Khan, A A

Khan, Z A

Rizvi, I H

Tanveer-ul-Haq,

English

eCommons@AKU

eCommons@AKUDepartment of Radiology Medical College, PakistanJanuary 1998Percutaneous nephrostomy: a non-operativemanagement of urinomas: 2 case reportsTanveer-ul-Haqtanveer.haq@aku.eduI H. RizviZ A. KhanA A. KhanFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_radiolPart of the Radiology CommonsRecommended CitationTanveer-ul-Haq, ., Rizvi, I. H., Khan, Z. A., Khan, A. A. (1998). Percutaneous nephrostomy: a non-operative management ofurinomas: 2 case reports. Journal of Pakistan Medical Association, 48(1), 21-23.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_radiol/233Percutaneous Nephrostomy: A Non-Operative Management ofUrinomas: 2 Case ReportsPages with reference to book, From 21 To 23 Tanveer-ul-Haq,I.H. Rizvi,Zahid A. Khan,Ateeque A. Khan ( Department of RadIology, Aga Khan University Hospital,Karachi. ) Introduction Uretero-retropentoneal fistulas (urinomas) occur most commonly following penetrating trauma orcalculi. Despite the large variety of surgical procedures advocated for the management of ureteralfistulas or urinornas, the results are suboptimal. Conservative treatment by endoscopic placement ofindwelling ureteral stents is often preferred1,2. Adaptation of antegrade percutaneous stents offers anexcellent conservative method of treatment for patients not suitable for surgery and even forendoscopic placement. PCN has also been used successfully in the management ofurinomas3,4.Case Reports Case No. 1A 27 year old male had a road traffic accident. His car rolled over after strikingwithanothervehicle. Hehad transient loss of consciousness for few minutes at the time of accident. He presented to theemergency room. with complaint of right flank pain. There was no associated injury. He washemodynamically stable. On physical examination, he was a healthy young male, fully conscious andoriented in time, space and person. His blood pressure was 120/70 mm Hg, pulse 80/min and Hb was12.2 Gm%. Serum creatinine was 1,5 mg%. Mild tenderness was identified in right renal region.Ultrasound showed possible contusion in anteroinferior part of right kidney and small amount of fluidin hepatorenal pouch. IVU examination revealed extravasation of contrast from right renal pelvis andcollection of contrast around renal pelvis and proximal ureter (Figure 1).Distal ureter was also outlined. This was suggestive of partial rupture of renal pelvis. An oval shapedcalculus was also seen in right mid ureter causing partial obstruction and mild dilatation of collectingsystem. An attempt to insert DJ stent retrogradely was unsuccessful. Later, a percutaneous nephrostomytube was placed (Figure 2).Nephrostogram performed two weeks later, showed prompt healing of unnorna (Figure 3)Subsequently, a percutaneous DJ stent was inserted for further management of ureteric calculus. DJstent was placed with the help of special glide (Temmo) wire which passed across the obstruction evenin the presence of stone and obstruction.Case No.2Sixty years old female known to have diabetes mellitus and hypertension presented in the emergencyroom with right sided abdominal pain, fever and vomiting for 10 days.Examination revealed a soft tissue mass on the right side of the abdomen. Initial laboratoryinvestigations showed leucocytosis, elevated levels of blood sugar and urinary tract infection.Ultrasound showed bilateral renal calculi, gross hydronephrosis on right as well as perinephriccollection of fluid. Left kidney was shrunken and scatted without any hydronephrosis. A nephrostomywas done on the subsequent day to relieve obstruction Nephrostogmrn done during the procedureshowed hydronephrosis and extravasation of contrastfrom the nghtupperureterwhichwas filling up alarge inegular cavity (Figure 4).Rest of the ureter could not be delineated. The drainedurine was pussy and later grew E. Coil. Patientshowed improvement with this treatment. The infection was controlled and her serum creatinine camedown to 5.5 mg% from initial 12.8 mg% in 8 days time. A repeat nephrostogram after a week showedreduced dilatation of the collecting system with better anatomical details and completely obstructedmid ureter by a stone. There was refilling of the cavity which also showed communication with theduodenum (Figure 5).It was assumed that the abscess cavity might have burst into the duodenum. Patient was dischargedwith the nephrostomy and recalled