E XTRAVASATIONS from the pelvicalyceal

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1 VOL. 112, No. 3 PELVICALYCEAL EXTRAVASATIONS* By FILEMON LOPEZ, M.D. BRONX, NEW YORK E XTRAVASATIONS from the pelvicalyceal system, previously considered rare, are being demonstrated with increasing frequency. Some of these extravasations are benign in nature, requiring only a conservative approach to management. However, a number of the conditions associated with pelvicalyceal extravasations may be life-threatening so that prompt diagnosis and treatment are absolutely necessary. The purpose of this paper is to acquaint the radiologist with some of the conditions associated with pelvicalyceal extravasations and to describe the salient roentgen characteristics of the different types of extravasation. Pelvicalyceal extravasations may be classified as follows: I. Spontaneous (renal backftow) A. Acute Obstruction i. Pyelosinus 2. Pyelotubular 3. Pyelolymphatic 4. Pyelointerstitial. Pyelovenous B. Chronic Obstruction i. Retroperitoneal 2. Intraperitoneal II. Post-traumatic extravasations i. Penetrating injury 2. Non-penetrating injury (a) Direct blunt injury (b) Lateral flexion injury 3. Surgical trauma REPORT OF CASES ACUTE URETERAL OBSTRUCTION CASE i. J. M., a 6s year old male, was admitted to the hospital because of sudden onset of right flank pain. Intravenous urography was performed a few hours after the onset of the pain. No radiopaque calculus was noted on the preliminary roentgenogram of the abdomen. The 30 minute urogram (Fig. I) showed indistinct calyces on the right, with extravasations presenting as horn-shaped opacifications adjacent to the calyces. The intrarenal portion of the renal pelvis was exquisitely outlined by contrast medium in the renal pelvis and hilum. The extravasated material was also seen in the periureteral tissues, outlining the wall of the proximal ureter. Dilatation of the right collecting system, with columnization of contrast material down to the ureterovesical junction was observed. A diagnosis of obstructive uropathy due to a calculus with extravasation was made. Twenty-four hours later, the patient was asymptomatic and a repeat urogram showed no abnormality. Comment. This case demonstrates the typical roentgenologic and clinical course of patients with spontaneous extravasation due to acute urinary tract obstruction. A mild degree of dilatation of the collecting system proximal to the level of obstruction is usually noted. Extravasation that occurs in cases of acute renal colic is a means of decompression so that the calyces and renal pelvis are never markedly dilated. Subcapsular collection of contrast material is not usually observed in these patients. The horn-shaped opacities adjacent to the calyces are typical. The differential diagnosis usually includes renal tuberculosis and papillary necrosis. CHRONIC OBSTRUCTION CASE II. J. M., a 68 year old male, was hospitalized because of an enlarging lump in the right groin which was subsequently found to be part of generalized lymphosarcoma. He also complained of a steady right flank pain of to 5 days duration. An enlarged prostate gland was found on physical examination. An intravenous urogram (Fig. 2A) demonstrated bilateral hydronephrosis with fish-hooking of both ureters. On the right, extravasation was noted in the renal sinus and retroperitoneal * Presented at the Seventy-first Annual Meeting of the American Roentgen Ray Society, Miami Beach, Florida, September 29- October 2, From the Departments of Radiology of the Montefiore Hospital and Medical Center, Morrisania Hospital Afliliate, and the Albert Einstein College of Medicine, Bronx, New York. 593

594 Filemon Lopez Jr IY, 1971 PENETRATING INJURY VIG. I. Case I. Thirty minute urogram shows extravasations presenting as horn-shaped opacifications adjacent to the calyces.

