Navigating the triple threat: Management of post-ESWL urinoma, steinstrasse, and obstructive uropathy: A challenging case report

Abstract

Urinoma (collection of urine) formation secondary to extracorporeal shock wave lithotripsy (ESWL) is one of the rare complications encountered postprocedure and co-existence of urinoma with steinstrasse is a rare and challenging scenario to manage in the setting of obstructive uropathy. ESWL is known for being noninvasive for breaking kidney and ureteric stones. Urinoma is a collection of urine outside the collecting system in the retroperitoneum or perirenal space. Early detection and management are necessary to prevent complications related to urinoma and steinstrasse. This case report is about a patient who developed urinoma and steinstrasse in the setting of obstructive uropathy after sessions of ESWL on the right side and was managed with a nephrostomy tube and trans-ureteral lithotripsy on the right side and percutaneous nephrolithotomy on the left side after 1 month.

Introduction

ESWL is a noninvasive technique that breaks down stones in the kidneys or ureters to relieve obstruction. It uses shock waves generated by a lithotripter [1]. The successful fragmentation of the stone depends on various factors like its size, location, hardness, and complexity. Among the known complications of ESWL, urinoma formation is one of the rare complications [2]. In literature, its incidence as a result of ESWL has been reported to be 1.5% and the incidence of steinstrasse formation is variable in different studies in different parts of the ureter. Urinoma is a collection of urine outside the collecting system that can be formed in the events of trauma, infection, malignancy, obstruction, radiation, and even sometimes iatrogenic. The detection of urinoma can be done on modalities like intravenous pyelography; ultrasonography, magnetic resonance imaging (MRI), noncontrast computed tomography (NCCT), and contrast-enhanced computed tomography on excretory phase [3]. Percutaneous aspiration can also be used to check for fluid creatinine levels. After diagnosis, Small urinomas are managed conservatively whereas large urinomas are drained through a nephrostomy tube followed by treatment of underlying cause. Some cases might also require the placement of retrograde double j stent to facilitate the healing process [4]. Here we are reporting a case of bilateral obstructive nephrolithiasis, for which the patient underwent ESWL sessions on the right side. After 1 week of ESWL session, urinoma was detected along with the formation of stone ladder distally which created difficulty in achieving retrograde access, and trans-ureteral pneumatic lithotripsy was done to clear the right-sided renal system and 6fr DJ stent was placed on the right side after securing right sided percutaneous nephrostomy for urinoma.

Case study

A 50-year-old, gentleman known case of bilateral obstructive nephrolithiasis was admitted to the urology ward with a complaint of bilateral flank pain. The pain was severe in intensity more on the right side with multiple episodes of vomiting. He had a session of ESWL 1 week back for right renal calculi. His baseline workup revealed deranged WBCs at 18,000 per microliter (normal range 4500 to 11,000 WBC per microliter) with a neutrophil count of 89% and lymphocyte count of 5.3%. His renal function tests were also deranged with Serum urea levels of 40 mmol/L, and blood creatinine levels of 270 micromol/L. Complete urine examination showed pus cells (5-10/HPF) and RBCs (10-20/HPF). Rests of the labs were unremarkable. Ultrasound of the abdomen revealed a calculus in the upper pole of the right kidney measuring about 1 × 1.2 cm causing moderate dilatation of the right renal pelvic calyceal system and ureter. There were few echogenic foci giving posterior acoustic shadowing in the distal part of the right ureter. There was an anechoic collection with a volume of about 100 mL in peri renal space adjacent to the right psoas muscle. A large calculus measuring 1.6 × 3.8 cm (AP x TR) was noted at the left renal pelvis causing mild dilatation of the pelvic calyceal system. NCCT abdomen was also done which showed right-sided hydronephrosis with dilated ureter which seems to communicate with a small hypodense fluid collection with CT density of 6 Hounsfield units (HU) in peri renal space abutting the right psoas muscle (Fig. 1). Marked adjacent inflammatory strandings were also noted. As per the history of right-sided ESWL 1 week back, it represents right proximal ureteric perforation with resultant urinoma formation. Multiple stone fragments lined up in the distal ureter giving a steinstrasse appearance are also seen in the right distal ureter adjacent to S1 vertebrae extending up to the coccyx with the largest of them measuring about 1.5 × 1.5 cm with Hounsfield unit (HU) of 1938 (Fig. 2). These stone fragments represent another complication of ESWL. A large staghorn calculus of about 1.6 × 3.0 × 3.7 cm (AP × TR × CC) of CT density 746 HU was noted in the renal pelvis causing moderate dilatation of the pelvic calyceal system. Another calculus measuring about 1.01 × 1.5 × 1.9 cm (AP × TR × CC) with a CT density of 361HU is noted at the upper pole of the left kidney and 1 × 0.9 × 0.8 cm (AP × TR × CC) with a CT density of 980 HU at the upper pole of the right kidney as well (Fig. 3).

