|Year : 2006 | Volume
| Issue : 4 | Page : 374-375
Bilateral urinoma due to an unilateral impacted ureteral calculus
FS Katumalla, S Lambe, SK Jariwala, KJ Mammen
Department of Urology, Christian Medical College and Hospital, Ludhiana - 141 008, India
K J Mammen
Department of Urology, Christian Medical College and Hospital, Ludhiana - 141 008
Source of Support: None, Conflict of Interest: None
| Abstract|| |
A unilateral impacted lower ureteric calculus presenting as bilateral urinoma is rare, and spontaneous rupture of the ureter being the cause is even rarer. It is important to distinguish this uncommon condition from the much commoner condition of urinary extravasation from forniceal rupture. We are reporting a case of left lower ureteric calculus causing spontaneous rupture at the upper ureter presenting as bilateral retroperitoneal urinoma.
Keywords: Ureteral calculus, ureteral rupture, urinoma
|How to cite this article:|
Katumalla F S, Lambe S, Jariwala S K, Mammen K J. Bilateral urinoma due to an unilateral impacted ureteral calculus. Indian J Urol 2006;22:374-5
| Introduction|| |
There are various clinical presentations of ureteric calculus, the commonest being a ureteric colic. Spontaneous extravasation occurs if there is a distal obstruction due to an impacted ureteric calculus, peri-ureteric masses or tumor of the renal pelvis, and is generally caused by forniceal rupture.
| Case Report|| |
A 32-year-old gentleman presented with one episode of acute left flank pain three months prior to admission and a swelling in the left flank of one week duration. On examination, the patient had a large tense cystic mass involving the left hypochondrium, left lumbar and left iliac regions. A soft cystic mass was also palpable in the right lumbar region and right iliac fossa. Contrast enhanced computer tomography revealed bilateral urinoma, left larger than the right [Figure - 1], with left hydroureteronephrosis. Ultrasonography revealed a defect in the left upper ureter with a left lower third ureteric calculus [Figure - 2]. The left-sided urinoma was drained with a 12 Fr pig tail catheter introduced through the left flank below the 12th rib under ultrasound guidance. This drained 1900 ml of clear urine. Urinomas on both sides disappeared with a single drainage on the left side. Left Ureterorenoscopy was attempted the next day but was unsuccessful as the stone was impacted and a mucosal flap was inadvertently raised at the VUJ while negotiating the Ureteroscope. Therefore, a left percutaneous nephrostomy (PCN) was done the subsequent day to decompress the upper urinary tract. Nephrostogram revealed a leak from the left upper ureter [Figure - 3], which was the site of ureteric rupture and urinary extravasation for the formation of the bilateral urinoma. Subsequently, the next day, a left open ureterolithotomy for a 15 mm lower ureteric impacted calculus and double 'J' stenting was done; The PCN was also removed the same day. Postoperative recovery was uneventful. Double 'J' stent was removed after one month. His ultrasonography at the end of one month showed normal kidneys on both sides with no urinoma on either side.
| Discussion|| |
Urinoma forms in case of impacted ureteric stone due to increased back pressure effects and rupture of pelvicalyceal system. It is the rupture of fornices that is commonly found. Spontaneous ureteric rupture is rare. Before a case of rupture of the ureter is described as 'spontaneous' the following should apply: (a) no external trauma; (b) no cystoscopic ureteric manipulation; (c) no external compression; (d) absence of destructive kidney disease; (e) absence of previous surgery. It is important to distinguish this uncommon condition from the much commoner condition of extravasations from forniceal rupture. In spontaneous rupture of the ureter the contrast material will not appear around calyces, but at the site of the ureteral rupture [Figure - 3]. In forniceal rupture, it is a release or pop off phenomenon which saves the kidney from further damage due to backpressure changes as found in Posterior urethral valves. There was bilateral urinoma in our patient due to impacted stone on the left side. This could be explained by the fact that the posterior perirenal fascia fuses with the muscularis fascia of the psoas major while the anterior perirenal fascia extends across the midline in front of the great vessels for a variable craniocaudal distance (L3-L5) and communicates across the midline through an antero-posterior two to ten-mm narrow channel. This case report is being published in view of its rarity.
| References|| |
|1.||Kumar R, Gupta R, Khullar S, Sharma S, Marwah A, Agarwal S, et al . The management of urinoma: The role of renal scintigraphy. BJU Int 2000;85:1154. |
|2.||El-Boghdadly SA. Spontaneous rupture of the ureter proximal to ureteric stone. J R Soc Med 1985;78:255-7. [PUBMED] [FULLTEXT]|
|3.||Dewan PA, Anderson P. Ureterocystoplasty: The latest developments. BJU Int 2001;88:744-51. [PUBMED] [FULLTEXT]|
|4.||Healy JC, Glass J. Kidney. In : Standring S, Mundy AR, editors. Gray's Anatomy Chapter 91. 39th ed. Churchill Livingstone: Elsevier; 2004. p. 1270-1. |
[Figure - 1], [Figure - 2], [Figure - 3]