A 4 mm vesicoureteric junction stone causing rupture of pelvicoureteric junction – case report

Abstract

We discuss the case of a 67-year-old man who presented with a right-sided abdominal pain and on subsequent radiological imaging(s) in the form of an enhanced computed tomography scan of the abdomen and pelvis followed by a delayed excretory phase (computed tomography urogram), found to have a distal 4 mm vesicoureteric junction stone which had caused a pelvicoureteric junction rupture which was evident on extravasation of contrast. This warranted an urgent surgical intervention in the form of ureteric stent insertion. This case clearly depicts that with even a small stone associated with severe flank pain, rupture or pelvicoureteric junction/calyces should be suspected and we should never overlook symptoms and push for medical expulsive therapy in patients who do not appear to be septic or obstructed. This work has been reported in line with the Surgical CAse REport (SCARE) criteria.

Introduction

Highlights

• Ureteric rupture secondary to a small ureteric stone.

• Urologists should never overlook a small stone with significant pain and should devise further follow-up plans and imaging, as explained in this case.

Spontaneous nontraumatic rupture of the ureter due to a tiny 4 mm stone is a rare phenomenon. However, a few cases of calyceal rupture have been reported. The pathophysiology behind this is the increase in the intraluminal pressure of the ureter, causing upstream dilation and rarely rupture of the upper tract causing extravasation of urine1. This is considered a urological emergency and is treated most of the time with an emergency stent followed by a ureterorenoscopy to fragment the stone at a later stage. This work has been reported in line with the Surgical CAse REport (SCARE) criteria2.

Case presentation

A 67-year-old known epileptic man presented at our institution’s emergency department with a day’s history of sudden onset right flank pain which migrated to right iliac fossa. The episode was associated with bouts of nausea and vomiting, along with chills and rigors.

He was reviewed by the general surgeons who appreciated tenderness over McBurney’s point with localized peritonism in the right iliac fossa giving it a clinical diagnosis of appendicitis.

The patient went on to have a computed tomography scan of the abdomen and pelvis with contrast (Fig. 1) to confirm the above, which was suggestive of an obstructive 4×3×3 mm right distal ureteric calculus, immediately proximal to the vesicoureteric junction and a retroperitoneal focus of fluid suspicious for a calyceal perforation resulting in a urine leak secondary to back pressure.

Figure 1.

Computer tomography scan of the abdomen and pelvis confirming a likelihood of a proximal ureteric injury.

The patient was referred to the urologists, who ascertained the above history and took a focussed urological anamnesis which did not include any previously known urological conditions or haematuria.

He subsequently had a computed tomography (CT) urogram done, which confirmed the diagnosis of a tiny distal ureteric calculus causing severe back pressure and consequent rupture of right pelvicoureteric junction (PUJ), which was evident from the active contrast extravasation from the right side of the urinary tract, at the PUJ (Fig. 2). There was a large unorganized collection of urinary contrast in the right side of the retroperitoneum, surrounding the upper and mid-course of the right ureter and the third part of duodenum. Extensive soft tissue stranding was also evident.

Figure 2.

Computed tomography urogram; clearly defining the site of extravasation at pelvicoureteric junction with patent distal ureter (marked with blue arrow).

His observations were stable and so was his blood (inflammatory markers and renal function), and his urine dip was only evident of microscopic haematuria.

He was taken to the emergency theatre and was stented with a standard 6 French-26 cm Double J stent. A retrograde pyelogram (RPG) confirmed extravasation of contrast at the level of PUJ. He had a smooth recovery post operation and was discharged on day 3 post operation.

He went on to have a ureterorenoscopy in 6 weeks’ time where no stone was identified and there was no extravasation of contrast or any filling defect on a retrograde pyelogram (Fig. 3). The patient was discharged with no further follow-up plan.

Figure 3.

Retrograde pyelogram illustrating a healed ureter on a re-look in 6 weeks.

Discussion

Ureteric injury is a rare phenomenon especially in a nontraumatic case like ours, iatrogenic cause being the most common factor. The earliest cases were described in 1856 by Diaz and Buenrostro3. Ruptures of the ureter can be classified into traumatic and nontraumatic causes. Calculi represent the most frequent cause of ureteral and renal pelvis rupture in the nontraumatic group – as in our case.

Understanding the pathophysiology becomes essential when discussing such case – the principal concept being that of increased intraluminal pressure causing a disruption in the calibre of the upper tract causing extravasation of contrast. This is mainly seen in the fornix, followed by the proximal ureter when the intraluminal pressure exceeds a critical level between 20 and 75 mmHg4.

The classic CT scan finding best illustrated on the excretory phase is that of active extravasation of contrast5,6. CT urogram is considered the imaging modality of choice when investigating urinary collecting systems leaks. It should also be a gold standard practice for all urologists to perform an on-table retrograde pyelogram in such cases as it would help ascertain the site of injury and aid in the correct positioning of the Double J ureteral stent, which would serve the purpose of sealing the leak before the patient comes back for a re-look in 4–6 weeks’ time. Amongst other treatment option, percutaneous nephrostomy are also reported, whilst conservative management has been reported in a very small group2,7.

Diagnostic dilemma can delay management – as in our case where the symptoms mimicked that of acute appendicitis, especially when renal functions are stable and in the absence of any urological history8. This has also been reported in case reports describing two patients who had initially presented with symptoms mimicking appendicitis and eventually were diagnosed with ureteric stones, which had caused spontaneous rupture of ureter9. Nevertheless, with the advent of technology and the availability of resources, there should be very low threshold for CT scan along with a delayed excretory phase to ascertain diagnosis.

Previous reports have suggested catastrophic after-math leading to nephrectomy when a ureteric rupture secondary to a stone led to urinoma and subsequent superinfection despite a stent, thus making it a time-critical condition for urologists10.

Conclusion

Ureteric rupture secondary to a urinary tract stone is a rare complication. This could even be caused by a small stone associated with flank pain in the presence of normal renal function and inflammatory markers, as in our case. But such scenarios should never be overlooked, and rupture or ureter/calyces should be suspected, and performing a CT urogram should be the ideal imaging modality to devise further management plans. The mainstay of managing such a scenario should always be an urgent decompression without failure.

Ethical approval

Patient ethical approval given to authors.

Patient consent

The patient’s consent was obtained verbally at the initiation of the case report as well as on a signed consent form.

Consent for publication

Written informed consent was obtained from the patient’s parents for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Sources of funding

None.

Author contribution

P.N. and Z.S. are joint first authors who contributed to this research in write up and collating data. F.S. is the second author who contributed to the study concept, data analysis and collection.

Conflicts of interest disclosure

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Research registration unique identifying number (UIN)

None.

Guarantor

F. Salimi.

Provenance and peer review

Not commissioned, externally peer reviewed.