after three weeks for a nephmstogram, which showed completehealing of cavity and enterorenal fistula (Figure 6).An antegrade double J stent was placed in for her subsequent management of stone and obstruction.Discussion A urinoma is an encapsulated extravasation of urine in retroperitoneum which can be secondary totrauma or which can occur spontaneously. The essential factors are continued renal function, rupture ofthe collecting system and distal obstruction. The extravasated urine causes lipolysis and stimulates anintense fibrous reaction which forms a thick wall5. The spontaneous rupture of the ureter is a rarecondition6. An obstructed renal system can easily be ruptured even with minor trauma as in our firstcase. Conservative management by indwelling catheters is atleast as effective as primary surgeiy7,8.Even percutaneous drainage alone is considered sufficient5 and results in satisfactory healing ofurinoma. This safe effective procedure allows non-operative management of urinoma. Recentexperience has proved that, for the treatment of fistulas, urinomas, urinary ascites and obstruction dueto a missed ureteral injury, the best results are achieved with initial nephrostomy followed byreconstruction when needed9. In one series nephrostomy was the definitive treatment in 44% of caseswith leakage and it protected any required reconstruction10. Distortion of the ureteral orifice by scartissue often makes retrograde introduction of indwelling catheters impossible; moreover, passage maybe impeded by a near dehiscence of the ureter oran incomplete dehiscence may be totally severedduring attempt at passage111. Obstructing calculus in ureter also impedes the retrograde passage ofcatheter. The antegrade percutaneous technique offers an attractive alternative to placement of anindwelling stent. In our first case stent placement via cystoscopy had failed. PCN did very well andurinoma was healed within 2 weeks. Subsequently, a DJ stent was placed percutaneously for furthermanagement of uretenc calculus which was causing partial obstruction. In the second case, thoughurinoma was infected with a fistulous communication between infected unnoma and duodenum, butstill, PCN was found to be a definite treatment and urinoma healed satisfactorily. In conclusion,percutaneous nephrostomy alone can be the primary treatment allowing healing of urinoma, which insome cases will be the only treatment required, while mothers it may be the initial minimally invasivetherapy till more definite treatment is done. In many cases this may avoid major surgeiy.References 1. Keamey, G.P,, Mahoney, EM. and Brown, H.P. Useful technique for long term urinary drainage byinlying ureteral stent Six year experience. Urology, 1979; 14: 126.134.2. Konigsberg, H.,Blunt, K,J, and Muecke, E.C. Use ofBoari flap in lower ureteral injuries. Urology,1975;5:75 1.755.3. Stables, D.P., Ginsberg, N.J. and Johnson, ML. Percutaneous nephrostomy: A series and review ofthe literature. Am. J. Roentgenol., 1978;130:75-82.4. Pfister, R.C. and Newhouse,’ JH. interveritional percutaneous pyeloureteral techniques; II.Percutaneous nephrostomy and other procedures. Radiol. Clin. NorthAm., 1979;17:351-363.5. Rohner. S., Tuchschmid, Y, and Graber, P. Perirenal urinoma (Abstract). Ann. Urol.,Paris,1994;28:259-64.6. Leuthardt, R., Berhardt, E., Gasser, T, et al. Spontaneous perforation of the ureter:Ararecomplicationofurolithiasis. Eur. J. Pediatr. Sung., 1994;4:205-6.7. Goldin, AR. Percutaneous ureteral splinting. Urology, 1977; 10:165-168.8. Lang, E.K., La-Nasa, J.A., Garrett, J. et al. The management of urinary fistulas and strictures withpercutaneous ureteral stent catheters. J. Urol., 1979; 122:736.740.9. Lang, E.K. and Glonoso, L. ‘Management of urinomas by percutaneous drainage procedures”.Radiol-Clin. North-Am., 1 986;24 551-559.10. Al-Ali, M. and Haddad, L.F. ‘The late treatment of 63 overlooked or complicated ureteral missileinjuries: The promise of nephrostomy and role of autotranspiantation’. J. Urol., 1996;156:1918-1921.11. Lang, E.K. Diagnosis and management of ureteral fistulas by percutaneous nephrostomy andantegrade stent catheter. Radiology, 1981; 138:311-317.

Percutaneous nephrostomy: a non-operative management of urinomas: 2 case reports

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Percutaneous nephrostomy: a non-operative management of urinomas: 2 case reports

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