Case 9582

Perinephric fluid in acute ureterolithiasis

Tzeliou V., Dimitriou Ch., Karvelis A., Sdrolia A., Marmareli P.(Radiology Depatment
G.H.Kastoria).
Giannikotsiou G., Tsiriopoulos I.(Urology Department G.H.Kastoria).

Radiology Department, General Hospital of Kastoria, Greece; Email:cdimitriou@ymail.com

Section: Uroradiology & Genital Male Imaging

Published: 2011, Dec. 22
Patient: 80 year(s), male

Clinical History
An 80-year-old male patient presented to the emergency department with right acute colicky flank
pain, radiating into pelvis. There was no history of acute trauma. Blood tests showed normal renal
function and WBC count. Urinalysis revealed microhematuria.
A second male patient (61-years-old) presented the next day, with the same clinical and laboratory
findings.

Imaging Findings
Ultrasound (US) examination of the first patient demonstrated a normal-appearing right kidney,
right hydronephrosis and hydroureter and a small amount of perinephric fluid (Figure 1). Repeated
US exam the next day revealed a ureteral calculus at the lower end of the right ureter (~2.5 cm from
the vesicoureteral junction [VUJ]). Hydronephrosis and hydroureter were also noted, without any
evidence of perinephric fluid (Figure 2).
The US exam of the second patient demonstrated a right kidney with normal length and
echotexture, mild hydronephrosis, a small amount of perinephric fluid and a ureteral calculus at the
level of the right vesicoureteral junction (Figure 3). The repeated US examination the next day
again showed the ureteral calculus and the mild hydronephrosis, but did not demonstrate the
 presence of perinephric fluid (Figure 4).
The US findings of the two patients (ureteral stone, hydronephrosis, hydroueter and perinephric
fluid) correspond to the secondary signs of acute ureteral obstruction.

Discussion
In the presence of acute ureteral obstruction, accumulation of fluid in the renal interstitium will
occur and renal edema will develop. The role of the renal lymphatics during obstruction is to drain
excess fluid. Renal lymphatics are distributed in two intrarenal locations: deep within the renal
parenchyma and in a subcapsular location. The deep lymphatics drain into the paraaortic lymph
nodes, by forming larger trunks. As these trunks exit the renal hilum, subcapsular lymphatics join
them [1].
The two systems of lymphatic channels communicate, via flow-directed valves, from the deep to the
subcapsular system. Except from the deep and subcapsular lymphatics, perinephric lymphatics also
exist and communicate freely with the subcapsular lymphatics, thus eventually draining into the
paraaortic lymph nodes [1].
During obstruction, initially there is increased lymphatic flow into the deep system and torwards the
renal hilum. In persistent, complete or high-grade obstruction, the progressive dilation of the renal
pelvis will result in compression of the hilar lymphatics and diversion of flow to the subcapsular
and perinephric lymphatics. In partial or intermittent obstruction, the diversion of lymphatic flow to
the subcapsular and perinephric lymphatics will not be significant [1].
The perinephric space is divided into multiple compartments by the fibrous bridging septa [2]. The
perinephric lymphatics run in or immediately adjacent to the bridging septa. Enlargement of the
perinephric lymphatics and thickening of the fibrous bridging septa of the perinephric space are
seen on CTs as linear perinephric stranding. Apart from the stranding of the perinephric fat, discrete
foci of fluid in the perinephric space can be identified. This fluid collects in, between or along the
fibrous bridging septa [1].
Forniceal rupture results in extravased urine and the demonstration of more focal, nonlinear
perinephric collections [3]. Acute rupture of the renal pelvis presents as substantial amounts of fluid
around the affected kidney.
If renal obstruction persists over time, renal lymphatics will drain excess fluid more effectively and
the overall lymphatic drainage will be reduced. Therefore, perinephric stranding might be expected
to diminish over time after reaching a maximum value (~8 h) [4].
The demonstration of ureteral stones (ureterolithiasis) in combination with dilatation of the
collecting system (hydronephrosis), dilatation of the ureter (hydroureter) and/or perinephric fluid
establish the diagnosis of an acute ureteral obstruction. Perinephric fluid alone is a good predictor of
acute obstruction if it is unilateral and the patient has no past history of acute trauma, chronic or
previous renal disease [5].

Final Diagnosis
Perinephric fluid in acute ureterolithiasis.

Differential Diagnosis List

 perinephric fluid due to complicating acute pyelonephritis, perinephric fluid due to complicating
acute renal failure

Figures

Figure 1 US examination (first patient)

Right kidney. Normal-sized right kidney with normal corticomedullary differentiation and
cortical thickness. Mild hydronephrosis. Perinephric fluid.
Radiolody Department,Gerenal Hospital of Kastoria,Greece.

