INSTRUCTIVE CASES
Urinary Extravasation during High Dose Excretory Urography in a 3-Week-Old
Infant
Soroosh Mahboubi, M.D., Gerald Mandell, M.D.
NEONATAL
URINARY ASCITES is seen times more often in males than in females.’ The most common age range is between 10 days and 6 weeks. A posterior urethral valve is the lesion most commonly associated with spontaneous urinary extravasation during excretory urography.2~5 Less frequently associated etiologies are ectopic ureterocele, ureteral stenosis, urethral atresia, seven
and
neurogenic bladder.’
There are three theoretical explanations for spontaneous extravasation. The calyceal fornix may rupture secondary to the back pressure of the distal obstruction allowing escapage of urine into the perirenal tissue and then into the peritoneum. A second possibility is the disruption of the renal parenchyma adjacent to the calyx, giving rise to a subcapsular urinoma which in turn ruptures into the peritoneum. Lastly, the extravasation may be explained by bladder rupture and urine leaking directly into the peritoneum. The kidney parenchyma is the usual site of perforation. In more than a third of patients, no site can be identified.2 From The Children’s Hospital of Philadelphia, Uniof Pennsylvania Medical Center, Philadelphia,
versity
PA 19104.
Correspondence
to:
Soroosh Mahboubi, M.D., De-
partment of Radiology, The Children’s Hospital of Philadelphia, 34th Street and Civic Center Blvd., Philadelphia, PA 19104.
In recent times, high doses of contrast material for intravenous urography have been employed with newborns: 3mllkg is the dosage schedule 3; 10 ml is the maximal dose with full-term newborn infants.1. Excretory urography with the newer high
dosages may incidentally demonstrate spontaneous urinary extravasation when there is a urethral valve or some other low urinary tract obstruction. However, in patients with suspected low obstruction the usual first study of choice would be the cystogram, followed by the intravenous urogram when needed. Case Report A 3-week-old male infant presented with 48-hour history of vomiting and diarrhea. The child was a product of a full-term uncomplicated pregnancy and a spontaneous vaginal delivery. At birth she weighed 6 lb, 3 oz and at presentation 7 lb, 3 oz. On physical examination bilateral soft masses were felt in both flanks of the abdomen. Biochemical studies showed a hyponatremia and a hyperkalemia. A plain roentgenogram of the abdomen revealed ascites and bilateral flank masses. Twelve ml of hypaque 50 per cent solution was injected intravenously. The urogram demonstrated bilateral hydroureters and a
844
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FIG. 1. Intravenous Urogram. Right kidney poorly visualized with an outer rim of extravasated opaque contrast, outlining an inner area of relative lucency, the kidney parenchyma. The most central opaque structure represents the dilated calyces.
Cystogram. Outer rim of extravasated opaque around area of relatively I~.icent right renal parenchyma. Most central opaque collecting system conFIG. 2.
contrast
tinuous with
hydronephrosis.
Extravasation of
material from the right collecting system was noted (Fig. 1). A cystogram utilizing Cystograffin solution performed later the same day showed a posterior urethral valve and right ureteral reflux (Fig. 2). the serum chemistry corrected. The child was placed on prophylactic Nafcillin and Gentamycin. The initial diversionary treatment consisted of a suprapubic &dquo;intracath&dquo; drainPrior to imbalance
operation, was
age.
general anesthesia conpresence of a posterior urethral
Cystoscopy
under
firmed the valve. The bladder
was
ureter.
of contrast media from the right kidney. leakage In the case presented, no surgical intervention was necessary to control the escape of urine from the right kidney. The condition corrected spontaneously after suprapubic drainage of the bladder and resection of the posterior urethral valve.
There
was
cursions. The procedure was discontinued and catheter drainage established. Two days later the remainder of the posterior valve was completely resected utilizing a perineal approach with a resectoscope. Two months after the resection, a repeat intravenous urogram demonstrated dramatic improvement in the renal collecting systems.
was no recurrence
References 1.
Baker, D. H., and Berdon, W. E.: The
use
and
safety of "high" dose in pediatric urography. A survey of the Society for Pediatric Radiology.
trabeculated and the
patulous. During right the operative procedure to resect the valve, the patient developed marked abdominal dist~ntit~n which restricted respiratory exureteral orifice
right
contrast
Radiology
103: 371, 1972.
Cywes, S., Wynne, J. M., and Louw, J. H.: Urinary ascites in the newborn with a report of two cases. J. Pediatr. Surg. 3: 350, 1968. 3. Dunbar, J. S., and Nogrady, B.: Excretory urography
2.
in the first year of life. Radiol. Clin. North Am. 10: 367, 1972. 4. Gregory, J., Schoenberg, H. W., Sana, U., and
Thompson, J.: Neonatal urinary ascites. Urology 5: 394, 1975.
5.
Mann, C. M., Leape,
L. L., and Holder, T. M.:
Neonatal urinary ascites: A Report of two cases of unusual etiology and a review of the literature.
J. Urol. 111: 6. Wheeler, J. S.:
124, 1974.
Spontaneous urinary
extravasation
655, during excretory urography. Urology 2: 1973.
845
Downloaded from cpj.sagepub.com at NORTH DAKOTA STATE UNIV LIB on May 20, 2015
Urinary Extravasation during High Dose Excretory Urography in a 3-Week-Old
Infant
Soroosh Mahboubi, M.D., Gerald Mandell, M.D.
