Spontaneous renal pelvis rupture with peri-nephric abscess and stone extrusion: A case report

Abstract

Spontaneous renal pelvis rupture with extrusion of calculus is an extremely rare event. This article reports a case of right pelvis rupture with perinephric abscess due to renal calculus, with discussion on the diagnostic approach used, and its management principle. The diagnosis was confirmed with intravenous urography using computed tomography. She underwent right ureteral splinting using double-J stent, ultrasound guided pigtail drain insertion initially followed by stone extraction later.

1 Introduction

This article reports an extremely rare case of spontaneous renal pelvis rupture with extrusion of calculus in peri-nephric space. 40-year-old female patient with history of right loin pain and fever for 1 month rushed to emergency after the pain suddenly aggravated. Patient was initially managed in the line of urosepsis and further workup done to elucidate the cause. Computed tomography intravenous urography (CT-IVU) revealed the right renal pelvis perforation with formation of peri-nephric abscess containing large calculus within [ Fig. 1 ]. She underwent right double-J stenting and ultrasound guided pig-tail drain insertion in the right perinephric space to drain the infected urinoma. She made an excellent recovery except for the right loin nagging discomfort responding to analgesics. After about 3 months of medical management of pain with analgesics, she underwent right flank exploration to remove the calculus.

2 Case summary

40 years old lady presented with complaints of right loin pain for 1 month which was associated with on and off fever. She has a history of taking over-the-counter analgesics for pain and fever. The pain suddenly became severe, prompting the patient to seek medical attention and attended to the emergency department of our hospital. Upon arrival, the patient had blood pressure of 90/60 mm of Hg, heart rate of 95 beats per minute and body temperature of 99 °F. She had no previous known comorbidities or any history of metabolic disorders.

The patient was evaluated with routine blood and urine tests which revealed a picture of Urosepsis with raised total leucocyte count (18,200 cells/mm ³ ), low hemoglobin concentration (9.8 gm/dL), turbid urine containing plenty of pus cells. Ultrasonography of abdomen and pelvis showed right mild hydronephrosis with about 50 cc of right peri-nephric collection and presence of 23 × 15mm calculus within the collection. CT-IVU was carried out to better elucidate the pathology which confirmed the same findings[ Fig. 1 ]. There was a rent seen in the pelvis with contrast extravasation in the delayed images.

She was started on intravenous crystalloids, analgesics and broad-spectrum antibiotics followed by emergency ultrasound-guided right percutaneous pig-tail drain insertion into the perinephric collection, cystoscopic right sided double-J stenting, and per-urethral catheterization. Urine and fluid samples taken at the time of percutaneous drain insertion failed to grow any organism within 48 hours of incubation. The patient improved symptomatically with decreasing drain output and was discharged after removal of the urethral catheter. She went home with drainage catheter and double-J stent in situ and was advised to maintain a daily drain output diary. The pig-tail drain was removed after 1 week once drain was nil and ultrasound ruled out any residual collection. Double-J stent was removed cystoscopically in 4 weeks on outpatient basis as there was no plan for stone removal.

At 4 weeks, at the time of double-J removal, she was re-evaluated with retrograde pyelogram to check for leakage [ Fig. 2 ]. On 2-week follow-up post-double-J removal, she complained of dull aching pain in right loin and ultrasound was done to rule out any hydronephrosis or any new peri-nephric collection. She was reassured and prescribed simple analgesics. After 6 weeks of double-J removal, she again presented with same complaints and this time she was admitted for open right flank retroperitoneal exploration and extraction of the calculus [ Fig. 3 ]. Intraoperatively there was dense fibrotic capsule formation in the gerota around the stone and adhesions at the lower pole of right kidney with thickening of gerota’s fascia and perinephric fat. Patient had uneventful recovery.