UNRECOGNISED URINOMA CAUSED BY INFILTRATIVE BLADDER CANCER

Introduction. Urinoma develops after disruption of collecting system of urinary tract and urine leak in surrounding tissue. Most common causes of urinoma are blunt or penetrating trauma. Less common causes are iatrogenic injuries or urinary tract obstruction. In this article authors present a rare case of the urinoma caused by infiltrative bladder cancer. Case report. Acutely ill, septic patient with ileus and profound azothaemia was admitted to medical intensive care unit. Native computerized tomography revealed moderate ileus, right kidney hydronephrosis, extensive retroperitoneal urinoma and vesical thickening with ureteral orifices’ infiltration. Computerized tomography guided percutaneous drainage was done. Upon stabilization, patient underwent transurethral bladder tumor electro resection (pathology report: infiltrative transitional cell tumor of urinary bladder). Radical cystectomy was done. Patient’s recovery was uneventful. Conclusion. Urinoma formed due to spontaneous rupture of collecting system based on ureteral obstruction caused by urinary bladder tumor is very rare clinical case scenario. In case of urinoma of unclear etiology invasive bladder cancer should be in mind.


Case report
Urology consult was called for a patient with ileus and hydronephrosis who had been admitted to MICU.Patient was a 83 year old male in acute distress, with clinical signs of moderate ileus (figure 1).There was obvious retroperitoneal urinoma -predominantly on the left side (figure 2, 3).for radical cystectomy.During the surgery, no obvious tear of the left pyelon or ureter were found, both ureters were stented with J-J stents and Bricker's urinary derivation was done.On 3 rd postoperative day, output at previously installed percutaneous drainage dramatically decreased and therefore drain was removed.Postoperative recovery was otherwise unremarkable.

Discussion
By definition urinoma is mass of extravasated urine delineated by perirenal fascia within reactively formed fibrous capsule.Urinoma might also manifest as a free fluid.[1] There are three factors necessary for urinoma (caused by urinary tract obstruction) to be developed: tear in pyelocaliceal (PC) system, functional kidney and distal obstruction.[2] Most often, urinoma is caused by trauma, less common causes are distal ureteral obstruction by calculus, pelvic masses or iatrogenic injuries.Pyelocaliceal system injury and urinary leakage trough a tear is not so rare, but in most of these cases urine leaks undergo spontaneous resolution and formed urinoma develops only in few instances.[3] Usual clinical presentation of urinoma include: mild to moderate flunk fullness/pressure/pain, atypical abdominal pain, poor appetite, weakness, weight loss.It takes time for urinoma to develop.Urinoma presentation depends of causes, extent, urinoma localization and of time window between time of injury of the PC system and time until diagnosis has been established.Rarely, if not recognized or left untreated urinoma may present as an ileus, peritonitis, abscesses, sepsis.In our case delayed establishing of correct diagnosis was the crucial for severe clinical presentation.
Method of choice for urinoma diagnosis is CT with radio contrast agents.In some cases (like in this one) where a use of contrast is contraindicated, native (non contrast) CT should be performed.In addition, an image guided percutaneous needle aspiration drainage (which is both diagnostic and therapeutic) might be done.[4] In most cases, small urinoma would reabsorb spontaneously, and drainage would not be necessary.[5] In some cases of large or persistent urinoma, or in case of moderate to severe illness (fever, sepsis), first step should be CT or US guided drainage.[6] Further treatment depends on a cause of the urinary obstruction and should be aimed accordingly.

Conclusion
Urinoma formation due to collecting system rupture because of ureteral obstruction caused by urinary bladder tumor is very rare clinical case scenario.In case of urinoma of unclear etiology invasive bladder cancer should be excluded.

Figure 1 .
Figure 1.Laboratory findings revealed severe azothaemia (creatinine level of 800 μmol/L), moderate acidosis (pH of 7,2 ), WBC of 19x10 9 , findings met criteria for sepsis.Computerized tomography (CT) scan findings were consistent with hydronephrosis grade 2 on the right and minimal hydronephrosis on the left side -urine had been leaking out trough the tear at the left kidney PC system (figure 2).

Figure 3 .
Figure 3. CT scan of the urinary bladder has shown irregularly thickened wall at the trigonal part of the bladder, more prominent on the left side 4).

Figure 4 .
Figure 4. Patient underwent urgent CT guided percutaneous drainage procedure, with drain placement at the left retro peritoneum.Drained fluid was tested and it was confirmed to be urine.Soon after the procedure the patient felt much better, ileus resolved and laboratory findings slowly normalized.Patient was scheduled for transurethral electro resection (TUR) of suspected urinary bladder tumor.During the TUR procedure tumorous obstruction of both ureteral orificial openings were seen.Pathology report confirmed infiltrative transitional cell cancer (TCC) of the urinary bladder.After TUR of bladder tumor, follow up ultrasonography (US) was done and it showed hydronephrosis stage one on the right side (partially unblocked right ureteral orifice by previous TUR BT), no hydronephrosis of the left kidney and small amount of perirenal fluid on the left side.Patient was scheduled