2 594 Filemon Lopez Jr IY, 1971 PENETRATING INJURY VIG. I. Case I. Thirty minute urogram shows extravasations presenting as horn-shaped opacifications adjacent to the calyces. Extravasated material is also seen in the periureteral tissues. Dilatation of the right collecting system down to the ureterovesical junction is noted. space. An indentation was present at the base of tile bladder due to the enlarged prostate. The patient was placed on catheter drainage and a repeat urogram (Fig. 2B) 2 weeks later showed marked improvement in the upper tracts with no evidence of hydronephrosis or extravasation. l he patient subsequently died of generalized lymphosarcoma without urinary tract involvemen t. Comment. This case is similar to the previous case except for the presence of chronic urinary tract obstruction secondary to prostatic enlargement. The extravasation was retroperitoneal and the response to conservative management was dramatic. On occasion, in cases of chronic urinary tract obstruction, extravasation can occur in traperitoneally, producing urine ascites. 4 CASE III. L. R., an IS year old female, was hospitalized because of Ilematuria following a stab wound in the left flank. An intravenous urogram (Fig. 3) showed prompt bilateral renal excretion with a moderate degree of ureteropelvic junction obstruction on the right. Retroperitoneal extravasation was noted on tile left, outlining the entire renal pelvis except the inferomedial border, indicating that the laceration was in the renal pelvis close to the ureteropelvic junction. A radiolucent line was observed representing the thickness of the wall of the renal pelvis and proximal ureter. At surgery, the diagnosis of laceration of the left renal pelvis was confirmed. Comment. Penetrating injuries to the pelvicalyceal structures are usually easy to diagnose. The demonstration of a radiolucent stripe representing the wall of the pelvis and1/or ureter, outlined by contrast material both within and around these structures, is pathognomonic of retroperitoneal extravasation (Fig. 4A). The ureter occasionally can be seen in the early phase of the urogram (Fig. 4B) as a lucent tubular defect in the pooi of extravasated contrast medium, another pathognomonic sign of retroperitoneal extravasation. NON-PENETRATING INJURY CASE IV. P. B., a 12 year old girl, was hospitalized following a football injury to the abdomen. Urinalysis showed numerous red blood cells. Intravenous urography demonstrated a large filling defect in the left renal pelvis and ureter (Fig. ), conforming to the contour of these structures. No appreciable dilatation of the upper tracts was present. The mucosa of the renal pelvis and ureter was outlined by contrast medium surrounding the radiolucent filling defect. Intraparenchymal and perihilar extravasations were also noted. A diagnosis of renal injury with blood clots in the collecting system and extrarenal extravasation was made. The patient was treated conservatively and a follow-up examination 2 weeks later showed no extravasations or filling defects in the urinary tract. Comment. Non-penetrating injury to the kidney due to direct blunt trauma is frequently seen in the younger age group. The demonstration of a filling defect that conforms to the

(B) Two weeks later, a repeat urogram shows no evidence of extravasation or hydronephrosis.

3 OL. 112, No. 3 Pelvicalyceal Extravasations 595 FIG. 2. Case II. (A) Urogram shows bilateral hydronephrosis with fish-hooking of both ureters. Extravasation is seen in the right renal sinus and retroperitoneal space. An indentation at the base of the bladder is demonstrated. (B) Two weeks later, a repeat urogram shows no evidence of extravasation or hydronephrosis. contour of the pelvis, ureter and/or bladder, with a radiopaque mucosal outline giving a double contrast configuration, is pathognomonic of intravasation in the urinary system. Significant dilatation is usually absent in spite of the presence of massive intravasation. This roent- FIG. 3. Case III. Urogram demonstrates bilateral renal excretion with a moderate degree of ureteropelvic junction obstruction on the right. Extravasated contrast material is seen surrounding the renal pelvis except the inferomedial border, indicating that the laceration is in the pelvis close to the ureteropelvic junction. A lucent line is seen (arrow) representing the thickness of the wall of the renal pelvis. 7

An opaque calculus is seen within the ureter causing obstructive uropathv.

4 596 Filemon Lopez JULY, 1971 FIG... This 51 ear old male presented with an acute onset of right flank pain. Urinalysis showed microscopic hematuria. (A) Excretory urogram demonstrates a radiolucent tubular structure in the pool of extravasated contrast medium, indicating retroperitoneal extravasation. An opaque calculus is seen within the ureter causing obstructive uropathv. (B) A 15 minute roentgenogram shows a lucent stripe representing the walls of the pelvis and ureter, outlined by contrast material both within and around these structures. This is another pathognomonic sign of retroperitoneal extravasation. genologic appearance differs from that of penpelvic and peniureteral extravasation, in which the walls of these structures are demonstrated as a radiolucent line.9 LATERAL FLEXION INJURY CASE v. A. L., a io year old boy, was struck on the left flank by a car. Urinalysis was normal. An intravenous urogram (Fig. 6A) revealed a normal left kidney and ureter. On the right, a slight fullness of the collecting system was noted with a cut-off at the level of the ureteropelvic junction. The ureter beyond this point was never visualized. A diagnosis of lateral flexion injury with rupture of the right ureteropelvic junction was made. Right retrograde pvelography (Fig. 6B) was performed on the same day, demonstrating complete laceration of tile ureteropelvic junction with retropenitoneal extravasation. The patient was operated upon and an endto-end anastomosis performed. Follow-up urograms showed no abnormality except for a deformity at the ureteropelvic junction presumably due to the surgical procedure. Comment. This type of kidney injury is very deceiving and can easily be missed if the physician is not alert. Trauma to the flank may cause sudden marked lateral flexion of the body, resulting in stretching of the contralateral ureter and impingement against the transverse process of the upper lumbar vertebrae.7 In these cases, the ureter distal to the laceration is usually not visualized. This type of injury demands immediate surgical intervention. SURGICAL TRAUMA CASE VI. H. H., a 70 year old hypertensive male, was hospitalized after an episode of chest pain, diaphoresis and headache followed by unconsciousness. Intravenous urography was performed to rule out a renal cause for the hypertension. A cyst in the lower pole of the left kidney was found and surgical unroofing of the

