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Cystoscopy complication help please!

Dear Dr,
My partner when he was 28yrs old, was admitted to hospital with severe abdo pain after taking Ceclor antibiotic for a suspected sinus infection (INR on admission was 3.2).  He had known Antiphospholipid disorder and was on warfarin at the time.  He had CT scanning which showed a distended bowel (constipation for 4 days).  His creatinine was 90, no obstruction in the ureters were detected and no kidney stones, but filling defects were noted that were thought to be not consistent with air bubbles.  He was however admitted under urology and underwent retrograde pyelography, cystoscopy and insertion of ureteric stents, and catheters.  The pain did not subside and the creatinine steadily rose to 360.  the urologist removed the stents and reinserted them, the creatinine rose further and another 3 procedures were undertaken over the next 24 hours.  His creatinine was 1200 by this stage and was in complete renal failure.  The CT scan and MRI showed a left adrenal haemorrhage after first operation and was found to be over-anticoagulated, INR was 8.7 during 2 operations and 11.7 on the last.  His INR was not monitored for 2 days  (1 of those a surgery day, and reading the following days INR of 8.7 was likely to be out of the theraputic range).
He subsequently was given vit K and INR came down to 1.5 at which time a needle biopsy was performed. His kidney unfortunately bled out and is now non-functioning.  It showed type 4 lupus nephritis.  His right kidney is also impaired with a creatinine sitting around 240.  He had other complications following this ordeal, AF, due to overhydration, multiple DVT's and PE's, stroke, heart attack etc.
... What I want to ask you is, in your opinion, is it usual practise to undergo these type of procedures with a known grossly over anticoagulated patient, without reversal?  
Would bleeding internally be a much higher risk?
Can cysoscopy itself cause adrenal haemorrhage and or ARF?  Or is it likely to be the "high" INR?

Your expert opinion would be GREATLY appreciated.
Thank  you.
4 Responses
Avatar universal
Please answer me someone!!!! lol
Avatar universal

There are acceptable INR ranges prior to each surgical procedure. For a cystoscopy and insertion of ureteral stents, this i am not exactly sure. However, acceptable range is about an INR of 2-3. The INR values depend if other underlying prothrombotic states like the presence of antiphopholipid syndrome, a cardiac valvular prosthesis and coagulation disorders are present. In this case, a higher INR may be required ( > 2 and less than 5). In your partner's case a balance between thrombosing and anticoagulation has to be achieved.An INR of 8 and 11 are extremely high and may increase bleeding risk and complications.The bleeding may have lead to the acute renal failure.

How is your partner?
Avatar universal

Hi there,
Thanks so much for the info.  My partner is fairly stable at the moment.  He has had 52 ureteric stent change operations in the last 8 years, and last Feb his urologist where we live now removed it as he believed he didn't need one to begin with.  So since then his one remaining (very compromised) kidney is stable and he has no stent or kidney pain.  
I was just interesed to know about the gross overanticoagulation at the time, as I feel the hospital neglected to show the necessary attention to his INR levels.
He is on a lot less drugs now which only has to be good for his kidney, his creatinine sits around 240.
Anyway thanks so much for your insight.

PS, ... I read in the Dr's operation notes that he said "I had some difficulty inserting the guidewire", in your opinion what could this mean?  Can that cause ureteric trauma or to
the bladder?  He used straight jj stents.
Avatar universal

I believe that in any form of instrumentation, there is always an increased risk of injuring the involved structure and also nearby tissues.One has to account surrounding events and other factors that may have contributed to the complications. "Difficulty in inserting the guidewire" may not necessarily mean that this could have caused the ureteric trauma.It may have been difficult initially but the surgeon may have successfully completed the procedure.
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