Fig. 1.

(A, B) Plain CT KUB (cross sectional axial views) showing circumscribed hypodense fluid (green arrows) in the peri-renal space associated with fluid tracking along the right ilio-psoas muscle. A large calculus in left renal pelvis (yellow arrow).

Fig. 2.

(A, B) Plain CT KUB (Coronal views) depicting urinary collection adjacent to right ilio-psoas muscle (green arrows). A (steinstrasse pattern) in right distal ureter and a lare calculus in left kidney (yellow arrows).

Fig. 3.

CT volume rendering showing a left renal calculi (green arrows) and steinstrasse pattern in right distal ureter (purple arrows).

The contrast study was avoided due to the deranged renal function tests mentioned above and decreased creatinine clearance levels which were less than 30 millimeters/min. After symptomatic treatment and broad-spectrum antibiotics, urinoma was aspirated by doing ultrasound-guided percutaneous right nephrostomy (PCN) under local anesthesia. After complete optimization, right-sided trans-ureteral pneumatic lithotripsy followed by placement of double J 6 French stent was done to relieve the obstruction (Fig. 4).

Fig. 4.

Post Management X -ray KUB depicting PCN tube and DJ stent on the right side with a large calculus in left kidney.

We found 4 stone fragments of different sizes during the procedure which were fragmented successfully (Fig. 5). His baseline investigations returned to normal after 1 week. Follow-up ultrasound showed significantly reduced hydronephrosis compared to preoperative status on the right side. Double J stent was removed after 6 weeks. The nephrostomy tube was removed after 10 days assuring complete drainage of urinoma on subsequent follow-up imaging.

Fig. 5.

Trans-ureteral-lithotripsy utilized for managing steinstrasse clearance.

Left-sided kidney stones were managed through percutaneous nephrolithotomy later in another surgical setting after complete optimization of the patient (Fig. 6) and a left-sided DJ stent was placed after achieving 100% stone clearance on the left side as well (Fig. 7).

Fig. 6.

PCNL utilized for large stone in the left kidney and 100% stone clearance achieved.

Fig. 7.

X-ray KUB depicting left side DJ stent insitu after PCNL.

