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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2014  |  Volume : 25  |  Issue : 5  |  Page : 1081-1083
Renal forniceal rupture in pregnancy secondary to obstructive renal stone presenting with acute renal failure

Department of Urology, Aga Khan University, Karachi, Pakistan

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Date of Web Publication2-Sep-2014

How to cite this article:
Jalbani IK, Ather M H. Renal forniceal rupture in pregnancy secondary to obstructive renal stone presenting with acute renal failure. Saudi J Kidney Dis Transpl 2014;25:1081-3

How to cite this URL:
Jalbani IK, Ather M H. Renal forniceal rupture in pregnancy secondary to obstructive renal stone presenting with acute renal failure. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2022 Jan 19];25:1081-3. Available from: https://www.sjkdt.org/text.asp?2014/25/5/1081/139946
To the Editor,

Renal forniceal rupture secondary to obstruc­tive stone during pregnancy is a rare pathology and, to the best of our knowledge, has been reported only twice before. We report a patient in the 5th week of pregnancy presenting to the emergency department with history of right flank pain, oliguria and progressive shortness of breath.

A 22-year-old lady with gestational amenor-rhea of five weeks, presented in the emergency room with progressive shortness of breath, flank pain and fever for the past two weeks. The colicky lumbar pain was associated with nausea and vomiting and dysuria. Over the past three days, she developed high-grade fever with rigors and chills, with progressively worsening shortness of breath. She is known to have right renal stones for the past many months and has been on homeopathic medication. On exami­nation, she had tachycardia with pulse of 110 beats and tachypnea with respiratory rate of 38/min. She was unable to maintain oxygen saturation on room air. On abdominal exami­nation, she had significant tenderness on the right lumbar region and right hypochondrium. A firm mass was palpable over the right lumbar region.

On further evaluation, she was found to have acute renal failure with a serum creatinine of 10 mg/dL and severe metabolic acidosis with arte­rial blood pH of 7.25 and serum bicarbonate of 10 meq/L. Her serum β-HCG was 3889 (nor­mal: 101-4870 Miu/mL). Ultrasound of the abdomen and pelvis was performed. Ultrasound of the pelvis revealed five-week gestational sac, but cardiac activity could not be appreciated owing to gestational age [Figure 1]. She had large perinephric with multiple stones in the renal pelvis with no significant dilatation of the col­lecting system and small shrunken left kidney; a possible diagnosis of renal forniceal rupture was made [Figure 2] and [Figure 3]. Hemodialysis had to be performed twice on the day of admission as there was significant metabolic acidosis even after 12 hours of first hemodialysis and an ultra­sound-guided right perinephric drain was also placed on the same day. A flexible cystoscopy-guided double J Stent was also passed and the position was confirmed on ultrasound. Her body fluid creatinine was 22.7 mg/dL. Owing to decreased drain output, the perinephric drain was taken out. Her serum creatinine came down to 1.4 mg/dL at discharge. Blood and urine culture grew β-Hemolytic Streptococcus Group B, and she was treated with Ceftriaxone and discharged on oral Cefixime. She is planned for percu­taneous nephrolithotomy (PCNL).
Figure 1: Ultrasound image showing gestational sac.

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Figure 2: Ultrasound image showing stone at the ureteropelvic junction (curved arrow), perinephric collection (straight arrow) and area of forniceal rupture (small arrow).

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Figure 3: Ultrasound image showing left atrophic small kidney.

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Renal forniceal rupture results in urinary extravasation from one or more calyces. This often results from acute obstruction, most fre­quently due to ureteric stone. In a series of 108 patients, Gershman et al noted that 74% of pa­tients had ureteric stone, of which 75% were in the distal ureter. [1] Multiple studies have des­cribed forniceal rupture secondary to rare etio­logies of ureteric compression or obstruction. These include pregnancy, [2] posterior urethral valve, [3] PUJ obstruction, [4] iatrogenic cause, [5],[6] vascular compression, [7],[8] and advanced genito­urinary malignancy [9] and use of intravenous contrast. [10]

Forniceal rupture is the radiological diagnosis; computerized tomography using intravenous contrast with renal protocol or intravenous urogram (IVU) are the investigations of choice. Ultrasound scan and magnetic resonance imaging can be alternate option for patients in whom computed tomography or IVU is contra-indicated. In this case, we only have ultrasound scan suggestive of forniceal rupture that was confirmed by raised body fluid creatinine (22 mg/dL) from the peri-nephric drain.

