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Journal of the Chinese Medical Association 75 (2012) 84e86

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Case Report

Bilateral ureteral complete obstruction with huge spontaneous urinoma

formation in a patient with advanced bladder cancer
Yeong-Chin Jou*, Cheng-Huang Shen, Ming-Chin Cheng, Chang-Te Lin, Pi-Che Chen
Department of Urology, Chiayi Christian Hospital, Chiayi, Taiwan, ROC
Received March 11, 2010; accepted February 1, 2011

Abstract
Spontaneous rupture of the collecting system with extravasation of urine and urinoma formation is usually associated with urinary tract
obstruction by a ureteral calculus. Tumor growth is an extremely rare cause of urinary extravasation. Here we report a case of bilateral
obstructive uropathy with a huge spontaneous left retroperitoneal urinoma caused by advanced infiltrative transitional cell carcinoma of the
urinary bladder. The point of leakage was located in the left renal pelvis. The urinary leakage ceased after percutaneous nephrostomy drainage,
and the patient subsequently underwent radical cystoprostatectomy. Histopathology revealed a high-grade urothelial carcinoma of the urinary
bladder with pelvic lymph node metastasis. The patient refused any adjuvant treatment and expired 6 months after the operation from
disseminated metastasis from bladder cancer.
Copyright 2012 Elsevier Taiwan LLC and the Chinese Medical Association. All rights reserved.
Keywords: bladder cancer; obstruction; urinoma

1. Introduction
Ureteral obstruction is a not uncommon complication of
bladder cancer and is associated with advanced tumor stage and
poor prognosis, while bilateral ureteral complete obstruction
caused by bladder tumor is infrequent.1 Spontaneous urinary
extravasation is not unusual and most commonly results from
ureteral obstruction by calculus. Ureteral obstruction by
neoplasm is a rare cause of spontaneous urinary extravasation.2
This case report describes a case of bilateral complete ureteral
obstruction with left-sided urinary extravasation and a huge
retroperitoneal urinoma caused by infiltrative transitional cell
carcinoma of the urinary bladder.
2. Case report
A 77-year-old male visited our emergency department due
to lack of passage of urine for 30 hours. On arrival, he had
* Corresponding author. Dr. Yeong-Chin Jou, Department of Urology, Chiayi
Christian Hospital, 539, Chung-Hsiao Road, Chiayi 600, Taiwan, ROC.
E-mail address: b729@cych.org.tw (Y.-C. Jou).

stable vital signs. Physical examination revealed a distended

left abdomen without tenderness or rebounding pain. There
was no distended urinary bladder and no flank knocking pain.
Laboratory analysis revealed elevated serum creatinine
(4.3 mg/dL) and blood urea nitrogen (46.3 mg/dL) levels. The
hemoglobin level was low, at 86 g/L, and the white blood cell
count was normal.
Ultrasound and abdominal noncontrast computed tomography (CT) disclosed bilateral hydronephrosis with a 20 cm
cystic lesion over the left retroperitoneal space (Fig. 1)
extending from the perirenal space along the psoas muscle to
the pelvic cavity. The urinoma was drained percutaneously
with an 8 F pigtail catheter. A persistent urinary drainage from
the percutaneous retroperitoneal drain tube of about
2000e3000 mL/d was noted, and no urine was drained from
a urethral Foley catheter. The serum creatinine and blood urea
nitrogen levels normalized (1.0 mg/dL and 14.6 mg/dL,
respectively) 2 days after drainage.
A contrast medium-enhanced CT was performed and
revealed obstructed a left ureter with a point of leakage over
the renal pelvis (Fig. 2). Cystoscopy was performed immediately after the CT study to attempt double-J stenting, and this

1726-4901/$ - see front matter Copyright 2012 Elsevier Taiwan LLC and the Chinese Medical Association. All rights reserved.
doi:10.1016/j.jcma.2011.12.005

Y.-C. Jou et al. / Journal of the Chinese Medical Association 75 (2012) 84e86

Fig. 1. The initial nonenhanced abdominal tomography showed bilateral

hydronephrosis (arrow) with a left retroperitoneal space urinoma (arrowhead).

revealed a contracted urinary bladder with a diffusely ulcerative bladder mucosa that was blocking the bilateral ureteral
orifices. Biopsies were taken over the ulcerative mucosa.
Bilateral percutaneous nephrostomy drainage was performed
after cystoscopy. Afterwards, the leakage point of the collecting system healed and the retroperitoneal drainage tube
became dry.
The pathology report for the biopsy revealed high-grade
transitional cell carcinoma. As there was no evidence of
lymph node and distal metastasis on serial imaging studies, the
patient subsequently underwent radical cystoprostatectomy

Fig. 2. The reconstructive abdominal computed tomography scan performed

after percutaneous drainage of the urinoma revealed a point of leakage (arrow)
over the renal pelvis with a huge retroperitoneal urinoma (arrowhead)
extending from the perirenal space to the iliac fossa. IB iliac bone;
RP renal pelvis.