5 VoL. 112, No. 3 Pelvicalyceal Extravasations 597.i I cyst was accomplished. A few days postoperatively the patient complained of left flank pain, and another urogram (l ig. 7) was obtained. At this time, extravasation from tile lower pole calyx of the left kidney was observed. The ureter was normal. File patient was treated conservatively and i week later a follow-up urogram demonstrated no extravasation. The patient was discharged very much improved. Comment. Extravasations are not infrequent after renal surgery and are particularly cornl IG. 5. Case IV. The intravenous urogram shows a long filling defect in the left renal pelvis and ureter conforming to the contour of these structures. No appreciable dilatation of the upper tracts is apparent. Intraparenchymal and perihilar extravasation is also demonstrated. 11G. 6. Case v. (4) 1. rogram shows a cut-off at the level of the ureteropelvic junction, and moderate fullness of the collecting system is apparent on the right. The ureter beyond the ureteropelvic juncti()n was never seen. There is minimal retroperitoneal extravasation noted. The left kidney and ureter were normal. (B) Retrograde urogram confirms the presence of ureteropelvic rupture with retropenitoneal extravasation. I FIG. 7. Case vi. Urogram demonstrates extravasation from the lower pole calyx into the retroperitoneal space. No dilatation of the ureter_is apparent.

6 598 Filemon Lopez JULY, 1971 mon after ureteropelvic surgery. As long as the ureter is not obstructed, the extravasation usually terminates spontaneously. In the presence of obstruction, even of the mildest degree, extravasation will continue and an urinoma may develop. DISCUSSION The phenomenon of spontaneous extravasation, formerly considered rare, is seen with increasing frequency as techniques and contrast media improve and the radiologist s awareness increases. Numerous case reports and discussions have appeared in the literature; however, only a few have met with the strict criteria of the diagnosis of spontaneous extravasation as outlined by Schwartz et al. #{176}These include absence of the following : (i ) recent instrumentation; ( 2) a previous surgery; () external trauma; (4) a destructive kidney lesion; () external compression; and (6) pressure necrosis produced by a stone in the pelvis or ureter. Renal backflow or spontaneous extravasation demonstrated du ring intravenous urography refers generally to the escape of contrast material outside the pelvicalyceal system. Spontaneous extravasation may be found in cases ofacute and chronic obstructive uropathy, although it is more frequently observed with acute obstruction. The mechanism of spontaneous extravasation due to acute ureteral obstruction is a sudden increase in intrapelvic pressure, causing rupture ofthe fornix ofone or more calyces.8 The contrast medium mixed with urine then escapes into the renal sinuses and collects in the peripelvic and periureteral areas. Pyelosinus extravasation is the most common type of spontaneous extravasation. The mechanism of pyelovenous backflow, the least common type of spontaneous extravasation, has been demonstrated by Green a al.3 Using microradiologic techniques and cadaver kidneys, they concluded that pyelovenous backflow takes place through rupture of a fornix. The hydronephrotic kidney allows pyelovenous backflow to occur at a much reduced pressure, when compared to a normal kidney. According to these authors, preferential pyelovenous backflow in hydronephrotic kidneys serves as a protective mechanism and may explain induced bacteremia seen in retrograde studies in patients with ureteral obstruction. The disti nction between spontaneous forniceal rupture and an acute rent of the pelvis or ureter, due to trauma, is important because the patients with spontaneous extravasation due to acute obstruction are not as ill as those with acute rent of the pelvis and ureter. Also, conservative management is usually indicated in most cases of spontaneous extravasation, while in cases of acute rent of the pelvis or ureter, surgical intervention is usually required. During intravenous urographv, the ureter is usually demonstrated down to the level of obstruction in cases of spontaneous extravasation. In cases ofacute rent, however, the ureter distal to the rupture is frequently not demonstrated. The relatively benign nature of spontaneous extravasation associated with renal colic is to be differentiated from extravasation due to rupture of the kidney following trauma. In the latter, renal function may be decreased or absent. A 30 second nephrogram may show a peripheral radiolucent line in the kidney due to blood bisecting the cortex.5 Dilatation of the upper tract is uncommon and the extravasation is predomina ntly subcapsular or intraparenchymal. Surgical intervention may be required, whereas it is never necessary in spontaneous extravasation. It should be noted, however, that spontaneous extravasation is not without complications. Hanrow4 described a perinephric abscess secondary to spontaneous urine extravasation associated with renal colic. Other reported complications include peripelvic urine granuloma, fibrolipomatosis, localized retroperitoneal fibrosis, and strictures of the upper ureter and calyceal infundibula. Spontaneous extravasation associated with chronic obstructive uropathy is not common. Urine may leak into the retro-

