Blackwell Science, LtdOxford, UKIJUInternational Journal of Urology0919-81722004 Blackwell Publishing Asia Pty LtdDecember 2004111210581064Original Article Ureteroscopic treatment

for stone-causing fornix ruptureP Kalafatis

et al. .

International Journal of Urology (2004) 11, 10581064

Original Article

Primary ureteroscopic treatment for obstructive ureteral stone-causing fornix rupture

PANAGIOTIS KALAFATIS, KONSTANTINOS ZOUGKAS AND ANASTASIOS PETAS Department of Urology, General Hospital of Rhodos Island, Rhodos, Greece
Abstract Background: Management of fornix rupture (FR) by obstructive stone is comprised of extravasation control and the elimination of the obstruction. For all patients, management initially remains conservative under close follow up. Endoscopic management of FR involved with an obstructive stone of the ureter or the pelviureteric junction (UPJ) consists mainly of stenting the ureter. Our endoscopic approach to this pathological entity comprises of the sole stenting of the ureter, as well as primary ureteroscopic lithotripsy followed by ureter stenting. Patients and methods: In the Department of Urology at the General Hospital of Rhodos Island, Rhodos, Greece, over the last 15 years, 51 of 86 patients with FR due to an obstructive stone, were treated endoscopically. Twenty-two patients underwent sole stenting of the ureter (option A) and 29 patients underwent primary ureteroscopic lithotripsy and stenting (option B). Results: The overall primary successful outcome was achieved in nine of the 22 patients (40.9%) in the group treated with sole stenting, while the remaining 59.1% required secondary interventions. However, 27 of the 29 patients (93.1%) treated with primary ureteroscopic lithotripsy and stenting required no auxiliary treatment. The primary successful outcome results for obstructive middle and lower ureteral stones with FR were eight out of 12 (66.6%) and 26 out of 27 (96.3%) for therapeutic options A and B, respectively. Upper obstructive ureteral stones with FR required secondary intervention in most cases, regardless of the therapeutic option chosen. (In nine out of 10 and one out of two cases for options A and B, respectively). The mean duration of hospitalization for options A and B were 7.6 and 5.3 days, respectively. The mean duration that the ureter stent remained in situ for A and B treatment options was 30.9 and 10.2 days, respectively. Conclusions: Sole stenting of the ureter is reserved for infected FR or for stones of the upper ureter or the UPJ. Ureteroscopic lithotripsy followed by double-J stenting of the ureter may offer a quick and safe therapeutic alternative for distal and middle obstructive ureteral stones with FR. fornix rupture, primary ureteroscopic treatment, urinoma, ureteric stone.

Key words

Introduction
Spontaneous rupture of the calyceal-fornix renalis (FR) along with urine extravasation in the perinephric space or the retroperitoneum is an uncommon complication of obstructive nephropathy. It is important to distinguish extravasation of the fornical backow type13 from that
Correspondence: P F Kalafatis MD, 27 Papanastasi Street, Rhodes 85100, Greece. Email: P_kal@yahoo.com Received 10 February 2003; accepted 25 May 2004.

owing to frank rupture of a diseased renal pelvis or the ureter.4 Involvement of FR in renal colic is not common, but the majority of FR is associated with ureteral obstruction by ureteral stones or stones of the pelviureteric junction.57 The onset of FR will be suspected by changes in clinical symptoms, while diagnosis will be based on the following symptoms and ndings: (i) an alteration of the typical characters of kidney colic to a growing diffuse lumbar pain and discomfort with symptoms of peritoneal irritation; (ii) leucocytosis and, in many

Ureteroscopic treatment for stone-causing fornix rupture

1059

cases, a temperature increase; (iii) a loss of retroperitoneal land marks (mainly a lack of clearness of the psoas shadow and an antalgic posture of the vertebral column to the diseased kidney), stone identication and signs of bowel paresis on the plain lm of the abdomen; (iv) uid extravasation of various quantities in peripelvic, perinephric or periureteral areas, combined or not with pyelocalyceal dilation in serial ultrasonographic investigations; (v) color duplex Doppler sonographic (CDDS) evaluation of blood perfusion in interlobularis renal arteries, with an estimation of their resistance index (RI) and pulsatility index (PI);810 (vi) contrast medium extravasation in peripelvic, perinephric or retroperitoneal spaces observed on intravenous pyelograms or computed tomography (CT) scans (when performed in selected cases); in addition to (vii) ndings from spiral CT scans of the retroperitoneum.6,7,1114 Management of FR due to ureteral lithiasis consists, in principle, of desobstruction and the control of the extravasation. Sole stenting of the ureter fullls these criteria and remains a widely accepted method of treatment for such a condition, even though it very often requires secondary ancillary interventions. Ureterorenoscopic lithotripsy, accepted as the rst option in ureteral calculi which must be operatively treated,1517 has been introduced in the management of FR by obstructive stone at the Department of Urology, General Hospital of Rhodos Island, Rhodos, Greece, with good results and minimal morbidity.18 The aim of the present study was: (i) to refer to our policy of the diagnosis and management of obstructive stones with FR; (ii) to present our experience on primary ureteroscopic treatment of such cases; and (iii) to evaluate the comparative efcacy and morbidity of the various endoscopic methods, emphasizing the efcacy and safety of primary ureteroscopic lithotripsy.

