We report a case of delayed hemorrhage occurring four weeks after robotic-assisted partial nephrectomy for renal cell carcinoma. The patient, a 59-year-old lady, presented with gross hematuria and hemodynamic instability. Computed tomography (CT) angiography demonstrated a pseudoaneurysm arising from the resection site. As part of the major hemorrhage protocol, the patient received blood products and tranexamic acid (TXA) for hemorrhage control. Definitive hemostasis was achieved through the selective angioembolization of the pseudoaneurysm. Following embolization, the patient developed upper urinary tract obstruction secondary to extensive intraluminal clot formation. Endoscopic evaluation revealed a significant clot burden within the bladder and ureter, necessitating clot evacuation and ureteric stent placement to restore urinary drainage. The patient recovered fully, with stable renal function and no recurrence of bleeding following stent removal. This case highlights a potential association between tranexamic acid use and extensive intraluminal clot formation in the setting of upper urinary tract bleeding, particularly when bleeding communicates directly with the collecting system.
Manolitsis et al. (Mon,) studied this question.