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SPONTANEOUS(NONTRAUMATIC) RETROPERITONEAL HAEMORRHAGEOF RENAL ORIGIN

Mohan S Gundeti, Mahendra Jain*, Dhananjay S Bokare*, Anand S Joshi*, Sushil S Rathi*, U G Oza**, J N Kulkarni**, S W Thatte+, A G Phadke++
*Sr. Resident Mch. Urology; **Asst. Professor; **Associate Prof.; ++MS Prof. and Head, Department of Urology, Bombay Hospital Institute of Medical Sciences, Mumbai.

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Spontaneous (nontraumatic) retroperitoneal haemorrhage of renal origin is a rare entity. Because of its varied clinical presentation the diagnosis is difficult and subsequent management may pose a dilemma in the treatment. With the, modern modalities of investigations like CT Scan, MRI, Digital subtraction angiography and high clinical index of suspicion the preoperative diagnosis is possible which helps in the management.

INTRODUCTION

Spontaneous retroperitoneal haemorrhage in absence of anticoagulation, arteritis, or trauma is most likely due to an underlying renal tumour. Other most common are angiomyolipoma and periarteritis.

The cause of bleeding becomes apparent in more than half cases after standard laboratory tests, CT scan, angiography and magnetic resonance imaging.

We recently treated five patients with spontaneous retroperitoneal haemorrhage which was secondary to renal malignancy in two, renal angio myolipoma in two and spontaneous rupture of renal cyst in one case. We present these cases and pertinent literature.

MATERIAL AND METHODS

CASE 1

12 year old male boy presented with severe left flank pain, no haematuria and no pertinent urological history in the past.

Physical examination revealed signs of haemorrhagic shock and left costovertebral angle tenderness. Laboratory evaluation revealed creatinine 1.0 mg%. Haemoglobin 7.0 gm%, urinalysis demonstrated no red blood cells.

Renal sonography revealed normal right kidney, left renal mass with perinephric haematoma. CT scan confirmed the lesion (tumour was enhancing with contrast) and no lymph nodes. Chest radiograph was normal.

After Resuscitation emergency left radical nephrectomy done through midline transperitoneal approach with initial vasculature control. Pathology findings revealed 3.5 x 3 x 3 cm ruptured and fleshy tumour in medulla continuous with haematoma, histopathology showed favourable histology stage II Wilm’s tumour was confirmed.

CASE 2

A 30 year lady with 7 months amenorrhoea presented with sudden onset left flank pain. Urinalysis and renal biochemistry normal. Sonography revealed left renal mass with perinephric haematoma with 7 months pregnancy. MRI has been done in view of pregnancy which showed mass of fat density, Angiomyolipoma with the perinephric haematoma of left kidney.

Fig. 1 : CT Scan shows tumor enchancing with contrast and perinephric haematoma.

 

TABLE 1 Spontaneous retroperitoneal haemorrhage of renal origin imaging techniques outcome and follow up.
Case No.	Sono-graphy	CT Scan	Size of tumour	MRI	Angio- graphy	Current status
I.	+ve	+ve	4 x 5 cm	Not done	Not done	Alive with disease 1 year follow up. Receiving chemotherapy.
II.	+ve	Not done	4 x 6 cm	+ve	Not done	Alive without disease 9 months follow up.
III.	+ve	+ve	6 x 4 cm	Not done	Not done	Alive without disease one year follow up.
IV.	+ve	+ve	cyst rupture	Not done	D stic and therapeutic	Resolved haematoma 11 months follow up.
V.	+ve	+ve	6 x 8 cm	Not done	Not done	Alive without disease 8 months follow up.

Left radical nephrectomy done; histology confirmed the diagnosis of angiomyolipoma subsequently she delivered a full term normal baby.

Fig. 2 : Specimen shows middle pole of kidney tumour mass with rupture.

Fig.3 : Lt renal mass upper pole with perinephric haematoma MRI image.

