從腰大肌膿瘍到輸尿管破裂：廣泛感染擴散合併尿液外漏

蔡宏偉¹、陳祺方¹

¹台灣基督長老教會馬偕醫療財團法人馬偕紀念醫院泌尿科

From Psoas Abscess to Ureteral Disruption: Extensive Infection Spread with Urinary Leakage

Hung Wei Tsai¹、 Chi-Fang Chen ¹

¹Department of Urology, MacKay Memorial Hospital, Taipei, Taiwan

Introduction:

We report a case of multifocal abscess with unusual spread complicated by ureteral injury.

A 76-year-old female presented with edema and oliguria. CT revealed extensive retroperitoneal and abdominal wall abscesses. Persistent drainage after surgery led to the diagnosis of ureteral disruption, requiring urinary diversion.This case highlights the importance of recognizing atypical infection spread and associated urinary tract injury.

Case description:

A 76-year-old female presented with bilateral lower limb edema and decreased urine output. Her past medical history was significant for Klebsiella pneumoniae bacteremia, chronic kidney disease, liver cirrhosis, prior ischemic stroke with residual left hemiparesis and dysphagia, untreated multiple myeloma, and hypertension.

Contrast-enhanced CT demonstrated multifocal rim-enhancing collections involving the left lower chest wall, flank, inguinal region, splenic recess, along the iliopsoas muscle, and subcapsular region of the left kidney, consistent with extensive retroperitoneal and abdominal wall abscess formation.

The patient underwent ultrasound-guided fasciotomy and drainage, yielding approximately 300 mL of purulent material with extensive retroperitoneal extension. Postoperatively, persistent high-output drainage raised suspicion of urinary tract communication. ureteroscopy revealed a ureteral defect at the mid–upper ureter (~17 cm from the orifice), with failure to identify the proximal ureter. A percutaneous nephrostomy was performed. At 3-month follow-up, retrograde pyelography demonstrated non-visualization of the left upper ureter and renal pelvis, suggesting persistent ureteral disruption, with grade 1 right vesicoureteral reflux. Definitive management options included ureteroureterostomy or long-term PCN.

Discussion and Summary:

Psoas abscess may spread extensively along fascial planes, especially in immunocompromised patients [3,4]. Persistent high-output drainage is a key clue to urinary tract injury. Ureteral disruption, although rare, may occur due to severe inflammation and tissue necrosis [1,2].Guidelines recommend urographic evaluation and early urinary diversion (e.g., PCN) in suspected cases [1,2].Management should be individualized, including reconstruction or long-term diversion depending on patient condition [1,2].

Reference:

[1] Serafetinidis E, et al. EAU Guidelines on Urological Trauma. 2024

[2] de’Angelis N, et al. WSES Guidelines on urinary tract injury. 2023

[3] Sato T, et al. Psoas abscess cohort study. 2021

[4] Armenta-Flores R, et al. Iliopsoas abscess review. 2026