Spontaneous Upper Urinary Tract Rupture Caused by Ureteric Stones: Clinical Characteristics and Validation of a Radiological Classification System

Background: This study seeks to validate a radiological classification system of spontaneous upper urinary tract rupture (sUUTR) and to analyse its relationship with clinical, laboratory and radiological characteristics of sUUTR. Methods: We analysed data from 66 patients with a computerised tomography (CT)-proven sUUTR treated with ureteral or nephrostomy catheter positioning. Comorbidities were scored with the Charlson Comorbidity Index (CCI). All CT scans were reviewed by two experienced radiologists and one urologist, who classified sUUTR in (a) local spread, (b) free fluid and (c) urinoma. Interobserver agreement for radiological score was evaluated with the Intraclass Correlation Coefficient (ICC) and Cohen’s Kappa analyses. Descriptive statistics and logistic regression models verified the association between clinical variables and sUUTR severity. Results: The interobserver agreement for sUUTR classification was high among radiologists and between the radiologists and the urologist (all Kappa > 0.7), with an overall high interrater reliability (ICC 0.82). Local spread, free fluid and urinoma were found in 24 (36.4%), 39 (59.1%) and 3 (4.5%) cases, respectively. Patients with free fluid/urinoma had higher rate of CCI ≥ 1 than those with local spread (40.5% vs. 16.7%, p = 0.04). Intraoperative absence of urine extravasation was more frequently found in patients with local spread than those with free fluid/urinoma (66.7% vs. 28.6%, p < 0.01). Multivariable logistic regression analysis revealed that local spread (OR 4.5, p < 0.01) was associated with absence of contrast medium extravasation during pyelography, after accounting for stone size, fever and CCI. Conclusions: The analysed sUUTR classification score had good inter/intra-reader reliability among radiologists and urologists. Absence of urine extravasation was five times more frequent in patients with local spread, making conservative treatment feasible in these cases.

Giant urinoma in a newborn boy with a posterior urethral valve: A сase report and review

Posterior urethral valve is the most common cause of infravesical obstruction in male newborns. Spontaneous rupture of the urinary collecting system with urine extravasation is a rare complication in this group of children. We present a case of urinoma in a patient with a posterior urethral valve at 4 weeks of age with renal insufficiency. The transurethral destruction of the valve and evacuation of the urinoma contributed to the restoration of the urodynamics and recovery of renal function. Urinoma is a rare manifestation of this defect, and its significance for predicting the preservation of renal function has not been fully determined yet. Reports about the occurrence of urine extravasation in the posterior urethral valve and studying kidney function in the long-term period can clarify the significance of this spontaneous mechanism of urinary tract decompression.

Perineal urethrostomy in the cat. Technique and complications

Perineal urethrostomy (PU) is the surgical procedure performed in the male cat in order to create a permanent stoma of the pelvic urethra to the skin of the perineal region. The first urehrostomy was devised on early sixties and since then many urethrostomy techniques were invented. On 1971 Wilson and Harrison invented a technique of PU that is currently used by the majority of surgeons, because of the better results and fewer complications compared to the other urethrostomy techniques. Indications for performing PU in the male cat include recurrent urethral obstruction associated with lower urinary tract disease, as an emergency procedure for the restoration of the patency of the obstructed urethra when all other conservative measures failed, priapism, strictures, trauma and urethral neoplasms. For a successful PU: 1) the pelvic urethra should be incised and anastomosed in the perineum cranial to the bulbourethral glands, 2) the urethra should be completely freed from its attachments to the ishium so as to decrease tension to the stoma, and 3) accurate apposition of the urethra to the skin should be performed to achieve first intention healing of the stoma site and avoid stricture formation. Complications following PU may include urethral stricture, ascending urinary tract infection, haemorrhage, subcutaneous urine extravasation resulting in sloughing and dehiscence of the stoma, skin fold dermatitis, urinary and fecal incontinence, bladder atony, iatrogenic perineal hernia and rectourethral fistula. Prepubic, subpubic or transpelvic urethrostomy may be used to salvage postoperative urethral stricture. Pepubic urethrostomy is the only salvage technique that has been evaluated long-term, but is associated with serious complications such as urine scalding, urinary incontinence and urinary tract infection. Perineal urethrostomy aims at relieving urethral obstruction and is part of the medical management of cats with recurrent or persistent urethral plug formation.

