Retroperitoneal urinoma complicating Burch colposuspension.

Burch colposuspension is an accepted and effective technique for correcting genuine stress incontinence w1x. Major complications are rare, but kinking of the ureter can occur in such a procedure especially in patients who have previously undergone hysterectomy w2x. Ureteral kinking can lead to a subtotal ureteral occlusion and hydronephrosis that may result in a rupture of the renal cavities and urinary extravasation. A 61-year-old woman presented with a history of urodynamically proven type II stress incontinence. In February 1989, at another institution, she had undergone transabdominal hysterectomy for uterine fibromatosis complicated by a vescicoureterovaginal fistula; in May 1989 she had the fistula repaired and the left ureter reimplanted; and in February 1990 she again underwent left ureteric reimplantation for symptomatic vescicoureteral reflux. In June 2000 the patient underwent standard Burch colposuspension w3x in our unit. At surgery it was difficult to free the bladder from the pubis and to expose the bladder neck and the anterior vaginal wall. After surgery the patient had a postvoiding residual that decreased to less than 100 ml on the fifth day and therefore she was discharged. During the following weeks she complained of repeated light right flank pain which the GP did not investigate. At 12 weeks she returned with severe right flank pain associated with asthenia and high serum creatinine (3.2 mgy dl). Ultrasonography showed a small left kidney and right hydronephrosis associated with a massive retroperitoneal fluid collection consistent with urinoma. A plain radiogram with contrast medium through the percutaneous nephrostomy confirmed the hydronephrosis with a massive urinoma between L1 and L5 that was drained (1000 ml) and showed the pelvic–ureteric junction (PUJ) rupture Ascending pyelography showed a blockage at the level of the ureteric orifice that extended cranially and laterally. At surgery there was an intense yellowish fibrous tissue which surrounded the ureter and formed a thick wall at the level of the ileopsoas muscle and the posterior peritoneum. The ureter was ischemic and extensively compromised and its distal end was kinked. It seemed unsafe to preserve the ureter and it was totally replaced with a non-modeled, retroperitonealized, isoperistaltic ileal segment. It is likely that the kinking of the distal ureter occurred by placing the sutures proximally to the bladder neck too close to the uretero–vesical junction and by pulling the sutures to Cooper’s ligament straight upwards. A literature review showed only one previous case of perirenal extravasation after Burch colposuspension, caused by a forniceal rupture w4x. In our patient the rupture occurred at the level of the PUJ and the ureter was totally replaced by an ileal segment. We present this case hoping to draw attention to this rare but significant complication and its possible treatment without recurring external diversion.