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URINE LEAK
Authored By: Bennett Greenspan and Dhanashree Rajderkar.
Patient: 41 year old female
History:

41-year-old woman with recurrent cervical cancer status post radical hysterectomy and pelvic lymph node dissection on 07/27/2010 and chemoradiation therapy presenting with feculent discharge per vagina. She is diagnosed to have bilateral hydronephrosis.

 

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Multimedia: 305816_4_submitted.avi
Cine

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PET scan

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PET coronal MIP

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Cystogram

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Contrast CT

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Contrast Enema
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Findings:

Renal scan: After 20 minutes of imaging, there is a small amount of retained activity in the left collecting system, which appears mildly enlarged  There is a small amount of retained activity in the right collecting system, which appears mildly enlarged.

Static images were then obtained after erect positioning and voiding. There is mild retained activity in bilateral collecting system. There is moderate activity in the lower pole calyx of the left collecting system. The right kidney appears ptotic.

The left ureter appears dilated. The right ureter appears dilated and is tortuous in the distal part. The bladder is distended and there is focal collection extending from superior and lateral to the urinary bladder on the right side, and to the right lower quadrant. The activity is seen arising from the superolateral aspect of the urinary bladder.

The estimated contribution of the right kidney to total renal function is 48% and that of the left kidney is 52%

To evaluate for obstruction, the patient was given furosemide via slow intravenous injection approximately 20 minutes after the start of the examination.  Sequential images were obtained for an additional 20 minutes with the patient in the erect position.  There is prompt clearance of pelvicalyceal activity on the left after diuretic administration.  On the right, there is mildly delayed clearance of activity from the pelvicalyceal system.  After diuretic administration, the half-time of tracer clearance from the right kidney is 13 minutes and from the left kidney is 2 minutes. 

IMPRESSION:

1.  Normal renal perfusion, function, with mildly dilated collecting system on both sides.

2.  No evidence of significant obstruction of either kidney.

3. Focal activity arising from the superolateral aspect of the bladder, with extension into the right lower quadrant, most likely represents urinoma. 

 PET/CT:  1. Large hypermetabolic pelvic mass compatible with invasive recurrent cervical cancer.

2. Hypermetabolic mesenteric and right external iliac lymph nodes compatible with nodal metastatic disease.

3. Bilateral hydronephrosis, left greater than right.

4. Multiple cystic pelvic masses, likely representing lymphoceles.

 CYSTOGRAM: No evidence of contrast extravasation from the urinary bladder.

COMPUTED TOMOGRAPHY OF THE ABDOMEN AND PELVIS WITH AND WITHOUT INTRAVENOUS CONTRAST (CT UROGRAPHY): Large fungating pelvic mass with central necrosis which engulfs the distal left ureter with extravasation of contrast from the ureter into the central necrotic portions of the mass and caudally into the vagina consistent with a ureterovaginal fistula. Collection of radiotracer within the necrotic mass likely explains the findings on recent nuclear renal scan.

Water-soluble contrast enema: 1. Colovaginal fistula in the distal sigmoid colon and proximal vagina.

2. Marked contour irregularity and narrowing within the sigmoid colon, which very likely is related to the patient's known pelvic mass. 

DDx:

1. Post operative seroma.

2. Urinoma.

3. Lymphocele.

Diagnosis:

•Rectovaginal and ureterovaginal fistula. Pelvic Lymphoceles.

  • Urine leak in the mass from the ureter into the mass.
General Discussion:

Urine leaks and urinomas result from disruption of the urinary collecting system at any level from the calyx to the urethra. Excreted radiotracer outside the genitourinary tract at either bone scintigraphy or renal scintigraphy may also allow a diagnosis of a urine leak. Like renal urine leaks, ureteral urine leaks may result from blunt or penetrating trauma, iatrogenic injury, or transmitted back pressure caused by downstream obstruction due to a ureteral stone, surgical ligature, or abdominal or pelvic mass.

Unlike renal urine leaks, ureteral urine leaks most commonly occur as a result of iatrogenic injury following genitourinary, retroperitoneal, pelvic, or gynecologic surgery. In patients who are not candidates for imaging with intravenous contrast material, scintigraphy plays a vital role in the diagnosis of ureteral urine leaks. Treatment of the  ureteral injuries is done with percutaneous urinoma drainage along with diversionary percutaneous nephrostomy with or without ureteral stent placement. Alternatively, they may place nephroureteral catheters across the site of ureteral injury.

A fistula that occurs in association with a malignancy of the female reproductive tract may be caused by a primary or recurrent tumor or may be a complication of surgery or radiation therapy. Identification of the cause, complexity, and location of a fistula is essential for optimal management planning. Vesicovaginal and enterovaginal fistulas are the most common types seen in association with gynecologic malignancies. Simple vesicovaginal fistulas usually have a diameter of less than 0.5 cm, are single, and occur in nonirradiated tissue. Complex vesicovaginal fistulas are typically larger, include multiple tracts, and occur in previously irradiated tissue.

References:

1. Priya Narayanan, MBBS, Marielle Nobbenhuis, MBBS, Karina M, Reynolds, FRCOG, Anju Sahdev, MD, Rodney H. Reznek, MBBCh, Andrea G. Rockall, MBBS, Fistulas in Malignant Gynecologic Disease: Etiology, Imaging, and Management, July 2009 RadioGraphics, 29, 1073-1083.

2. Nicola Mumoli,and Marco Cei,  Clinical picture: Ureteral urinomaQ J Med 2010; 103:623–624.

3. Helen C. Addley, MRCP, FRCR • Hebert Alberto Vargas, MD • Penelope L. Moyle, MBChB • Robin Crawford, MD, FRCS, FRCO, Evis Sala, MD, PhD, FRCR, Pelvic Imaging Following Chemotherapy and Radi­ation Therapy for Gyne­cologic Malignancies, RadioGraphics 2010; 30:1843–1856.

4. Ross L. Titton, MD, Debra A. Gervais, MD, Peter F. Hahn, PhD, MD, Mukesh G. Harisinghani, MD, Ronald S. Arellano, MD, Peter R. Mueller, MD, Urine Leaks and Urinomas: Diagnosis and Imaging-guided Intervention, RadioGraphics 2003; 23:1133–1147

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Additional Details:

Case Number: 305816Owner(s): Bennett Greenspan and Dhanashree RajderkarLast Updated: 12-07-2011
Anatomy: Genitourinary (GU)   Pathology: Other
Modality: CT, GI, Nuc Med, GU, PETAccess Level: Readable by all users, writable by NucMed Certifiers
Keywords: ureterovaginal and colovaginal fistula

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Certified by Bennett Greenspan on 09-24-2011

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