Renal Forniceal Rupture: Is Conservative Management Safe?

Recent advances in the treatment of renal stones using flexible ureteroscopys

Upper urinary tract stones are a common urological disease that can be treated by flexible ureteroscopy (FURS) through the natural urinary tract, in addition to extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy. The advantages of FURS are less trauma, faster recovery, and fewer complications, while its disadvantages include poor results of lithotripsy and stone extraction when dealing with larger stones, and prolonged operation time. Over the last two decades, the emergence of new technologies such as FURS combined with negative pressure suction, robot-assisted FURS, and artificially intelligent FURS, coupled with improvements in laser technology (the use of thulium fiber lasers and the invention of single-use flexible ureteroscopes (su-fURS) suitable for primary level application, have significantly increased the global adoption of FURS. This surge in usage holds a promising future in clinical application, benefiting a growing number of patients with renal calculi. Accompanied by changes in technical concepts and therapeutic modalities, the scope of indications for FURS is broadening, positioning it as a potential primary choice for urolithiasis treatment in the future. This review outlines the progress in employing FURS for the treatment of renal calculi in order to generate insights for further research.

Predictors of forniceal rupture in patients with obstructing ureteral calculi: Analysis of multicenter data

Background

Renal forniceal rupture (FR) is a unique complication of obstructive uropathy. This study aimed to identify the predictors of FR among patients presenting with renal colic due to obstructing ureteral calculi.

Materials and Methods

After obtaining ethics approval, electronic records of patients from three National Guard hospitals in Saudi Arabia were reviewed between 2016 and 2020 to identify patients who presented with renal colic and were diagnosed with FR due to obstructive ureteric stones (FR group). An equivalent number of consecutive patients presenting with renal colic due to obstructing ureteric stones without FR was selected as a control group (non-FR group). Patients were grouped according to age group (<30, 30-40, 41-50, and >50 years), body mass index (BMI) class, gender, comorbidities, grade of hydronephrosis, location of the stone in the ureter, size of the stone (<3 mm, 3-7 mm, and >7 mm), and stone former status. Baseline patients' and stone characteristics were compared, and a regression analysis was performed to identify predictors of FR.

Results

A total of 50 patients with FR were identified, and a control group of 50 patients without FR were selected. The baseline patients' and stone demographic characteristics in terms of age (P = 0.42), gender (P = 0.275), BMI (P = 0.672), comorbidity, grade of hydronephrosis (P = 0.201), and stone location (P = 0.639) were comparable between the FR group and the non-FR group. However, the stone size was statistically significant between both groups (P = 0.014). On multivariable analysis, it was found that the stone size was associated with a significantly higher increase in the incidence of FR (odds ratio [OR]: 6.5 [1.235-34.434]; P = 0.027). Furthermore, the age group between 30 and 40 years was potentially at a lower risk for FR (OR: 0.262 [0.069-0.999]; P = 0.049).

Conclusion

This multicenter study showed that the stone size 3-7 mm had a six-fold increase in the chance of FR, and the age group between 30 and 40 years is potentially at a lower risk for FR.

Is conservative management safe in patients with acute ureterolithiasis and perirenal stranding?

In patients presenting with ureterolithiasis, perirenal stranding is frequently observed in non-contrast computed tomography. Because perirenal stranding may be caused by tears in the collecting system, previous studies have described an increased risk of infectious complications and suggested broad empiric antibiotic therapy and immediate decompressing of the upper urinary tract. We hypothesized that these patients can also be managed conservatively. Therefore, we retrospectively identified patients with ureterolithiasis and perirenal stranding and compared diagnostic and treatment characteristics as well as treatment outcomes between patients undergoing conservative versus interventional management by ureteral stenting, percutaneous drainage or primary ureteroscopic stone removal. We classified perirenal stranding as mild, moderate or severe based on its radiological extent. Of 211 patients, 98 were managed conservatively. Patients in the interventional group had larger ureteral stones, more proximal ureteral stone location, more severe perirenal stranding, higher systemic and urinary infectious parameters, higher creatinine levels, and received more frequent antibiotic therapy. The conservatively managed group experienced a spontaneous stone passage rate of 77%, while 23% required delayed intervention. In the interventional and conservative groups, 4% and 2% of patients, respectively, developed sepsis. None of the patients in either group developed a perirenal abscess. Comparison of perirenal stranding grade between mild, moderate and severe in the conservatively treated group showed no difference in the spontaneous stone passage and infectious complications. In conclusion, conservative management without prophylactic antibiotics for ureterolithiasis and perirenal stranding is a valid treatment option as long as no clinical or laboratory signs of renal failure or infections are observed.

