bleeding, the operative field was obscured, making it impossible to accurately identify the cause and location of the bleeding. On November 7, 2024, “bilateral terminal renal artery embolization” was performed, yet no obvious bleeding points were detected during the operation ( Fig. 2 a and b).

After the operation, there was no significant improvement in the patient’s bleeding condition compared with that before the operation. Through the fourth MDT consultation, it was speculated that the single “J” tube was highly likely to be the cause of the upper urinary tract bleeding ( Fig. 3 a–e). Therefore, the single “J” tube was promptly removed. Surprisingly, no fresh hematuria occurred after the tube removal, and the Hb and platelet (PLT) levels increased steadily ( Fig. 4 a and b). Since absorbable gelatin sponges were used for embolization during the operation, two weeks after the patient’s discharge, the re – examined serum creatinine level decreased significantly to 168 μmol/L ( Fig. 4 c), and hemodialysis was discontinued.