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Urine Leaks and Urinomas: Diagnosis and Imaging-guided Intervention¹

¹ From the Department of Radiology, Massachusetts General Hospital, 55 Fruit St, White 270, Boston, MA 02114. Recipient of a Certificate of Merit award for an education exhibit at the 2002 RSNA scientific assembly. Received February 11, 2003; revision requested March 17 and received March 27; accepted March 31. Address correspondence to D.A.G. (e-mail: dgervais@partners.org).

View larger version (125K): [in a new window]   Figure 1a.  Renal urine leak and urinoma in a 24-year-old man who sustained left renal trauma in a motor vehicle accident. (a) Contrast material-enhanced CT scan shows a fracture of the left kidney and a surrounding perinephric urinoma. Faint high attenuation is seen within the urinoma laterally (arrow), a finding that represents a leak of enhanced urine from the renal collecting system. (b) Delayed phase CT scan obtained slightly caudad to the left kidney 10 minutes later shows increased attenuation of the urinoma. Note the contrast material in the dependent portion of the urinoma collection (arrow). (c) Contrast-enhanced CT scan obtained after 3 months of conservative therapy demonstrates an interval decrease in the size of the urinoma, with a small amount of contrast material in the dependent portion of the urinoma (arrow). Note that the anterior renal fracture fragment (arrowheads) is surrounded by a smaller urinoma and is now closer to the remainder of the kidney.

View larger version (123K): [in a new window]   Figure 1b.  Renal urine leak and urinoma in a 24-year-old man who sustained left renal trauma in a motor vehicle accident. (a) Contrast material-enhanced CT scan shows a fracture of the left kidney and a surrounding perinephric urinoma. Faint high attenuation is seen within the urinoma laterally (arrow), a finding that represents a leak of enhanced urine from the renal collecting system. (b) Delayed phase CT scan obtained slightly caudad to the left kidney 10 minutes later shows increased attenuation of the urinoma. Note the contrast material in the dependent portion of the urinoma collection (arrow). (c) Contrast-enhanced CT scan obtained after 3 months of conservative therapy demonstrates an interval decrease in the size of the urinoma, with a small amount of contrast material in the dependent portion of the urinoma (arrow). Note that the anterior renal fracture fragment (arrowheads) is surrounded by a smaller urinoma and is now closer to the remainder of the kidney.

View larger version (138K): [in a new window]   Figure 1c.  Renal urine leak and urinoma in a 24-year-old man who sustained left renal trauma in a motor vehicle accident. (a) Contrast material-enhanced CT scan shows a fracture of the left kidney and a surrounding perinephric urinoma. Faint high attenuation is seen within the urinoma laterally (arrow), a finding that represents a leak of enhanced urine from the renal collecting system. (b) Delayed phase CT scan obtained slightly caudad to the left kidney 10 minutes later shows increased attenuation of the urinoma. Note the contrast material in the dependent portion of the urinoma collection (arrow). (c) Contrast-enhanced CT scan obtained after 3 months of conservative therapy demonstrates an interval decrease in the size of the urinoma, with a small amount of contrast material in the dependent portion of the urinoma (arrow). Note that the anterior renal fracture fragment (arrowheads) is surrounded by a smaller urinoma and is now closer to the remainder of the kidney.

View larger version (173K): [in a new window]   Figure 2a.  Renal urine leak in a 57-year-old man with oliguria and renal insufficiency. The patient had undergone renal transplantation 1 week earlier. (a) CT scan of the right lower quadrant of the transplanted kidney demonstrates a fluid collection medial to the right ureteropelvic junction (arrow). (b) Sequential dynamic images obtained at renal scintigraphy with technetium-99m dimercaptosuccinic acid help confirm an anastomotic leak at the level of the transplant ureteropelvic junction, with progressive accumulation of radiotracer outside the collecting system over time (arrows).

View larger version (87K): [in a new window]   Figure 2b.  Renal urine leak in a 57-year-old man with oliguria and renal insufficiency. The patient had undergone renal transplantation 1 week earlier. (a) CT scan of the right lower quadrant of the transplanted kidney demonstrates a fluid collection medial to the right ureteropelvic junction (arrow). (b) Sequential dynamic images obtained at renal scintigraphy with technetium-99m dimercaptosuccinic acid help confirm an anastomotic leak at the level of the transplant ureteropelvic junction, with progressive accumulation of radiotracer outside the collecting system over time (arrows).

View larger version (136K): [in a new window]   Figure 3a.  Renal urine leak and urinoma in a 20-year-old man who sustained right renal trauma in a motor vehicle accident. (a) Contrast-enhanced CT scan shows a fracture of the right kidney and a surrounding perinephric urinoma. (b) Delayed phase CT scan obtained 1 week later shows a persistent large perinephric urinoma. Note the high-attenuation contrast material in the dependent portion of the collection (arrow), a finding that indicates active leakage of enhanced urine. The patient developed progressive abdominal pain with initial conservative treatment, and a percutaneous urinoma drainage catheter was placed under US guidance. (c) CT scan obtained after percutaneous drainage of the perinephric urinoma helps confirm optimal placement of the drainage catheter. (d) Sagittal US image obtained 4 weeks after urinoma drainage catheter placement demonstrates complete resolution of the perinephric urinoma and continued healing of the right renal fracture.

View larger version (123K): [in a new window]   Figure 3b.  Renal urine leak and urinoma in a 20-year-old man who sustained right renal trauma in a motor vehicle accident. (a) Contrast-enhanced CT scan shows a fracture of the right kidney and a surrounding perinephric urinoma. (b) Delayed phase CT scan obtained 1 week later shows a persistent large perinephric urinoma. Note the high-attenuation contrast material in the dependent portion of the collection (arrow), a finding that indicates active leakage of enhanced urine. The patient developed progressive abdominal pain with initial conservative treatment, and a percutaneous urinoma drainage catheter was placed under US guidance. (c) CT scan obtained after percutaneous drainage of the perinephric urinoma helps confirm optimal placement of the drainage catheter. (d) Sagittal US image obtained 4 weeks after urinoma drainage catheter placement demonstrates complete resolution of the perinephric urinoma and continued healing of the right renal fracture.

View larger version (131K): [in a new window]   Figure 3c.  Renal urine leak and urinoma in a 20-year-old man who sustained right renal trauma in a motor vehicle accident. (a) Contrast-enhanced CT scan shows a fracture of the right kidney and a surrounding perinephric urinoma. (b) Delayed phase CT scan obtained 1 week later shows a persistent large perinephric urinoma. Note the high-attenuation contrast material in the dependent portion of the collection (arrow), a finding that indicates active leakage of enhanced urine. The patient developed progressive abdominal pain with initial conservative treatment, and a percutaneous urinoma drainage catheter was placed under US guidance. (c) CT scan obtained after percutaneous drainage of the perinephric urinoma helps confirm optimal placement of the drainage catheter. (d) Sagittal US image obtained 4 weeks after urinoma drainage catheter placement demonstrates complete resolution of the perinephric urinoma and continued healing of the right renal fracture.

