腎臟包膜下外滲與尿液囊腫生成是否來自阻塞性尿路結石,醫源性手術過程,或是創傷後導致的結果?
廖丞晞1,2,3、王柏仁1,3、沈敬棟1,3、賴金湖1,2,3
1國軍台中總醫院外科部泌尿外科; 2中國醫藥大學生物醫學研究所; 3國防醫學院臨床醫學研究所
Is Renal Subcapsular Extravasation and Urinoma Formation Caused by Obstructive Urolithiasis, Iatrogenic Procedure, or Post.Traumatic Injury Result?
Cheng-Hsi Liao1,2,3, Bo-Ren Wang1,3, Jing-Dung Shen1,3, and Chin-Hu Lai1,2,3
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.
Abstract:
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 107/05/22 at TAFGH and discharged from ORT ward on 107/05/31.
But unfortunately, she complained low-grade fever, LLQ abdominal pain, nausea sensation with vomiting for 3 times since 107/06/14 morning after she got discharged from ORT admission more than 2 weeks. So she visited our SER again, where Sono. of abdomen and IVP+ PV revealed hydronephrosis with extravasation of L’t collecting system on U/3 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. She complained 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, though it’s very rare. 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. Besides, ORT doctor performed the previous percutaneous vertebroplasty, which resulted in the rupture of renal cortex might be also taken into consideration, and maybe peri-renal hematoma, L’t occurred then, just not found. Eventually during this time admission, emergent surgery of ureterorenoscopy with L’t sided double-J catheter placement were arranged and well-performed right away. Her symptoms got progressively improved after the surgery and 5 days observation. No fever or renal function impairment was noted, and she finally got discharged again luckily.
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.