V07_No_4.pdf


Clinical Pathology Case

275Urology Journal   Vol 7   No 4   Autumn 2010

A Complication After Percutaneous Nephrolithotomy
Farzaneh Sharifiaghdas, Nasser Simforoosh, Ardalan Ozhand

Urol J. 2010;7:275-7.
www.uj.unrc.ir

Urology and Nephrology Research 
Center, Shahid Labbafinejad 

Medical Center, Shahid Beheshti 
University, M.C., Tehran, Iran

CASE PRESENTATION
A 24-year-old woman with 
left renal pelvis and lower 
calyceal stones was admitted for 
percutaneous nephrolithotomy 
(PCNL) (Figure 1).

The surgery was uneventful. 
Nephrostomy tube and ureteral 
stent were removed on the 2nd
postoperative day. Soon after, 
urine leakage from the site of 
the nephrostomy tube and fever 
developed. Temperature was as 

to 20 000/mm3, with neutrophils as 
the dominant part (80%), 
was reported.

Double J stent was inserted 
through ureteroscope. On the 

3rd postoperative day, the patient 
showed signs and symptoms of 
obstipation, vomiting, abdominal 
tenderness and rebound tenderness, 
and high fever. Plain abdominal 
x-ray at supine and upright position 
revealed air fluid level and no 
evidence of gas pattern in the pelvis 
(rectum) and sentinel loop in the 
left upper quadrant (Figure 2).
Chest x-ray revealed pleural 
effusion in both sides (Figure 3).

QUIZ
What could be the possible 
cause of the abdominal pain and 
obstipation?

What is your suggestion as the next 
step of diagnosis and treatment?

Figure 1. Intravenous urography demonstrates a 3-cm stone in the left kidney.

A B



Clinical Pathology Case

276 Urology Journal   Vol 7   No 4   Autumn 2010

patient was discharged thereafter. 

Differential diagnoses for this patient are as 
follows:

1- Bowel injury: That may mimic signs and 
symptoms of urinoma. But by the bladder 
drainage and placement of  double-J ureteral 
stent, patient’s symptoms will not disappear 
and will deteriorate continuously. 

2- Splenic and liver injury: In which, the serum 
level of hemoglobin decreases. There is a 
distention of abdominal cavity, and the patient 
suffers from signs and symptoms of shock. 

3- Pleural effusion: Patient complains from fever 
and dyspnea. Chest x-ray reveals a blunted 
costovertebral angle. The bowel movement 
decreases; thus, the patient may have vomiting 
in absence of obstipation. Plain abdominal 
x-ray reveals air fluid pattern level.

Conservative treatment with potassium chloride 
(KCl) 30 mEq /day, ceftriaxone 1 gr twice/
day, and metronidazole 500 mg three times/day 
was started. The patient was under close follow-
up. Abdominopelvic computed tomography 
scan with contrast medium showed a huge 
retroperitoneal urinoma, which extended from 
the lower pole of the left kidney to the ipsilateral 
pelvic cavity. A massive pleural effusion was also 
seen in both sides (Figure 1).

Indwelling urethral catheter was placed into 
the bladder and the patient was kept nil per os 
(NPO) until the 7th postoperative day. On the 
7th postoperative day, the patient showed signs 
of bowel movement, defecation, and gas passage. 
Vomiting stopped and the temperature became 
normal (37.1ºC). Repeated ultrasonography 
and chest x-ray on the 7th postoperative day 
revealed a normal kidney without any evidence 
of urinoma or pleural effusion (Figure 2). The 

Figure 2. Plain Abdominal radiography shows multiple air fluid 
level patterns and empty pelvic cavity.

Figure 3. Chest x-ray reveals bilateral pleural effusion.

Answers:



Clinical Pathology Case

277Urology Journal   Vol 7   No 4   Autumn 2010

4- Ileus: It is usually related to decreased serum 
level of potassium, and mimics all signs and 
symptoms of urinoma formation.

This case highlights that urinary leakage and 
urinoma formation may mimic the signs 
and symptoms of iatrogenic bowel injury, 
and conservative treatment is successful in 
management of this condition.

Figure 1. Abdominopelvic computed tomography demonstrates 
a huge urinoma extending to the ipsilatral pelvic cavity.

Figure 2. Normal chest x-ray after conservative treatment.