View larger version (117K): [in a new window]   Figure 3d.  Renal urine leak and urinoma in a 20-year-old man who sustained right renal trauma in a motor vehicle accident. (a) Contrast-enhanced CT scan shows a fracture of the right kidney and a surrounding perinephric urinoma. (b) Delayed phase CT scan obtained 1 week later shows a persistent large perinephric urinoma. Note the high-attenuation contrast material in the dependent portion of the collection (arrow), a finding that indicates active leakage of enhanced urine. The patient developed progressive abdominal pain with initial conservative treatment, and a percutaneous urinoma drainage catheter was placed under US guidance. (c) CT scan obtained after percutaneous drainage of the perinephric urinoma helps confirm optimal placement of the drainage catheter. (d) Sagittal US image obtained 4 weeks after urinoma drainage catheter placement demonstrates complete resolution of the perinephric urinoma and continued healing of the right renal fracture.

View larger version (131K): [in a new window]   Figure 4a.  Renal urinoma in a 39-year-old man who sustained right renal trauma from a stab wound. (a) Contrast-enhanced CT scan shows a fracture of the right kidney and a surrounding perinephric fluid collection (arrow). (b) On a contrast-enhanced CT scan obtained 7 days later, the perinephric fluid collection has increased in size and now demonstrates a high-attenuation rim. Percutaneous drainage of the presumed liquefied and infected hematoma was performed. (c) Sagittal US image obtained on the same day as b shows a fluid collection inferior to the right kidney. An 8-F drainage catheter was placed under US guidance. (d) Contrast-enhanced CT scan obtained 7 days after c shows a smaller but persistent perinephric fluid collection. High-volume catheter outputs persisted. Evaluation of the creatinine level of the fluid collection confirmed the diagnosis of urinoma. Antegrade ureteral stent placement was performed. Contrast material was injected through the percutaneous drainage catheter 5 days later due to decreased catheter output. (e) Pyelogram shows that the size of the urinoma cavity has decreased (arrow), but that communication between the percutaneous urinoma drainage catheter and the renal collecting system persists (arrowheads). (f) Contrast-enhanced CT scan obtained 10 days after e shows interval resolution of the perinephric urinoma. The combined use of the urinoma drainage catheter and ureteral stent promoted healing of the collecting system.

View larger version (132K): [in a new window]   Figure 4b.  Renal urinoma in a 39-year-old man who sustained right renal trauma from a stab wound. (a) Contrast-enhanced CT scan shows a fracture of the right kidney and a surrounding perinephric fluid collection (arrow). (b) On a contrast-enhanced CT scan obtained 7 days later, the perinephric fluid collection has increased in size and now demonstrates a high-attenuation rim. Percutaneous drainage of the presumed liquefied and infected hematoma was performed. (c) Sagittal US image obtained on the same day as b shows a fluid collection inferior to the right kidney. An 8-F drainage catheter was placed under US guidance. (d) Contrast-enhanced CT scan obtained 7 days after c shows a smaller but persistent perinephric fluid collection. High-volume catheter outputs persisted. Evaluation of the creatinine level of the fluid collection confirmed the diagnosis of urinoma. Antegrade ureteral stent placement was performed. Contrast material was injected through the percutaneous drainage catheter 5 days later due to decreased catheter output. (e) Pyelogram shows that the size of the urinoma cavity has decreased (arrow), but that communication between the percutaneous urinoma drainage catheter and the renal collecting system persists (arrowheads). (f) Contrast-enhanced CT scan obtained 10 days after e shows interval resolution of the perinephric urinoma. The combined use of the urinoma drainage catheter and ureteral stent promoted healing of the collecting system.

View larger version (112K): [in a new window]   Figure 4c.  Renal urinoma in a 39-year-old man who sustained right renal trauma from a stab wound. (a) Contrast-enhanced CT scan shows a fracture of the right kidney and a surrounding perinephric fluid collection (arrow). (b) On a contrast-enhanced CT scan obtained 7 days later, the perinephric fluid collection has increased in size and now demonstrates a high-attenuation rim. Percutaneous drainage of the presumed liquefied and infected hematoma was performed. (c) Sagittal US image obtained on the same day as b shows a fluid collection inferior to the right kidney. An 8-F drainage catheter was placed under US guidance. (d) Contrast-enhanced CT scan obtained 7 days after c shows a smaller but persistent perinephric fluid collection. High-volume catheter outputs persisted. Evaluation of the creatinine level of the fluid collection confirmed the diagnosis of urinoma. Antegrade ureteral stent placement was performed. Contrast material was injected through the percutaneous drainage catheter 5 days later due to decreased catheter output. (e) Pyelogram shows that the size of the urinoma cavity has decreased (arrow), but that communication between the percutaneous urinoma drainage catheter and the renal collecting system persists (arrowheads). (f) Contrast-enhanced CT scan obtained 10 days after e shows interval resolution of the perinephric urinoma. The combined use of the urinoma drainage catheter and ureteral stent promoted healing of the collecting system.

View larger version (126K): [in a new window]   Figure 4d.  Renal urinoma in a 39-year-old man who sustained right renal trauma from a stab wound. (a) Contrast-enhanced CT scan shows a fracture of the right kidney and a surrounding perinephric fluid collection (arrow). (b) On a contrast-enhanced CT scan obtained 7 days later, the perinephric fluid collection has increased in size and now demonstrates a high-attenuation rim. Percutaneous drainage of the presumed liquefied and infected hematoma was performed. (c) Sagittal US image obtained on the same day as b shows a fluid collection inferior to the right kidney. An 8-F drainage catheter was placed under US guidance. (d) Contrast-enhanced CT scan obtained 7 days after c shows a smaller but persistent perinephric fluid collection. High-volume catheter outputs persisted. Evaluation of the creatinine level of the fluid collection confirmed the diagnosis of urinoma. Antegrade ureteral stent placement was performed. Contrast material was injected through the percutaneous drainage catheter 5 days later due to decreased catheter output. (e) Pyelogram shows that the size of the urinoma cavity has decreased (arrow), but that communication between the percutaneous urinoma drainage catheter and the renal collecting system persists (arrowheads). (f) Contrast-enhanced CT scan obtained 10 days after e shows interval resolution of the perinephric urinoma. The combined use of the urinoma drainage catheter and ureteral stent promoted healing of the collecting system.

