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Ureteral Rupture and Bone Scintigraphy
OG22'"5347 /78/2 203-038,5$02, GO/C' THE ,JDURNAL OF' UR.OL0.3Y
Copyright ©
by The 'ij.Jillia:::ns
Vlilkins Co.
BONE
RUPTURE MOI-ffa... MMED MOINUDDIN*
AND
JOHN F. ROCKETT
From the Division of Nuclear Medicine, Baptist Memorial Hospital, Memphis, Tennessee
ABSTRACT
The scintigraphic findings are described of upper ureteral rupture seen incidentally on bone scan in a 30-year-old patient after retrograde pyelography. This case is presented to alert physicians to look for non-osseous abnormalities on the bone scan. Upper ureteral rupture owing to trauma is rare because of its anatomical location, since it is protected by psoas muscle and lumbar vertebrae. 1 However, it may be perforated occasionally during cystoscopy, particularly if stenosis or obstruction is present. Its prompt recognition and appropriate treatment are necessary to avoid complications such as abscess or fistula formation, urinoma, loss of renal function on the involved side and, occasionally, death. Gross or microscopic hematuria, although a reliable sign, may not be present in all cases. 1 A high index of suspicion is needed in the absence of hematuria to confirm the diagnosis by excretory urography (IVP) and retrograde pyelography, which are the most sensitive tests to locate the site and size of urinary leakage. Herein we describe a case of perforation of the upper ureter diagnosed incidentally on bone scan.
clearly on the scan. Hence, any type of renal lesion, such as a cyst, neoplasm, dysfunction, abscess, infarction and so forth, can be identified readily if the scan is done when the radiopharmaceutical is still circulating in the kidneys. 2 Normally,
CASE REPORT
A 30-year-old man was hospitalized with severe back, right lower quadrant and right testicular pain radiating into the right lower extremity 6 to 7 weeks in duration. He had had similar complaints associated with hematuria 2 years previously. Physical examination was negative except for tenderness in the right flank, right lower quadrant and right costovertebral angle. Appropriate tests showed 24 to 30 red blood cells per high power field in the urine. An IVP was normal with no evidence of calculus. Cystoscopy and retrograde pyelography (fig. 1) were negative except for slight persistent narrowing of the right ureter at the level ofL3. The left side was normal. To rule out lnmbar vertebral pathology a bone scan was done using 15 mCi. ssmtechnetium stannous pyrophosphate intravenously and a gamma camera. The posterior scintiphoto showed a triangular area of radioactivity just below the inferior pole of the right kidney (fig. 2, A). A close--up view defined the abnormality better, which was between the inferior pole of the and iliac crest projecting from the proximal ureter is compatible with extravasation of urine. There ·was increased ctU.lUa'CCl lll the system of the right kidney compared to the kidney, was consistent with obstruction. The left kidney was normal and was used as a control. the ureters are not visualized unless they are dilated. Because of these findings an !VP was repeated, which confirmed the scintig-rnphic impression (fig. 3). A ureteral stent was inserted. Convalescence was uneventful. The primary indication for a bone scan is the diagnosis of bony disease-like neoplasms, infections (osteomyelitis), radiographically occult fracture and so forth. The mechanism of localization of radiolabeled phosphates in the bone is dependent on blood flow and bone turnover. This radiopharmaceutical is excreted primarily by the kidneys, which are imaged Accepted for publication January 13, 1978. * Requests for reprints: Division of Nuclear Medicine, Baptist Memorial Hospital, Memphis, Tennessee 38146. 365
Fm. 1. Retrograde pyelography shows narrowing of right ureter
at L3 level.
ureters are not seen unless they are dilated and, hence, obstructive uropathy also can be identified. Sometimes soft tissue tumors also are seen on the total body bone scan either because of chemical affinity of radiopharmaceutical for the tumor or on the basis of hypervascularity. '3 This should not be confused with extravasation of urine, although the intensity of radioactivity will be helpful in deciding whether it is a tumor.
366
MOINUDDIN AND ROCKETT
FIG. 2. A, posterior bone scintigraphy shows extravasation of urine below inferior pole of right kidney with pooling of radioactivity in collecting system. Left kidney is normal. B, spot film of right kidney with clearer definition of area of extravasation.
In our case a bone scan was done to rule out lumbar vertebral pathology because the description of pain was not typical of ureteral colic. The diagnosis of extravasation of urine was purely an incidental finding. We do not suggest that bone scanning is a test of choice in suspected cases of ureteral perforation but instead emphasize the value of clinically unsuspected findings on total body scintigraphy, which may be of great help to the referring physician. Retrograde pyelography and IVP are adequate sensitive tests for the diagnosis of extravasation of urine. REFERENCES
1. Evans, R. A. and Smith, M. J. V.: Violent injuries to the upper
ureter. J. Trauma, 16: 558, 1976. 2. Vieras, F. and Boyd, C. M.: Diagnostic value of renal imaging incidental to bone scintigraphy with 99mTc-phosphate compounds. J. Nucl. Med., 16: 1109, 1975. 3. Manoli, R. S. and Soin, J. S.: Concentration of 9gm Tc Pyp in a benign leiomyoma of the uterus. Clin. Nucl. Med., 2: 60, 1977.
