廖丞晞^1,2,3、張皓智^1,3、吳榮倫^1,3、賴金湖^1,2,3

¹國軍台中總醫院泌尿外科; ²中國醫藥大學臨床醫學研究所; ³國防醫學院臨床醫學研究所

Cheng-Hsi Liao^1,2,3, Hao-Chih Chang^1,3, Jung-Lun Wu^1,3, and Chin-Hu Lai^1,2,3

¹Division of Urology, Department of Surgery, Taichung Armed Forces General Hospital, Taichung, Taiwan, R.O.C.; ²Graduate Institute of Biomedical Science, China Medical University, Taichung, Taiwan, R.O.C.; ³Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, R.O.C.

 

A 63-year-old woman suffered from traumatic injury (autobike rider, hit by a vehicle) since 2 weeks ago. She denied systemic disease such as hypertension, diabetes mellitus, or urolithiasis before. At that day, she was sent to our SER due to traumatic injury with compression fracture of T10、T11 & L2, and then she got admitted in our ORT ward for emergent operation of percutaneous vertebroplasty of T10、T11 & L2 with cement on 107/5/22 at TAFGH and discharged from ORT ward on 5/31.

But unfortunately, she complained low-grade fever, LLQ abdominal pain, nausea sensation with vomiting for 3 times since 107/06/14 morning. So she visited our SER again, where Sono. of abdomen and IVP+ PV revealed hydronephrosis with extravasation of L’t collecting system & urinary tract. Other laboratory studies showed no leukocytosis with neutrophil predominant, but urine routine showed mild pyuria and hematuria. The following abdominal CT scan accidently revealed a large left side kidney sub-capsular fluid accumulation with obvious extravasation. In addition, lower third of left ureteral stones with obstructive uropathy was also evident. Due to the persistent LLQ abdominal pain and L’t flank pain. Thus, ureteral stone with obstructive uropathy causing rupture of the pelvic system and the urinoma formation was first considered. But curiously, the previous traumatic injury caused by the traffic accident seemed to be the major problems, because it might damage the normal renal pelvic system structures. Finally, emergent operation of ureterorenoscopy with L’t side double-J catheter placement were arranged and well-performed right away. Her symptoms got progressively improved after the surgery and 5 days admission observation. No fever or renal function impairment was noted.

Urinomas forming due to obstruction from ureteral calculi are very rare. But we assumed that previous trauma (traffic accident) might lead to the renal pelvic structures damage, and then the urolithiasis would strengthen the effect of the fornical rupture, which caused extravasation with urinomas. Most patients complain of fever, nausea, vomiting, flank pain, ileus, and pain in the abdomen. The initial evaluation includes renal ultrasonography or IVP, followed by an abdomen and pelvis CT without contrast. The initial management is conservative. If the size of the urinoma does not decrease after several days, a percutaneous catheter under CT or ultrasound can be placed. Fluid analysis shows a significantly higher creatinine level and a lower glucose concentration relative to the serum. Urinomas may lead to complications such as abscess formation and electrolyte imbalances. The practicing clinician should have a high index of suspicion for this rare but serious entity to be able to promptly diagnose and manage this condition.