View larger version (118K): [in a new window]   Figure 4e.  Renal urinoma in a 39-year-old man who sustained right renal trauma from a stab wound. (a) Contrast-enhanced CT scan shows a fracture of the right kidney and a surrounding perinephric fluid collection (arrow). (b) On a contrast-enhanced CT scan obtained 7 days later, the perinephric fluid collection has increased in size and now demonstrates a high-attenuation rim. Percutaneous drainage of the presumed liquefied and infected hematoma was performed. (c) Sagittal US image obtained on the same day as b shows a fluid collection inferior to the right kidney. An 8-F drainage catheter was placed under US guidance. (d) Contrast-enhanced CT scan obtained 7 days after c shows a smaller but persistent perinephric fluid collection. High-volume catheter outputs persisted. Evaluation of the creatinine level of the fluid collection confirmed the diagnosis of urinoma. Antegrade ureteral stent placement was performed. Contrast material was injected through the percutaneous drainage catheter 5 days later due to decreased catheter output. (e) Pyelogram shows that the size of the urinoma cavity has decreased (arrow), but that communication between the percutaneous urinoma drainage catheter and the renal collecting system persists (arrowheads). (f) Contrast-enhanced CT scan obtained 10 days after e shows interval resolution of the perinephric urinoma. The combined use of the urinoma drainage catheter and ureteral stent promoted healing of the collecting system.

View larger version (102K): [in a new window]   Figure 4f.  Renal urinoma in a 39-year-old man who sustained right renal trauma from a stab wound. (a) Contrast-enhanced CT scan shows a fracture of the right kidney and a surrounding perinephric fluid collection (arrow). (b) On a contrast-enhanced CT scan obtained 7 days later, the perinephric fluid collection has increased in size and now demonstrates a high-attenuation rim. Percutaneous drainage of the presumed liquefied and infected hematoma was performed. (c) Sagittal US image obtained on the same day as b shows a fluid collection inferior to the right kidney. An 8-F drainage catheter was placed under US guidance. (d) Contrast-enhanced CT scan obtained 7 days after c shows a smaller but persistent perinephric fluid collection. High-volume catheter outputs persisted. Evaluation of the creatinine level of the fluid collection confirmed the diagnosis of urinoma. Antegrade ureteral stent placement was performed. Contrast material was injected through the percutaneous drainage catheter 5 days later due to decreased catheter output. (e) Pyelogram shows that the size of the urinoma cavity has decreased (arrow), but that communication between the percutaneous urinoma drainage catheter and the renal collecting system persists (arrowheads). (f) Contrast-enhanced CT scan obtained 10 days after e shows interval resolution of the perinephric urinoma. The combined use of the urinoma drainage catheter and ureteral stent promoted healing of the collecting system.

View larger version (135K): [in a new window]   Figure 5a.  Ureteral urine leak and urinoma in a 73-year-old man who had undergone abdominoperineal resection for rectal cancer. (a) Contrast-enhanced CT scan demonstrates a fluid collection in the left sigmoid mesentery. (b) CT scan obtained 1 day later during CT-guided needle aspiration demonstrates delayed attenuation of the fluid collection. Results of needle aspiration confirmed that the collection represented a urinoma. Postaspiration evaluation revealed that the cavity had completely resolved, and no percutaneous drainage catheter was placed. The patient underwent left percutaneous nephrostomy to divert urine flow. Attempts at antegrade ureteral stent placement were unsuccessful. (c) Prone antegrade pyelogram obtained following nephrostomy and unsuccessful stent placement demonstrates enhancement and a guide wire within the left ureter. A focal outpouching of extraluminal contrast material (arrow) is seen at the level of complete ureteral transection. (d) Photograph of the 10-F, 20-cm ureteral stent (Boston Scientific, Watertown, Mass) demonstrates that the stent has two pigtails with multiple side holes. This stent may be placed across the level of a ureteral injury, with side holes above and below the level of the urine leak. It is completely internal and is usually removed through the urinary bladder. Ureteral stents come in variable lengths and are typically 8-10 F in diameter. (e) Abdominal radiograph obtained following left retrograde ureteral stent placement demonstrates the stent in satisfactory position.

View larger version (152K): [in a new window]   Figure 5b.  Ureteral urine leak and urinoma in a 73-year-old man who had undergone abdominoperineal resection for rectal cancer. (a) Contrast-enhanced CT scan demonstrates a fluid collection in the left sigmoid mesentery. (b) CT scan obtained 1 day later during CT-guided needle aspiration demonstrates delayed attenuation of the fluid collection. Results of needle aspiration confirmed that the collection represented a urinoma. Postaspiration evaluation revealed that the cavity had completely resolved, and no percutaneous drainage catheter was placed. The patient underwent left percutaneous nephrostomy to divert urine flow. Attempts at antegrade ureteral stent placement were unsuccessful. (c) Prone antegrade pyelogram obtained following nephrostomy and unsuccessful stent placement demonstrates enhancement and a guide wire within the left ureter. A focal outpouching of extraluminal contrast material (arrow) is seen at the level of complete ureteral transection. (d) Photograph of the 10-F, 20-cm ureteral stent (Boston Scientific, Watertown, Mass) demonstrates that the stent has two pigtails with multiple side holes. This stent may be placed across the level of a ureteral injury, with side holes above and below the level of the urine leak. It is completely internal and is usually removed through the urinary bladder. Ureteral stents come in variable lengths and are typically 8-10 F in diameter. (e) Abdominal radiograph obtained following left retrograde ureteral stent placement demonstrates the stent in satisfactory position.

View larger version (127K): [in a new window]   Figure 5c.  Ureteral urine leak and urinoma in a 73-year-old man who had undergone abdominoperineal resection for rectal cancer. (a) Contrast-enhanced CT scan demonstrates a fluid collection in the left sigmoid mesentery. (b) CT scan obtained 1 day later during CT-guided needle aspiration demonstrates delayed attenuation of the fluid collection. Results of needle aspiration confirmed that the collection represented a urinoma. Postaspiration evaluation revealed that the cavity had completely resolved, and no percutaneous drainage catheter was placed. The patient underwent left percutaneous nephrostomy to divert urine flow. Attempts at antegrade ureteral stent placement were unsuccessful. (c) Prone antegrade pyelogram obtained following nephrostomy and unsuccessful stent placement demonstrates enhancement and a guide wire within the left ureter. A focal outpouching of extraluminal contrast material (arrow) is seen at the level of complete ureteral transection. (d) Photograph of the 10-F, 20-cm ureteral stent (Boston Scientific, Watertown, Mass) demonstrates that the stent has two pigtails with multiple side holes. This stent may be placed across the level of a ureteral injury, with side holes above and below the level of the urine leak. It is completely internal and is usually removed through the urinary bladder. Ureteral stents come in variable lengths and are typically 8-10 F in diameter. (e) Abdominal radiograph obtained following left retrograde ureteral stent placement demonstrates the stent in satisfactory position.

