Gross hematuria from an ileal conduit as a first presentation of portal hypertension

Abstract

A 76-year-old man who underwent cystoprostatectomy with ileal conduit urinary diversion for muscle-invasive bladder cancer presented to his urologist 4 years later with episodes of spontaneous gross hematuria filling his ostomy bag with fresh clots. Physical examination, urine culture, urine cytology, peripheral smear, complete blood count, loopogram, CT-intravenous pyelogram, loop endoscopy, bilateral ureteroscopy, liver function tests, CT angiography, (99m)Tc-tagged red cell scan, hepatitis panel, measurement of transjugular wedge pressure, transjugular liver biopsy with pathologic analysis and re-evaluation of CT angiogram. Hematuria secondary to portal hypertension. The patient initially underwent revision of the ureteroileal anastomosis on the basis of the results of the (99m)Tc-tagged red cell scan, but hematuria recurred 9 months later. Once the hepatology service identified portal hypertension, the patient was taken to the operating room for ligation of a large venous communication between the ileal conduit and a branch of the inferior epigastric vein. He recovered well and was asymptomatic for 8 months. He was followed up by the hepatology service for his newly diagnosed portal hypertension secondary to cirrhosis.