To describe the clinical presentations, diagnostic findings, and outcomes of a rare case of significant perirenal hematoma following ESWL, managed with a kidney-sparing approach.

A retrospective review of clinical and imaging data of a post-ESWL perirenal hematoma case was conducted. Management involved embolization and laparotomy with kidney preservation, and follow-up confirmed symptom resolution.

A 21-year-old healthy male presented with left flank pain and vomiting, one month after undergoing three sessions of ESWL for a pelvic-ureteric junction stone. He was tachycardic, hypertensive, and had a declining hemoglobin level despite transfusions. Labs showed thrombocytopenia but normal renal function. Chest X-ray revealed a left-sided pleural effusion. CT imaging demonstrated a large hyperdense left perinephric hematoma (8 × 8 × 10 cm), compressing the kidney, along with a lower pole renal calculus.

Diagnosis of a post-ESWL perinephric hematoma was made. The patient underwent super-selective embolization of an actively bleeding accessory artery, but continued hemoglobin drop necessitated exploratory laparotomy. Intraoperatively, a large retroperitoneal hematoma was evacuated. The left kidney showed surface oozing and loss of the capsule but was otherwise viable. Hemostasis was achieved with surgical sealants, and a chest tube drained 1100 ml of blood from the pleural effusion.

The patient received seven units of blood and four units of fresh frozen plasma intraoperatively. His post-operative course was stable, with improvement in hemoglobin and no recurrence. At follow-up, he remained symptom-free.

This case highlights that although ESWL is generally safe, severe complications like perinephric hematoma can occur even in young, healthy patients. The incidence of such hematomas ranges from 0.28% to 4.1%.

Our patient developed flank pain, vomiting, and hemodynamic instability after ESWL. Despite multiple transfusions, his hemoglobin continued to drop, and imaging revealed a large perinephric collection with pleural effusion. Although super-selective embolization was attempted, persistent bleeding necessitated surgical intervention through exploratory laparotomy.

While some post-ESWL hematomas can be managed conservatively with monitoring and supportive care, rapid clinical deterioration requires prompt surgical management. Factors that may have contributed to this patient’s outcome include multiple ESWL sessions within a short timeframe, a lower pole stone requiring higher energy levels, and a possible vascular anomaly.

This case emphasizes the importance of vigilance after ESWL. Patients presenting with flank pain, hemoglobin drop, or signs of instability should be urgently evaluated to prevent life-threatening outcomes.

This case highlights a rare but severe complication of large perinephric hematomas post-ESWL, necessitating urgent embolization and laparotomy. Early recognition and tailored intervention are key to preventing adverse outcomes