Minimally invasive intervention of forniceal rupture in a solitary functioning kidney: A case report

Abstract

Renal Forniceal rupture is a common urological emergency, most commonly due to an underlying ureteral obstruction. There is no standardized management for forniceal rupture. We report a 70-year-old female who presented with vague abdominal symptoms, and acute on Chronic Kidney Disease. Plain Computed Tomography scan of the abdomen/pelvis revealed grossly disturbed renal anatomy, with a large perinephric collection, and an obstructing pelvic-ureteric junction stone. She was initially managed with intravenous antibiotics, percutaneous drain and percutaneous nephrostomy placement. She subsequently underwent right flexible ureteroscopy and double-J stenting. Prompt, early intervention resulted in return of renal anatomy and facilitated early recovery.

Highlights

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Treatment based on extent and severity of rupture, patients’ clinical condition, and current renal function.
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Intervention should be reserved for complicated cases or cases with sizable urinoma.
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The cause of raised intra pelvic pressure should be identified and treated accordingly.
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Ultimately aggressive and prompt management is needed to prevent from further complications.

1 Introduction

Renal forniceal rupture (RFR) is a serious urological emergency, often encountered in urologic practice. Yet, there is still an obscurity about its definitive pathogenesis, and there are no definite guidelines for its management. It can occur at any age, and usually occurs in setting of acute distal obstruction leading to increased renal pelvic pressure. It most commonly occurs secondary to obstructing calculus, in 75–80 % of cases. Other potential rare causes include urinary retention, posterior urethral valves, pregnancy and iatrogenic injuries. Urinary extravasation maybe clinically occult or may manifests symptoms of acute abdomen. We report a case of an elderly female incidentally diagnosed with renal forniceal rupture. in a solitary functioning kidney secondary to an obstructing calculus. She was successfully treated with percutaneous drain and percutaneous nephrostomy (PCN) placement initially, followed by definitive endourological management. Early intervention was crucial in this case, as it allowed for the restoration of normal renal anatomy despite the grossly deranged structures and large perinephric collection, underscoring the significance of reporting this case.

2 Case

A 70-year-old old female; known diabetic, hypertensive, and chronic kidney disease, initially presented to the emergency unit with complaints of vague abdominal complaints, associated with nausea and vomiting for 3 days. On examination she was found to be hemodynamically stable with unremarkable examination. Her higher mental function was preserved. Investigations at the time revealed leucocytosis of 14 × 10 ⁹ /L and elevated serum creatinine 758 μmol/L (although her nadir value was around 180 μmol/L). Urine analysis was negative for infection. A plain computed tomography scan of the abdomen and pelvis revealed malrotated right kidney with moderate hydronephrosis, obstructing pelvic-ureteric junction stone of 11 × 7 mm with a subcapsular collection producing mass effect on renal parenchyma and displacing it medially and disrupting its contour, left kidney was shrunken, atrophic with stones ( Fig. 1 ). The patient denied any history of flank pain, prior history of urolithiasis or any prior intervention for stone disease.

She underwent both perinephric drain and right percutaneous nephrostomy placement the following day. Both drains yielded clear fluid, with high drain fluid creatinine, suggestive of urine, and thus confirming forniceal rupture. She was kept on intravenous antibiotics empirically. Over the course of the following week, her serum creatinine levels returned to her nadir levels, and her Drain and PCN fluid culture were negative. A Follow-up CT with intravenous contrast was performed, showing contrast leakage into perirenal collection on delayed phase, irregular contour and abnormal configuration of right kidney with heterogenous on delayed films good contrast excretion into the nephrostomy ( Fig. 2 ). A CT Nephrostogram demonstrated return of normal architecture of Renal Parenchyma, with minimal perinephric leak ( Fig. 3 ).