View larger version (42K): [in a new window]   Figure 5d.  Ureteral urine leak and urinoma in a 73-year-old man who had undergone abdominoperineal resection for rectal cancer. (a) Contrast-enhanced CT scan demonstrates a fluid collection in the left sigmoid mesentery. (b) CT scan obtained 1 day later during CT-guided needle aspiration demonstrates delayed attenuation of the fluid collection. Results of needle aspiration confirmed that the collection represented a urinoma. Postaspiration evaluation revealed that the cavity had completely resolved, and no percutaneous drainage catheter was placed. The patient underwent left percutaneous nephrostomy to divert urine flow. Attempts at antegrade ureteral stent placement were unsuccessful. (c) Prone antegrade pyelogram obtained following nephrostomy and unsuccessful stent placement demonstrates enhancement and a guide wire within the left ureter. A focal outpouching of extraluminal contrast material (arrow) is seen at the level of complete ureteral transection. (d) Photograph of the 10-F, 20-cm ureteral stent (Boston Scientific, Watertown, Mass) demonstrates that the stent has two pigtails with multiple side holes. This stent may be placed across the level of a ureteral injury, with side holes above and below the level of the urine leak. It is completely internal and is usually removed through the urinary bladder. Ureteral stents come in variable lengths and are typically 8-10 F in diameter. (e) Abdominal radiograph obtained following left retrograde ureteral stent placement demonstrates the stent in satisfactory position.

View larger version (105K): [in a new window]   Figure 5e.  Ureteral urine leak and urinoma in a 73-year-old man who had undergone abdominoperineal resection for rectal cancer. (a) Contrast-enhanced CT scan demonstrates a fluid collection in the left sigmoid mesentery. (b) CT scan obtained 1 day later during CT-guided needle aspiration demonstrates delayed attenuation of the fluid collection. Results of needle aspiration confirmed that the collection represented a urinoma. Postaspiration evaluation revealed that the cavity had completely resolved, and no percutaneous drainage catheter was placed. The patient underwent left percutaneous nephrostomy to divert urine flow. Attempts at antegrade ureteral stent placement were unsuccessful. (c) Prone antegrade pyelogram obtained following nephrostomy and unsuccessful stent placement demonstrates enhancement and a guide wire within the left ureter. A focal outpouching of extraluminal contrast material (arrow) is seen at the level of complete ureteral transection. (d) Photograph of the 10-F, 20-cm ureteral stent (Boston Scientific, Watertown, Mass) demonstrates that the stent has two pigtails with multiple side holes. This stent may be placed across the level of a ureteral injury, with side holes above and below the level of the urine leak. It is completely internal and is usually removed through the urinary bladder. Ureteral stents come in variable lengths and are typically 8-10 F in diameter. (e) Abdominal radiograph obtained following left retrograde ureteral stent placement demonstrates the stent in satisfactory position.

View larger version (109K): [in a new window]   Figure 6a.  Ureteral urinoma in a 40-year-old man with recurrent fevers following pelvic exenteration and ileal loop diversion. (a) Contrast-enhanced delayed phase CT scan demonstrates a presacral urine collection with high attenuation. A percutaneous urinoma drainage catheter (not shown) was placed. (b) Pyelogram obtained after injection of contrast material through the urinoma drainage catheter shows communication of the urinoma with the ileal loop (arrow). Both kidneys were obstructed, and bilateral percutaneous nephrostomy was performed. Management options included ureteral stent placement (if technically possible) and, as a last resort, surgical revision. Stent deployment was attempted. (c) Spot radiograph obtained during stent placement demonstrates a guide wire that has been placed antegrade via the right kidney through the ureteral anastomosis and out the ileal loop. After percutaneous access to the ileal loop via the kidney was established, an exchange-length guide wire (arrows) was inserted to help place a retrograde catheter. A percutaneous nephrostomy catheter (not shown) was left in place. Arrowheads indicate the percutaneous urinoma drainage catheter. (d) Photograph of an 8-F, 30-cm biliary urinary drainage catheter (Boston Scientific) demonstrates that the catheter is long with a single pigtail. The catheter is suitable for ureteral stent placement in patients with ileal loops. In such patients, the distal portion of the stent is external to the patient and is confined within the ileostomy drainage bag. This particular design with a Luer-lock hub facilitates over-the-wire exchanges. These catheters come in lengths of 30 or 45 cm and are typically 8-10 F in diameter. (e) Lateral radiograph shows a right percutaneous nephrostomy catheter (arrow) and a right biliary urinary drainage catheter (arrowheads) placed across a right ureteral-ileal loop anastomotic injury.

View larger version (149K): [in a new window]   Figure 6b.  Ureteral urinoma in a 40-year-old man with recurrent fevers following pelvic exenteration and ileal loop diversion. (a) Contrast-enhanced delayed phase CT scan demonstrates a presacral urine collection with high attenuation. A percutaneous urinoma drainage catheter (not shown) was placed. (b) Pyelogram obtained after injection of contrast material through the urinoma drainage catheter shows communication of the urinoma with the ileal loop (arrow). Both kidneys were obstructed, and bilateral percutaneous nephrostomy was performed. Management options included ureteral stent placement (if technically possible) and, as a last resort, surgical revision. Stent deployment was attempted. (c) Spot radiograph obtained during stent placement demonstrates a guide wire that has been placed antegrade via the right kidney through the ureteral anastomosis and out the ileal loop. After percutaneous access to the ileal loop via the kidney was established, an exchange-length guide wire (arrows) was inserted to help place a retrograde catheter. A percutaneous nephrostomy catheter (not shown) was left in place. Arrowheads indicate the percutaneous urinoma drainage catheter. (d) Photograph of an 8-F, 30-cm biliary urinary drainage catheter (Boston Scientific) demonstrates that the catheter is long with a single pigtail. The catheter is suitable for ureteral stent placement in patients with ileal loops. In such patients, the distal portion of the stent is external to the patient and is confined within the ileostomy drainage bag. This particular design with a Luer-lock hub facilitates over-the-wire exchanges. These catheters come in lengths of 30 or 45 cm and are typically 8-10 F in diameter. (e) Lateral radiograph shows a right percutaneous nephrostomy catheter (arrow) and a right biliary urinary drainage catheter (arrowheads) placed across a right ureteral-ileal loop anastomotic injury.

