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Urol Case Rep
Urol Case Rep
Urology Case Reports
2214-4420
Elsevier

S2214-4420(24)00185-2
10.1016/j.eucr.2024.102831
102831
Trauma and Reconstruction
Traumatic rupture of congenital pelviureteric junction obstruction
Razi Basil basilrazi1@gmail.com
⁎
Steigler Amy
Cole-Clark Dane
Self Duncan
Latif Edward
Department of Urology, Gosford Hospital, Gosford, NSW, Australia
⁎ Corresponding author. Gosford Hospital, Gosford, NSW, 2250, Australia. basilrazi1@gmail.com
23 8 2024
9 2024
23 8 2024
56 10283122 7 2024
7 8 2024
22 8 2024
Crown Copyright © 2024 Published by Elsevier Inc.
2024

https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
The kidney is frequently injured in blunt abdominal trauma, accounting for 10 % of such cases and being the most commonly affected genitourinary organ in all traumas. Pelviureteric junction obstruction (PUJO) is typically a congenital and asymptomatic anatomical dilatation to the renal pelvis. This article reports on a 21-year-old male who ruptured a congenital PUJO following blunt abdominal trauma. He was managed with a retrograde ureteric stent and a staged pyeloplasty. This case highlights a rare case of urogenital injury due to blunt trauma and explores the impact of congenital anomalies can contribute to injury and lead to significant complications.

Keywords

AAST
Pelviureteric junction obstruction
Pyeloplasty
Renal trauma
Trauma
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pmc1 Introduction

The majority of trauma in Australia is a result of blunt trauma, with the kidneys being one of the most frequently injured solid organs.1, 2, 3, 4 The risk of renal injury is increased in patients with pre-existing renal abnormalities, where there is relatively minor blunt trauma.5,6 Management of renal trauma is guided by the haemodynamic status of the patient and the American Association for the Surgery of Trauma (AAST) grade of injury. With the rapid increase in the availability and access to interventional techniques, there has been a relative shift towards non-operative management.

Pelviureteric junction obstruction (PUJO) is an impaired functional drainage of the kidney which is most commonly congenital. It is often asymptomatic and detected incidentally on imaging or retrograde pyelogram (RGP) (Fig. 1).7 Here we report a 21-year-old male with a ruptured PUJO following blunt abdominal trauma.Fig. 1 Schematic diagram demonstrating a pelviureteric junction obstruction (PUJO). Key finding of hydronephrosis of renal pelvis and calyces (Adapted from https://oxfordurologyassociates.uk/).

Fig. 1

2 Case presentation

A 21-year-old male presented to a regional teaching Hospital with severe left flank pain after following blunt trauma during a soccer game. He experienced severe persistent left flank pain, associated with vomiting but no other symptoms, in particular macroscopic haematuria. His medical history included left renal calculi managed conservatively a decade ago. He was otherwise healthy, with no regular medications, a non-smoker, and occasional weekend binge drinking.

On presentation he was haemodynamically stable, afebrile, with left flank and iliac fossa tenderness, without superficial bruising or a palpable mass. Urinalysis showed microscopic haematuria. Routine blood tests revealed an elevated creatinine (143 μmol/L), decreased eGFR (60 ml/min/1.73m2), elevated white cell count (12 × 10⁹/L), and normal haemoglobin (154 g/L).

A multi-phase computed tomography (CT) scan identified an AAST grade IV left kidney injury with partial disruption of the renal pelvis and proximal ureter, contrast extravasation and a urinoma (Fig. 2). There was no renal parenchymal or arterial injury. The calyces were moderately dilated and contrast was seen in the distal left ureter on the 20 minute delayed phase. The right kidney was normal, and no other intra-abdominal injuries were found. Initial treatment included cystoscopy and a detailed RGP and ureteric stent insertion. The RGP showed a classic finding of a PUJO of a ‘balloon on string’ appearance (Fig. 3). There was no concern for a ureteric stricture given his previous history of stones.Fig. 2 Axial (left) and coronal (right) CT demonstrating site of extravasation (arrows) with left sided hydronephrosis and developing urinoma.

Fig. 2

Fig. 3 Intra-operative RGP showing classical appearance of a PUJO and site of extravasation (arrow).

