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  Table of Contents  
LETTER TO THE EDITOR
Year : 2015  |  Volume : 52  |  Issue : 3  |  Page : 473-474
 

Bladder cancer presenting with spontaneous subcapsular urinoma of kidney


Department of Urology, C. S. M. Medical University (Upgraded King George's Medical College), Lucknow, Uttar Pradesh, India

Date of Web Publication18-Feb-2016

Correspondence Address:
A Goel
Department of Urology, C. S. M. Medical University (Upgraded King George's Medical College), Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.176744

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How to cite this article:
Goyal N K, Goel A, Singh V, Sankhwar S N. Bladder cancer presenting with spontaneous subcapsular urinoma of kidney. Indian J Cancer 2015;52:473-4

How to cite this URL:
Goyal N K, Goel A, Singh V, Sankhwar S N. Bladder cancer presenting with spontaneous subcapsular urinoma of kidney. Indian J Cancer [serial online] 2015 [cited 2019 Aug 22];52:473-4. Available from: http://www.indianjcancer.com/text.asp?2015/52/3/473/176744


Sir,

A urinoma is a well-defined fluid collection formed by encapsulation of extravasated urine. It usually follows an obstructing ureteral calculus.[1] Other important causes include renal trauma and iatrogenic injuries.[2] Unusual causes include obstructive uropathy caused by posterior urethral valves, gynecological malignancies, gravid uterus, pelvi-ureteric junction obstruction, and vascular extrinsic compression. However, tumor obstruction leading to forniceal rupture and urinoma formation is very rare.

A 55-year-old woman presented with history of painless gross hematuria, urinary frequency and urgency for 3 months. There was no history of abdominal pain, ureteral colic, trauma, or previous surgery. Her physical examination revealed a smooth surfaced mass in the left flank region. Abdominal ultrasonography showed bilateral hydro-ureteronephrosis, a well-defined subcapsular fluid collection of left kidney, and a large bladder mass, which was confirmed to be a solid-looking growth at the trigone of bladder on cystoscopy. Bilateral ureteral orifices could not be visualized due to large growth. Her renal function parameters were normal. Contrast enhanced computed tomography (CECT) [Figure 1] and [Figure 2] confirmed a large (13.5 × 9.0 × 7.5 cm) subcapsular urinoma of left kidney, bilateral hydro-ureteronephrosis, and an enhancing bladder mass at the trigone. Ultrasound-guided percutaneous aspiration and left-sided nephrostomy drainage with a pigtail catheter resolved the urinoma. Histopathology of transurethrally resected tumor demonstrated high-grade, muscle invasive, transitional cell carcinoma (T2 G3). Patient underwent radical cystectomy and ileal conduit diversion and is doing well.
Figure 1: Contrast-enhanced CT scan (coronal cut) of the abdomen showing large subcapsular urinoma of left kidney (solid arrow) and enhancing bladder mass (arrow head)

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Figure 2: Sagittal section of CT scan showing large subcapsular urinoma of left kidney with no perinephric stranding or extension

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Three essential factors, responsible for urinoma formation, are continued renal function, rupture of the collecting system, and distal obstruction.[3] Most commonly, it is associated with obstructing ureteral calculi. This acute onset obstruction leads to sudden rise in intra-pelvic pressure causing rupture of the collecting system.[1] The extravasated urine sets a low-grade inflammation and lipolysis, followed by encapsulation of the urine by fibroblastic activity.[3] Urinomas are usually not associated with chronic obstruction.[4] Forniceal rupture following malignancy is relatively uncommon due to gradually progressive hydronephrosis.[5] In the largest reported series of 108 patients, only 8.3% of urinomas were caused by malignant ureteral compression, but none of them was caused by a bladder tumor.[1] An extensive literature search revealed only two such cases of bladder tumor presenting with urinoma formation. In year 1976, Twersky et al. reported the first case of urinoma caused by a bladder tumor.[4] Second patient had a high-grade bladder tumor with ureteric orifice involvement.[3] The pathophysiology of forniceal rupture caused by bladder tumor is difficult to understand. First, a bladder growth generally takes time to grow, so it does not lead to an acute onset obstruction, leading to sudden rise of intra-pelvic pressure. Secondly, urine usually passes through the ureteric orifices that are entirely overgrown by the tumor and even directly infiltrated by the tumor. Thirdly, as it is a very distal obstruction, considerable pressure on the renal collecting system should have been compensated by the entity of reno-ureteral unit. Another peculiar aspect of this case is a large size, well-localized sub-capsular urinoma with no perinephric extension or stranding, which usually accompanies this entity because of surrounding lipolysis.

 
  References Top

1.
Gershman B, Kulkarni N, Sahani DV, Eisner BH. Causes of renal forniceal rupture. BJU Int 2011;108:1909-11.  Back to cited text no. 1
    
2.
McInerney D, Jones A, Roylance J. Urinoma. Clin Radiol 1977;28:345-51.  Back to cited text no. 2
[PUBMED]    
3.
Ali Khan S, Desai PG, Jayachandran S, Smith NL. Urinoma: A rare presentation of carcinoma of the bladder. Urol Int 1985;40:97-9.  Back to cited text no. 3
[PUBMED]    
4.
Twersky J, Twersky N, Phillips G, Coppersmith H. Peripelvic extravasation, urinoma formation and tumor obstruction of the ureter. J Urol 1976;116:305-7.  Back to cited text no. 4
[PUBMED]    
5.
Singh I, Joshi M, Mehrotra G. Spontaneous renal forniceal rupture due to advanced cervical carcinoma with obstructive uropathy. Arch Gynecol Obstet 2009;279:915-8.  Back to cited text no. 5
    


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