85

with bilateral pelvic lymph node dissection and ileal conduit

urinary diversion 2 weeks after the drainage by percutaneous
nephrostomy.
Infiltrative tumor over the posterior wall and trigone of the
urinary bladder with perivesical soft tissue involvement was
noted during surgical exploration. The post-cystoprostatectomy
pathology report demonstrated high-grade transitional cell
carcinoma infiltrating the full thickness of the bladder wall, with
perivesical soft tissue invasion and pelvic lymph node metastasis (stage pT3N1M0, according to American Joint Committee
on Cancer, 6th edition). Both ureters were encased in the
infiltrative bladder tumor, with no tumor growth in their lumens.
The postoperative course was smooth, and there was no
recurrence of hydronephrosis or urinary extravasation on
ultrasound follow-up after the operation. The patient refused
any adjuvant treatment and expired 6 months after surgery
from disseminated metastasis of bladder cancer.

3. Discussion
Ureteral obstruction by bladder tumor is not uncommon
and is usually associated with advanced disease. In 1998,
Haleblian et al retrospectively evaluated 415 patients with
transitional cell carcinoma of the urinary bladder who had
received radical cystectomy. Their results showed a significant
correlation between hydronephrosis and advanced cancer
stage, as well as decreased patient survival. More than 90% of
patients with bilateral obstruction had disease with extravesical extension.3
In 2007, Bartsch et al reviewed 788 patients who had
bladder cancer treated with radical cystectomy and revealed
that the incidence of unilateral hydronephrosis was 13.7% and
the incidence of bilateral hydronephrosis was 3.2%. They also
demonstrated that hydronephrosis without tumor involvement
over the ureteral orifice was a significant marker for advanced
disease.1 Leibovitch et al reviewed 122 cases of invasive
transitional cell carcinoma of the urinary bladder and
concluded that the 5-year survival rate in patients with ureteral
obstruction was significantly lower than in those without
obstruction.4
Spontaneous rupture of the collecting system is relatively
rare, and is usually associated with urinary tract obstruction.
Cooke and Bartucz reported 14 cases of spontaneous urinary
extravasation over the upper urinary tract and demonstrated
that incidence of urine extravasation was 0.1% in patients who
underwent intravenous urography examination. Ureteral stone
was the most common cause of obstruction.5
Koga et al reported 11 cases of spontaneous peripelvic
extravasation. Urinary obstruction was caused by calculi in
nine cases, by invasion of sigmoid carcinoma in one case, and
by ureteral tumor (transitional cell carcinoma) in one.2 In
2006, Lien et al reviewed the literature and found that ureteral
stones caused 50% of the cases of spontaneous urinary
extravasation, followed in frequency by intravenous urography, pregnancy, enlarged prostate, neoplasm, and aortic
aneurysm.6

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Y.-C. Jou et al. / Journal of the Chinese Medical Association 75 (2012) 84e86

There are two etiologies for spontaneous urinary extravasation from the upper urinary tract: caliceal fornix extravasation and ureteral (or peripelvic) rupture. The former is caused
by a sudden increase in renal pelvis pressure and backflow of
urine into the renal sinus in patients with acute obstruction.
This is considered to be a protective physiological mechanism
producing decompression that may protect the kidney from
high-pressure injury.6,7 The latter results from direct injury by
a stone during its passage.8,9
The mechanism underlying urinary extravasation in tumor
disease may be different from that caused by a stone owing to
the gradual increase in intrarenal pressure. The actual mechanism of neoplasm-related urinary extravasation is unclear
because only a limited number of cases have been reported.
The treatment of perirenal extravasation should be individualized. Conservative follow-up, endoscopic treatment,
percutaneous urinary drainage, and surgical correction of
obstruction have all been suggested depending on the underlying cause and amount of extravasated fluid.10
Although ureteral obstruction induced by a bladder cancer
is not uncommon, bladder cancer-related urinary tract
obstruction leading to urinary leakage and urinoma formation
is very rare. This case report reminds us that when peripelvic
urine extravasation is noted in a patient without any sign of
urinary calculi, further evaluation for malignant disease should
be performed.

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