Urinoma

Atraumatic Bilateral Renal Subcapsular Urinomas in a Young, Healthy Female

BACKGROUND

Urinomas are rare and generally result from trauma to any part of the urinary collecting system. Appropriate imaging is crucial in the timely diagnosis and management of urinomas and for ruling out other etiologies such as subcapsular renal hematomas and perinephric abscesses.

CASE REPORT

A 31-year-old woman with no past medical history or known trauma presented to the Emergency Department (ED) with a week of right flank pain, abdominal pain, and intermittent fevers. On point-of-care ultrasound (POCUS), she was found to have a complex right perinephric collection, later confirmed with computed tomography (CT) imaging. She was treated with intravenous (IV) antibiotics and discharged after a 3-day hospital admission with instructions to follow up with Urology. A day later, she was readmitted with worsening bilateral flank pain and persistent fevers. Image-guided percutaneous aspirations of her bilateral perinephric fluid collections revealed both urine and blood. A right ureteral stent was then placed with ultimate resolution of her symptoms. Why Should an Emergency Physician Be Aware of This? Urinomas without history of trauma are rare and should be on the differential for patients presenting with flank pain and infectious symptoms. Urinomas or other expanding perinephric fluid collections can result in superimposed infection, rupture, secondary hypertension, and renal failure. Here, we present an atypical case of atraumatic bilateral renal subcapsular urinomas with hemorrhagic components in a young and healthy woman. Our case further outlines the utility of POCUS in the ED for the timely diagnosis and management of this disease process.

Evaluation of urinary extravasation after non-operative management of traumatic renal injury: a multi-center retrospective study

PURPOSE

Urinary extravasation is one of the major complications after non-operative management of traumatic renal injury and may lead to urinary tract infection and sepsis. The purpose of this study was to evaluate these factors in patients with traumatic renal injury.

METHODS

This was a multi-center, retrospective, observational study performed at three tertiary referral hospitals in Osaka prefecture. We included patients with traumatic renal injury transported to the centers between January 2008 and December 2018. We excluded patients who either died or underwent nephrectomy within 24 h after admission. We investigated the occurrence of urinary extravasation and the related factors after traumatic renal injury using multivariable logistic regression analysis.

RESULTS

In total, 146 patients were eligible for analysis. Their median age was 44 years and 68.5% were male. Their median Injury Severity Score was 17. Renal injuries were graded as American Association for Surgery of Trauma (AAST) grade I in 33 (22.6%), II in 27 (18.5%), III in 38 (26.0%), IV in 28 (19.2%), and V in 20 (13.7%) patients. Urinary extravasation was diagnosed in 26 patients (17.8%) and was statistically significantly associated with AAST grades IV-V (adjusted odds ratio, 33.8 [95% confidence interval 7.12-160], p < 0.001).

CONCLUSION

We observed urinary extravasation in 17.8% of patients with non-operative management of traumatic renal injury and the diagnosed was made in mostly within 7 days after admission. In this study, the patients with AAST grade IV-V injury were associated with having urinary extravasation.

Urinoma following blunt renal trauma in a patient with anomalous solitary kidney: A case report

INTRODUCTION AND IMPORTANCE

Blunt traumatic injury to the genitourinary system is uncommon. Urinoma formation may occur in patients with blunt trauma after high grade renal injuries. In such cases, the presence of solitary kidney must be ruled out as it may affect treatment decisions.

CASE PRESENTATION

A 21 years old male presented to our facility with complaints of abdominal pain and frank hematuria following physical assault. Physical examination revealed tenderness at the right flank. Laboratory evaluation showed a decreased hemoglobin level and urinalysis showed proteinuria and marked hematuria. Imaging findings were consistent with AAST Grade IV right renal injury affecting the renal pelvis with urinoma formation and congenital megacalyces. Incidental finding of unilateral renal agenesis on the left side was also noted. Our patient underwent Ureteroscopy with double-J stenting. Subsequent ultrasonography after the procedure showed resolution of the perirenal collection.

DISCUSSION

The presence of solitary kidney must be ruled out in cases of high grade renal trauma as operative procedures may lead to catastrophic consequences in such cases. Urinoma formation after renal trauma may occur if the renal pelvis is injured and should be managed preferably by urinary diversion in the form of ureteral stenting over other operative procedures, especially in patients with anomalous solitary kidney.

CONCLUSION

Presence of bilateral kidneys should be confirmed before subjecting patients with high grade renal injury to operative procedures. Early ureteric stenting appears to be an effective method of urinary diversion for management of symptomatic urinomas in patients with anomalous solitary kidney.

