INTRODUCTION: Spontaneous rupture (SR) of the urinary collecting system with perirenal and retroperitoneal extravasation of the urine is an unusual condition that is typically caused by ureteral-obstructing calculi. The authors present a retrospective study of 10 cases. They report evaluation, endoscopic management, and follow-up assessments.
METHODS: Between 1998 and 2008, 10 patients were admitted for SR of the urinary collecting system proximal to a lithiasic obstruction. There were 6 males and 4 females. The mean patient age was 51.5 years. At presentation, all patients had sudden severe flank pain. There were no other urinary symptoms. All patients had a physical examination, laboratory blood and urine analyses, and radiography, ultrasonography, intravenous urography (IVU), and/or computed tomography (CT). Ureteroscopy was performed. Ureteral stones were fragmented with a pneumatic lithotripter.
RESULTS: Ultrasonography and IVU or CT showed a perinephric collection due to urine extravasation that was compatible with rupture of the renal collecting system. SR was secondary to an obstructing calculus in all cases. Patients were managed successfully by primary endoscopic treatment of ureteroscopic lithotripsy and stenting. Follow-up was unremarkable.
CONCLUSION: SR of the urinary collecting system is a very rare pathological condition. It should be considered in cases of unusual renal colics. Ureteroscopic lithotripsy followed by double-J stenting of the ureter appears to be a quick, safe, and effective management approach.
KEYWORDS: Pelvis rupture; Ureteral rupture; Ureteral calculus; Computed tomography; Ureterel stent; Endoscopic lithotripsy
CORRESPONDENCE: Dr. Sallami SatÃ¢a, Department of Urology, La Rabta Hospital-University, Tunis 1007, Tunisia ().
CITATION: UroToday Int J. 2009 Dec;2(6). doi:10.3834/uij.1944-5784.2009.12.07
Spontaneous rupture (SR) of the urinary collecting system with urine extravasation into the perinephric space is a rare pathologic condition. It is usually associated with ureteral obstruction by calculi [1,2]. Other rare causes include neoplasms, trauma, and iatrogenic procedures [1,2,3,4,5,6,7].
The authors present a retrospective study of 10 cases of urinary collecting system rupture with perirenal and retroperitoneal space extravasation of urine. They discuss their experience with endoscopic treatment of SR caused by lithiasic obstruction of the ureter. Evaluation, management, and follow-up assessments are presented.
Between 1998 and 2008, 10 patients were admitted to the authors' department for SR of the urinary collecting system proximal to a lithiasic obstruction. There were 6 males and 4 females. The mean patient age was 51.5 years (range, 27-80 years). Two patients had a history of ipsilateral nephrolitiasis; 4 patients had lumbar pain.
At presentation, all patients had sudden severe flank pain; 4 patients had pain on the right side and 6 patients had pain on the left side. There were no other urinary symptoms. Most patients had nausea but only 1 had vomiting. Vital signs were stable; 6 patients had a fever.
All patients had a physical examination and a plain radiography of the kidneys, ureters and bladder (KUB). Six patients also had ultrasonography, 2 patients had intravenous urography (IVU), and 4 patients had computed tomography (CT). The patients were also evaluated with complete blood analysis, urea and creatinine measurement, urinalysis, urine culture, and blood culture if indicated.
Endoscopic treatment was used for all patients. Ureteroscopy (URS) was performed with antibiotic coverage, with the patient under general anesthesia.
URS was performed using an 8F semirigid ureteroscope (Richard Wolf Medical Instruments GmbH, Kittlingen, Germany) with retrograde opacification and under fluoroscopic control. Ureteral stones were fragmented with a pneumatic lithotripter (Swiss lithoclast®, Le Sentier, Switzerland) using a 2.4F (0.8-mm-thick) 668 mm long probe.
Special care was taken during URS and pneumatic ureteroscopic lithotripsy (PL) to avoid intraluminal pressure increase. This was accomplished by inserting a 6 Ch catheter up to the position of the stone. The catheter remained in situ during the procedure. Irrigation fluid was given manually in small quantities by an assistant.