FIG. 3. Repeat IVP confirming findings in figure 2, B
Copyright ©
by The 'ij.Jillia:::ns
Vlilkins Co.
BONE
RUPTURE MOI-ffa... MMED MOINUDDIN*
AND
JOHN F. ROCKETT
From the Division of Nuclear Medicine, Baptist Memorial Hospital, Memphis, Tennessee
ABSTRACT
The scintigraphic findings are described of upper ureteral rupture seen incidentally on bone scan in a 30-year-old patient after retrograde pyelography. This case is presented to alert physicians to look for non-osseous abnormalities on the bone scan. Upper ureteral rupture owing to trauma is rare because of its anatomical location, since it is protected by psoas muscle and lumbar vertebrae. 1 However, it may be perforated occasionally during cystoscopy, particularly if stenosis or obstruction is present. Its prompt recognition and appropriate treatment are necessary to avoid complications such as abscess or fistula formation, urinoma, loss of renal function on the involved side and, occasionally, death. Gross or microscopic hematuria, although a reliable sign, may not be present in all cases. 1 A high index of suspicion is needed in the absence of hematuria to confirm the diagnosis by excretory urography (IVP) and retrograde pyelography, which are the most sensitive tests to locate the site and size of urinary leakage. Herein we describe a case of perforation of the upper ureter diagnosed incidentally on bone scan.
clearly on the scan. Hence, any type of renal lesion, such as a cyst, neoplasm, dysfunction, abscess, infarction and so forth, can be identified readily if the scan is done when the radiopharmaceutical is still circulating in the kidneys. 2 Normally,
CASE REPORT
A 30-year-old man was hospitalized with severe back, right lower quadrant and right testicular pain radiating into the right lower extremity 6 to 7 weeks in duration. He had had similar complaints associated with hematuria 2 years previously. Physical examination was negative except for tenderness in the right flank, right lower quadrant and right costovertebral angle. Appropriate tests showed 24 to 30 red blood cells per high power field in the urine. An IVP was normal with no evidence of calculus. Cystoscopy and retrograde pyelography (fig. 1) were negative except for slight persistent narrowing of the right ureter at the level ofL3. The left side was normal. To rule out lnmbar vertebral pathology a bone scan was done using 15 mCi. ssmtechnetium stannous pyrophosphate intravenously and a gamma camera. The posterior scintiphoto showed a triangular area of radioactivity just below the inferior pole of the right kidney (fig. 2, A). A close--up view defined the abnormality better, which was between the inferior pole of the and iliac crest projecting from the proximal ureter is compatible with extravasation of urine. There ·was increased ctU.lUa'CCl lll the system of the right kidney compared to the kidney, was consistent with obstruction. The left kidney was normal and was used as a control. the ureters are not visualized unless they are dilated. Because of these findings an !VP was repeated, which confirmed the scintig-rnphic impression (fig. 3). A ureteral stent was inserted. Convalescence was uneventful. The primary indication for a bone scan is the diagnosis of bony disease-like neoplasms, infections (osteomyelitis), radiographically occult fracture and so forth. The mechanism of localization of radiolabeled phosphates in the bone is dependent on blood flow and bone turnover. This radiopharmaceutical is excreted primarily by the kidneys, which are imaged Accepted for publication January 13, 1978. * Requests for reprints: Division of Nuclear Medicine, Baptist Memorial Hospital, Memphis, Tennessee 38146. 365
Fm. 1. Retrograde pyelography shows narrowing of right ureter
at L3 level.
ureters are not seen unless they are dilated and, hence, obstructive uropathy also can be identified. Sometimes soft tissue tumors also are seen on the total body bone scan either because of chemical affinity of radiopharmaceutical for the tumor or on the basis of hypervascularity. '3 This should not be confused with extravasation of urine, although the intensity of radioactivity will be helpful in deciding whether it is a tumor.
366
MOINUDDIN AND ROCKETT
FIG. 2. A, posterior bone scintigraphy shows extravasation of urine below inferior pole of right kidney with pooling of radioactivity in collecting system. Left kidney is normal. B, spot film of right kidney with clearer definition of area of extravasation.
In our case a bone scan was done to rule out lumbar vertebral pathology because the description of pain was not typical of ureteral colic. The diagnosis of extravasation of urine was purely an incidental finding. We do not suggest that bone scanning is a test of choice in suspected cases of ureteral perforation but instead emphasize the value of clinically unsuspected findings on total body scintigraphy, which may be of great help to the referring physician. Retrograde pyelography and IVP are adequate sensitive tests for the diagnosis of extravasation of urine. REFERENCES
1. Evans, R. A. and Smith, M. J. V.: Violent injuries to the upper
ureter. J. Trauma, 16: 558, 1976. 2. Vieras, F. and Boyd, C. M.: Diagnostic value of renal imaging incidental to bone scintigraphy with 99mTc-phosphate compounds. J. Nucl. Med., 16: 1109, 1975. 3. Manoli, R. S. and Soin, J. S.: Concentration of 9gm Tc Pyp in a benign leiomyoma of the uterus. Clin. Nucl. Med., 2: 60, 1977.
FIG. 3. Repeat IVP confirming findings in figure 2, B