Percutaneous application of fibrin sealant in surgically recalcitrant urinomas following oncocytoma resection.

Surgical application of fibrin sealant is well established as a hemostatic agent. However, reports of its percutaneous application and its uses within the urinary tract are limited. Presented below are two patients with recalcitrant urinomas despite diversion therapy following partial nephrectomy for oncocytomas. Both patients were successfully treated with percutaneous application of fibrin sealant via a sheath at the time of percutaneous perinephric drain removal. Follow-up imaging demonstrated resolution of the urinomas with stabilization of creatinine. Percutaneous application of fibrin sealant may be considered as an alternative treatment for recalcitrant urinomas prior to surgical intervention, though more studies are required to confirm its effectiveness and safety.

Percutaneous Obliteration of Urinary Leakage after Partial Nephrectomy Using N-Butyl-Cyanoacrylate Obliteration of the Urinoma with or without Coil Embolization of the Fistula Tract.

PURPOSE: To retrospectively evaluate the safety and efficacy of the percutaneous obliteration of urinary leakage after partial nephrectomy (PN) using coils and N-butyl-cyanoacrylate (NBCA). MATERIALS AND METHODS: Data of 10 consecutive patients who underwent percutaneous obliteration of urinary leakage after PN using coil and NBCA between February 2016 and May 2018 were retrospectively reviewed. A urinary fistulography was performed via the drainage catheter. If the fistulous tract was clearly visualized, super-selective embolization of the fistulous tract with coils and urinoma cavity sealing with NBCA was performed. In cases where the fistulous tract could not be clearly visualized, only urinoma cavity sealing was performed. Outcomes and complications were assessed by reviewing medical records and computed tomography (CT). RESULTS: In 7 (70%) patients who showed obvious urinary fistulous tract, coil embolization of the urinary fistulous tract, followed by sealing of the urinoma cavity with NBCA, was performed. Obliteration of the urinoma without coil embolization of the fistula tract was performed in 3 patients (30%) in whom a distinct fistulous tract could not be visualized. The median number of treatment sessions required to achieve clinical success was 1 (range, 1-5). Four patients underwent multiple repeated procedure with successful results. All patients showed gradual decrease in size or complete disappearance of urinoma on follow-up CT without evidence of urinary leakage during the follow-up period (mean, 44.6 weeks; range, 11-117 weeks). There were no procedure-related complications. CONCLUSIONS: Percutaneous obliteration of urinary leakage after PN using coils and NBCA is safe and effective.

Perinephric transplant fluid collection approach and management.

Renal transplant is the treatment of choice for end-stage renal disease. Perirenal fluid collections are a common surgical complication postrenal transplant that may lead to early graft loss, considerable morbidity, and excess financial loss, if not diagnosed and managed early. The causes of posttransplant fluid collections are urinary leak, lymphocele, hematoma, and seroma, which can be further complicated by abscess formation if becomes infected. Urine leak is considered the most common urological complication postrenal transplant. Diagnosis can be made by biochemical analysis of the fluid drainage with the simultaneous comparison to that of serum. Radiological imaging is also essential for confirming the diagnosis of urinary leak that may not necessarily identify the site of the leak. The management of urinary leak is usually surgical unless the leak is small. The choice of surgery depends on the location of the leak, the vascularization of the involved ureter, and the presence of any complications caused by the leak. This article reviews the differential diagnoses of perirenal fluid collections in postrenal transplant period and focuses on the clinical assessment of urinoma and management options according to the latest evidence-based medicine.

Diagnosis and management of urinary extravasation after high-grade renal trauma.

Renal trauma research has historically focused on parenchymal injuries and the risk of bleeding. However, much less is known about the diagnosis and optimal management of urinary extravasation, which complicates ~30% of high-grade renal injuries. Immediate or delayed ureteral stenting is the most common procedure used to treat collecting system injuries when intervention is needed. However, the lack of evidence-based guidelines leaves the diagnosis and management of urinary extravasation largely dependent upon physicians' experience, initial and follow-up imaging protocols, and the definitions used for grading the injuries. The knowledge gaps in the management of urinary extravasation that need to be addressed include the timing of excretory-phase CT imaging, patterns of clinically significant urinary extravasation, predictors of complications when urinary extravasation occurs, protocols for obtaining and interpreting follow-up imaging, and the role of ureteral stenting and other interventions in management. To improve the management of urinary extravasation after high-grade renal trauma, large, multi-institutional prospective trails assessing different diagnostic and therapeutic protocols are needed.

Does routine repeat imaging change management in high-grade renal trauma? Results from three level 1 trauma centers.

PURPOSE: Guidelines call for routine reimaging of Grade 4-5 renal injuries at 48-72 h. The aim of the current study is to evaluate the clinical utility of computed tomography (CT) reimaging in high-grade renal injuries. MATERIALS AND METHODS: We assembled data on 216 trauma patients with high-grade renal trauma at three level 1 trauma centers over a 19-year span between 1999 and 2017 in retrospectively collected trauma database. Demographic, radiographic, and clinical characteristics of patients were retrospectively reviewed. RESULTS: In total, 151 cases were Grade 4 renal injuries, and 65 were Grade 5 renal injuries. 53.6% (81) Grade 4 and 15.4% (10) Grade 5 renal injuries were initially managed conservatively. Of the 6 asymptomatic cases where repeat imaging resulted in intervention, 100% had collecting system injuries at initial imaging. Collecting system injuries were only present in 42.9% of cases where routine repeat imaging did not trigger surgical intervention. Collecting system injury at the time of initial imaging was a statistically significant predictor of routine repeat imaging triggering surgical intervention (p = 0.022). Trauma grade and the presence of vascular injury were not significant predictors of intervention after repeat imaging in asymptomatic patients. CONCLUSION: In asymptomatic patients with high-grade renal trauma, the number needed to image is approximately one in eight (12.5%) to identify need for surgical intervention. There is potentially room to improve criteria for routine renal imaging in high-grade renal trauma based on the more predictive imaging finding of collecting system injury.