Milwaukee, WI) and in selected cases, CT and spiral CT scans. Quantication of urine extravasation was mainly based on sonographic observations and ndings and, for practical reasons, was classied in two grades (Table 1). Grade I: Fluid collection in proximity to the pelvicocalyceal system, which is not always dilated, and small amount of perirenal extravasation mainly limited around the lower renal pole (Fig. 1). Grade II: Large uid collection in perinephric area with expansion along the ureter in the retroperitoneum (Fig. 2).11,12,14 Management of patients and their follow-up comprised of close clinical observation, repeated laboratory tests, plain X-rays, repeated ultrasounds of the abdomen and retroperitoneum, repeated CDDS of both kidneys and spiral CT scans (in certain cases). Except in two cases, intravenous pyelograms were not performed. Initial treatment of the 86 patients with FR caused by obstructive ureteral stones consisted of bed rest, controlled uid resuscitation and prophylactic antibiotic coverage. Subsequently, 35 of the 86 patients
Table 1 Details of 51 patients with ureteral stone causing Fornix rupture Variables Number of patients (%) Male Female Patient age (mean, years) Male Female Mean stone size (mm) Stone size (%) >5 mm 5 mm Stone localization Upper ureter Middle ureter Lower ureter Middle and lower ureter Side of FR Right Left Grade of urine extravasation Grade I Grade II Option A 29 (56.8) 16 6 37.3 41.6 33.1 6.5 12 (41.4) 17 (58.6) 10 (45.5) 6 (20.7) 21 (72.4) 27 (93.1) 11 (37.9) 18 (62.1) 8 (27.6) 13 (59.1) Option B 22 (43.2) 14 15 51.2 66.4 36.0 5.3 8 (36.4) 14 (63.6) 2 (6.9) 5 (22.7) 7 (31.8) 12 (54.5) 10 (45.5) 12 (54.5) 9 (40.9) 21 (72.4) Overall 51 30 21 44.3 54.0 34.5 5.7 20 (39.2) 31 (60.8) 12 11 28 39 (23.5) (21.6) (54.9) (76.5)

Patients and methods

Methods

Between June 1988 and June 2003, we evaluated and treated 86 patients with urinary extravasation due to FR. All patients had kidney colic caused by a stone of the ureter or the UPJ. Imaging modalities concerned in the diagnosis of FR primarily included a serial ultrasonographic and CDDS evaluation of the kidneys and retroperitoneum (Acuson 128XP with a 3.52.5 MHz transducer, Acuson, Mountain View, CA, and General Electric Logiq 500 proseries with a 26 MHz transducer, GE Medical Systems,

21 (41.2) 30 (58.8) 17 (33.3) 34 (66.7)

FR, fornix rupture; option A, sole stenting of the ureter; option B, ureteroscopy lithotripsy mechanical stone extraction ureter stenting.

1060

P Kalafatis et al.

Fig. 1 Longitudinal. Grade I urine extravasation in perinephric space, limited close to the kidney mainly in peripelvic region and around the lower renal pole. Pyelocalyceal dilation is of low grade.

Fig. 2 Longitudinal section. Grade II urine extravasation with an urinome expansion along the lower renal pole and the ureter (arrows). Pyelocalyceal dilation remains detectable.

(40.7%) were primarily treated conservatively while the 51 patients (59.3%) were introduced to primary invasive management. The latter consisted of two options: (a) primary sole stenting of the ureter (29 patients); and (b) primarily ureteroscopic (URS), comprising lithotripsy in situ, fragment extraction and stenting of the ureter. Finally, secondary ancillary interventions, such as URS, in situ lithotripsy, mechanical stone removal and shockwave lithotripsy (SWL), were performed when it was necessary. Primary stenting of the ureter was performed via cystoscope under local anesthesia of the urethra. We advanced a double-J stent through the ureteral orice up to the kidney. This was left in place for 2530 (mean, 28.3) days. In cases where the ureteral stone was not removed in the meantime, a secondary attempt with URS and lithotripsy followed by ureter stenting for 1015 days, was performed. Emigration of the stone towards the kidney during primary stenting was followed by delayed extracorporeal SWL at least 20 days after FR onset. Primary URS and lithotripsy with stenting were mostly performed with local anesthesia of the urethra, analgesia and intravenous sedation. Certain patients were treated under general anesthesia. The procedures were performed using a 6.9 Fr, 41-cm long, semirigid ureteroscope with two working ports of 2.3 and 3.4 Fr (Micro-6 Semi-Rigid Ureteroscope; ACMI, Southborough, MA) in addition to a

