Extravasation of Urine Associated with Bilateral Complete Ureteral Duplication, Vesicoureteral Reflux and Benign Prostatic Hyperplasia.

We report a rare case of extravasation of urine, which may be associated with bilateral complete ureteral duplication, vesicoureteral reflux (VUR), and benign prostatic hyperplasia (BPH). A 71-year-old male presented with a complaint of right abdominal pain. An extravasation of urine was noted, and was improved by indwelling urethral catheterization. Transurethral resection of the prostate and the endoscopic subureteral injection of dextanomer/hyaluronic acid were performed for the treatment of BPH and VUR, respectively. The post-surgery recovery was successful.

Introduction

Vesicoureteral reflux (VUR) may concur with complete ureteral duplication, and extravasation of urine may rarely occur due to bladder outlet obstruction in a patient with benign prostatic hyperplasia (BPH). A duplicated collecting system is one of the most common congenital renal tract abnormalities, with an incidence of 0.7–4%.1, 2 Bilateral complete ureteral duplication occurs more often in women than in men. Complete ureteral duplication occurs in one-third of incomplete ureteral duplication. Patients with ureteral duplication may have urinary stones, ureterocele, VUR and obstructive uropathy. We report an extremely rare case of extravasation of urine, which may be associated with bilateral complete ureteral duplication, VUR, and BPH.

Case presentation

A 71-year-old Japanese male presented with a complaint of episodic right abdominal pain. No remarkable findings were observed on physical examination. The patient had noticed straining in urination 1 year before. Laboratory examination showed an elevation of C-reactive protein (5.96 mg/dL) and serum creatinine (4.43 mg/dL). Transabdominal ultrasonography showed prostatic enlargement with a prostatic volume of 76.8 mL. Extravasation of urine into the retroperitoneal space was also found in computed tomography (Fig. 1a). Bilateral complete ureteral duplications were observed in magnetic resonance imaging (Fig. 1b). Extravasation of urine was improved by indwelling urethral catheter. Serum levels of CRP and creatinine were improved to 1.17 mg/dL and 1.98 mg/dL, respectively, after 1 week. A video urodynamic study was performed 3 weeks after indwelling urethral catheter. Left VUR was noted after filling contrast medium at 40 mL, and right VUR at 90 mL. We could not find detrusor overactivity and detrusor sphincter dyssynergia that might cause VUR (Fig. 2). Cystoscopy showed bilateral dilated ureteral orifices and an enlarged prostate projecting into the bladder. Thus, the patient was diagnosed with BPH and bilateral VUR. Transurethral resection of the prostate (TUR-P) and endoscopic subureteral injection of dextranomer/hyaluronic acid (ESI) were performed (Fig. 3). At 5 days after removal of the urethral catheter postoperatively, the patient could urinate with no postvoid residual urine. Postoperative recovery was successful with a maximum urinary flow rate of 11.5 mL/s, average urinary flow rate of 7.8 mL/s, and VUR was not found after 3 months postoperatively.

Figure 1

a) CT showing an extravasation of urine to retroperitoneal space. b) MRI showing bilateral complete ureteral duplication.

Figure 2

Results of video-urodynamic study. Filling phase showed stable detrusor. However, left VUR appeared at filling 40 mL of diluted contrast medium and bilateral VUR at 90 mL. Video image demonstrated a) left VUR at filling 40 mL and b) progressing bilateral VUR at filling 180 mL with marked bladder deformity. c) Infusion was stopped at 400 mL due to noticeable VUR. d) In voiding phase, the patient could not void with acontractile detrusor and without detrusor sphincter dyssynergia.

Figure 3

Cystoscopic findings. The arrows show a) left ureteral orifice before treatment and b) after paraureteral injection of dextranomer/hyaluronic acid, c) right ureteral orifice before treatment and d) after paraureteral injection of dextranomer/hyaluronic acid.

Discussion

Ureteral duplication is often asymptomatic. This patient had no complaints until the extravasation of urine. Ureteral stone and urinary tract infections have been reported to occur in bilateral complete ureteral duplication. However, to the best of our knowledge, this seems to be the first report of a case of extravasation of urine due to BPH associated with bilateral ureteral duplication and VUR. It has been reported that ESI is an effective treatment for VUR with a neurogenic bladder regardless of bladder compliance. We carried out TUR-P for the purpose of relieving bladder outlet obstruction, and ESI was performed to prevent bilateral VUR due to ureteral duplication, which had been confirmed within a 90 mL bladder filled by a preoperative urodynamic study. From our experience, the extravasation of urine should be considered when patients have flank pain associated with bilateral ureteral duplication and voiding dysfunction due to BPH.

Conclusion

This was a rare case of extravasation of urine associated with bilateral complete ureteral duplication, BPH and bilateral VUR. Extravasation of urine was eliminated by an indwelling urethral catheter, and TUR-P and ESI were successful for BPH and VUR.

Conflict of interest

I have no conflict of interest with regard to our case report.