Fig. 3

Six weeks later his ureteric stent was removed and a subsequent diuretic diethylenetriaminepentaacetic acid (DTPA) scan demonstrated a 31 % left sided renal function contribution with a T ½ of 22 minutes, consistent with a left sided PUJO. The patient proceeded to a routine laparoscopic left (Anderson-Hynes) pyeloplasty. A short segment was excised and the reconstructed PUJ translocated anterior to a lower pole crossing vessel. Histopathology was benign, with no evidence of malignancy. Three months following the pyeloplasty, he is pain free without any urinary issues and a repeat DTPA now shows a left sided clearance T ½ of 9 minutes.

3 Discussion

Genitourinary tract trauma occurs in up to 5 % of trauma, and up to 10 % of abdominal traumas involve the kidney.1, 2, 3, 4 Sport related blunt renal trauma occur in approximately 6 % of paediatric cases and 11 % in adult cases.4 The AAST grading is a validated scale and predictor for morbidity and correlates with the risk of nephrectomy in blunt trauma. The goals in renal trauma management are controlling bleeding, nephron sparing and avoiding long term complications.8,9 Renal trauma management has significantly shifted towards a non-operative approach with the evolution of medical technology and access to interventional procedures.10 Disruption of the pelviureteric junction is a recognised relative indication for operative intervention due to risk of urinary extravasation and formation of urinoma.

Pelviureteric junction obstruction (PUJO) is a functional impairment of the drainage of urine from the renal pelvis into the proximal ureter. PUJO is more commonly detected in the paediatric population, has a higher prevalence in males and is twice as more likely to affect the left kidney than the right.7,11 Congenital PUJO most commonly occurs due to an aperistaltic segment of the PUJ/ureter or in the case here due to a vessel crossing the PUJ. They can often remain asymptomatic until imaging for other causes, detecting severe hydronephrosis.

Pre-existing genitourinary abnormalities are known to increase the risk for blunt renal trauma.6,12,13 They should also be considered in high grade renal injuries in relatively minor and isolated injury force mechanisms, such as the one presented here. A hydronephrotic kidney has decreased tissue strength and is unable to withstand the same external force compared to a normal kidney due to a higher intra-pelvic pressure.13,14 A blunt force to the abdomen would suddenly increase the intra-abdominal leading to excessive force on an already fragile renal pelvis.

There are 10 previous reports of traumatic PUJO, five occurred in adults and only two in females. The absence of haematuria does not exclude significant genitourinary trauma, as three cases (including the present) did not report any haematuria. Of the five adult cases only one was managed conservatively as the injured kidney was likely not significantly contributing to his overall renal function.10 One patient underwent a laparotomy and nephrectomy and was found to also have a 5 cm parenchymal laceration.15 The remaining three cases similar to our case, also had preserved renal parenchyma, were managed with drainage of their kidney (one with a nephrostomy) and then proceeded to an elective Anderson-Hynes pyeloplasty.10,16,17

Prompt diagnosis of renal pelvis disruption is crucial as delayed diagnosis has shown to result in a higher rates of nephrectomy.18 A multi-phase CT, including a 5–20 minute delayed phase should be gold standard in cases of trauma. It allows accurate assessment of the renal parenchyma, blood supply and urinary excretion. Management of PUJ disruption should aim for renal conservation and prevention of mortality and long-term morbidity.

4 Conclusion

Congenital PUJO patients are higher risk and vulnerable to relatively low impact trauma and should be adequately investigated with a multi-phase and delayed CT imaging. We report the successful management of isolated congenital PUJO disruption with retrograde ureteral stent, with subsequent pyeloplasty.

Ethics approval and consent to participate

Ethics was not required for this case report.

Informed consent

Consent was obtained from the patient for the publication and for publication.

Availability of data and material

All data generated or analysed during this study are included in this published article.

Funding

No specific funding or grants were received for this research from any funding body.

CRediT authorship contribution statement

Basil Razi: Writing – review & editing, Writing – original draft, Visualization, Investigation, Formal analysis, Data curation, Conceptualization. Amy Steigler: Writing – review & editing, Writing – original draft, Visualization, Investigation, Formal analysis, Data curation, Conceptualization. Dane Cole-Clark: Writing – review & editing, Writing – original draft, Visualization, Investigation, Formal analysis, Data curation, Conceptualization. Duncan Self: Writing – review & editing, Writing – original draft, Visualization, Investigation, Formal analysis, Data curation, Conceptualization. Edward Latif: Writing – review & editing, Writing – original draft, Visualization, Supervision, Investigation, Formal analysis, Data curation, Conceptualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Abbreviations

AAST American Association for the Surgery of Trauma

CT Computed Tomography

DTPA diethylenetriaminepentaacetic acid

PUJO Pelviureteric junction obstruction

Acknowledgements

Not applicable.
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