|Year : 2018 | Volume
| Issue : 1 | Page : 68-70
Incidental detection of perinephric urinary leak on bone scintigraphy in a patient with urinary bladder carcinoma
Shelvin Kumar Vadi1, Vaishnavi Dasagrandhi1, Anish Bhattacharya1, Shrawan Kumar Singh2, Bhagwant Rai Mittal1
1 Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Urology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||16-Jan-2018|
Dr. Anish Bhattacharya
Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
| Abstract|| |
A 71-year-old male patient with urothelial carcinoma of the bladder was referred for 99mTc-methylene diphosphonate bone scintigraphy to assess for skeletal metastasis. While the bone scan showed no abnormal skeletal uptake, tracer activity was detected in the extrarenal region of the left renal fossa on the planar image; single photon emission computed tomography-computed tomography (CT) demonstrated tracer pooling in the perirenal collection. In addition, the CT detected nontracer-avid parenchymal lung nodules and hypodense liver lesions consistent with metastatic disease. The perinephric urinary leak was drained by percutaneous drainage, confirmed by diuretic renography the following day.
Keywords: Bladder carcinoma, bone scintigraphy, diuretic renography, single photon emission computed tomography-computed tomography, urinary leak
|How to cite this article:|
Vadi SK, Dasagrandhi V, Bhattacharya A, Singh SK, Mittal BR. Incidental detection of perinephric urinary leak on bone scintigraphy in a patient with urinary bladder carcinoma. Indian J Nucl Med 2018;33:68-70
|How to cite this URL:|
Vadi SK, Dasagrandhi V, Bhattacharya A, Singh SK, Mittal BR. Incidental detection of perinephric urinary leak on bone scintigraphy in a patient with urinary bladder carcinoma. Indian J Nucl Med [serial online] 2018 [cited 2022 Nov 29];33:68-70. Available from: https://www.ijnm.in/text.asp?2018/33/1/68/223244
A 71-year-old male was diagnosed as a case of high-grade urothelial carcinoma of the bladder 2 years ago. He underwent six cycles of intravesical Bacille Calmette-Guerin and was on clinical follow-up. Now, he presented with hematuria and dysuria for the past 2 months. A contrast-enhanced computed tomography (CT) done 10 days earlier showed a residual/recurrent lesion in the bladder. Transurethral resection showed muscle invasive recurrent urothelial carcinoma.99m Tc-methylene diphosphonate bone scintigraphy was performed for the assessment of skeletal metastasis but showed no abnormal skeletal tracer uptake. However, planar images showed extrarenal pooling of tracer in the left perirenal region [Figure 1].
|Figure 1: Whole body 99mTc-methylene diphosphonate bone scintigraphy shows diffuse abnormal tracer activity (arrow) in the left perirenal region. There is no evidence of any osteoblastic skeletal lesions|
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Single photon emission computed tomography-CT (SPECT-CT) performed to localize the abnormal tracer activity demonstrated abnormal tracer pooling in the perirenal collection extending over to the left iliac fossa consistent with a urinary leak [Figure 2]. On re-evaluation, a history of mild abdominal pain in the left flank was elicited. In addition, SPECT-CT also identified hypodense liver lesions and parenchymal nodules in the visualized lung segments. In the present clinical context, these findings were consistent with metastatic disease. The patient was managed with immediate percutaneous drainage of the urinary collection.99m Tc-ethylene dicysteine (EC) diuretic renography done the following day showed slow pooling of tracer activity in the region of lower pole of the left kidney in the initial dynamic study [Figure 3]. The subsequent prevoid, postvoid, and delayed images at 3 h also showed abnormal tracer activity in the perinephric and lower polar region of the left kidney. A whole body (vertex to midthigh) positron emission tomography-CT performed 2 days after the bone scan also showed tracer-avid lesions in the liver and lungs, further characterizing the malignant/metastatic nature of these lesions. The patient is currently undergoing chemotherapy.
|Figure 2: Single photon emission computed tomography-computed tomography of the abdomen shows perirenal collection of tracer activity in orthogonal views (a -axial, b - sagittal, c - coronal) consistent with perirenal leak. In addition, non tracer-avid hepatic (d) and pulmonary lesions (e) are detected on computed tomography|
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|Figure 3:99mTc-ethylene dicysteine renal scintigraphy shows pooling of tracer in the region of the lower pole of the left kidney in dynamic (a), prevoid (b), postvoid (c), and delayed (d) static images|
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Urinary leak although common after abdominal trauma may also result from transmitted backpressure from a ureteral stone, pelvic mass, pregnancy, retroperitoneal fibrosis, or ureteropelvic junction obstruction. Ureteric obstruction by neoplasm is a rare cause of spontaneous urinary leak. Urinoma resulting from bladder malignancy is rare and usually associated with vesicoureteric junction involvement., Although bone scan is not used for evaluation of urinary leak per se, the accumulation of radiotracer outside the urinary system can be detected with SPECT-CT. Although there are reports of urinary leak diagnosed from other tracers,,,, the diagnosis of unsuspected urinary leak from bone scan is rare., In this patient, hybrid scintigraphic imaging diagnosed an unsuspected urinary leak and also detected nonskeletal distant metastases, thereby aiding in clinical management.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Koga S, Arakaki Y, Matsuoka M, Ohyama C. Spontaneous peripelvic extravasation of urine. Int Urol Nephrol 1992;24:465-9.
Gershman B, Kulkarni N, Sahani DV, Eisner BH. Causes of renal forniceal rupture. BJU Int 2011;108:1909-11.
Ali Khan S, Desai PG, Jayachandran S, Smith NL. Urinoma – A rare presentation of carcinoma of the bladder. Urol Int 1985;40:97-9.
Ma HY, Blaufox MD. An unusual urine leak with urolithiasis. Clin Nucl Med 2013;38:919-21.
Gunatunga I, Facey P, Bartley L, Rees J, Singh S, Fielding P, et al.
Perinephric urinoma secondary to perforated UPJ obstruction diagnosed using tc-99m mercaptoacetyltriglycine (MAG3) SPECT/CT. Clin Nucl Med 2007;32:317-9.
Ngai S, Stuckey SL. Peri-aortofemoral prosthesis urinoma: Diagnosis by tc-99m MAG3 SPECT/CT and differentiation from simultaneous hepatobiliary excretion. Clin Nucl Med 2008;33:337-9.
Banzo I, Martinez-Rodriguez I, Quirce R, Jimenez-Bonilla J, Sainz-Esteban A, Barragán J, et al.
Incidental detection of renal transplantation urinary leakage on FDG-PET/CT imaging for evaluation of lung metastases. Clin Nucl Med 2009;34:924-6.
Sainz-Esteban A, Jiménez MI, Villanueva JG, Cobo A, Olmos R. Unsuspected urinoma of an obstructed kidney detected in a bone scan in a patient with lung cancer. Clin Nucl Med 2014;39:922-5.
Al Tamimi AS, Magsombol B, Ng A, Ng D. Perinephric urinoma due to locally advanced recto-sigmoid tumor: Incidental finding on bone scan. World J Nucl Med 2014;13:132-4.
[Figure 1], [Figure 2], [Figure 3]