CASE 35: Urinoma Associated with Outflow Obstruction

Deceased donor kidney recipient (made no urine prior to transplantation) who had a ureteral stent and a retro-peritoneal drain placed at the time of transplantation. The urinary catheter (increasing amounts of urine being produced) and the retro-peritoneal drain (no output) were removed prior to discharge. Recipient presented to the ER 36 hours after discharge complaining of abdominal pain associated initially with frequency that evolved into oliguria. The site of the transplant showed a tender palpable mass. CT scan images revealed a 22 cm × 14 cm fluid collection (green arrows) around the transplanted kidney (yellow arrows). The ureteral stent could be seen (orange arrow). The recipient was re-admitted with a diagnosis of bladder outlet obstruction leading to increased urinary pressure causing a hypertensive urinary leak at the ureter to bladder anastomosis. Initial treatment was with re-insertion of a urinary catheter (to relieve the urinary obstruction) and placement of a retro-peritoneal drain (to evacuate the collection).

Deceased donor kidney recipient (made no urine prior to transplantation) who had a ureteral stent and a retro-peritoneal drain placed at the time of transplantation. The urinary catheter (increasing amounts of urine being produced) and the retro-peritoneal drain (no output) were removed prior to discharge. Recipient presented to the ER 36 hours after discharge complaining of abdominal pain associated initially with frequency that evolved into oliguria. The site of the transplant showed a tender palpable mass. CT scan images revealed a 22 cm × 14 cm fluid collection (green arrows) around the transplanted kidney (yellow arrows). The ureteral stent could be seen (orange arrow). The recipient was re-admitted with a diagnosis of bladder outlet obstruction leading to increased urinary pressure causing a hypertensive urinary leak at the ureter to bladder anastomosis. Initial treatment was with re-insertion of a urinary catheter (to relieve the urinary obstruction) and placement of a retro-peritoneal drain (to evacuate the collection).

The initial drain fluid creatinine (19 mg/dL) decreased to the same value as the serum creatinine (1.5 mg/dL) within 4 days, and the drain volume decreased to minimal over the same time period. A percutaneous nephrostomy obtained at that time showed no evidence of urinary extravasation. Although rare, this case illustrates an instance where bladder outlet obstruction was solely accountable for a urinary leak at the recently constructed ureter-to-bladder anastomosis.