CASE 3

54 yr old woman presented with sudden onset of left flank pain, no history of genitourinary symptoms or past major illness. Renal biochemistry and urinalysis were normal. Haemoglobin was 12 gm%; renal sonography demonstrated a normal right kidney and left kidney with renal mass with echogenicity around. A CT scan confirmed the extensive left perinephric haematoma with mass. Chest radiography normal, bone scan normal.

Left radical nephrectomy done through 11th rib bed incision. Pathological findings revealed 10 x 7 x 5 cm mass in lower pole. Histopathology revealed renal cell carcinoma, involving capsule and perinephric fat with a definite communication with haematoma.

CASE 4

A 40 year male had sudden left flank pain. Examinationrevealed only left costovertebral angle tenderness; renal sonography revealed bilateral renal cyst with left perinephric haemorrhage. CT scan compatible with same findings. A renal angiogram revealed left cyst rupture with feeding vessel to the cyst. No evidence of tumour. At the same time selective embolisation with microcoil (stainless steel) of the feeding vessel done. Follow up revealed the regression of haematoma.

Fig. 4 : Specimen photograph showing angiomyolipoma ruptured with perinephric haematoma.

Fig. 6

CASE 5

72 year old man otherwise healthy presented with left flank pain and painless haematuria. Physical examination normal.

Haemoglobin urinalysis and renal biochemistry normal. Sonography revealed left renal mass with perinephric haematoma. CT examination showed mass of negative and varying densities with perinephric haematoma.

Left radical nephrectomy done; histology confirmed the diagnosis of renal angiomyolipoma.

Fig. 5
	Fig. 7

 

DISCUSSION

 

Fig. 8 : Plain X-ray showing stainless steel coil in feeding vessel after embolisation.

Spontaneous rupture of renal parenchyma is said to have been first reported in 1700 by Bonet. In 1856 Wounderlich first described the clinical picture of spontaneous renal bleeding with dissection of blood into the subcapsular and orperinephric spaces. [1]

Polkey and Vynalek [2] reviewed the world literature before 1933 and analysed 178 cases of spontaneous nontraumatic perirenal haematoma. Since then numerous terms have been used including spontaneous perirenal haematoma, [3] spontaneous subcapsular renal haemorrhage, [4] non traumatic perirenal haematoma and spontaneous perinephric haematoma. The abscence of external trauma has been stressed in virtually all reports. [5] Mc dougal and associates reviewed the literature through 1974 and found that 33% of cases were due to malignant renal tumours, 24% benign renal tumours with angiomyolipoma being the most common and 18% to vascular disease with periarteritis being the most common.

Spontaneous, retroperitoneal bleeding has been reported secondary to adrenal tumours [6] and on chronic haemodialysis patients. [7]

The clinical presentation of these patients may vary greatly depending on the degree and duration of bleeding. Sudden onset of flank or upper abdominal pain, nausea and vomiting, haematuria and a decreasing haemoglobin are common findings. Urinalysis frequently is normal. Sometimes if haematoma dissects into retrocaceal region the appearance may resemble acute appendicitis. [8]

In the past intravenous urography [9] with nephrotomography often has been pathognomonic in patients with subcapsular haematoma. The apperance is that of slightly opacified linear renal capsular contrasted between haematoma one side and perinephric fat on other, with the nonopacified haematoma compressing and flattening the opacified renal parenchyma.

When the haematoma is perinephric the affected kidney may demonstrate displacement, poor visualisation with ureteral displacement and obliteration of psoas margin.

Sonography is the rapid noninvasive technique which can be used as a screening modality because ultimately patient will require CT scan [10] which is the currently standard mode of investigation tolook for the aetiology and in our patients it has given 100% diagnostic accuracy.

Magnetic resonance imaging certainly may assist in the diagnosis. However there has been no reports of experience of its use in this situation, and when the small tumours are considered it may be useful or when CT scan is contraindicated for some purpose as in our case no IV (A case of pregnancy with retroperitoneal haemorrhage).

Selective renal angiography has been advised to rule out vascular lesions such as periarteritis, arteriosclerotic aneurysm A malformation but in our four cases the diagnosis was established so we didn’t use except in case no III where it was both diagnostic and therapeutic.