Assessment of Outcome
The outcome of surgical management was assessed by 3 criteria: (1) size of stone fragmentation, (2) degree of removal of the fragments, (3) absorption of the extravasation. Follow-up is reported over a period of 8 months included clinical assessment, ultrasound examination, and urine culture.
Physical examination revealed tenderness in the flank and inguinal regions in all cases. Kidney function tests were normal in all patients. Leukocytosis was revealed in 7 patients. Urine analysis commonly showed erythrocyte and rarely showed leukocyte only.
The KUB X-ray showed an opacity consistent with a ureteric stone in 8 patients. Its size ranged from 5 mm to 15 mm; it was < 10 mm in 8 patients. Abdominal ultrasonography demonstrated minimal hydronephrosis and minimal perirenal collection (Figure 1). The emergency intravenous urogram revealed massive extravasation of the contrast around the pelvis and the kidney (Figure 2).
An unenhanced CT scan showed a proximal ureteral calculus in 3 patients and an iliac ureteral calculus in 1 patient. After contrast material injection, delayed phase images showed extravasation of the contrast medium from the urinary collecting system into the perirenal space. This was diagnosed as a urinoma from rupture of the renal pelvis Figure 3. The radiological and endoscopic tests revealed that the perforations were in the proximal ureter (n=6), renal pelvis (n=2) Figure 4, distal ureter (n=1), and upper renal calyx (n=1).
URS showed a distal ureteral stone in 2 patients, iliac ureteral stone in 1 patient, and proximal ureteral stone in 7 patients.
All patients received primary endoscopic treatment with ureteral stenting. Stones were completely fragmented by endocorporeal pneumatic lithotripsy in 9 patients and extracted by Dormia basket in 1 patient.
A double-J catheter was inserted in all cases with a 16 CH bladder catheter which was removed at the 3rd postoperative day. The mean length of hospitalization was 7.6 days (range, 2-10 days). The double-J stent was removed after 6 weeks.
Assessment of Outcome
Follow-up radiography showed that 7 patients had total fragmentation of the stone, 1 patient was stone-free, and 2 patients had a migration of the stone toward the kidney. The latter 2 patients were treated by extracorporeal shock wave lithotripsy (ESWL) with total fragmentation.
Follow-up ultrasonography showed a decrease of perirenal fluid after an average of 5 days (range, 3-7 days), followed by a total resorption of perirenal fluid collection at the 1-month evaluation. Only 1 patient required a percutaneous drainage of the perirenal collection with total resorption.
No second ureteroscopy was needed. No early or late major complications were detected. Eight months after the extravasation, all patients were stone-free in radiological explorations without clinical problems.
In 1927, Henline reported the first case of SR of the upper calyx secondary to a ureteral calculus that was seen very late in the progression and diagnosed at autopsy . In 1902, Kiister collected 10 cases of SR in 30,000 autopsies . In 1952, Orkin reported a case of SR of the ureter and reviewed 26 case reports that had been published over a period of 57 years . Since then, many cases have been described in the literature [10,11,12,13,14]. Kalafatis et al  reported the first series of this complication. It seems from these reports that spontaneous ureteric rupture is a rare entity, usually occuring secondary to ureteric stone . The relatively high incidence of SR in the present authors' department may be explained by the high frequency of urinary stones in Tunisia. Most patients had been wrongly treated symptomatically, with or without long delay in treating their urinary stones. Because the authors' department is a referral center, almost all complicated cases are sent there.
Etiology of SR
One possible cause of a ruptured ureter is stone impaction, which leads to pressure necrosis. Another cause is trauma to the ureter as the stone passes through it. In either case, when the intraureteric pressure increases during an attack of renal colic, the damaged tissue may be ruptured . Before a case of rupture of the ureter can be described as spontaneous the following should apply: no external trauma, no cystoscopic ureteric manipulation, no external compression, absence of destructive kidney disease, and absence of previous surgery .