Eggerath et al [11] classified urine extravasation secondary to forniceal rupture in two types. Type 1 is contained extravasation due to minor tear in calyceal secondary to temporarily raised intrapelvic pressure. Type 2 is continuous urine leak secondary to persistently raised intrapelvic pressure.

Management of forniceal rupture depends on the type of extravasation. Type 1 is managed without any surgical intervention and type 2 often needs intervention. Majority of cases are managed with percutaneous nephrostomy, JJ stent or both, followed by definitive treatment of cause. In this case, nephrostomy could not be performed as the collecting system was not dilated.

To the best of our knowledge, forniceal rup­ture in pregnancy secondary to obstructive stone in the renal pelvis has rarely been reported in the literature. [12],[13] The patient was managed with perinephric drain and double J stent placement under local anesthesia using flexible cystoscopy. The position of the stent was confirmed on intraoperative ultrasound so as to avoid fluoroscopy.

Conflict of interest: None

   References Top

1.Gershman B, Kulkarni N, Sahani DV, Eisner BH. Causes of renal forniceal rupture. BJU Int 2011;108:1909-11.  Back to cited text no. 1
2.Van Winter JT, Ogburn PL Jr, Engen DE, Webb MJ. Spontaneous renal rupture during preg­nancy. Mayo Clin Proc 1991;66:179-82.  Back to cited text no. 2
3.Ahmed S, Borghol M, Hugosson C. Urinoma andurinary ascites secondary to calyceal perfo­ration in neonatal posterior urethral valves. Br J Urol 1997;79:991-2.  Back to cited text no. 3
4.Hirselj DA, Zmaj PM, Firlit CF. Occult uretero-pelvic junction obstruction presenting as anuria and urinary ascites in an infant with antenatal, unilateral hydronephrosis. J Pediatr Urol 2009; 5:405-7.  Back to cited text no. 4
5.Bannowsky A. Iatrogenic fornix rupture caused during retrograde manipulation of the ureter: A case report. Cases J 2008;1:320.  Back to cited text no. 5
6.Donahue LA, Cockett AT. Iatrogenic forniceal rupture. Urology 1988;32:544-5.  Back to cited text no. 6
7.Edmonds RD, Tomaszewski JJ, Jackman SV, Chaer RA. Staged endourologic and endo-vascular repair of an infrarenal inflammatory abdominal aortic aneurysm presenting with forniceal rupture. J Vasc Surg 2008;48:1332-4.  Back to cited text no. 7
8.Obrand DI, Mijangos J, Brassard R, Brock G, Steinmetz OK. Ureteropelvic urinary extra­vasation due to iliac artery aneurysm. Ann Vasc Surg 1998;12:468-70.  Back to cited text no. 8
9.Spurlock JW, Burke TW, Dunn NP, Heller PB, Collins HS, Park RC. Calyceal rupture with perirenal urinoma in a patient with cervical carcinoma. Obstet Gynecol 1987;70:511-3.  Back to cited text no. 9
10.Niggemann P, Brehmer B, Schuermann K. Bilateral renal fornix rupture following intra-arterial contrast medium application for infra-renal aortic stent placement. Cardiovasc Intervent Radiol 2006;29:157-9.  Back to cited text no. 10
11.Eggerath A, Friedrichs R. Evaluation of sponta­neous renal extravasation of contrast media in the excretory urogram. Radiologe 1985;25:224-9.  Back to cited text no. 11
12.Klasen J, Rabenalt R, Heinen W, Blondin D. Fornix rupture caused by a ureteral stone during pregnancy: Non-contrast-enhanced MR urogra-phy. Urologe A 2010;49:1172-5.  Back to cited text no. 12
13.Mullins J, Semins MJ, Bohlman ME, Matlaga BR. HASTE MRU in the evaluation of acute flank pain. Int Braz J Urol 2011;37:781-2.  Back to cited text no. 13

Correspondence Address:
Dr. Imran Khan Jalbani
Department of Urology, Aga Khan University, Karachi
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DOI: 10.4103/1319-2442.139946

PMID: 25193914

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  [Figure 1], [Figure 2], [Figure 3]

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