View larger version (126K): [in a new window]   Figure 6c.  Ureteral urinoma in a 40-year-old man with recurrent fevers following pelvic exenteration and ileal loop diversion. (a) Contrast-enhanced delayed phase CT scan demonstrates a presacral urine collection with high attenuation. A percutaneous urinoma drainage catheter (not shown) was placed. (b) Pyelogram obtained after injection of contrast material through the urinoma drainage catheter shows communication of the urinoma with the ileal loop (arrow). Both kidneys were obstructed, and bilateral percutaneous nephrostomy was performed. Management options included ureteral stent placement (if technically possible) and, as a last resort, surgical revision. Stent deployment was attempted. (c) Spot radiograph obtained during stent placement demonstrates a guide wire that has been placed antegrade via the right kidney through the ureteral anastomosis and out the ileal loop. After percutaneous access to the ileal loop via the kidney was established, an exchange-length guide wire (arrows) was inserted to help place a retrograde catheter. A percutaneous nephrostomy catheter (not shown) was left in place. Arrowheads indicate the percutaneous urinoma drainage catheter. (d) Photograph of an 8-F, 30-cm biliary urinary drainage catheter (Boston Scientific) demonstrates that the catheter is long with a single pigtail. The catheter is suitable for ureteral stent placement in patients with ileal loops. In such patients, the distal portion of the stent is external to the patient and is confined within the ileostomy drainage bag. This particular design with a Luer-lock hub facilitates over-the-wire exchanges. These catheters come in lengths of 30 or 45 cm and are typically 8-10 F in diameter. (e) Lateral radiograph shows a right percutaneous nephrostomy catheter (arrow) and a right biliary urinary drainage catheter (arrowheads) placed across a right ureteral-ileal loop anastomotic injury.

View larger version (28K): [in a new window]   Figure 6d.  Ureteral urinoma in a 40-year-old man with recurrent fevers following pelvic exenteration and ileal loop diversion. (a) Contrast-enhanced delayed phase CT scan demonstrates a presacral urine collection with high attenuation. A percutaneous urinoma drainage catheter (not shown) was placed. (b) Pyelogram obtained after injection of contrast material through the urinoma drainage catheter shows communication of the urinoma with the ileal loop (arrow). Both kidneys were obstructed, and bilateral percutaneous nephrostomy was performed. Management options included ureteral stent placement (if technically possible) and, as a last resort, surgical revision. Stent deployment was attempted. (c) Spot radiograph obtained during stent placement demonstrates a guide wire that has been placed antegrade via the right kidney through the ureteral anastomosis and out the ileal loop. After percutaneous access to the ileal loop via the kidney was established, an exchange-length guide wire (arrows) was inserted to help place a retrograde catheter. A percutaneous nephrostomy catheter (not shown) was left in place. Arrowheads indicate the percutaneous urinoma drainage catheter. (d) Photograph of an 8-F, 30-cm biliary urinary drainage catheter (Boston Scientific) demonstrates that the catheter is long with a single pigtail. The catheter is suitable for ureteral stent placement in patients with ileal loops. In such patients, the distal portion of the stent is external to the patient and is confined within the ileostomy drainage bag. This particular design with a Luer-lock hub facilitates over-the-wire exchanges. These catheters come in lengths of 30 or 45 cm and are typically 8-10 F in diameter. (e) Lateral radiograph shows a right percutaneous nephrostomy catheter (arrow) and a right biliary urinary drainage catheter (arrowheads) placed across a right ureteral-ileal loop anastomotic injury.

View larger version (103K): [in a new window]   Figure 6e.  Ureteral urinoma in a 40-year-old man with recurrent fevers following pelvic exenteration and ileal loop diversion. (a) Contrast-enhanced delayed phase CT scan demonstrates a presacral urine collection with high attenuation. A percutaneous urinoma drainage catheter (not shown) was placed. (b) Pyelogram obtained after injection of contrast material through the urinoma drainage catheter shows communication of the urinoma with the ileal loop (arrow). Both kidneys were obstructed, and bilateral percutaneous nephrostomy was performed. Management options included ureteral stent placement (if technically possible) and, as a last resort, surgical revision. Stent deployment was attempted. (c) Spot radiograph obtained during stent placement demonstrates a guide wire that has been placed antegrade via the right kidney through the ureteral anastomosis and out the ileal loop. After percutaneous access to the ileal loop via the kidney was established, an exchange-length guide wire (arrows) was inserted to help place a retrograde catheter. A percutaneous nephrostomy catheter (not shown) was left in place. Arrowheads indicate the percutaneous urinoma drainage catheter. (d) Photograph of an 8-F, 30-cm biliary urinary drainage catheter (Boston Scientific) demonstrates that the catheter is long with a single pigtail. The catheter is suitable for ureteral stent placement in patients with ileal loops. In such patients, the distal portion of the stent is external to the patient and is confined within the ileostomy drainage bag. This particular design with a Luer-lock hub facilitates over-the-wire exchanges. These catheters come in lengths of 30 or 45 cm and are typically 8-10 F in diameter. (e) Lateral radiograph shows a right percutaneous nephrostomy catheter (arrow) and a right biliary urinary drainage catheter (arrowheads) placed across a right ureteral-ileal loop anastomotic injury.

View larger version (118K): [in a new window]   Figure 7.  Ureteral urine leak in a 46-year-old woman with bilateral ureteral fistulas to the vagina. The patient had undergone total abdominal hysterectomy and pelvic irradiation for cervical cancer. Bilateral antegrade stent deployment was unsuccessful. Bilateral antegrade pyelogram, obtained following bilateral ureteral occlusion with stainless steel coils (arrowheads) and placement of an absorbable gelatin sponge slurry, demonstrates complete ureteral occlusion on the left side and nearly complete occlusion on the right side. Some leakage of previously administered contrast material into the right side of the pelvis (arrow) is seen. The patient will have bilateral percutaneous nephrostomy catheters for the rest of her life.

View larger version (126K): [in a new window]   Figure 8a.  Ureteral urine leak and urinoma in a 73-year-old man who presented with abdominal pain 2 weeks after undergoing low anterior resection. (a) CT scan demonstrates an extensive intraperitoneal fluid collection in the left side of the pelvis. The fluid collection extended superiorly into the lesser sac (not shown). Because of the extensive nature of the collection, a percutaneous drainage catheter was placed under US guidance. (b) Sagittal US image demonstrates the percutaneous drainage catheter (arrow), which has been advanced into the complicated intraperitoneal fluid collection. The collection completely collapsed following drainage despite the appearance of multiple septa within the collection (arrowheads). (c) Intravenous pyelogram obtained 3 days after b and 10 minutes after contrast material injection demonstrates persistent extravasation of contrast material in the left side of the pelvis (arrow), a finding that helped confirm the diagnosis of urinoma. A left percutaneous nephrostomy catheter (not shown) was placed. (d) Antegrade pyelogram obtained following left percutaneous nephrostomy demonstrates a distal contrast material leak (arrow). Despite combination treatment with percutaneous nephrostomy and a urinoma drainage catheter (arrowheads), outputs from the latter remained high. Neither antegrade nor retrograde ureteral stent placement was successful. The urologist wanted to defer definitive surgical treatment for 3-6 months due to a perioperative myocardial infarction. Ureteral embolization was offered as a temporizing measure to divert urine flow from the ureteral leak. (e) Antegrade pyelogram demonstrates two Gianturco coils (arrowheads) in the distalmost portion of the left ureter above the transection. Contrast material from prior injections is seen inferiorly (arrow). (f) CT scan obtained 2 weeks after e demonstrates an interval decrease in the size of the pelvic urinoma due to urinary diversion from the site of the ureteral leak.