VOL. 112, No. Pelvicalyceal Extravasations 599 peritoneal region, in which instance correction of the obstruction is all that is required to produce relief.

Spontaneous intraperi toneal extravasation is a potentially lethal condition producing signs ofperitonitis, but seldom causing signs or symptoms to implicate the urinary tract.

7 VOL. 112, No. Pelvicalyceal Extravasations 599 peritoneal region, in which instance correction of the obstruction is all that is required to produce relief. Leakage may occur into the peritoneal cavity, producing urine ascites. Spontaneous intraperi toneal extravasation is a potentially lethal condition producing signs ofperitonitis, but seldom causing signs or symptoms to implicate the urinary tract. Emergency laparotomy is frequently required as a therapeutic measure. Most of the reported cases have been in the neonatal age group;4 i i adult cases are also described in the literature.2 SUMMARY The characteristic roentgen features of the different types of pelvicalyceal extravasation are discussed and illustrated. The demonstration of a linear lucent tubular structure or a linear radiolucent stripe during intravenous urography is pathogno-. monic of retroperitoneal extravasation. Spontaneous extravasations due to acute urinary tract obstruction usually are benign and require conservative management. Chronic obstruction associated with intraperitoneal extravasation (urine ascites) and lateral flexion injury to the kidney may be life threatening so that prompt recognition and emergency treatment are mandatory. Other types of post-traumatic extravasation present a fairly characteristic clinicoradiologic picture and management should be individualized. Department of Radiology Montefiore Hospital and Medical Center Bronx, New York RE FERENCES I. BRAUN, W. T. Peripelvic extravasations during intravenous urography. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1966, 98, GLEN, S. E. Spontaneous intraperitoneal rupture of hydronephrosis. Brit. 7. Urol., 1969, 4!, GREEN, N., 1INGERHUT, A., and FRENCH, S. Mechanism of renovascular backflow. Radiology, 1969, 92, HARROW, R. B. Urinary extravasation associated with renal colic causing perinephric abscess. AM. J. ROENTGENOL., RAD. THERAPY & Nu- CLEAR MED., 1966, 98, LOPEZ, F. A., STERN, W. Z., SIEGELMAN, S. S., and JACOBSON, H. G. Nephrogram: valuable indicator ofrenal abnormalities. AM. J. ROENT- GENOL., RAD. 1HERAPY & NUCLEAR MED., 1969, io#{243}, MONCADA, R., WANG, J., and LOVE L. Neonatal ascites associated with urinary outlet obstruction (urines ascites). Radiology, 1968, 9 o, i i NEY, C., and 1 RI EDEN BERG, R. Trauma of ureter. In: Radiographic Atlas of the Genito-Uri. nary System. J. B. Lippincott Company, Philadelphia, 1966, pp OLssoN, 0. Studies on backflow in excretion urography. Ada radiol., 1948, Suppl RABINOWITZ, J. A., KELTER, R. J., and WOLF, B. S. Benign peripelvic extravasation associated with renal colic. Radiology, 1966, 86, SCHWARTZ, A., CAINE, M., HERMANN, G., and BI I-FERMANN, W. Spontaneous renal extravasation during intravenous urography. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1966, 98,

8 This article has been cited by: 1. Haopeng Pang, Xuefei Dang, Zhenwei Yao, Xiaoyuan Feng, Guangyao Wu Bilateral spontaneous urinary extravasation shown by computed tomography urography in a patient with benign prostatic hyperplasia. Radiology Case Reports 10:4, [CrossRef]

Excretory urography (EU) or IVP US CT & radionuclide imaging

Excretory urography (EU) or IVP US CT & radionuclide imaging MRI arteriography studies requiring catherization or direct puncture of collecting system EU & to a lesser extent CT provide both functional