The diagnosis and management of renal trauma

Background: Renal trauma is less common but often occurs in polytrauma. Most trauma is blunt and the severity of the injury varies in different circumstances. Assessment: There is a series of features that should prompt investigation but none are reliably seen in all trauma cases and a low threshold for suspecting renal injury should be taken. A urine dip is essential. Investigation: Computerised tomography is the main modality. Follow-up imaging may be used if complications arise and ultrasound may be used in some cases. Management: Approaches include surgical, radiological and conservative. The latter has been achieved in all grades but intervention will be required in haemodynamic instability. Complications: Haemorrhage, infection and urine extravasation are common and require intervention. There are many long-term complications and hypertension can occur by a variety of mechanisms.

Effectiveness of Solifenacin for Managing of Bladder Spasms in Patients With Urethroplasty

To evaluate the efficacy and safety of solifenacin in the treatment of bladder spasms after urethroplasty. Patients underwent urethroplasty were randomly assigned to the study group ( n = 165) and the control group ( n = 150). Patients in the study group were treated with solifenacin for 7 days. Patients in the control group were placebo. Each group was further divided into four subgroups: paracentetic suprapubic cystostomy subgroup, traditional suprapubic cystostomy subgroup, former suprapubic cystostomy subgroup, and urethral catheter subgroup. A visual analogue scale (VAS) was used to measure the severity of bladder spasms. The mean duration of spasms, the frequency of spasms, and the incidences of urine extravasation and radiating pain were recorded each day. There were no significant differences in the VAS scores and mean duration of bladder spasms between the study and control groups . However, there was a significantly lower VAS score in the patients taking solifenacin in the paracentetic suprapubic cystostomy subgroup ( p < .05). A similar tendency was noted in the mean duration of bladder spasms in this subgroup. In a comparison of the daily and nightly frequency of spasms within the four subgroups, a significant improvement was noted in the control group within 5 days. A similar difference was not noted within 6 days in the study group. The short-term therapy with solifenacin is an effective and safe method for decreasing the frequency of bladder spasms after urethroplasty. Patients undergoing paracentetic suprapubic cystostomy might be the only subset to benefit from this treatment.

Rotational and Axial Pattern Flaps in a Cat for Wound Reconstruction Secondary to Urethral Rupture

A 3 yr old intact male domestic shorthair cat was presented with urine extravasation from urethral rupture. Extensive skin necrosis developed in the perineal region and left hind limb that necessitated delayed primary wound closure with a caudal superficial epigastric axial pattern flap, scrotal and preputial rotational skin flaps, and perineal urethrostomy.

The relative contribution of urine extravasation to elevation of plasma creatinine levels in acute unilateral ureteral obstruction

Introduction: Rising levels of plasma creatinine in the setting of acute unilateral ureteral obstruction (AUUO) often reflects acute renal failure, mandating kidney drainage. We hypothesize that reabsorption of peri-renal urine extravasation (PUE), a common result of UUO, contributes significantly to the elevation in plasma creatinine, rendering the latter an inaccurate benchmark for renal function. We explored this hypothesis in a rat model of AUUO and PUE.Methods: In total, 20 rats were equally divided into 4 groups. Groups 1 and 2 underwent unilateral ligation of the ureter with infiltration of rat’s urine (index group) or saline (control) into the peri-renal space. Two additional control groups underwent perirenal injection of either urine or saline without AUUO. Plasma creatinine levels were determined immediately prior to the procedure (T0), and hourly for 3 hours (T1, T2 and T3). Renal histology was investigated after 3 hours.Results: Rats in the index group had a significantly greater increase in plasma creatinine levels over 3 hours compared to all other groups (p < 0.05). At T3, average plasma creatinine levels for the index group increased by 96% (0.49 ± 0.18 mg/dL) compared to 46% (0.23 ± 0.06 mg/dL increase) in the AUUO and saline group, and less than 15% rise in both the non-obstructed control groups. Our study limitations includes lack of spontaneous PUE and intraperitoneal surgical approach.Conclusions: Absorption of peri-renal urine in the presence of AUUO is a significant contributor to rising plasma creatinine levels, beyond those attributable to the obstruction alone, and may overestimate the extent of the true renal functional impairment.