Answer for BIR CoW 05 Nov 2023
Right ureteric injury with urinoma
Findings
Right proximal ureter appears tortuous with abrupt cut off noted at a distance of around 11.8 cm from right pelviureteric junction with surrounding T2 hyperintense collection seen extending into pelvis. The collection is seen communicating inferiorly with vaginal vault –possibility of peritoneal vaginal fistula.
Discussion
Urinomas and uriniferous fluid collections are often used interchangeably, with urinomas being considered as encapsulated urine collections resulting from urine leakage. Urinomas are typically formed when urine extravasates into the retroperitoneum, leading to the encapsulation of urine by causing lipolysis of the surrounding fat. Causes of Urinomas include urinary obstruction due to conditions such as calculi, ureteropelvic junction obstruction, retroperitoneal fibrosis, retroperitoneal malignancy, and various conditions causing bladder outlet obstruction. They can also be a result of abdominopelvic trauma (renal trauma or bladder rupture), surgical procedures (e.g., ureteric injury or ureteroileal anastomotic leak), and diagnostic instrumentation (e.g., extracorporeal shock wave lithotripsy - ESWL, ureteroscopy). Location and Morphology: Urinomas can have different morphologies, including localised perirenal urinomas, diffuse perirenal urinomas, subcapsular urinomas, intrarenal urinomas and retroperitoneal urinomas. Radiographic Features: Various imaging modalities can be used to detect urinomas, including fluoroscopy, intravenous pyelogram, ultrasound, CT (computed tomography), and MRI (magnetic resonance imaging). Urinomas typically appear as thinned-walled anechoic collections on ultrasound, with water attenuation on CT, low signal intensity on T1-weighted MRI, and very high signal intensity on T2-weighted MRI. Contrast-enhanced studies during the excretory phase can directly demonstrate urine leakage due to contrast extravasation from the urinary tract. In our case laparotomy was done and right ureter was traced. Cutoff noted at right distal ureter. Distal 3 to 4 cm of right ureteric stump attached to the urinary bladder, showed compromised vascularity. Right ureteroneocystostomy was done and DJ stent placed.
References:
1)Titton R. L., Gervais D. A., Hahn P. F., Harisinghani M. G., Arellano R. S., Mueller P. R. Urine Leaks and Urinomas: Diagnosis and Imaging-guided Intervention. RadioGraphics. 2003;23(5):1133–1147. doi: 10.1148/rg.235035029.
2)Sebastià C, Quiroga S, Boyé R, Cantarell C, Fernandez-Planas M, Alvarez A. Helical CT in Renal Transplantation: Normal Findings and Early and Late Complications. Radiographics. 2001;21(5):1103-17. doi:10.1148/radiographics.21.5.g01se131103
3)Gross J. A., Lehnert B. E., Linnau K. F., Voelzke B. B., Sandstrom C. K. Imaging of Urinary System Trauma. Radiologic Clinics of North America. 2015;53(4):773–788. doi: 10.1016/j.rcl.2015.02.005.
Findings
Right proximal ureter appears tortuous with abrupt cut off noted at a distance of around 11.8 cm from right pelviureteric junction with surrounding T2 hyperintense collection seen extending into pelvis. The collection is seen communicating inferiorly with vaginal vault –possibility of peritoneal vaginal fistula.
Discussion
Urinomas and uriniferous fluid collections are often used interchangeably, with urinomas being considered as encapsulated urine collections resulting from urine leakage. Urinomas are typically formed when urine extravasates into the retroperitoneum, leading to the encapsulation of urine by causing lipolysis of the surrounding fat. Causes of Urinomas include urinary obstruction due to conditions such as calculi, ureteropelvic junction obstruction, retroperitoneal fibrosis, retroperitoneal malignancy, and various conditions causing bladder outlet obstruction. They can also be a result of abdominopelvic trauma (renal trauma or bladder rupture), surgical procedures (e.g., ureteric injury or ureteroileal anastomotic leak), and diagnostic instrumentation (e.g., extracorporeal shock wave lithotripsy - ESWL, ureteroscopy). Location and Morphology: Urinomas can have different morphologies, including localised perirenal urinomas, diffuse perirenal urinomas, subcapsular urinomas, intrarenal urinomas and retroperitoneal urinomas. Radiographic Features: Various imaging modalities can be used to detect urinomas, including fluoroscopy, intravenous pyelogram, ultrasound, CT (computed tomography), and MRI (magnetic resonance imaging). Urinomas typically appear as thinned-walled anechoic collections on ultrasound, with water attenuation on CT, low signal intensity on T1-weighted MRI, and very high signal intensity on T2-weighted MRI. Contrast-enhanced studies during the excretory phase can directly demonstrate urine leakage due to contrast extravasation from the urinary tract. In our case laparotomy was done and right ureter was traced. Cutoff noted at right distal ureter. Distal 3 to 4 cm of right ureteric stump attached to the urinary bladder, showed compromised vascularity. Right ureteroneocystostomy was done and DJ stent placed.
References:
1)Titton R. L., Gervais D. A., Hahn P. F., Harisinghani M. G., Arellano R. S., Mueller P. R. Urine Leaks and Urinomas: Diagnosis and Imaging-guided Intervention. RadioGraphics. 2003;23(5):1133–1147. doi: 10.1148/rg.235035029.
2)Sebastià C, Quiroga S, Boyé R, Cantarell C, Fernandez-Planas M, Alvarez A. Helical CT in Renal Transplantation: Normal Findings and Early and Late Complications. Radiographics. 2001;21(5):1103-17. doi:10.1148/radiographics.21.5.g01se131103
3)Gross J. A., Lehnert B. E., Linnau K. F., Voelzke B. B., Sandstrom C. K. Imaging of Urinary System Trauma. Radiologic Clinics of North America. 2015;53(4):773–788. doi: 10.1016/j.rcl.2015.02.005.
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!