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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 26  |  Issue : 2  |  Page : 215-216

Large perinephric urinoma acting as a pop-off in a patient with asymptomatic upper ureteric stone


Division of Urology, Lourdes Institute of Nephro-Urology, Lourdes Hospital, Kochi, Kerala, India

Date of Submission03-Aug-2020
Date of Decision11-Aug-2020
Date of Acceptance14-Oct-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Dr. H Krishna Moorthy
Division of Urology, Lourdes Institute of Nephro-Urology, Lourdes Hospital, Kochi - 682 012, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_18_20

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  Abstract 


Perinephric extravasation of urine with subsequent urinoma formation is a rare complication of neglected, obstructing ureteric calculi. It is associated with symptoms such as fever, lumbar pain and vomiting. We present the case of a minimally symptomatic patient who had an obstructed left upper ureteric calculus causing left hydronephrosis and a large perinephric urinoma, which probably was acting as a pop-off mechanism. Our patient was successfully managed by ureteroscopic lithotripsy with double J stenting.

Keywords: Perinephric, ureteric calculus, urinoma


How to cite this article:
Saswade K, Sonawane G, Pillai BS, Sam MP, Moorthy H K. Large perinephric urinoma acting as a pop-off in a patient with asymptomatic upper ureteric stone. Kerala Surg J 2020;26:215-6

How to cite this URL:
Saswade K, Sonawane G, Pillai BS, Sam MP, Moorthy H K. Large perinephric urinoma acting as a pop-off in a patient with asymptomatic upper ureteric stone. Kerala Surg J [serial online] 2020 [cited 2020 Dec 2];26:215-6. Available from: http://www.keralasurgj.com/text.asp?2020/26/2/215/300226




  Introduction Top


Instinctive break of the pelvicalyceal collecting system and subsequent urinary eructation in the perirenal and retroperitoneal space is a rare complication of obstructive uropathy. It is usually related with obstructed ureteric calculus.[1] Other uncommon causes include ureteric obstruction secondary to posterior urethral valves, prostatic hyperplasia and pelvic neoplasms.[2] In general, this condition occurs in neglected obstructive pathologies in the ureter and present with symptoms such as fever, lumbar pain and vomiting. However, it is very rare to find large perinephric urinoma with obstructed, but relatively asymptomatic ureteric stones. This paper reports the case of a 53-year-old diabetic male patient, who was evaluated for fullness of the left lumbar region, with no other significant symptoms.


  Case Report Top


A 53-year-old male patient presented with fullness of the left loin for 5 days. He was diabetic, was on oral hypoglycaemic drugs for the last 10 years and had well-controlled blood sugar levels. Physical examination showed minimally tender swelling in the left lumbar region. Routine blood examination and renal function tests were normal. Urine showed microhaematuria. Ultrasound scan of the abdomen showed large perinephric collection of fluid with a calculus of 7 mm at the upper ureter and mild hydronephrosis of the left kidney. Computed tomography urogram showed a large left perinephric urinoma extending up to the lower ureteric region with 6.6-mm obstructed left upper ureteric calculus and mild left hydronephrosis [Figure 1]a and [Figure 1]b and [Figure 2]. The patient was successfully managed by ureteroscopic lithotripsy with double J stenting. [Figure 3] shows the completely resolved urinoma in the ultrasound scan of the kidney done 1 month after treatment.
Figure 1: (a) Obstructed left upper ureteric calculus. (b) Perinephric urinoma

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Figure 2: Extension of perinephric urinoma up to the distal ureter

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Figure 3: Ultrasound scan picture of resolved perinephric urinoma, 1 month after treatment

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  Discussion Top


Urinoma is a collection of extravasated urine leaked from the pelvicalyceal collecting system of kidneys. Urinomas may be caused by either obstructive or non-obstructive pathologies. Obstructive causes include pregnancy, ureteral calculi, pelvic masse, posterior urethral valves, congenital anomalies, post-radiation scarring, enlarged lymphatic glands, retroperitoneal fibrosis and prostate enlargement. Non-obstructive causes of urinoma include external trauma to the kidneys or the urinary collecting system and injury during various pelvic, gynaecological, retroperitoneal and genitourinary surgeries.[3]

Urinoma is generally confined to the perinephric space, and patients with urinoma typically present with flank pain and abdominal distension with mild fever, resembling ascites.[4] The excessive increase in intraluminal pressure in the urinary tract results in rupture of the calyceal fornix, which is the weakest part of the collecting system. Rupture of fornices leads to perinephric collection of urine.[5] Subcapsular urinoma includes collection of urine in between the kidney's parenchyma and capsule, whereas perirenal urinoma consists of urine collection in between Gerota's fascia and the capsule. Small-to-moderate perinephric urinomas can occur in severely obstructed, neglected ureteric stones. However, it is very rare to see large perinephric urinomas tracking down to the lower ureteric area subsequent to a minimally obstructed, relatively asymptomatic upper ureteric stone. Our patient was a diabetic for the past 10 years, which would have masked the symptoms of obstruction and the urinoma would have acted as a pop-off mechanism to relieve obstruction in this case, by taking up the brunt of pressure inside the pelvi-calyceal system. The management options of urinomas could vary depending on the status of kidney at the time of diagnosis. Large urinomas which are not promptly managed can develop complications such as pyelonephritis, pyonephrosis and abscess formation. Our case was successfully managed with ureteroscopic removal of stone and double J stenting.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Koktener A, Unal D, Dilmen G, Koc A. Spontaneous rupture of the renal pelvis caused by calculus: A case report. J Emerg Med 2007;33:127-9.  Back to cited text no. 1
    
2.
Singh I, Joshi M, Mehrotra G. Spontaneous renal forniceal rupture due to advanced cervical carcinoma with obstructive uropathy. Arch Gynecol Obstet 2009;279:915-8.  Back to cited text no. 2
    
3.
Gautam R, Shaikh T, Attarde N, Gupta S, Wani J, Ghosalkar MM, et al. Urinoma: A rare complication of ureteral calculi. Int J Res Med Sci 2015;3:2440-2.  Back to cited text no. 3
    
4.
Titton RL, Gervais DA, Hahn PF, Harisinghani MG, Arellano RS, Mueller PR. Urine leaks and urinomas: Diagnosis and imaging-guided intervention. Radiographics 2003;23:1133-47.  Back to cited text no. 4
    
5.
Tseng PC, Liu TY, Pan SJ, Sung DS. Spontaneous perirenal urinoma associated with ureteropelvic junction obstruction in a child: A case report. Pediatr Neonatol 2009;50:121-4.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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