Area of Interest: Kidney;

Imaging Technique: Ultrasound;
Procedure: Diagnostic procedure;
Special Focus: Pathology;

Right kidney. Perinephric fluid.

Radiology Department,General Hospital of Kastoria,Greece.

Area of Interest: Kidney;

Imaging Technique: Ultrasound;
Procedure: Diagnostic procedure;
Special Focus: Oedema;
 Right kidney. Perinephric fluid. Hydronephrosis. Dilatation of the right upper ureter.
Radiology Department,General Hospital of Kastoria,Greece.

Area of Interest: Kidney;

Imaging Technique: Ultrasound;
Procedure: Diagnostic procedure;
Special Focus: Pathology;

Figure 2 Repeated US exanination (first patient)

Ureteral calculus (~2,5cm from the right vesicoureteral junction).

Radiology Department,General Hospital of Kastoria,Greece.

Area of Interest: Urinary Tract / Bladder;

Imaging Technique: Ultrasound;
Procedure: Diagnostic procedure;
Special Focus: Calcifications / Calculi;
 Right kidney. Mild hydronephrosis. Dilatation of the right upper ureter. No perinephric fluid.

Radiology Department,General Hospital of Kastoria,Greece.

Area of Interest: Kidney;

Imaging Technique: Ultrasound;
Procedure: Diagnostic procedure;
Special Focus: Dilatation;

Figure 3 US examination (second patient)

Ureteral calculus with posterior acoustic shadowing at the level of the right VUJ.
Radiology Department,General Hospital of Kastoria,Greece.

Area of Interest: Urinary Tract / Bladder;

Imaging Technique: Ultrasound;
Procedure: Diagnostic procedure;
Special Focus: Calcifications / Calculi;
 Right kidney. Mild hydronephrosis. Perinephric fluid.
Radiology Department,General Hospital of Kastoria,Greece.

Area of Interest: Kidney;

Imaging Technique: Ultrasound;
Procedure: Diagnostic procedure;
Special Focus: Pathology;

Perinephric fluid(arrows).
Radiology Department,General Hospital of Kastoria,Greece.

Area of Interest: Kidney;

Imaging Technique: Ultrasound;
Procedure: Diagnostic procedure;
Special Focus: Oedema;

Figure 4 Repeated US examination (second patient)

 Ureteral calculus at the level of the right VUJ.
Radiology Department,General Hospital of Kastoria,Greece.

Area of Interest: Urinary Tract / Bladder;

Imaging Technique: Ultrasound;
Procedure: Diagnostic procedure;
Special Focus: Calcifications / Calculi;

Right kidney. No perinephric fluid.

Radiology Department,General Hospital of Kastoria,Greece.

Area of Interest: Kidney;

Imaging Technique: Ultrasound;
Procedure: Diagnostic procedure;
Special Focus: Oedema;

MeSH
Ureteral Calculi [C12.777.809.851]
Calculi of the ureter, usually the result of the passage of one originating in the kidney. It occurs
usually in mid-life, rarely in children; and is more frequent in males than females. (From CMIT, 5th
 ed)

Ureteral Obstruction [C12.777.725.776]

References
[1] Michael J.Varanelli, et al. (2001) Relationship between duration of pain and secondary signs of
obstruction of the urinary tract on unenhanced helical CT AJR 177(2):325-30

[2] Kunin M. (1986) Bridging septa of the perinephric space:anatomic,pathologic,and diagnostic

considerations Radiology 158(2):361-5

[3] Neal C.Dalrymple, et al. (2000) Pearls and pitfalls in the diagnosis of ureterolithiasis with
unenhanced helical CT Radiographics. 20(2):439-47

[4] R.C.Smith, D.M.Coll (2002) Helical computed tomography in the diagnosis of ureteric colic
BJUInternational 86:33-41

[5] Mathias Prokop, Michael Galanski (2003) Spiral and Multisliced Computed Tomography of the
Body Thieme p.653-4

Citation
Tzeliou V., Dimitriou Ch., Karvelis A., Sdrolia A., Marmareli P.(Radiology Depatment
G.H.Kastoria).
Giannikotsiou G., Tsiriopoulos I.(Urology Department G.H.Kastoria).

Radiology Department, General Hospital of Kastoria, Greece; Email:cdimitriou@ymail.com (2011,

Dec. 22)
Perinephric fluid in acute ureterolithiasis {Online}
URL: http://www.eurorad.org/case.php?id=9582