Spontaneous perforation of the ureter: clinical presentation and endourologic management

A Case of Spontaneous Ureteral Rupture Mimicking Renal Colic

A 67-year-old female presented to the emergency department with acute-onset severe left flank pain as well as nausea and vomiting. Physical examination was notable for left-sided abdominal, flank tenderness, and costovertebral angle tenderness. Laboratory workup revealed an elevated lactate of 9.2 mmol/L and elevated serum creatinine of 1.14 mg/dL, with an estimated glomerular filtration rate of 53 mL/minute/1.73m². Urinalysis showed moderate leukocyte esterase with microscopy showing 12 white blood cells and three red blood cells per high-power field. CT of the abdomen and pelvis with intravenous contrast was notable for moderate amounts of left-sided perinephric and periureteric fluid without the presence of an obstructing calculus. Due to the amount of perinephric and periureteric fluid without associated nephrolithiasis, the differential diagnosis was broadened to include spontaneous ureter rupture as well as concern for malignancy. A delayed post-contrast CT scan of the abdomen and pelvis was obtained, which confirmed a spontaneous proximal and mid-ureter rupture. Spontaneous ureter rupture is a rare disease process with significant morbidity and mortality. It often poses a diagnostic dilemma due to a lack of clinical awareness and varied presentation. Diagnosis rests upon obtaining delayed post-contrast CT of the abdomen and pelvis. Currently, there are no standardized treatment guidelines, although most experts utilize minimally invasive endourological approaches in their treatment plans.

Case of bilateral hydronephrosis and spontaneous ureteral rupture as a rare complication of prostate biopsy

Development of bilateral hydronephrosis and ureteric rupture has never been reported in the published literature so far. We describe a case of 51years old gentleman who developed this complication aftertrans-rectal ultrasound guided prostate biopsy. The patient was treated with bilateral double-J stent insertion, intravenous antibiotic therapy and recovered completely. There have been reports of hydronephrosis with or without ureteric rupture in the world literature. The causes reported have been such as malignancy, stones, retroperitoneal fibrosis, iatrogenic manipulation, trauma, degenerative kidney conditions and spontaneous causes. This could lead to development of retroperitoneal urinoma, urosepsis, abscess formation, infection and renal impairment.

Spontaneous ureteric rupture due to high pressure chronic retention

Spontaneous ureteric rupture is a rare phenomenon which can be traumatic or non-traumatic that may arise from ureteric obstruction, trauma, mucosal inflammation from urolithiasis, connective tissue disease or retroperitoneal fibrosis. High pressure chronic retention is characterised by noctural enuresis, a tense palpable bladder, hypertension, progressive renal impairment, bilateral hydronephrosis and hydroureter on imaging. Obstructive urological symptoms are typically absent in uncomplicated cases. We report the case of a 69-year-old male who presented with high pressure chronic retention and spontaneous ureteric rupture demonstrated on a noncontrast CT. This patient was managed with a urethral catheter on free drainage and a retrograde ureteric stent. The patient's condition improved, and the stent was removed after a uretero-pyeloscopy which revealed no extravasation. He later underwent a successful transurethral resection of the prostate.

Tubular Dysfunction and Ruptured Ureter in a Child with Menkes Syndrome

Children with Menkes disease may develop various urological and renal problems that evolve as the disease progresses. A 4-year-old boy with Menkes disease had multiple bladder diverticula and a history of recurrent urinary tract infection caused by urea-splitting organisms. The child developed urosepsis and right pyelonephritis. Subsequent investigations revealed multiple right renal stones and a ruptured right ureter. The child also developed hypokalemia, hypophosphatemia, and normal anion gap metabolic acidosis that required electrolyte and potassium citrate supplement. Further assessment revealed renal tubular dysfunction. Our case suggests that regular imaging surveillance, monitoring of renal function and electrolyte profile, and tubular function assessment should be considered in children with Menkes disease.

Spontaneous Upper Urinary Tract Rupture Caused by Ureteric Stones: Clinical Characteristics and Validation of a Radiological Classification System

