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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 314-316

Devastating complication due to rupture of obstructive perinephric urinoma with secondary pyonephrosis necessitating nephrectomy of nonfunctional kidney in a child


Department of Pediatrics, Gujarat Medical Education and Research Society Medical College, Sola, Sarkhej Gandhinagar, Sola, Ahmedabad, Gujarat, India

Date of Web Publication16-Dec-2015

Correspondence Address:
Nehal Patel
Department of Pediatrics, Gujarat Medical Education and Research Society Medical College, Sola, Near Gujarat High Court, Sarkhej Gandhinagar Highway, Sola, Ahmedabad - 380 060, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-4848.171937

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  Abstract 

Rupture of the pelvicalyceal urinary collecting system causing perirenal and retroperitoneal extravasation of the urine and subsequent mass with secondary infection is a rare complication of ureteral-obstructing calculi. We report a rare case of calyceal rupture with urinoma formation in a child presenting with acute abdomen and nonremitting fever due to secondary pyonephrosis. The retroperitoneal mass on abdomen sonography was confirmed as urinoma communicating with the upper ureter on computed tomography (CT). Gross anatomical observation during surgical intervention revealed extensive pyonephrosis with adhesions involving the adjacent intestinal loop. In addition to complete resection and removal of urinoma, nephrectomy of nonfunctioning right kidney was performed. Patient was discharged after an uneventful postoperative period of 7 days.

Keywords: Calculi, nephrectomy, pyonephrosis, urinoma


How to cite this article:
Patel N, Thanvi R, Jain A, Sathvara P. Devastating complication due to rupture of obstructive perinephric urinoma with secondary pyonephrosis necessitating nephrectomy of nonfunctional kidney in a child . Arch Med Health Sci 2015;3:314-6

How to cite this URL:
Patel N, Thanvi R, Jain A, Sathvara P. Devastating complication due to rupture of obstructive perinephric urinoma with secondary pyonephrosis necessitating nephrectomy of nonfunctional kidney in a child . Arch Med Health Sci [serial online] 2015 [cited 2019 Jul 20];3:314-6. Available from: http://www.amhsjournal.org/text.asp?2015/3/2/314/171937


  Introduction Top


Spontaneous rupture of the urinary collecting system and subsequent urine extravasation in the perirenal and retroperitoneal space is an uncommon complication of obstructive uropathy. [1] It is usually associated with ureteral obstruction by calculi. Other rare causes include ureteric obstruction secondary to posterior urethral valves, prostatic hyperplasia, trauma, and pelvic neoplasms. [2] Occasionally, it may be related with pregnancy, abdominal aorta aneurysm, and retroperitoneal fibrosis. [3] However, large urinoma with fulminant secondary pyonephrosis necessitating nephrectomy of nonfunctional kidney in a child is not described. We report herein a case of urinoma complicated by pyonephrosis due to an obstructive calculus in the upper ureter.


  Case Report Top


A 12-year-old boy was transferred to our hospital with chief complaints of subacute febrile illness with continuous abdominal pain in right flank for 2 weeks. He continued to suffer intermittent episodes of high-grade fever with chills despite 1 week of in-hospital intravenous antibiotics at different institute. His abdominal pain aggravated since 1 week and had started vomiting for 2 days. He did not experience abdominal pain or trauma in recent past. Surprisingly he did not complaint of difficulty in urine or stool, burning micturition, or frequency of micturition. His vitals were normal except for sinus tachycardia. Physical examination revealed severe tenderness in the right flank and inguinal region. Abdomen was not distended and bowel sounds were normal. His hematological investigation revealed leukocytosis with mild anemia, while biochemistry reported normal renal function tests. Urine analysis showed erythrocytes with plenty of leukocytes. A plain standing abdominal radiograph was remarkably normal. Ultrasonography of abdomen showed a large retroperitoneal mass. Patient's symptoms continued with pain and vomiting and an abdominal computed tomography (CT) was performed.

Plain CT images revealed grossly enlarged right kidney with multiple foci of medullary calcification in upper and mid poles, right-sided gross hydronephrosis (pyonephrosis) with thinned out renal parenchyma, and dilated ureter [Figure 1] and [Figure 2]. There was a 9 mm calculus in right upper ureter with upper calyceal rupture with involvement of mid and lower calyx along with 9 × 4 cm sized collection extending inferiorly in perinephric region [Figure 3]. Enhancing thickened right upper ureter wall with calcification of inner wall suggestive of ureteritis. The left kidney was normal. Delayed scan of right pelvicalyceal system showed nonfunctioning right kidney. In addition, diethylene triamine pentaacetic acid (DTPA) renal scan showed only relative function of 11.86% in right kidney [Figure 4]. CT scan does not report any structural ureteropelvic junction obstruction, but the long standing obstruction probably due to the stone resulted in nonfunctional right kidney.
Figure 1: (a and b) Sagittal sections of abdominal computed tomography (CT) showing grossly enlarged right kidney with multiple foci of medullary calcification with right-sided gross hydronephrosis (pyonephrosis) with urinoma extending in to perinephric space

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Figure 2: (a and b) Coronal sections abdominal CT confi rming the above findings

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Figure 3: (a and b) Coronal section of abdominal CT with arrow showing calculus in right upper ureter with calyceal rupture

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Figure 4: Diethylene triamine pentaacetic acid (DTPA) renal scan showing function of both the kidneys

