BERKELEY, CA (UroToday.com) - Among 23 patients undergoing rigid and flexible ureteroscopy for lateralizing essential hematuria (i.e. unremarkable radiographic, serum, and urine cytology studies), an identifiable lesion was noted in 18 (78%).

The predominant pathology was a small venous rupture (78%), a renal papillary hemangioma was noted in only 2 patients and a stone was found in 2 patients, this is contrary to other studies in which a hemangioma on a renal papilla was the most common finding. All lesions were noted either on the papilla or along the fornix. In all 18 patients with an identifiable lesion treatment was given, most commonly using a holmium: YAG laser (.5 to 1.0 J at 5 -10 pulses per second) alone or in combination with a neodymium: YAG laser (20 watts) in a noncontact application. Remarkably, among the treated patients the authors noted 100% success (i.e. no recurrent bleeding) with a median follow-up of 6 years (1.5 - 9 yrs) however, 3 of these patients (17%) required a second ureteroscopic procedure during the follow-up period due to recurrent bleeding which actually brings the success rate for an initial treatment down to 83%. The latter figure is more in keeping with the success rate reported by others dealing with this disease entity. Of interest, among the 5 patients in whom no site of bleeding could be identified and no treatment rendered all 5 stopped bleeding after the ureteroscopy suggesting that the diagnostic endoscopic procedure may have some therapeutic benefit of its own possibly due to the increased intraluminal pressure during ureteroscopy which could possibly collapse and seal a small venous rupture?

Three tips when working with patients with essential lateralizing hematuria are worth remembering. First, have the patient be very active prior to the procedure as it is easiest to find the site of bleeding if they are bleeding at the time of the ureteroscopy. Second, examine the calyces in order: upper, middle, and lastly lower. If the flexible ureteroscope is passed first into the lower pole the shaft of the endoscope can bruise the upper pole infundibulum and may thereby mislead the examiner. Third, after accessing the upper tract remove the irrigant and decompress the collecting system, if this is not done the small venous rupture will be missed due to compression from the pressure of the irrigating fluid. One must be patient and wait and look (after 3 - 10 minutes) a small trickle of blood will be seen to be emanating from one of the infundibula.

Mugiya S, Ozono S, Nagata M, Takayama T, Furuse H, and Ushiyama T

J. Urol. 178(2):517-520, August 2007
doi:10.1016/j.juro.2007.03.098

UroToday.com Laparoscopic & Robotic Section

Written by Ralph V. Clayman, MD, a Contributing Editor with UroToday.

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