Background: This study seeks to validate a radiological classification system of spontaneous upper urinary tract rupture (sUUTR) and to analyse its relationship with clinical, laboratory and radiological characteristics of sUUTR. Methods: We analysed data from 66 patients with a computerised tomography (CT)-proven sUUTR treated with ureteral or nephrostomy catheter positioning. Comorbidities were scored with the Charlson Comorbidity Index (CCI). All CT scans were reviewed by two experienced radiologists and one urologist, who classified sUUTR in (a) local spread, (b) free fluid and (c) urinoma. Interobserver agreement for radiological score was evaluated with the Intraclass Correlation Coefficient (ICC) and Cohen’s Kappa analyses. Descriptive statistics and logistic regression models verified the association between clinical variables and sUUTR severity. Results: The interobserver agreement for sUUTR classification was high among radiologists and between the radiologists and the urologist (all Kappa > 0.7), with an overall high interrater reliability (ICC 0.82). Local spread, free fluid and urinoma were found in 24 (36.4%), 39 (59.1%) and 3 (4.5%) cases, respectively. Patients with free fluid/urinoma had higher rate of CCI ≥ 1 than those with local spread (40.5% vs. 16.7%, p = 0.04). Intraoperative absence of urine extravasation was more frequently found in patients with local spread than those with free fluid/urinoma (66.7% vs. 28.6%, p < 0.01). Multivariable logistic regression analysis revealed that local spread (OR 4.5, p < 0.01) was associated with absence of contrast medium extravasation during pyelography, after accounting for stone size, fever and CCI. Conclusions: The analysed sUUTR classification score had good inter/intra-reader reliability among radiologists and urologists. Absence of urine extravasation was five times more frequent in patients with local spread, making conservative treatment feasible in these cases.

Spontaneous Ureteric Rupture and Its Implications in the Emergency Department: A Case Report

INTRODUCTION

Spontaneous ureteric rupture is uncommon and has a wide range of presentations. Accurate diagnosis and timely treatment is necessary to avoid potential serious complications.

CASE REPORT

We present the case of a 55-year-old female who presented with severe right lower abdominal pain with rebound tenderness, vomiting, and a single episode of hematuria. A computed tomography with intravenous contrast of the abdomen and pelvis showed a 0.3-centimeter right upper ureteric calculus, with hydronephrosis and ureteric rupture. In view of the scan findings, a diagnosis of spontaneous ureteric rupture secondary to urolithiasis was made. The patient underwent a percutaneous nephrostomy and ureteric stenting.

CONCLUSION

Spontaneous rupture of the ureter is an uncommon diagnosis for which clinical and laboratory signs may not always be reliably present. A high index of suspicion is required for diagnosis, which is usually confirmed on advanced imaging. It may occur in serious complications of urinoma and abscess formation. As such, accurate diagnosis and timely treatment is crucial.

Recurrent MALT lymphoma presenting as renal calyceal-pelvic rupture. What is the cause of this break?

Urinary collecting system rupture is an uncommon condition that usually occurs with symptoms of acute abdomen, secondary to peritoneal irritation by urine leaking. We report a case of a 49-year-old man admitted to our emergency department because of a worsening deep lower abdominal pain started 3 days before. The abdominal computed tomography revealed urine extravasation suggesting for urinoma. Because of patient pathological history of lymphoma, despite its apparent state of remission, he underwent a positron emission tomography - computed tomography with ¹⁸[F]-FDG and magnetic resonance in order to rule out a recurrence. Imaging supported the diagnostic hypothesis of a lymphatic recurrence that had compressed "ab-extrinseco" the urinary tract so much to break it. Based on our experience we can suggest that nontraumatic calyceal-pelvic rupture is an extremely rare manifestation of an onset of lymphoma.

Spontaneous Perforation of the UPJ: A Case Report and Review of the Literature

Spontaneous rupture of the ureter is an uncommon condition defined by non-traumatic extravasation of urine. Causative factors leading to rupture include urinary calculi, malignancies, instrumentation or trauma. Ureteral rupture can lead to numerous complications, including abscess formation, urinomas, and urosepsis. Minimal literature is available regarding spontaneous ureteral perforation, especially at the ureteropelvic junction. We present a rare case of spontaneous perforation of the ureter at the ureteropelvic junction caused by an undiagnosed non-compliant bladder. This case illustrates a previously undescribed cause of spontaneous ureteral perforation and the importance of prompt identification and treatment.

Spontaneous ureteric rupture, a reality or a faux pas?

BACKGROUND

Rupture of the urinary collecting system with or without any perinephric extravasation is an extremely rare occurrence and usually known to occur following an obstructive pathology. Spontaneous or non-traumatic rupture, in the absence of any distal obstruction, though reported in literature, is not yet a proven entity and needs to be distinguished from physiological forniceal rupture, to validate its occurrence. Our case illustrates that spontaneous ureteric rupture does exist and requires a high level of vigil for prompt diagnosis and early simple management.

CASE PRESENTATION

A 65 year old non diabetic gentleman presented with a 2 day history of right sided severe abdominal pain with no history of any prior trauma, surgery, urinary retention or calculus disease. His ultrasound whole-abdomen was suggestive of increased liver echogenicity, but his contrast enhanced CT scan (CECT) documented a ureteric rupture, with leakage of contrast from the upper ureters, well away from the renal pelvis He was promptly managed with cysto-ureteroscopy, retrograde pyelography (RGP) and double-J (DJ) stenting. His post operative course was uneventful and he was discharged on the second post operative day, without event. An RGP at 6 weeks of follow up showed no contrast extravasation from the ureter and his DJ stent was removed without event.