In the majority of the patients with spontaneous perinephric haematoma the aetiology becomes apparent with basic laboratory screening as well as coagulation and radiographic studies occasionally in some patients there is therapeutic dilemma as in case no. III.

In 1974 Pollac and Popky [11] reported 22 patients with spontaneous renal haemorrhage, of which 20 cases were caused by tumour. Therefore meticulous operative exploration was advised for these patients.

In 1982 Bagley [12] and associates reported 4 patients with similar findings and they likewise advised exploration with the consideration of nephrectomy. In contrast Howalt [13] and Squirs advised a conservative approach (nonoperative) based on 3 cases if diagnostic studies failed to demonstrate a significant aetiology.

We advise the therapeutic approach depending on the diagnosis because today with the better resolution of imaging modalities the near to 100% diagnosis can be achieved and if possible kidney can be salvaged as in case no. III. In suspected cases a follow up CT scan after 6 wks to 8 wks is advised. Once the haematoma regresses it is possible to make a definite diagnosis. [4] The role of exploration and biopsy is difficult. Due to haematoma it is difficult to approach the small tumours, so nephrectomy is desirable whenever the mass is there, provided opposite kidney is normal.

Fig. 9	Fig. 10

CONCLUSION

Spontaneous perinephric haematoma is an uncommon occurrence but can easily be diagnosed by newer imaging modalities like CT scan, MRI and selective angiography. Once diagnosed the aetiology often becomes apparent. The most common causes are renal cell carcinoma and angiomyolipoma. Renal cyst rupture is very rare which we have reported.

The therapeutic approach either conservative or surgical should be on the basis of aetiology of retroperitoneal haemorrhage.

It is a dilemma regarding the management of retroperitoneal haemorrhage due to renal tumours as the staging of the tumour will have to be reconsidered at a higher stage due to spillage. This may have to be substantiated by large no of case studies. The Wilms tumour was treated as per NWTS criteria at a higher stage and received chemotherapy.

REFERENCES

1. Wunderlich CRA. Handbook der pathologic and therapie. 2nd ed. Cited by Polkey and Vynalke.
2. Polkey HJ, Vynalek WJ. Spontaneous non traumatic perirenal and renal hematomas. Arch Surg 1933; 26 : 196.
3. Pollack HM, Popkey G. Spontaneous subcapsular renal haemorrhage : its significance and roentgenographic diagnosis. J Urol 1972; 108 : 539.
4. Uson AC. Nontraumatic perirenal hematomas a report based on 7 cases. J Urol 1959; 81 : 388.
5. Mc. Dougal WS. Spontaneous rupture of kidney with perirenal hematoma. J Urology 1975; 114 : 181.
6. Swift DJ. Spontaneous retroperitoneal haemorrhage a diagnostic challenge. J Urol 1980; 123 : 577.
7. Milutinovich J. Spontaneous retroperitoneal bleeding in patients on chronic haemodialysis. Ann Inter Med 1977; 86 : 189.
8. Mackkenzie AR. Spontaneous subcapsular renal hematoma report of case misdiagnosed as Ac. Appendicitis. J Urol 1960; 84 : 243.
9. Pollack HM, Popky. Roentgenographic manifestations of spontaneous renal haemorrhage. Radiology 1974; 110 : 1.
10. Sagel SS. Detection of Retroperitoneal haemorrhage by computed tomography. Amer J Roentgen 1977; 129 : 403.
11. A. Richard Kendall spontaneous subcapsular renal hematoma diagnosis and management. J Urol 1988; 139 : 246.
12. Bagley DH. Spontaneous retroperitoneal haemorrhage from renal carcinoma. JAMA 1982; 248 : 720.
13. Howalt JS. Spontaneous rupture of the kidney : A case of a traumatic retroperitoneal bleeding. Amer J Surg 1972; 123 : 484.
14. Novicki DE. The evaluation and management of spontaneous haemorrhage. J Urol 1980; 123 : 764.

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