Managing renal forniceal rupture secondary to ureteric calculi in line with the NICE 2019 Renal and Ureteric Stone Guidelines

Objective:

To synthesise all available data to determine the best management for urolithiasis-related renal forniceal rupture (RFR), with particular reference to the National Institute for Health and Care Excellence (NICE) 2019 Renal and Ureteric Stone Guidelines.

Methods:

PubMed search to March 2020 using permutations of renal, forniceal, fornix, calyceal, calyx and rupture. Non-English abstracts, editorial comments, letters to the editor and abstracts of conference proceedings were excluded.

Results:

An initial PubMed search retrieved 126 titles which were screened for relevance and five further titles were added from associated references. 64 abstracts were subsequently assessed, with 25 articles proceeding to full paper review.

Conclusions:

In cases of RFR secondary to ureteric calculi, management options, including conservative management, for the stone should be considered without the decision being influenced by the presence of the rupture. Perirenal abscesses secondary to RFR are rare, occurring in less than 0.25% of cases. Evidence supports restricting antibiotic prophylaxis to patients with a history of recurrent urinary tract infections or a positive urine culture, in line with the European Association of Urology’s antibiotic stewardship general management principle. RFR is not inherently a contraindication to primary ureteroscopy, which has particularly relevance with the drive to meet the 2019 NICE recommendations.

Level of evidence:

Not applicable to this literature review.

Renal pelvic rupture: A case report of an unexpected cause

INTRODUCTION

Renal pelvic rupture (RPR) is a rare condition, that is most usually caused by obstructive calculi. In another hand, primal ureteral tumors are also uncommon, with only a few cases reporting their involvement in a RPR.

PRESENTATION OF CASE

We report a case with a multimodality discussion of an ureteral tumor, with a spontaneous renal pelvic rupture (RPR) forming a large retrorenal urohematoma.

DISCUSSION

Only few series reported the subject of RPR in the English literature. Only some single cases reported the causality of urinary tract tumors in RPR. RPR is an imaging based diagnosis. Herein, upper urinary tract tumors show a variable appearances at imaging.

CONCLUSION

By reporting this case, we highlight the role of both computed tomography (CT) and magnetic resonance (MR) imaging in the diagnosis of the RPR and their accuracy in the detection of the ureteral tumor. We also consolidate the effectiveness of the conservative attitude in the management of the RPR.

Spontaneous renal fornix rupture in pregnancy and the post partum period: a systematic review of outcomes and management

BACKGROUND

Spontaneous renal fornix rupture (SRFR) causing urinoma is an uncommon but serious condition in pregnancy. Limited information is available to describe the natural history and outcomes to guide appropriate treatment. The aim of this study was to determine the natural history and outcomes of SRFR to determine appropriate management recommendations.

METHODS

A systematic review of literature databases was performed, using the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) checklist from 1950 - April 2020. Inclusion criteria included any urinary extravasation from the kidney or ureter during pregnancy, or in the 8 weeks following delivery, confirmed via imaging or surgery. Haematomas and non-confirmed cases were excluded.

RESULTS

A total of 1579 records were originally identified, of which 39 case reports were appropriate for inclusion. SRFR was most commonly reported during the first pregnancy (72%), 19/30 during the third trimester and 9 in the post-natal period. All patients presented with pain, with haematuria positive on urine dipstick in only 36% of 26 reported cases. Ultrasound was the most frequently used imaging modality, resulting in a diagnosis in 42% of cases. All cases reported on treatment procedures including ureteric stents (46%), percutaneous drain (15%), conservative management (15%), nephrostomy (13%) and ureteral catherization (10%). Long term urological outcomes were positive, however women suffering SRFR were significantly more likely to undergo pre-term labour.

CONCLUSION

While selected cases may be successfully managed conservatively, urinary diversion, through ureteric stents, should be considered the management of choice in these individuals. Clinicians should be mindful of an increased risk of premature delivery and its' associated negative fetal outcomes.

Spontaneous bilateral renal pelvis rupture during CT in the absence of urinary tract obstruction: case report

BACKGROUND

Atraumatic renal pelvis rupture without pre-existing renal or ureteric pathology is an uncommon event. It is reported in the setting of acute urinary tract obstruction, most often secondary to ureteric calculi. Typical symptoms include acute flank pain and nausea, mimicking pyelonephritis or other causes of acute abdomen. Spontaneous rupture occurring bilaterally without identifiable urinary tract obstruction is exceedingly rare, and has yet to be reported in current English literature. Possible contributing pathophysiological mechanisms can be postulated from reported cases of rupture with observed obstruction.

CASE PRESENTATION

A 58-year-old woman undergoing multiphasic computed tomography (CT) for evaluation of asymptomatic microscopic haematuria developed on-table bilateral renal pelvis rupture seen only after contrast administration, on the delayed phase. There was no significant past medical history of note. The patient remained asymptomatic throughout and after the study, and was managed conservatively. Follow-up radiographical imaging over a month showed resolution of urinoma and no further contrast extravasation. No complications or recurrence was subsequently noted.