NEONATAL
URINARY ASCITES is seen times more often in males than in females.’ The most common age range is between 10 days and 6 weeks. A posterior urethral valve is the lesion most commonly associated with spontaneous urinary extravasation during excretory urography.2~5 Less frequently associated etiologies are ectopic ureterocele, ureteral stenosis, urethral atresia, seven
and
neurogenic bladder.’
There are three theoretical explanations for spontaneous extravasation. The calyceal fornix may rupture secondary to the back pressure of the distal obstruction allowing escapage of urine into the perirenal tissue and then into the peritoneum. A second possibility is the disruption of the renal parenchyma adjacent to the calyx, giving rise to a subcapsular urinoma which in turn ruptures into the peritoneum. Lastly, the extravasation may be explained by bladder rupture and urine leaking directly into the peritoneum. The kidney parenchyma is the usual site of perforation. In more than a third of patients, no site can be identified.2 From The Children’s Hospital of Philadelphia, Uniof Pennsylvania Medical Center, Philadelphia,
versity
PA 19104.
Correspondence
to:
Soroosh Mahboubi, M.D., De-
partment of Radiology, The Children’s Hospital of Philadelphia, 34th Street and Civic Center Blvd., Philadelphia, PA 19104.
In recent times, high doses of contrast material for intravenous urography have been employed with newborns: 3mllkg is the dosage schedule 3; 10 ml is the maximal dose with full-term newborn infants.1. Excretory urography with the newer high
dosages may incidentally demonstrate spontaneous urinary extravasation when there is a urethral valve or some other low urinary tract obstruction. However, in patients with suspected low obstruction the usual first study of choice would be the cystogram, followed by the intravenous urogram when needed. Case Report A 3-week-old male infant presented with 48-hour history of vomiting and diarrhea. The child was a product of a full-term uncomplicated pregnancy and a spontaneous vaginal delivery. At birth she weighed 6 lb, 3 oz and at presentation 7 lb, 3 oz. On physical examination bilateral soft masses were felt in both flanks of the abdomen. Biochemical studies showed a hyponatremia and a hyperkalemia. A plain roentgenogram of the abdomen revealed ascites and bilateral flank masses. Twelve ml of hypaque 50 per cent solution was injected intravenously. The urogram demonstrated bilateral hydroureters and a
844
Downloaded from cpj.sagepub.com at NORTH DAKOTA STATE UNIV LIB on May 20, 2015
FIG. 1. Intravenous Urogram. Right kidney poorly visualized with an outer rim of extravasated opaque contrast, outlining an inner area of relative lucency, the kidney parenchyma. The most central opaque structure represents the dilated calyces.
Cystogram. Outer rim of extravasated opaque around area of relatively I~.icent right renal parenchyma. Most central opaque collecting system conFIG. 2.
contrast
tinuous with
hydronephrosis.
Extravasation of
material from the right collecting system was noted (Fig. 1). A cystogram utilizing Cystograffin solution performed later the same day showed a posterior urethral valve and right ureteral reflux (Fig. 2). the serum chemistry corrected. The child was placed on prophylactic Nafcillin and Gentamycin. The initial diversionary treatment consisted of a suprapubic &dquo;intracath&dquo; drainPrior to imbalance
operation, was
age.
general anesthesia conpresence of a posterior urethral
Cystoscopy
under
firmed the valve. The bladder
was
ureter.
of contrast media from the right kidney. leakage In the case presented, no surgical intervention was necessary to control the escape of urine from the right kidney. The condition corrected spontaneously after suprapubic drainage of the bladder and resection of the posterior urethral valve.
There
was
cursions. The procedure was discontinued and catheter drainage established. Two days later the remainder of the posterior valve was completely resected utilizing a perineal approach with a resectoscope. Two months after the resection, a repeat intravenous urogram demonstrated dramatic improvement in the renal collecting systems.
was no recurrence
References 1.
Baker, D. H., and Berdon, W. E.: The
use
and
safety of "high" dose in pediatric urography. A survey of the Society for Pediatric Radiology.
trabeculated and the
patulous. During right the operative procedure to resect the valve, the patient developed marked abdominal dist~ntit~n which restricted respiratory exureteral orifice
right
contrast
Radiology
103: 371, 1972.
Cywes, S., Wynne, J. M., and Louw, J. H.: Urinary ascites in the newborn with a report of two cases. J. Pediatr. Surg. 3: 350, 1968. 3. Dunbar, J. S., and Nogrady, B.: Excretory urography
2.
in the first year of life. Radiol. Clin. North Am. 10: 367, 1972. 4. Gregory, J., Schoenberg, H. W., Sana, U., and
Thompson, J.: Neonatal urinary ascites. Urology 5: 394, 1975.
5.
Mann, C. M., Leape,
L. L., and Holder, T. M.:
Neonatal urinary ascites: A Report of two cases of unusual etiology and a review of the literature.
J. Urol. 111: 6. Wheeler, J. S.:
124, 1974.
Spontaneous urinary
extravasation
655, during excretory urography. Urology 2: 1973.
845
Downloaded from cpj.sagepub.com at NORTH DAKOTA STATE UNIV LIB on May 20, 2015