CONCLUSION

Spontaneous ureteric rupture, in the absence of any inciting cause, is an entity which exists and is easily manageable, once diagnosed timely. Thus, the need to maintain a high index of vigil, in order to identify this clinically entity at the earnest, institute prompt treatment and hence ensure that a "spontaneous" rupture, doesn't become a "faux pas" in the true sense of the word.

Spontaneous rupture of the ureter

Spontaneous rupture of the ureter is a very rare condition and usually results from ureteral obstruction by a calculus. Only theoretical mechanisms have been proposed and no possible explanation has yet been reported in the literature. Intravenous contrast-enhanced computed tomography is the most informative study with high sensitivity. Treatment should be individualised, and depends on the state of the patient. Minimally invasive endourological procedures with double-J catheter placement and percutaneous drainage offer excellent results. Conservative management with analgesics and antibiotic coverage may be an alternative to surgery. Herein, we present a case of spontaneous rupture of the proximal ureter with no evidence of an underlying pathological condition.

Spontaneous ureteral rupture and review of the literature

INTRODUCTION

Spontaneous ureteral rupture is defined as non-traumatic urinary leakage from the ureter. This is a diagnosis that, although uncommon, is important for emergency physicians to know about. The literature is relatively sparse.

MATERIALS AND METHODS

This was a retrospective review of patients who were diagnosed with spontaneous ureteral rupture. From 2006 to 2012, 18 patients were diagnosed by radiography (computed tomography or intravenous urogram) with spontaneous ureteral rupture. These cases all showed extravasation of the contrast outside the excretory system. We evaluated underlying causes, diagnostic and therapeutic procedures, and outcomes.

RESULTS

There were 9 men and 9 women with a median age of 59 years (range, 22-82 years). In 56% of patients, a ureteral stone was the cause; in 17% of, a ureteral stricture; in 1 patient, a ureteral tumor; and in the remaining 22%, no cause was identified. In 13 patients (72.2%), primary ureteroscopy to place D-J stents was performed. The average duration of ureteral catheter stenting was 21 days (range, 8-45 days). The other 5 patients (27.8%) were managed conservatively with antibiotic treatment and the outcome was good.

CONCLUSIONS

Ureteral stones most commonly cause spontaneous ureteral rupture. In our experience, most patients received ureteroscopy and Double-J stenting. Conservative management with antibiotics also had good outcomes. Most patients had sudden onset of abdominal or flank pain. Spontaneous ureteral rupture should be kept in the differential diagnosis of patients with acute abdominal or flank pain in the emergency department.

Spontaneous urinary extravasation: detection rate with 64-row multidetector computed tomography in patients presenting with acute abdomen

The aim of this study was to detect the rate of spontaneous urinary extravasation (SUE) with computed tomography (CT) in patients presenting with acute abdomen. Seven hundred thirteen abdominal CT examinations with i.v. contrast media requested mainly from the emergency department and urology clinics for sudden onset abdominal pain, flank pain, nonspecific abdominal pain with nausea and vomiting, and renal colic between September 2007 and August 2011 were retrospectively reviewed. Only adult patients were included in the study. Three patients with SUE were detected. One had a mid-ureteral stone while the etiology for the other two patients was unknown. Two of the patients were treated conservatively; one was treated with stenting with a double-j catheter. SUE should be considered in the differential diagnosis of patients presenting with acute abdomen and perinephric-periureteral fluid collection inconsistent with stone size and who are occasionally stone free. Early and precise diagnosis of SUE plays an important role in the management protocol of patients presenting with acute abdomen.

A rare case of upper ureter rupture: ureteral perforation caused by urinary retention

Perforation of the ureter is a rare condition that causes a series of problems including retroperitoneal urinoma, urosepsis, abscess formation, infection, and subsequent renal impairment. There are causative factors that induce ureteric rupture, including malignancy, urinary calculi, idiopathic retroperitoneal fibrosis, recent iatrogenic manipulation, external trauma, degenerative kidney conditions, urography with external compression, and spontaneous causes. We report a rare case of ureteric rupture caused by urinary retention. The patient was treated with temporary percutaneous drainage and antibiotics. The present case illustrates that urinary retention can induce not only bladder rupture, but also ureteric rupture. It is thus of paramount importance to effectively manage patients with voiding problems.

Rupture of the ureter mimicking acute renal infarction: case report and review of the literature

We describe a case of acute rupture of the left proximal ureter as a result of lithiasis. The patient presented with a clinical picture of renal infarction: unilateral flank pain, more than 500 red blood cells per microliter urine and increased serum LDH levels. Abdominal ultrasound as well as a CT scan showed no abnormalities. Only CT angiography of the kidneys was able to demonstrate an acute rupture of the left proximal ureter with extravasation of contrast. Intravenous pyelogram confirmed this rupture with leaking of the contrast. One day after admission the patient urinated a 2 mm large calciumoxalate-monohydrate stone, the likely cause of the rupture. The rupture healed spontaneously. A review of the literature is given.