CONCLUSIONS

Spontaneous rupture of the renal pelvis can be a rare complication of intravenous contrast administration even in cases without identifiable urinary tract obstruction, and it can occur bilaterally. Cases can uncommonly be asymptomatic but typical symptoms should prompt evaluation of the kidneys, particularly when they are not included in the initial study or no delayed phase is protocolled. Interval imaging for resolution of urinoma and contrast extravasation is clinically relevant to monitor for and avoid infective sequelae.

Bilateral renal forniceal rupture due to retroperitoneal hematoma after femoral venous access

Retroperitoneal hematoma is a potential complication of femoral venous access that rarely leads to bilateral ureteral obstruction. We present the case of a 73-year-old woman who underwent an ablation procedure for atrial fibrillation complicated by laceration of an aberrant obturator artery during femoral venous cannulation, leading to a compressive retroperitoneal hematoma, bilateral ureteral obstruction, acute renal failure, and renal forniceal rupture. The patient was successfully treated with embolization of the inferior epigastric artery and aberrant obturator artery, hematoma evacuation, and ureteral stent placement. This case illustrates a rare complication of arterial laceration during femoral venous access without ultrasound guidance.

Spontaneous rupture of the renal calyx secondary to a vesicoureteral junction calculus

BACKGROUND

Spontaneous urinary collecting system rupture is caused by increased ureteral intraluminal pressure secondary to an obstruction. Rarely, a small stone exerts high intraureteral pressure especially if it is located distally. Many management modalities with good outcomes have been implicated.

PURPOSE

Herein, we present a case of nontraumatic rupture of the renal calyx due to a 4 mm obstructing stone at the vesicoureteral junction.

BASIC PROCEDURES

CT scan of abdomen and pelvis without contrast, CT scan of the abdomen and pelvis with intravenous contrast, Cystoscopy, Double-J ureter stent, Urinary Foley catheter.

MAIN FINDINGS

The diagnosis was confirmed by CT imaging. Non-contrast enhanced CT scan of abdomen and pelvis showed obstructive calculi measuring 4 mm in the right vesicoureteral junction. Contrast-enhanced CT scan revealed leakage of contrast in the perinephric space at the right major calyx with intact bilateral ureters, suggestive of calyceal rupture. The treatment involved antibiotics and double-J stenting.

PRINCIPAL CONCLUSIONS

This case demonstrates that spontaneous calyceal rupture should be suspected in urolothiasis patients presenting for a severe pain even if the calculus is small (less than 5 mm) and the laboratory markers are normal. An immediate management is required to relief symptoms and prevent further complications.

Evaluation of the clinical significance of sonographic perinephric fluid in patients with renal colic

OBJECTIVE

To evaluate the significance of sonographic perinephric fluid collection on the emergent management of patients with acute urinary stone obstruction.

METHODS

We conducted a prospective study with retrospective analysis. Since January 2016 through July 2017, patients admitted to our tertiary hospital's emergency department (ED) with suspected symptomatic urinary stones underwent ultrasound evaluation. Images were prospectively interpreted by experienced radiologist who analyzed each case for the following imaging features: hydronephrosis, perinephric fluid and urethral stone identification. The presence and measurements of perinephric fluid were re-evaluated by second radiologist who was blinded for the first reader's measurements. Retrospective analysis was conducted to evaluate for an association between perinephric fluid collection and the following outcome variables: need for analgesics, the number of doses of analgesics and the amount of morphine (mg) in the ED, elevation of creatinine levels, hospitalization and need for urological interventions.

RESULTS

The need for analgesics, the number of doses of analgesics and the amount of morphine were significantly associated with the presence of perinephric fluid (p < 0.05). The odds ratio for the need for analgesics was 3.8 in the presence of any perinephric fluid, and 8.9 in the presence of moderate/severe perinephric fluid. No other patient outcome variables were found to be significantly associated with the presence of perinephric fluid (p > 0.05).

CONCLUSIONS

This study shows a correlation between sonographic evidence of perinephric fluid and more severe pain. Therefore, an emergency physician can consider the evidence of perinephric fluid, in acute urethral stone obstruction, a predictor for more severe pain.

Inguinal Herniation of Perinephric Tissue: Case Report and Review of the Literature

Inguinal hernias containing a kidney or perinephric tissue are extremely rare and usually related to cases involving a kidney positioned in the pelvis. We report the case of a 79-year-old man who presented with abdominal pain and scrotal swelling. He was found on imaging to have an inferiorly displaced kidney with an inguinal herniation of Gerota fascia, as well as an obstructing ureteral stone with an associated forniceal rupture. The unusual renal anatomy, as well as the management of a forniceal rupture, is discussed.