Urinoma and Urinothorax: Report of a Case

The case of a 47-year-old female who presented with urinoma and urinothorax due to left ureteral calculus obstruction is reported. The left kidney was surgically resected, while the urinothorax was evacuated by therapeutic thoracentesis, which resulted in withdrawal of 18 liters of straw-colored pleural fluid.

Postoperative Complications After Robotic Partial Nephrectomy

Objectives: To assess the incidence of postoperative arterial malformation (AM) and urine leak/urinoma (UL) after robotic partial nephrectomy (RPN) in a contemporary series and to evaluate risk factors for these complications. Materials and Methods: All RPNs were queried from Institutional Review Board-approved retrospective and prospective nephrectomy databases. Demographics, perioperative variables, and postoperative complications were collected. Differences between cohorts were analyzed using univariate analysis. Postoperative complications were graded using the Clavien-Dindo system. UL was defined in the context of signs and symptoms of a collection with supporting evidence of urine collection through drainage or aspiration. AM was identified based on postoperative imaging indicative of arteriovenous fistula or pseudoaneurysm and/or requirement for selective embolization. Predictors of AM and UL were assessed by univariate analysis. Results: A total of 395 RPNs were performed by four urologists between January 2014 and October 2018. Tumor complexity, defined by nephrometry score, was significantly greater in the prospective cohort (p = 0.01). Overall incidence of postoperative complications was 5.6% with cohort-specific incidences of 5.3% and 5.8%. The retrospective cohort had a greater percentage of complications classified as ≥IIIa: 8/13 (61.5%) vs 2/8 (25%). Overall incidence of AM was 2.3% with cohort-specific incidence of 3.1% (7/225) vs 1.1% (2/170). Overall incidence of UL was 0.25% with cohort-specific incidence of 0.55% (1/225) and 0.0% (0/170). The difference in incidence of both complications between cohorts was significant (p < 0.05). No significant predictors for AM were identified. Conclusions: The incidence of postoperative complications after RPN remains low (5.3% vs 5.8%, overall: 5.6%). UL and AM are becoming rarer with experience, despite increasing surgical complexity (0.55% vs 0%, 3.1% vs 1.1%).

Perinephric Urinoma Secondary to Malignancy in a Pediatric Patient

Perinephric urinomas commonly arise following traumatic injury or high-grade obstruction from kidney stones or lower urinary tract disorders. Not only are spontaneous urinomas rare in the pediatric population, but malignancy presenting with perinephric urinomas have only been described in the adult population. In this case report, we report flank pain from a spontaneous perinephric urinoma as the presenting symptom of lymphoma in a pediatric patient.

[Cystic abdominal mass as a complication due to posterior urethral valves]

A case of urinoma with posterior urethral valves and its management is presented. Diagnostic investigations and therapy strategies are discussed. Though rare, this possibility should be considered in the differential diagnosis of neonates presenting with rapidly expanding cystic masses in the abdomen. Early diagnosis and management are the most important prognostic factors that ensure a good outcome in such cases.

Maternal urinoma during pregnancy

Urinoma is peripelvic extravasation of urine seen as the squeal of urinary trauma or stones. Little is known about maternal urinoma during pregnancy. A 27-year-old primigravida presented with gradual worsening right flank pain at 21(5/7) weeks of gestation. She denied any past medicosurgical history. Initial work-up revealed cost-vertebral angle tenderness and mild hydronephrosis by ultrasonography. Her symptom worsened and follow-up ultrasonography was performed 48 h later, which showed worsened hydronephrosis with large perinephric fluid collection. A Double-J stent was placed under cystoscopy. After the placement, the patient's symptoms improved quickly. The stent was removed three weeks later. The patient delivered vaginally at 39 weeks of gestation without complication. Maternal urinoma during pregnancy developed in the right side of the kidney in five of six reported cases (83.3%), and all were seen in the second half of pregnancy. All showed flank pain as the initial presentation. Ultrasonography for diagnosis was used in half of the patients. Fifty percent underwent Double-J stent before delivery and 16.7% after delivery. All cases delivered at term and 33.3% underwent cesarean delivery. Maternal urinoma is an important differential diagnosis for flank pain during pregnancy. Double-J stent placement was the main management. Close monitoring of the symptom with serial ultrasonography may be the key for diagnosis.

Fetal urinoma: two new cases and a review of the literature

OBJECTIVE

To evaluate the functional prognosis of kidneys affected prenatally by urinomas.

METHODS

This was a retrospective review of cases of fetal urinoma reported in the literature, as well as two of our own cases.

