Retrograde endoscopic intra-renal injection of Fibrin sealant for upper urinary tract unexplained hematuria: A unique case report.

Introduction

Upper urinary tract hematuria represents a unique clinical challenge that often necessitates endoscopic exploration as well as renal embolization in certain pathologies. Huge advances in retrograde instrumentation have enabled urologists to perform more minimally invasive approaches for upper urinary tract diseases. In this case we present our experience with endoscopic exploration and injection of Fibrin sealant (TISSEEL®) for the upper urinary tract unexplained hematuria.

Case report

This is a 35 years old female not known to have any chronic medical illnesses presented to our institute with left flank pain associated with gross hematuria. The patient had a history of selective left renal artery embolization in 2008 in another hospital for an unknown reason. Her laboratory investigations were: Hgb 9.7 g/dl, PLT 480 × 109/L, PTT 30 sec, PT 12.3 sec, and INR 0.9. Abdomen and pelvis computed tomography scan showed a left renal pelvic stone which was formed near to the embolization coil. The patient underwent a left flexible ureteronephroscopy and we discovered a renal stone over what we assumed was part of the coil from the previous embolization, Holmuim laser was used to dust the stone, and extraction of the coil was done [Fig. 1]. Hematuria resolved and the patient was discharged home. However, a week later the patient developed sever gross hematuria with clots and her Hgb dropped to 6.8 mg/dl. Renal and aortic angiography was done and it was unremarkable [Fig. 2]. The patient was evaluated by a Hematologist regarding any bleeding disorders and no hematological cause could have been identified. Flexible ureteronephrosopy was done again and showed clots in the left renal pelvis with no obvious cause or active bleeding [Fig. 3]. We used two " 5 French " open-ended ureteral catheters which were directed into the renal pelvis over dual guide wire access with the aid of fluoroscopy as well as a flexible ureteroscope to inject Fibrin sealant (TISSEEL®) into the renal pelvis [Fig. 3]. 4 months follow up of the patient revealed resolution of the hematuria with no recurrent episodes.

Fig. 1

(A) Endoscopic vision of the embolization coil appearing into renal pelvis, (B) removed part of coil post flexible ureteronephroscopy, (C) Blood clots extracted from renal pelvis over embolization coil.

Fig. 2

(A) Full Abdominal Angiography, (B) Left renal Angiography with no evidence of active bleeding.

Fig. 3

(A) Second endoscopic exploration showed UUT blood clots (B) Fibrin sealant " TISSEL ″ injection by endoscopic vision.

Discussion

The first use of any type of blood product for hemostasis was described by Bergel in 1909 and used plasma. The commercial use of Fibrin glue began in the 1970s with the development advanced fractionation techniques that allowed the development of concentrated Fibrinogen. In 2005 Uribe and colleagues experimented different hemostatic agents and their interactions if they got in contact with urine and Fibrin sealant showed excellent result even after 5 days. Sharma et al. used endoscopic injection of Fibrin glue for the treatment of urinary tract pathology which showed promising results. Fibrin glue had been used to repair the collecting system in experimental studies, there are multiple reports describing the use of fibrin glue in the endoscopic management of urinary fistulae but scarce literature when it comes to its use as a treatment for unexplained hematuria. Fibrin glue is composed of Fibrinogen, Thrombin, Calcium, and Aprotonin (fibrinolysis inhibitor), all of which are critical to its role as a hemostatic agent and tissue sealant.,

Furthermore, one of the most commonly used intra-renal injections to treat unexplained hematuria is Silver Nitrate. Multiple case reports described the technique and its common side effects namely flank pain, nausea and the most serious one renal pelvis obstruction due to precipitation of Silver Nitrate which binds to Chloride and forms crystals, also ureteral stenosis as a long term complication has been described in a case report. In order to treat upper urinary tract gross hematuria, we have to find and manage the underlying condition. In our case we assumed the cause of the patient's hematuria to be the coil but it was not confirmed although multiple angiographies and endoscopic explorations were performed. Our report represented the feasibility of Fibrin glue injection as a less invasive method of management of any upper urinary tract unexplained gross hematuria. However, Fibrin glue could potentially migrate and cause obstruction; nevertheless, there have been no clinical reports to date of such a complication. We report no complications secondary to Fibrin glue injection up to 4 months of follow up. In conclusion, retrograde endoscopic injection of Fibrin sealant (TISSEEL®) demonstrates a new alternative approach for unexplained upper urinary tract hematuria. Although renal angiography and flexible ureteronephroscopy remain the gold standard to diagnose and treat most of upper urinary tract pathologies, retrograde endoscopic injection of Fibrin sealant offers a safe minimally invasive technique that may avoid morbidity of further invasive ones in such challenging patients. Therefore, it is reasonable in our opinion to attempt endoscopic injection of Fibrin sealant for such cases prior to proceeding to more invasive procedures.