(Kiosk 1) Rare Case: Massive Urinoma in Spinal Cord Injury Patient with Severe Unilateral Hydronephrosis

Case Diagnosis: A 50-year-old male with history of T9 complete paraplegia presents to rehabilitation unit with flank pain, found to have large urinoma on imaging requiring emergent nephrostomy and kidney embolization.

Case Description: A 50-year-old male with history of T9 complete paraplegia, neurogenic bladder, and right hydronephrosis s/p stent placement and removal was admitted to the spinal cord injury unit for rehabilitation after a prolonged hospitalization for treatment of a left septic hip. Persistent flank pain prompted a renal US/CT which demonstrated severe right hydronephrosis 2/2 obstructed ureter c/b development of a large urinoma and renal pelvis injury. The patient underwent emergent right percutaneous nephrostomy and retroperitoneal drain placement followed by laparoscopic total nephrectomy. The surgery was c/b IVC and small bowel injury necessitating conversion to open repair and abortion of the planned right nephrectomy. The post-operative course was c/b ileus and suspected SBO in the SICU, resulting in NG placement and initiation of TPN. The patient recovered and underwent right kidney embolization. Follow up CTA abdomen demonstrated persistent perfusion to the kidney, requiring repeat right kidney embolization. In the following month, the right percutaneous nephrostomy tube was removed, and the patient was discharged home.

Discussion: Renal cysts are a common complication in SCI patients; however, the threshold for diagnostic workup in the event of clinical symptoms or lab abnormalities should be low. Cyst conversion into large urinomas can be masked by spinal cord syndrome paresthesia and contralateral renal compensation, resulting in delayed diagnoses.

Setting: Spinal Cord Injury unit at VA Medical Center

Assessment/Results: The patient responded well to rehabilitation post-embolization and was able to discharge home.

Conclusion: This case highlights the importance of timely intervention and prompt investigation of concerning renal symptoms in high-risk SCI patients. Providers need to be aware of this curable condition that may be obscured by spinal cord syndrome and contralateral renal compensation.