Bilateral Spontaneous Urinoma in a Cyanotic Child.

BACKGROUND: Urinoma is an encapsulated collection of extravasated urine, secondary to trauma or obstructive uropathy. Spontaneous bilateral urinoma is rare. CASE CHARACTERISTICS: 7-year-old boy with cyanotic heart disease and fever of unknown origin. OBESERVATION: The ultrasound abdomen and CT abdomen revealed bilateral spontaneous urinoma which was aspirated and was found to be infected. Following intravenous atibiotics the child became afebrile, with subsequent renal scans showing no recurrence. MESSAGE: Hypoxia and consequent polycythemia may be responsible for perinephric leaks leading to Non-traumatic spontaneous urinoma.

High Grade Urothelial Carcinoma of Renal Pelvis Presenting as Spontaneous Urinoma.

Perirenal urine extravasation, also known as urinoma, occurs usually after renal trauma. Spontaneous urinoma is a very rare pathology in daily urology practice. The patients with spontaneous urinoma usually present with flank pain, and radiologic imagings confirm the diagnosis. Ultrasonography, intravenous urography, and computed tomography are the radiologic modalites for the diagnosis. We report a case of spontaneous urinoma in a patient with renal pelvic tumor.

Traumatismo renal grado IV parenquimatoso con ruptura de la vía y urinoma secundario. Manejo conservador / Renal injury grade IV: Laceration and secondary urinoma. Conservative management

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Imaging assessment of renal injuries in children and adolescents: CT or ultrasound?

BACKGROUND: Since the introduction of the ALARA ("as low as reasonably achievable") concept, ultrasound (US) has been progressively advocated for paediatric diagnostic imaging. This study aimed to analyse the role and accuracy of US in paediatric renal trauma. METHODS: From 1999 to 2009, the tertiary-care-hospital database was retrospectively evaluated for renal trauma with regards to aetiology, type of injury, diagnostics, management and outcome. RESULTS: Forty-seven patients (29 males, 18 females; median age=14years, range 1-17 years) were identified. US was initially applied in 45 patients with correct results in 86.6%. Computed tomography (CT) was performed in 16 patients in the acute trauma setting - complementary to US in 14 cases, with a diagnostic accuracy of 93%. Most renal injuries were grade I° (n=30), followed by grade III° (n=8), IV° (n=5), and II°/V° (n=2 each). All patients were initially managed conservatively and followed by US. Clinical deterioration necessitated surgery in four patients (2 nephrectomies, 1 partial nephrectomy, 1 urinoma drainage). The outcome was generally favourable with a renal preservation rate of 95%. CONCLUSION: With respect to the ALARA principle, US can be safely and reliably applied as the first-line diagnostic imaging technique and for follow-up for suspected traumatic paediatric renal injuries.

Unsuspected urinoma of an obstructed kidney detected in a bone scan in a patient with lung cancer.

A 60-year-old woman with an adenocarcinoma of the lung was referred to our department for a bone scan to assess the extension of the metastatic bone disease. The images showed several foci of radiotracer uptake in the bone consistent with malignant involvement. Besides, a considerable accumulation of tracer was shown in the right perinephric region as well as in the renal pelvis. SPECT/CT images demonstrated a superior perirenal urine leak due to rupture of the collecting system. The leakage was treated by urinary catheter decompression with complete recovery after 4 weeks.

Transient large urinoma following hysterectomy.

This case report describes the formation of a very large urinoma 1 day after vaginal surgery. A 59-year-old woman was diagnosed with a urinoma measuring 30.5 cm in length, 23 cm in the transverse plane and 12 cm in the anteroposterior dimension on day 1 after a vaginal hysterectomy and prolapse repair surgery. The urinoma resolved completely after trans-abdominal catheter drainage. This case demonstrates that even a large urinoma can initially be managed conservatively. Furthermore, it emphasizes the importance of the early detection and management of urinary tract injuries after vaginal surgery.

[Conservative management of symptomatic or asymptomatic urinoma after grade III blunt renal trauma: a report of three cases].

The management of urinoma after blunt renal trauma is still controversial, ranging from percutaneous drainage or ureteral stent placement for the symptomatic urinoma and waiting for spontaneous vanishment of the asymptomatic urinoma. We present two cases of symptomatic urinoma and a case of asymptomatic urinoma after renal laceration. All patients underwent selective renal arterial embolization for vascular complications, including active bleeding, pseudoaneurysm and arteriovenous fistula. Urinomas, which had been observed in all cases gradually reduced and vanished 1-24 months later. All cases were successfully managed without catheterization or percutaneous drainage for urinoma.

Inferior vena cava filter penetration resulting in renal pelvis rupture with urinoma formation.

Inferior vena cava (IVC) filter penetration is common and most often asymptomatic. However, penetration may potentially result in a variety of complications, including aortic trauma and small bowel perforation. Described is a case of IVC filter penetration resulting in renal pelvis perforation with urinoma formation.