View larger version (100K): [in a new window]   Figure 8b.  Ureteral urine leak and urinoma in a 73-year-old man who presented with abdominal pain 2 weeks after undergoing low anterior resection. (a) CT scan demonstrates an extensive intraperitoneal fluid collection in the left side of the pelvis. The fluid collection extended superiorly into the lesser sac (not shown). Because of the extensive nature of the collection, a percutaneous drainage catheter was placed under US guidance. (b) Sagittal US image demonstrates the percutaneous drainage catheter (arrow), which has been advanced into the complicated intraperitoneal fluid collection. The collection completely collapsed following drainage despite the appearance of multiple septa within the collection (arrowheads). (c) Intravenous pyelogram obtained 3 days after b and 10 minutes after contrast material injection demonstrates persistent extravasation of contrast material in the left side of the pelvis (arrow), a finding that helped confirm the diagnosis of urinoma. A left percutaneous nephrostomy catheter (not shown) was placed. (d) Antegrade pyelogram obtained following left percutaneous nephrostomy demonstrates a distal contrast material leak (arrow). Despite combination treatment with percutaneous nephrostomy and a urinoma drainage catheter (arrowheads), outputs from the latter remained high. Neither antegrade nor retrograde ureteral stent placement was successful. The urologist wanted to defer definitive surgical treatment for 3-6 months due to a perioperative myocardial infarction. Ureteral embolization was offered as a temporizing measure to divert urine flow from the ureteral leak. (e) Antegrade pyelogram demonstrates two Gianturco coils (arrowheads) in the distalmost portion of the left ureter above the transection. Contrast material from prior injections is seen inferiorly (arrow). (f) CT scan obtained 2 weeks after e demonstrates an interval decrease in the size of the pelvic urinoma due to urinary diversion from the site of the ureteral leak.

View larger version (189K): [in a new window]   Figure 8c.  Ureteral urine leak and urinoma in a 73-year-old man who presented with abdominal pain 2 weeks after undergoing low anterior resection. (a) CT scan demonstrates an extensive intraperitoneal fluid collection in the left side of the pelvis. The fluid collection extended superiorly into the lesser sac (not shown). Because of the extensive nature of the collection, a percutaneous drainage catheter was placed under US guidance. (b) Sagittal US image demonstrates the percutaneous drainage catheter (arrow), which has been advanced into the complicated intraperitoneal fluid collection. The collection completely collapsed following drainage despite the appearance of multiple septa within the collection (arrowheads). (c) Intravenous pyelogram obtained 3 days after b and 10 minutes after contrast material injection demonstrates persistent extravasation of contrast material in the left side of the pelvis (arrow), a finding that helped confirm the diagnosis of urinoma. A left percutaneous nephrostomy catheter (not shown) was placed. (d) Antegrade pyelogram obtained following left percutaneous nephrostomy demonstrates a distal contrast material leak (arrow). Despite combination treatment with percutaneous nephrostomy and a urinoma drainage catheter (arrowheads), outputs from the latter remained high. Neither antegrade nor retrograde ureteral stent placement was successful. The urologist wanted to defer definitive surgical treatment for 3-6 months due to a perioperative myocardial infarction. Ureteral embolization was offered as a temporizing measure to divert urine flow from the ureteral leak. (e) Antegrade pyelogram demonstrates two Gianturco coils (arrowheads) in the distalmost portion of the left ureter above the transection. Contrast material from prior injections is seen inferiorly (arrow). (f) CT scan obtained 2 weeks after e demonstrates an interval decrease in the size of the pelvic urinoma due to urinary diversion from the site of the ureteral leak.

View larger version (136K): [in a new window]   Figure 8d.  Ureteral urine leak and urinoma in a 73-year-old man who presented with abdominal pain 2 weeks after undergoing low anterior resection. (a) CT scan demonstrates an extensive intraperitoneal fluid collection in the left side of the pelvis. The fluid collection extended superiorly into the lesser sac (not shown). Because of the extensive nature of the collection, a percutaneous drainage catheter was placed under US guidance. (b) Sagittal US image demonstrates the percutaneous drainage catheter (arrow), which has been advanced into the complicated intraperitoneal fluid collection. The collection completely collapsed following drainage despite the appearance of multiple septa within the collection (arrowheads). (c) Intravenous pyelogram obtained 3 days after b and 10 minutes after contrast material injection demonstrates persistent extravasation of contrast material in the left side of the pelvis (arrow), a finding that helped confirm the diagnosis of urinoma. A left percutaneous nephrostomy catheter (not shown) was placed. (d) Antegrade pyelogram obtained following left percutaneous nephrostomy demonstrates a distal contrast material leak (arrow). Despite combination treatment with percutaneous nephrostomy and a urinoma drainage catheter (arrowheads), outputs from the latter remained high. Neither antegrade nor retrograde ureteral stent placement was successful. The urologist wanted to defer definitive surgical treatment for 3-6 months due to a perioperative myocardial infarction. Ureteral embolization was offered as a temporizing measure to divert urine flow from the ureteral leak. (e) Antegrade pyelogram demonstrates two Gianturco coils (arrowheads) in the distalmost portion of the left ureter above the transection. Contrast material from prior injections is seen inferiorly (arrow). (f) CT scan obtained 2 weeks after e demonstrates an interval decrease in the size of the pelvic urinoma due to urinary diversion from the site of the ureteral leak.