RESULTS

Twenty-three patients with a prenatal diagnosis of urinoma (five bilateral) were included in the analysis. Postnatal ipsilateral renal function was observed in only six of the 28 renal units (i.e. around 20%).

CONCLUSIONS

Although the precise causes of urinomas are still unknown, this review shows that in the event of a fetal urinoma, the probability of a non-functional dysplastic ipsilateral kidney lies at around 80%. In-utero puncture only appears to be justified in cases where fluid accumulation has mass effects on adjacent major structures.

Second Prize: Forced versus Minimal Intravenous Hydration in the Management of Acute Renal Colic: A Randomized Trial

BACKGROUND AND PURPOSE

The management of acute renal colic is a problem commonly encountered by both urologists and emergency medicine physicians. The classic approach to managing uncomplicated acute renal colic involves hydration, along with imaging and pain control. Previous studies have suggested that hydration has a significant impact on patient comfort, as well as spontaneous stone passage. This study evaluated the effects of maintenance v forced hydration and its effect on the pain experienced from renal colic.

PATIENTS AND METHODS

Forty male and 18 female patients with a mean age of 41 years suspected to have acute renal colic were identified in the emergency department. After screening and informed consent, the patients were enrolled in the study, and 43 patients were eventually available for analysis. Patients received intravenous (IV) analgesia, imaging with a noncontrast CT scan of abdomen and pelvis, and assignment to either forced IV hydration with 2 L of normal saline over 2 hours (N = 20) or minimal IV hydration at 20 mL of normal saline per hour (N = 23). A visual analog pain scale was completed hourly for a total of 4 hours. Demographic information, laboratory and imaging results, narcotic use in morphine equivalents (ME), and pain scores were recorded and compared. Spontaneous stone passage rates were also calculated by careful patient follow-up. Results were considered statistically significant at p < 0.05.

RESULTS

Stone size was equivalent in the two treatment groups (p > 0.05). There was no difference in the narcotic requirement in ME (p = 0.644) between the two groups. Similarly, there was no difference in hourly pain score or stone-passage rates between the groups (p > 0.05).

CONCLUSIONS

Treatment of uncomplicated renal colic has traditionally included vigorous intravenous hydration, as well as medications for the control of pain and nausea. Our data suggest that maintenance intravenous fluids are as efficacious as forced hydration with regard to patient pain perception and narcotic use. Moreover, it appears the state of hydration has little impact on stone passage.

Complications of Renal Trauma

Renal trauma is rare, and significant complications from renal trauma are generally rarer still occurring in less than 5% in modern series. Close follow-up of injured patients and scrupulous use of imaging, including computed tomography scan, arteriogram, or retro-grade pyelogram when appropriate, increase detection rates and establish the diagnosis in most patients. Treatment varies by etiology and may range from watchful waiting to percutaneous drainage to, in rare cases, nephrectomy.

Bilateral spontaneous perinephric urinomas: Case report and review of the literature

Urinoma is defined as an encapsulated collection of extravasated urine in the perirenal or paraureteral space. Urinomas in childhood are rare and usually either secondary to obstructive uropathies or due to blunt or penetrating trauma leading to injuries of the collecting system and/or ureter. Spontaneous perinephric urinomas are rare. We report the case of an 8-year-old boy with bilateral spontaneous perinephric urinomas secondary to an abnormally elevated voiding pressure with detrusor sphincter dyssynergia. The available literature on this subject is reviewed, and clinical features, pathophysiology, and treatment of this entity are discussed.

Late-onset ureteric urinoma with intermittent jet flow as a complication of ureterolithotomy

We present the case of a late-onset urinoma in a 47-year-old man with a history of right ureterolithotomy performed 6 months previously, following 2 unsuccessful attempts at extracorporeal shock wave lithotripsy. The ipsilateral kidney was nonfunctional and hydronephrotic. The urinoma did not show enhancement on contrast-enhanced CT and intravenous pyelography. Sonography revealed turbulence in the urinoma and jet flow from the ureter. Lab studies of fluid obtained by percutaneous puncture and aspiration yielded misleading findings for urine and revealed the presence of hemosiderin-laden macrophages. The urinoma was surgically resected and ureteroneocystostomy was performed.

Ureteral stenting in the management of urinoma after severe blunt renal trauma in children

Posttraumatic urinomas are well-described complications associated with the nonoperative management of major blunt renal injuries. Urinoma drainage using a percutaneously placed catheter has been the traditional method used to alleviate symptoms and promote resolution without the need for open intervention. The authors describe 2 pediatric cases in which urinomas associated with grade IV renal lacerations were treated successfully utilizing internal ureteral stents.