Discussion

There are many treatment modalities available for renal and ureteric stones for instance percutaneous nephrolithotomy (PCNL), trans-ureteral lithotripsy (TUL), and extracorporeal shock wave lithotripsy (ESWL) [5]. The decision of utilization of these techniques depends upon many factors. These factors can range from the size of the stone, position, complexity, hardness, and associated any risk factors or complications [6]. ESWL is a noninvasive technique utilized mostly for the breakage of stones in kidneys, and upper and mid ureters. ESWL is less effective for stones of size more than 20 mm [7]. ESWL is contraindicated in pregnancy, obesity, skeletal deformity, and untreated urinary tract infections. The complications of ESWL are categorized as infectious, related to stone fragments like obstruction, pain, fever, steinstrasse formation, and due to tissue effects like hematoma formation and bleeding in renal, gastrointestinal, and cardiovascular systems [8]. Incidence of urinoma formation is rare with less than 1.5%. Many factors may predispose to urinoma formation such as the size of the calculus, location of the stone, pre-existing kidney disease, number of ESWL sessions diabetes, etc. [9]. Urinoma development in ESWL has been attributed to the intensity of shock waves that cause injury to surrounding renal tissue leading to urine leakage and collection in peri-renal area. Urinoma usually presents as flank pain, fever, hematuria, and heaviness in the lumbar region. Diagnosis usually depends on imaging studies like intravenous urography, ultrasound, MRI, and computed tomography which reveal a collection of urine in peri-renal or retroperitoneal space. Most of the urinomas are managed through percutaneous drainage and double J stents as reported in the literature. Some cases may require open surgical intervention [10]. If urinomas are not detected or treated promptly it can lead to sepsis, abscess formation, peritonitis, and even death of the patient. In our case report, urinoma secondary to ESWL was treated promptly through nephrostomy drainage and trans-ureteral lithotripsy along with double J stent placement for better drainage of the collecting system under cover of broad-spectrum antibiotics.

Literature has very few examples of urinoma formation after ESWL Mehmet Turgut et al reported the formation of urinoma after ESWL which was managed through percutaneous drainage and antibiotics due to rupture of the upper ureter [11]. Similarly in another study, Zhang Junwei et al. [12] reported a case of post-ESWL urinoma formation which was managed through retrograde placement of double J stents.

Alkibay et al. and Liu et al. reported a similar rare entity of urinoma formation due to ESWL which was evacuated through surgical drainage [13,14].

Hence after going through a deep insight into the literature about previously reported urinoma cases worldwide, we came to know that the cases reported about the formation of urinoma due to ESWL is less (Table 1), and its co-existence with steinstrasse makes it more novel and complexity increases more if the opposite renal system is also obstructed by large stone burden as in our case then such complexity demands competent multimodal urological health care.

Table 1.

It depicts previously reported cases including this one regarding urinoma formation due to ESWL (extracorporeal shock wave lithotripsy) and their respective management.

Author	Year	Age in years	Gender	Presenting complaints	Diagnostic modalities used	Management
Alkibay et al. [13]	1992	25	Female	Fever and left lower abdomen mass	Ultrasound and CT scan	Surgical drainage via a subcostal flank incision
Turgut et al. [11]	2007	32	Female	Severe discomfort in the right upper abdomen with fever and nausea	X-ray plain KUB, Ultrasound CT	Percutaneous nephrostomy catheter
Liu et al. [14]	2016	63	Male	Abdominal distension and abdominal pain	CT and MRI	Surgical drainage and repair of ureters during laparotomy
Junwei et al. [12]	2019	30	Male	Severe right flank pain	Ultrasound and CT	Trans-ureteral lithotripsy and double j stents.
Our case	2024	50	Male	Bilateral flank pain and anuria	Ultrasound and CT	PCN &Trans-ureteral lithotripsy and double j stents.

Conclusion

Urinoma is one of the rare but severe complications of ESWL. It is important to keep in mind the possibility of urinoma formation due to extracorporeal shock wave lithotripsy as if not detected early can prove fatal. The co-existence of steinstrasse along with urinoma demands tran-ureteral lithotripsy to gain retrograde access and the complexity increases in the settings of bilateral obstructing systems where percutaneous nephrolithotomy can also be utilized as part of multimodal therapy for complete clearance of stones. Urologists and healthcare professionals should be aware of the management of ESWL-related complications and their prompt management in complex situations.

Patient consent

We confirm that we have obtained written, informed consent from the patient for the publication of this case report. The patient has been thoroughly informed about the details that will be published and understands the implications of the publication. The written consent is stored securely and is available for review by the editorial team upon request.