輸尿管結石體外震波碎石術後的輸尿管破裂 – 病例報告
顏怡安1、黃逸修2,3
1臺北榮民總醫院 教學部；2臺北榮民總醫院 泌尿部；3國立陽明交通大學醫學系泌尿學科
Ureteral rupture after shock wave lithotripsy for ureteral urolithiasis: A Case Report
Yi-An Yen1, Eric Yi-Hsiu Huang2,3
1 Department of Medical Education, 2 Department of Urology,
Taipei Veterans General Hospital, Taipei, Taiwan,
3 Department of Urology, School of Medicine and Shu-Tien Urological Science Research Center,
National Yang Ming Chiao Tung University, Taipei, Taiwan;
Introduction:
Extracorporeal shock wave lithotripsy (ESWL) is a noninvasive therapeutic option of urolithiasis with low complication rate, which made it become one of the most commonly used first-line therapy for both renal and ureteral stones whenever calculi were within certain size. Ureteral rupture is a rare complication of ESWL in treating ureteral stone, and was definitely diagnosed by evidence of contrast extravasation from the ureter on a contrast-enhanced urography. Here we would like to present a male case of contrast extravasation after ESWL for a lower ureteral stone. Percutaneous nephrostomy (PCN) with subsequent ureteroscopic lithotripsy (URSL) and double-J stenting were implemented as definitive treatment.
Case report:
A 53-year-old male was diagnosed to have a left lower ureteral stone and underwent ESWL at other hospital. Exaggerated left flank and abdominal pain with nausea and cold sweating developed about 8 hours after ESWL which drove him to visit our emergency department (ED). Upon arrival, his vital signs showed stable without fever. Physical examination revealed significant left lower abdominal tenderness with slightly rebound pain. Knocking tenderness at left costal-vertebral angle was also noticed. Laboratory data showed leukocytosis with white-cell count 16090 per microliter. Computed tomography urography (CTU) showed contrast extravasation from left upper ureter with peripheral fat stranding and left hydronephrosis. Left PCN for urinary drainage was implemented, followed by URSL and left double-J ureteral stenting. PCN was removed afterwards and the post-operative course was uneventful.
Ureteral rupture was an uncommon complication of ESWL for ureteral stones with only few case reports as opposed to subcapsular renal hematoma formation or urinary tract infection after ESWL for renal stones. Urinoma formation may result in subsequent bacterial infection, abscess formation, or upstream hydronephrosis causing obstructive nephropathy as it gradually enlarged. Although immediate surgical intervention is under debate and currently there is no evidence-based guideline suggestion, nephrostomy with or without ureteric stenting is within urologist consensus. The most challenging part of clinical practice is timely diagnosis, since its initial presentation may mimic other acute abdomen, which was more common, advanced imaging with contrast administration should be arranged if highly clinical suspicion. Herein, we presented a very typical scenario with a characteristic CTU.
Conclusions:
Ureteral rupture after ESWL for ureteral stones is a rarely reported complication, which may be potentially life-threatening. Despite percutaneous nephrostomy with ureteric stenting warrants good patient outcomes, prognosis mainly related to early detection and timely management. Consequently, persistent flank or abdominal pain after ESWL for ureteral stones should raise clinical suspicion and further imaging is necessary for early detection and prevent catastrophic complications.