Uriniferous perirenal pseudocyst. An unusual cause of a calcified abdominal mass in the neonate

Radiologically visible calcification in the wall of a uriniferous perirenal pseudocyst is rare. This unusual finding was seen in a newborn infant who was found to have a left flank mass on the first day of life. When perirenal pseudocysts occur in infants, they are usually caused by congenital obstructive lesions of the urinary tract.

Ultrasonography of the ureters

It is difficult to visualize the normal canine or feline ureters ultrasonographically; however, diagnosis of various abnormalities associated with ureteral dilation is possible in many instances. Ultrasonography is a practical method for diagnosis of ectopic ureter, ureterocele, and certain causes of ureteral obstruction that compares favorably with contrast radiography because it is quicker, does not involve use of contrast media or ionizing radiation, and usually requires no sedation or anesthesia. Ultrasonography is a convenient method for examining adjacent organs, principally the kidneys and bladder, that may be affected in animals with ureteral abnormalities. Also, ultrasound guidance facilitates certain interventional diagnostic procedures for the ureters.

Urinoma secondary to surgical spinal fusion: radiologic diagnosis and treatment

We have presented a case of urinoma secondary to ureteral injury during spinal fusion via retroperitoneal approach demonstrated by CT. The presumed diagnosis of urinoma was confirmed and treated by interventional radiologic techniques.

Case report: metastatic transitional cell carcinoma presenting in a urinoma

We describe a case of transitional cell carcinoma (TCC) metastasising into a urinoma cavity in a patient where the primary tumour arose at the ipsilateral ureterovesical junction. Seeding of transitional cell carcinoma into contiguous structures following surgical intervention has been reported, but to our knowledge, this is the first report of spread into a distant urinoma.

Urinoma masquerading as pancreatic pseudocyst

In this article, we report on a patient with recurrent pancreatitis who had received multiple celiac plexus injections for control of pain, and then developed a cystic mass adjacent to the body and tail of the pancreas suggestive of a pancreatic pseudocyst. The cystic mass proved to be a urinoma. The distinction between pancreatic pseudocyst and urinoma was made by CT scan with intravenous contrast utilizing delayed films, which demonstrated leakage of contrast into the cystic structure. This is the first report of a urinoma that resembled a pancreatic pseudocyst.

Urological myths

Images

Contained neonatal urinoma: management and functional results

Between 1970 and 1985, 10 male newborns with a contained urinoma were treated at our institution. An underlying congenital obstructive uropathic condition was discovered in every patient, the most common of which was posterior urethral valves. All 10 patients underwent surgical correction of the primary obstructive process. Direct drainage of the urinoma was required in 4 patients because of progressive clinical symptoms. Radiographic and renal functional parameters returned to normal at followup. Clinical presentation, evaluation, treatment and pathophysiology of this rare entity are discussed.

Pyelosinus extravasation and urinoma associated with malignancy. Computed tomography demonstration

We report 3 cases of abdominal malignancy with urinary tract obstruction and pyelosinus extravasation. Urinomas were present in 2 cases. The computed tomographic findings are emphasized, including the distribution of the extravasated urine reflecting the partitioning in the perirenal space. The cases presented within an eighteen-month period suggest pyelosinus extravasation and urinoma formation may not be uncommon in malignant disease affecting the retroperitoneum and pelvis.

Spontaneous urinoma due to retroperitoneal fibrosis and aortic aneurysm

Images

Neonatal urinomas: imaging considerations

Neonatal urinomas can be defined as encapsulated extravasations of urine occurring secondary to congenital obstructive uropathies. Since 1978, four patients with proven urinomas have been studied at the Medical University of South Carolina, three of which had posterior urethral valves and the fourth, a segmental ureteral atresia. They were classified into three major types; subcapsular, diffuse perirenal and localized perirenal. The radiologic and imaging appearances are demonstrated. We found the most efficacious approach for identification of neonatal urinomas to be renal ultrasound, voiding cystourethrography and the Tc-99m DPTA renal scintigraphy.

Ultrasonographic diagnosis of uriniferous perirenal pseudocyst

A child with a traumatic uriniferous perirenal pseudocyst was presented. The diagnosis was not made by routine radiological studies, but ultrasound examination demonstrated a perirenal fluid accumulation clearly. The usefulness of the ultrasound examination in the diagnosis of this condition was emphasized. The characteristic finding in ultrasonogram consists of a hydronephrotic kidney and its invagination into the echolucent mass. When perirenal cystic lesions are demonstrated by ultrasound, the junctional zone between the cyst and kidney should be carefully checked for signs of invagination of the kidney into the cyst.