504 DISCUSSION Chronic ITP is an acquired bleeding diathesis with an im- mune origin. The onset and clinical course of the disease show variations. Platelet counts and the severity of the dis- ease are important predictors of potential symptoms. Mild and moderately severe forms of ITP are asymptomatic in the absence of trauma, whereas in severe cases of ITP, clin- ical manifestations consist mostly of mucocutaneous bleed- ing such as purpura, petechiae, nosebleeds, and gingival bleedings. Gastrointestinal bleeding, hematuria, and in- tracranial hemorrhages are relatively more severe con- ditions and occasionally fatal [1-3,6,7]. In a meta-analysis conducted by Cohen et al. [1] in 1,817 patients, the rate of age-adjusted fatal hemorrhage risk for patients who were younger than 40 years, between 40 and 60 years, and older than 60 years was 0.004, 0.012, and 0.130, respectively. Spontaneous perirenal and subcapsular renal bleeding are rarely seen clinical manifestations that lead to serious problems. The most important etiologic factors are angio- myolipoma and renal cell carcinoma. Among other causes are chronic hemodialysis, vascular pathologies such as atherosclerosis and arteritis, anticoagulant therapy, and hemorrhagic diathesis [2,4-9]. Because the clinical course of the disease in patients with perirenal hematoma varies according to the severity of bleeding, the therapeutic ap- proach is closely related to the clinical condition of the patient. In cases of persistent bleeding and a worsening general health state, surgical treatment predominates, whereas in patients with stable vital parameters, pallia- tive treatment can be performed. None of the very rarely encountered cases of renal bleeding due to ITP reported mortality. In two cases we found during a literature search, bedrest, steroid therapy, and platelet suspensions were sufficient without the need for surgical management. According to the guidelines of the American Hematologic Association, hospitalization is required for patients with mucocutaneous bleeding and platelet counts less than 20.000 /mm3; for candidates for surgery, the American Hematologic Association recommends increasing platelet 3 counts to above 50.000/mm . Our case of bilateral perirenal hematoma secondary to ITP with a concurrent bilateral distal ureteral stone is the first such case report in the literature. In the management of distal ureteral stones, ESWL and ureteroscopic litho- tripsy are effective and safe treatment modalities, but in patients with hemorrhagic diathesis, extreme care should be exercised for ESWL. In a case report presented in Japan, safe use of ESWL was mentioned in a ureteral stone patient with ITP [10]. In a study performed in patients with hemor- rhagic diathesis, the frequency of severe perirenal bleeding secondary to ESWL was reported to be 4.1% and to be asso- ciated with patient age. In contrast to this study, Ruiz Marcellan et al. [9] did not report any cases of hematoma or bleeding in 17 patients with hemorrhagic diathesis fol- lowing ESWL. However, in patients with hemorrhagic dia- thesis, coagulation tests should be done because of the risk Korean J Urol 2012;53:502-504 Akyüz et al of hematoma occurrence, and platelet counts should be in- creased above 50.000/mm3. As far as we know, our case had undergone a single session of ESWL nearly 2 months pre- viously for a left ureteral stone. Even though the risk of de- velopment of perirenal hematoma secondary to ESWL in- creases in chronic ITP, the absence of any urinary system symptoms in our patient after ESWL and the application of ESWL targeted to the distal ureter suggest that the bleeding was not a complication of ESWL but rather origi- nated from thrombocytopenia due to ITP. Still, stasis and compression resulting from hydronephrosis caused by bi- lateral distal ureteral stones might be influential in the de- velopment of perirenal hematoma. In conclusion, urinary system diseases can be seen in pa- tients with bleeding diathesis, such as chronic ITP, and re- lated hematologic test results should be carefully evaluated in the following up and treatment of these patients. In these cases, therapeutic procedures targeting urinary system ab- normalities can be optimally performed after normalizing hematologic test results while continuing ITP therapy with- out making any change in the current treatment modalities. 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