Traumatic urine leak

Case contributed by Michael P Hartung

Presentation

Fall off bicycle with traumatic handlebar injury to the abdomen.

Patient Data

Gender: Male

Presentation (outside facility, day 0)

ct

Splenic lacerations with small amount of hemoperitoneum. 

Small amount of left perinephric blood with possible small cortical laceration or cyst. Dilated pelvis with strandy densities suggesting blood clot. 

Repeat scan after transfer (day 1)

ct

Excretory phase imaging due to prior contrast injection. 

Small urine leak around the left kidney which appears to be emanating from the upper pole via a thin channel which is best differentiated on the portal venous phase, as it is obscured by increasing contrast accumulation on the delayed phase. No excretion into the ureter, likely due to clot obstructing the pelviureteral junction, which results in mild hydronephrosis.

Esophogram was performed due to mild pneumomediastinum on the chest images (not shown), accounting for the contrast in the colon. 

Ureteroscopy and stent placement (day 2)

Fluoroscopy

Ureteroscopy and stent placement without filling defects, contour irregularity, or urine leak.

Case Discussion

Blunt abdominal injury resulting in left superior pole collecting system injury and urine leak. 

A few observations/teaching points:

  • Outside facility CT inappropriately did NOT have delayed images. Trauma scans positive for any significant injury should get delayed images, particularly in the setting of hemoperitoneum. As a result, the urine leak was not immediately appreciated. 
  • Clot filling and obstructing the collecting system can be fairly subtle, and is best appreciated with delayed, excretory phase images. 
  • A small urine leak (such as this one) was successfully managed non operatively. Ureteroscopy performed on day 2 showed resolution of the clot and mild hydronephrosis, with temporary double J stent placed to facilitate healing. 

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