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On abdominal laparotomy, there was gross pyonephrosis of right kidney with secondary adhesions involving the adjacent intestinal structure. Owing to extensive necrosis of right renal parenchyma, surgical excision of nonfunctional right kidney along with nearby retroperitoneal tissue was performed. The histopathological examination of the excised renal mass revealed the changes of chronic pyelonephritis with nonfunctional hyalinized glomerulies replacing the normal glomerulies [Figure 5]. The pus and blood cultures did not grow any specific organism probably because of the prior treatment with antibiotics. As the urine pH was normal and we could not get the 24-h urine analysis for calcium and oxalate crystals and inhibitors in urine due to financial constraint, the etiology of stone formation remained uncertain. Fourier transform infrared spectroscopy confirmed the stone to be of calcium oxalate monohydrate type with78% calcium oxalate and 22% calcium phosphate. We assumed that the stone formation was due to excess salt intake due to hard water supply at patient was due to excess: low water intake, and a probable previous urinary infection contributing together. Patient responded to broad spectrum antibiotics and was discharged after 10 days of in-hospital care.
Figure 5: (a and b) Histopathological specimen showing multiple inflammatory cell infi ltration with hyalinized glomerulies

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  Discussion Top


Urinoma is an encapsulated collection (i.e., urine leak from the urinary system; kidney, ureter, bladder, or urethra) and usually located in the perirenal space, but at times found in the retroperitoneal space, peritoneal cavity, or pleural cavity. Spontaneous urinoma is rare. Symptoms may set in gradually and atypically, leading to delayed diagnosis. These may be misdiagnosed as ascites, abdominal or pelvic abscesses, or hematomas or cystic masses. The treatment of urinoma requires prompt diagnosis, and mostly resolves spontaneously once underlying cause is rectified. Small urinomas subside spontaneously with conservative management, whereas large urinomas may require intervention like percutaneous drainage, ureteral stenting, or open surgery. The initial management of this sick child should have been an ultrasound-guided percutaneous drainage of the perinephric urinoma and a percutaneous nephrostomy to drain the pyonephrosis. But as the urinoma in our patient was already complicated by secondary pyonephrosis with extensive loss of normal parenchymal tissue of right kidney it required nephrectomy along with the extensive dissection of the retroperitoneal tissue.

There are many reports of urinoma and its complications in adult population. [4],[5],[6],[7] But this entity is rare in pediatric and neonatal age group with only few cases reported in literature. [8],[9],[10] In this case, patient presented with right lumbar pain associated with acute febrile symptoms, without any symptoms of obstructive uropathy. A CT scan revealed pyonephrosis with nonfunctioning right kidney secondary to rupture of the upper calyceal group with mid and lower calyx involvement due to upper ureteral obstruction by calculi. The patient successfully underwent laparotomy with right nephrectomy as treatment. The diagnosis was delayed due to the atypical clinical presentation and patient's inability to communicate his symptoms. Diagnostic imaging played a crucial role in promptly identifying and determining the cause and extent of the urinoma/pyonephrosis.


  Conclusion Top


We present this case to illustrate the rare, but devastating complication of urinary tract infection secondary to ureteric calculus. In children with atypical presentations, the diagnosis is often delayed and that may lead to complication. The timely detection of urinoma can prevent the complication and prompt treatment can save the kidney.

 
  References Top

1.
Koktener A, Unal D, Dilmen G, Koc A. Spontaneous rupture of the renal pelvis caused by calculus: A case report. J Emerg Med 2007;33:127-9.  Back to cited text no. 1
    
2.
Singh I, Joshi M, Mehrotra G. Spontaneous renal forniceal rupture due to advanced cervical carcinoma with obstructive uropathy. Arch Gynecol Obstet 2009;279:915-8.  Back to cited text no. 2
    
3.
Lien WC, Chen WJ, Wang HP, Liu KL, Hsu CC. Spontaneous urinary extravasation: An overlooked cause of acute abdomen in ED. Am J Emerg Med 2006;24:347-9.  Back to cited text no. 3
    
4.
Akpinar H, Kural AR, Tüfek I, Obek C, Demirkesen O, Solok V, et al. Spontaneous ureteral rupture: Is immediate surgical intervention always necessary? Presentation of four cases and review of the literature. J Endourol 2002;16:179-83.  Back to cited text no. 4
    
5.
Stravodimos K, Adamakis I, Koutalellis G, Koritsiadis G, Grigoriou I, Screpetis K, et al. Spontaneous perforation of the ureter: Clinical presentation and endourologic management. J Endourol 2008;22:479-83.  Back to cited text no. 5
    
6.
Doehn C, Fiola L, Peter M, Jocham D. Outcome analysis of fornix ruptures in 162 consecutive patients. J Endourol 2010;24:1869-73.  Back to cited text no. 6
    
7.
Sallami S, Ben Rhouma S, Rebai S, Gargouri MM, Horchani A. Spontaneous rupture of the upper urinary tract caused by ureteral calculi: Effectiveness of primary ureteroscopic treatment. UroToday Int J 2009;2:5784-92.  Back to cited text no. 7
    
8.
Patel RM, Unni Moopan MM, Kim H: Subcapsular urinoma. Unusual form of 'Page kidney' in newborn. Urology 1984; 23:585-7.  Back to cited text no. 8
    
9.
Macpherson RI, Gordon L, Bradford BF. Neonatal urinomas: Imaging considerations. Pediatr Radiol 1984;14:396-9.  Back to cited text no. 9
[PUBMED]    
10.
Tseng PC, Liu TY, Pan SJ, Sung DS. Spontaneous perirenal urinoma associated with ureteropelvic junction obstruction in a child: A case report. Pediatr Neonatol 2009;50:121-4.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


This article has been cited by
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Christopher Thom,Matthew Eisenstat,James Moak
The Journal of Emergency Medicine. 2018; 55(1): 96
[Pubmed] | [DOI]



 

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