View larger version (112K): [in a new window]   Figure 8e.  Ureteral urine leak and urinoma in a 73-year-old man who presented with abdominal pain 2 weeks after undergoing low anterior resection. (a) CT scan demonstrates an extensive intraperitoneal fluid collection in the left side of the pelvis. The fluid collection extended superiorly into the lesser sac (not shown). Because of the extensive nature of the collection, a percutaneous drainage catheter was placed under US guidance. (b) Sagittal US image demonstrates the percutaneous drainage catheter (arrow), which has been advanced into the complicated intraperitoneal fluid collection. The collection completely collapsed following drainage despite the appearance of multiple septa within the collection (arrowheads). (c) Intravenous pyelogram obtained 3 days after b and 10 minutes after contrast material injection demonstrates persistent extravasation of contrast material in the left side of the pelvis (arrow), a finding that helped confirm the diagnosis of urinoma. A left percutaneous nephrostomy catheter (not shown) was placed. (d) Antegrade pyelogram obtained following left percutaneous nephrostomy demonstrates a distal contrast material leak (arrow). Despite combination treatment with percutaneous nephrostomy and a urinoma drainage catheter (arrowheads), outputs from the latter remained high. Neither antegrade nor retrograde ureteral stent placement was successful. The urologist wanted to defer definitive surgical treatment for 3-6 months due to a perioperative myocardial infarction. Ureteral embolization was offered as a temporizing measure to divert urine flow from the ureteral leak. (e) Antegrade pyelogram demonstrates two Gianturco coils (arrowheads) in the distalmost portion of the left ureter above the transection. Contrast material from prior injections is seen inferiorly (arrow). (f) CT scan obtained 2 weeks after e demonstrates an interval decrease in the size of the pelvic urinoma due to urinary diversion from the site of the ureteral leak.

View larger version (132K): [in a new window]   Figure 8f.  Ureteral urine leak and urinoma in a 73-year-old man who presented with abdominal pain 2 weeks after undergoing low anterior resection. (a) CT scan demonstrates an extensive intraperitoneal fluid collection in the left side of the pelvis. The fluid collection extended superiorly into the lesser sac (not shown). Because of the extensive nature of the collection, a percutaneous drainage catheter was placed under US guidance. (b) Sagittal US image demonstrates the percutaneous drainage catheter (arrow), which has been advanced into the complicated intraperitoneal fluid collection. The collection completely collapsed following drainage despite the appearance of multiple septa within the collection (arrowheads). (c) Intravenous pyelogram obtained 3 days after b and 10 minutes after contrast material injection demonstrates persistent extravasation of contrast material in the left side of the pelvis (arrow), a finding that helped confirm the diagnosis of urinoma. A left percutaneous nephrostomy catheter (not shown) was placed. (d) Antegrade pyelogram obtained following left percutaneous nephrostomy demonstrates a distal contrast material leak (arrow). Despite combination treatment with percutaneous nephrostomy and a urinoma drainage catheter (arrowheads), outputs from the latter remained high. Neither antegrade nor retrograde ureteral stent placement was successful. The urologist wanted to defer definitive surgical treatment for 3-6 months due to a perioperative myocardial infarction. Ureteral embolization was offered as a temporizing measure to divert urine flow from the ureteral leak. (e) Antegrade pyelogram demonstrates two Gianturco coils (arrowheads) in the distalmost portion of the left ureter above the transection. Contrast material from prior injections is seen inferiorly (arrow). (f) CT scan obtained 2 weeks after e demonstrates an interval decrease in the size of the pelvic urinoma due to urinary diversion from the site of the ureteral leak.

View larger version (142K): [in a new window]   Figure 9.  Extraperitoneal bladder injury in an 88-year-old man who had undergone transurethral resection of the prostate gland. Gross hematuria was seen postoperatively. CT cystogram demonstrates extraperitoneal contrast material leakage from the right side of the urinary bladder (arrow). The contrast material extends posteriorly along the medial aspect of the right levator ani muscle. The patient was successfully treated conservatively with a transurethral bladder catheter.

View larger version (141K): [in a new window]   Figure 10.  Extraperitoneal bladder injury in a 58-year-old man who had undergone radical retropubic prostatectomy and bilateral pelvic lymph node dissection. Continuous high outputs from the surgical drains were seen postoperatively. CT cystogram demonstrates extraperitoneal urine and contrast material leakage into the prevesical space of Retzius (arrows). The patient was successfully treated conservatively with a transurethral bladder catheter.

View larger version (156K): [in a new window]   Figure 11a.  Intraperitoneal bladder injury in a 65-year-old man who had undergone laparoscopic low anterior resection. Continuous high outputs from the surgical drains were seen postoperatively. (a) CT cystogram demonstrates a bladder catheter and contrast material within the urinary bladder. Note the contrast material posterior to the bladder (arrowheads) and the surgical drain traversing the urinary bladder dome (arrow). (b) CT cystogram obtained cephalad to a demonstrates intraperitoneal leakage of contrast material into the right paracolic gutter and adjacent to the cecum (arrow). The surgical drain was removed, and the patient was successfully treated with prolonged bladder catheter drainage alone. Although most intraperitoneal bladder injuries require surgical intervention, many iatrogenic injuries to the bladder are minor and can be managed conservatively.

View larger version (138K): [in a new window]   Figure 11b.  Intraperitoneal bladder injury in a 65-year-old man who had undergone laparoscopic low anterior resection. Continuous high outputs from the surgical drains were seen postoperatively. (a) CT cystogram demonstrates a bladder catheter and contrast material within the urinary bladder. Note the contrast material posterior to the bladder (arrowheads) and the surgical drain traversing the urinary bladder dome (arrow). (b) CT cystogram obtained cephalad to a demonstrates intraperitoneal leakage of contrast material into the right paracolic gutter and adjacent to the cecum (arrow). The surgical drain was removed, and the patient was successfully treated with prolonged bladder catheter drainage alone. Although most intraperitoneal bladder injuries require surgical intervention, many iatrogenic injuries to the bladder are minor and can be managed conservatively.

View larger version (142K): [in a new window]   Figure 12a.  Intraperitoneal bladder injury in a 70-year-old man who had undergone subtotal cystectomy with orthotopic neobladder formation from the cecum. Increased output from the surgical drains was seen 1 week after surgery. (a) CT cystogram shows contrast material within the neobladder. Note the intraperitoneal contrast material leak posteriorly (arrows). (b) CT scan demonstrates a second component of intraperitoneal leakage superiorly into the left lower abdomen adjacent to bowel loops. The posterior and anterior components of the urinoma were both drained under CT guidance with 10-F percutaneous drainage catheters. (c) CT scan demonstrates that the transgluteal urinoma drainage catheter has been advanced into the posterior collection shown in a. (d) CT scan shows that the percutaneous urinoma drainage catheter has been advanced into the anterior collection shown in b. Outputs from the collections diminished over a period of 1 week, and the drainage catheters were removed.

View larger version (147K): [in a new window]   Figure 12b.  Intraperitoneal bladder injury in a 70-year-old man who had undergone subtotal cystectomy with orthotopic neobladder formation from the cecum. Increased output from the surgical drains was seen 1 week after surgery. (a) CT cystogram shows contrast material within the neobladder. Note the intraperitoneal contrast material leak posteriorly (arrows). (b) CT scan demonstrates a second component of intraperitoneal leakage superiorly into the left lower abdomen adjacent to bowel loops. The posterior and anterior components of the urinoma were both drained under CT guidance with 10-F percutaneous drainage catheters. (c) CT scan demonstrates that the transgluteal urinoma drainage catheter has been advanced into the posterior collection shown in a. (d) CT scan shows that the percutaneous urinoma drainage catheter has been advanced into the anterior collection shown in b. Outputs from the collections diminished over a period of 1 week, and the drainage catheters were removed.