Urine extravasation commonly results from disruption of the urinary collecting system at any level from the calyx to the urethra. Most commonly, renal urine leakage results from trauma [4,5]. Obstruction of the genitourinary system due to a stone, pelvic mass, pregnancy, retroperitoneal fibrosis, or posterior urethral valve can increase intraluminal pressure and cause rupture of the collecting system. Rarely, iatrogenic injury causes renal urine leak [6,7,15,17].
Diagnosis of SR
Urine extravasation may be clinically occult or may present with acute abdominal symptoms. High temperature and leukocytosis usually accompany the clinical symptoms. Therefore, it is not uncommon to confuse this condition with other acute abdominal emergencies . Hydronephrosis, paralytic ileus, electrolyte imbalances, or abscess formation may accompany the extravasation [4,11]. Retroperitoneal sepsis is a common complication, and deaths have been reported .
Plain KUB X-ray and serial ultrasonography are used for initial evaluation of the urinary system. The KUB may show loss of a retroperitoneal landmark, a stone, or signs of paralytic ileus . Serial ultrasonographic examination confirms the hydronephrosis and increase of fluid in the perirenal or pararenal space .
Resistance index and pulsatility index values in the interlobular arteries, evaluated by color duplex Doppler sonography, significantly increase in acute hydronephrosis [15,19]. Intravenous pyelograms and CT with delayed images (obtained 5-20 min after contrast medium injection) show contrast medium extravasation in the peripelvic, perinephric, or retroperitoneal spaces [4,15]. The CT scan shows renal pelvis rupture and stone ureteral obstruction. It is sometimes mandatory to confirm the diagnosis .
The SR diagnosis was established on the patient's history and on ultrasound and intravenous urogram findings . The main differential diagnosis is fornix rupture, which is a much more common condition. It is distinguishable from SR of the upper urinary tract by the presence of a renal parenchymal lesion.
Management of SR
Treatment of SR primarily consists of stone removal and control of urinary extravasation. Antibiotic coverage is mandatory in all cases. Open surgery provides drainage of the retroperitoneal space with removal of the stone. El-Boghdadly  and Saad et al  reported successful endoscopic treatment by stone extraction with dormia basket. This success was also observed in the patient treated with this technique in the present investigation.
Stenting of the ureter is a treatment method for urinary rupture with upper ureteral and ureteropelvic junction stones. An immediately placed ureteral stent can stop extravasation and provide appropriate treatment . Stenting of the ureter alone does not always lead to a successful outcome. A secondary ureteroscopic stone fragmentation or delayed ESWL  may be required in an attempt to resolve the obstruction and its cause. Stenting of the lithiasic-obstructed ureter remains a good option for the acute phase of an infection or for controlling an expanded extravasation.
The present authors did not find any previously reported recommendations for the management of SR. However, distal and middle obstructive stones associated with rupture may be treated by ureteroscopic lithotripsy combined with ureteral stenting with high success rate. Kalafatis et al  reported an 87% success rate with this technique. In the present study, 7 patients had total fragmentation of the stone, 1 patient was stone-free, and 2 patients had total fragmentation after treatment by ESWL. The stone is not always seen during ureterorenoscopy and a ureteral stent should be placed in all cases .
Ureteroscopic lithotripsy followed by double-J stenting of the ureter may offer a quick and safe therapeutic alternative for obstructive ureteral stones with SR. It resolved the rupture and stones in almost all cases and required no auxiliary treatment . The present and previous authors  successfully managed their patients using only endourologic procedures. Follow-up ultrasonography or CT-scan is mandatory to be sure that there is total resorption of the perirenal and retroperitoneal fluid collection .
Primary ureteroscopic lithotripsy and stone extraction, combined with ureter stenting, is a reliable, efficient, and safe method to treat SR of the upper urinary tract caused by a ureteral calculus and its consequences.
Conflict of Interest: none declared
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