Al Ghazal A et al, 2014: Capsulotomy for treatment of compartment syndrome in patients with post extracorporeal shock wave lithotripsy renal hematomas: safe and effective, but also advisable?
Al Ghazal A, Schnoeller TJ, Baechle C, Steinestel J, Jentzmik F, Steffens S, Hirning C, Schrader M, Schrader AJ
Department of Urology, Ulm University Medical Center, Prittwitzstrasse43,D- 89075 Ulm, Germany.
PURPOSE: To examine whether surgical decompression of hematomas by capsulotomy can help to improve long-term renal function following extracorporeal shock wave lithotripsy (SWL). MATERIALS AND METHODS: This study retrospectively identified 7 patients who underwent capsulotomy for post SWL renal hematomas between 2008 and 2012. The control group comprised 8 conservatively treated patients. The median follow-up time was 22 months. RESULTS: The two groups were comparable in age, gender, body mass index, risk
factors for developing hematomas (renal failure, urinary flow impairment, indwelling ureteral stent and diabetes mellitus) and the selected SWL modalities. Hematoma size was also similar. However, significantly more patients in the surgical group had purely intracapsular hematomas (85.7% vs. 37.5%) without a potentially pressure-relieving capsular rupture. There were no significant differences in
the post-interventional drop in hemoglobin, rise in retention parameters or drop in glomerular filtration rate (GFR). No capsulotomy-related complications were observed, but surgery required a significantly longer hospital stay than conservative management (median, 9 days vs. 5 days). The two groups also showed comparable recovery of renal function at long-term follow-up (median change in GFR from baseline, 97.1% and 97.8%, respectively). CONCLUSION: Since renal function did not differ between the two treatment groups, the conservative management remains the standard treatment for post-SWL renal hematoma.
Urol J. 2014 Jul 8;11(3):1569-74.
To discuss the most efficient therapeutic approach for patients with subcapsular hematomas after SWL is an important and interesting issue. It is logical to assume that a compression of the renal parenchyma during a relatively long period might result in reduced renal function. The question raised by the authors was if capsculotomy with the aim of reducing the pressure would be beneficial. Unfortunately the question cannot be answered from this retrospective analysis, because in the conservatively treated group significantly more patients already had a pressure reduction by capsule rupture. Although difficult to identify it would have been of great interest to compare those without spontaneous rupture treated conservatively, those without rupture treated conservatively and those being decompressed by capsulotomy. But such stratification would probably have been impossible because of the small number of patients.
The question remains: does decompression improve the end result despite the risk with open capsulotomy and if so, is it necessary with open capsulotomy or would it be enough with a percutaneous puncture and drain?