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Emphysematous urinoma
Pankaj N Maheshwari, NN Trivedi, VB Kausik, VP Parmar
R G Stone Clinic, Mumbai, India
Correspondence Address:
Pankaj N Maheshwari
R G Stone Clinic, Mumbai
India
How to cite this article:
Maheshwari PN, Trivedi N N, Kausik V B, Parmar V P. Emphysematous urinoma
.J Postgrad Med 2004;50:217-218
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How to cite this URL:
Maheshwari PN, Trivedi N N, Kausik V B, Parmar V P. Emphysematous urinoma
. J Postgrad Med [serial online] 2004 [cited 2023 May 29 ];50:217-218
Available from: https://www.jpgmonline.com/text.asp?2004/50/3/217/12581 |
Full Text
Ureteroscopy is a commonly performed endourological procedure. Although complications after ureteroscopy are rare (less than 2%), urinary infection is the commonest problem. Emphysematous pyelonephritis (EPN) is a rare life-threatening infection characterised by the presence of gas within the renal parenchyma, collecting system and perinephric tissue. Here, immediate nephrectomy is often considered essential. Such an emphysematous infective process may occur in collections of urine (urinoma) that occur secondary to a urinary leak.[1] We describe a case of emphysematous infection of a post-ureteroscopy urinoma with interesting radiological findings, a so-called 'emphysematous urinoma'.
Case History
A 68-year-old diabetic lady presented three weeks after ureteroscopy for left ureteric calculus with left flank pain, fever, altered sensorium, hypotension (BPE coli; rarely Klebsiella pneumoniae and Candida, have been described.
The sequence of events that led to the present condition can only be speculated. Presumably there was a subcapsular collection due to fornicial tear caused by the high irrigation-pressures during ureteroscopy. This collection could have been infected with E coli. The high ambient glucose concentration in the collection with poor blood supply (conditions thought to be conducive to gas formation) might have led to the picture of emphysematous urinoma.
A potential source of gas in the urinoma could be a fistulous communication with a loop of bowel. This source was excluded by contrast study. The other potential source of gas could have been the catheterisation of the urinary tract. The absence of gas in the collecting system makes this less likely.
Earlier literature suggests nephrectomy as the only option for fulminant EPN. However, this itself is a hazardous intervention in a septic, unstable patient with circulatory or liver failure, with mortality of about 40%. Currently the trend is towards conservative treatment with antibiotics, relief of obstruction and percutaneous drainage when necessary.[5] Huang has classified EPN into four classes.[3] Class 1 and 2 where the gas is limited to the collecting system or the parenchyma, had excellent results with renal conservation. Extensive infection (Class 3 and 4), especially when associated with thrombocytopenia, acute renal function impairment, disturbance of consciousness, or shock, needed nephrectomy. In our patient, the conservative strategy worked well and led to uneventful recovery.
References
| 1 | Rao PS, Ravindran A, Elsamaloty H, Modi KS. Emphysematous urinoma in a renal transplant patient. Am J Kidney Dis 2001;38:E29. |
| 2 | Patterson JE, Andriole VT. Bacterial urinary tract infections in diabetes. Infect Dis Clin North Am 1997;11:735-50. |
| 3 | Huang JJ, Tseng CC. Emphysematous pyelonephritis: Clinico-radiological classification, management, prognosis, and pathogenesis. Arch Intern Med 2000;160:797-805. |
| 4 | Lin CH, Huang JJ, Liu HL, Lee SY, Hsieh RY, Tseng CC. Renal cell carcinoma complicated by emphysematous pyelonephritis in a non-diabetic patient with renal failure. Nephron 2002;92:227-9. |
| 5 | Ku JY, Kim ME, Lee NK, Park NK. Emphysematous pyelonephritis recovered by ureteral stenting in a functionally solitary kidney. Urol Int 2002;69:321-2. |
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