View larger version (148K): [in a new window]   Figure 12c.  Intraperitoneal bladder injury in a 70-year-old man who had undergone subtotal cystectomy with orthotopic neobladder formation from the cecum. Increased output from the surgical drains was seen 1 week after surgery. (a) CT cystogram shows contrast material within the neobladder. Note the intraperitoneal contrast material leak posteriorly (arrows). (b) CT scan demonstrates a second component of intraperitoneal leakage superiorly into the left lower abdomen adjacent to bowel loops. The posterior and anterior components of the urinoma were both drained under CT guidance with 10-F percutaneous drainage catheters. (c) CT scan demonstrates that the transgluteal urinoma drainage catheter has been advanced into the posterior collection shown in a. (d) CT scan shows that the percutaneous urinoma drainage catheter has been advanced into the anterior collection shown in b. Outputs from the collections diminished over a period of 1 week, and the drainage catheters were removed.

View larger version (151K): [in a new window]   Figure 12d.  Intraperitoneal bladder injury in a 70-year-old man who had undergone subtotal cystectomy with orthotopic neobladder formation from the cecum. Increased output from the surgical drains was seen 1 week after surgery. (a) CT cystogram shows contrast material within the neobladder. Note the intraperitoneal contrast material leak posteriorly (arrows). (b) CT scan demonstrates a second component of intraperitoneal leakage superiorly into the left lower abdomen adjacent to bowel loops. The posterior and anterior components of the urinoma were both drained under CT guidance with 10-F percutaneous drainage catheters. (c) CT scan demonstrates that the transgluteal urinoma drainage catheter has been advanced into the posterior collection shown in a. (d) CT scan shows that the percutaneous urinoma drainage catheter has been advanced into the anterior collection shown in b. Outputs from the collections diminished over a period of 1 week, and the drainage catheters were removed.

View larger version (152K): [in a new window]   Figure 13.  Type 2 urethral injury in a 62-year-old man who had undergone laparoscopic radical prostatectomy. Voiding cystourethrography with injection of contrast material through a bladder catheter was performed in anticipation of early postoperative removal of the catheter. Voiding cystourethrogram obtained during contrast material injection shows a small, contained posterior urethral leak (arrows). The bladder catheter was left in place in keeping with the usual postoperative protocol.

View larger version (105K): [in a new window]   Figure 14a.  Type 3 urethral injury in an 18-year-old man who had sustained a crush injury to the pelvis. (a) Retrograde urethrogram shows contrast material extravasation above and below the urogenital diaphragm (arrows). Note the fracture of the right superior pubic ramus (arrowheads) and contrast material within the urinary bladder from prior contrast-enhanced CT. (b) Photograph demonstrates a regular Foley catheter (14-F suprapubic tube; Bard, Covington, Ga) loaded on a trocar-type introducing device for US-guided percutaneous placement. (c) Cystogram shows the suprapubic tube after US-guided placement.

View larger version (19K): [in a new window]   Figure 14b.  Type 3 urethral injury in an 18-year-old man who had sustained a crush injury to the pelvis. (a) Retrograde urethrogram shows contrast material extravasation above and below the urogenital diaphragm (arrows). Note the fracture of the right superior pubic ramus (arrowheads) and contrast material within the urinary bladder from prior contrast-enhanced CT. (b) Photograph demonstrates a regular Foley catheter (14-F suprapubic tube; Bard, Covington, Ga) loaded on a trocar-type introducing device for US-guided percutaneous placement. (c) Cystogram shows the suprapubic tube after US-guided placement.

View larger version (89K): [in a new window]   Figure 14c.  Type 3 urethral injury in an 18-year-old man who had sustained a crush injury to the pelvis. (a) Retrograde urethrogram shows contrast material extravasation above and below the urogenital diaphragm (arrows). Note the fracture of the right superior pubic ramus (arrowheads) and contrast material within the urinary bladder from prior contrast-enhanced CT. (b) Photograph demonstrates a regular Foley catheter (14-F suprapubic tube; Bard, Covington, Ga) loaded on a trocar-type introducing device for US-guided percutaneous placement. (c) Cystogram shows the suprapubic tube after US-guided placement.

View larger version (117K): [in a new window]   Figure 15a.  Type 3 urethral injury in a 56-year-old man with a history of urethritis. (a) Retrograde urethrogram shows a large periurethral collection of contrast material (arrow). (b) CT scan obtained following an unsuccessful attempt at transurethral bladder catheter placement shows the catheter and foci of air and contrast material within the periurethral space (arrow). Because a transurethral catheter could not be advanced into the urinary bladder, a suprapubic tube (not shown) was placed. (c) US image obtained 7 days after suprapubic tube placement demonstrates an abscess within the perineum due to urine leakage (arrow). An 8-F drainage catheter (not shown) was placed under US guidance. The abscess eventually resolved, permitting subsequent surgical reconstruction of the urethra.

View larger version (121K): [in a new window]   Figure 15b.  Type 3 urethral injury in a 56-year-old man with a history of urethritis. (a) Retrograde urethrogram shows a large periurethral collection of contrast material (arrow). (b) CT scan obtained following an unsuccessful attempt at transurethral bladder catheter placement shows the catheter and foci of air and contrast material within the periurethral space (arrow). Because a transurethral catheter could not be advanced into the urinary bladder, a suprapubic tube (not shown) was placed. (c) US image obtained 7 days after suprapubic tube placement demonstrates an abscess within the perineum due to urine leakage (arrow). An 8-F drainage catheter (not shown) was placed under US guidance. The abscess eventually resolved, permitting subsequent surgical reconstruction of the urethra.

View larger version (116K): [in a new window]   Figure 15c.  Type 3 urethral injury in a 56-year-old man with a history of urethritis. (a) Retrograde urethrogram shows a large periurethral collection of contrast material (arrow). (b) CT scan obtained following an unsuccessful attempt at transurethral bladder catheter placement shows the catheter and foci of air and contrast material within the periurethral space (arrow). Because a transurethral catheter could not be advanced into the urinary bladder, a suprapubic tube (not shown) was placed. (c) US image obtained 7 days after suprapubic tube placement demonstrates an abscess within the perineum due to urine leakage (arrow). An 8-F drainage catheter (not shown) was placed under US guidance. The abscess eventually resolved, permitting subsequent surgical reconstruction of the urethra.