7.5 Fr exible ber uretero-renoscope with a 3.6 Fr instrument channel (Richard Wolf, Knittlingen, Germany). Initially, we performed electrohydraulic lithotripsy (EHL) using a 1, 9 or 3 Fr probe. From 1999, we used a low-power (1020 watt) holmium yttriumaluminum-garnet laser device (Medilas-H Dornier; MedTech, Germering, Germany) with 200 or 600 mm bers and we occasionally used a ballistic intracorporeal pneumatic lithotriptor (Wolf-Lithoclast; Richard Wolf, Germany) with a 3 Fr probe (for use through the semirigid ureteroscope).The irrigating uid was given manually by the assistant and in small quantities each time. After lithotripsy we attempted to remove the stone fragments with baskets or grasping forceps when necessary. The endoscopic procedures were performed under video-endoscopy, which facilitated the coordination of the working team. All patients received a 6 Fr double-J ureter stent and a 16 Fr bladder catheter, which were removed at the 1015th and 3rd day, respectively.
Inclusion criteria for the various therapeutic approaches

Primary conservative The main criteria for treat patients this way were: (i) mild symptoms and good patient tolerability; (ii) normal temperature (or <38C) with an absence of urinary tract infection (UTI); (iii) stone size and location which was considered to be instantly removable; and (iv) tendency

Ureteroscopic treatment for stone-causing fornix rupture

1061

of urine extravasation, in correlation to the hydronephrosis, to be reabsorbed. Primary invasive option A: Stenting of the ureter The main criteria to treat patients this way were: (i) increase in symptom intensity combined with generalized abdominal pain and discomfort; (ii) clinical ndings, high body temperature and labor results showing induction to sepsis; (iii) stone size >5 mm; (iv) stone localization in the pyelocalyceal junction or in the upper ureter; (v) pregnancy; and (vi) an increase of urine extravasation independent from hydronephrosis grading. Primary invasive option B: Ureteroscopic lithotripsy and stenting Criteria to treat patients ureteroscopically were: (i) absence of UTI; (ii) stone size 10 mm; (iii) stone localization preferably in the lower and middle ureteral segment; (iv) women; (v) men without prostate enlargement which may cause insuperable difculties when using a semirigid instrument by URS, problems we eliminated using a exible ureterorenoscope; and (vi) an increase or persistence of urine extravasation over 24 h.
Criteria for therapy outcome

Stone fragmentation smaller than 2.5 mm was considered to be successful fragmentation, while we classied the urinary tract as stone free upon complete removal of the fragments. We considered a successful outcome as when successful fragmentation and/or a stone free urinary tract, combined with complete absorption of urine extravasation, was achieved.

Results
Pertinent patient characteristics are given in Table 1, which demonstrates a relatively comparable patient cohort in both groups, with the main exception concerning percentages of stone localization. To eliminate this item we invented a subgroup for both treatment options, comprising patients with stones localized only in middle and distal ureter. Of those treated with primary intervention (51 patients; mean age, 43.7 years), 30 patients were male and 21 patients were female. The mean stone size was 5.7 mm. Stones were localized in the upper, middle and lower ureter in 12, 11 and 28 cases, respec-

tively. Most of the stones (39, 76.5%) were localized in the middle and distal ureter. Fornix rupture was detected in 21 and 30 cases on the right and left side, respectively. Urine extravasation was estimated as grade I in 33.3% and grade II in 66.7% of patients. Twenty-two (43.2%) and 29 (56.8%) patients were treated according to options A and B, respectively (Table 1). Primary successful outcome, independence from stone localization in the ureter, was been achieved in nine out of 22 patients (40.9%) and 27 out of 29 patients (93.1%) treated by options A and B, respectively. The overall estimation of the use of required secondary interventions (SWL, URS, lithotripsy or the use of endoscopic ancillary instruments) for patients treated according to the option A is 13 out of 22 patients (59.1%). Delayed SWL was required by six out of 22 patients (27.3%) treated by option A. In the subgroup with middle and distal ureter calculosis (comprising 39 patients), a successful outcome was registered in eight of the 12 patients (66.7%) and in 26 of the 27 patients (96.3%) treated by options A and B, respectively. The higher success rate in favor of option B given was proven by Fischers exact test to be statistically signicant (P < 0.01). Twelve of the 51 (23.6%) patients with middle and distal obstructive stones underwent primary stenting. Secondary interventions were required by four of these 12 patients (33.3%, Table 2). Two of the 12 patients were pregnant. Diagnosis and stone localization, as well as nal treatment, of the rst pregnant patient was completed postpartum by the use of URS, lithotripsy and stenting. The second pregnant patient observed spontaneous stone passage 12 days after ureteral stenting. In two male patients in this group, the insertion of the semirigid URS was not possible due to an undesirable erection during the general anesthesia. Both required no secondary intervention. The remaining eight patients in this group underwent sole stenting, fullling the inclusion criteria listed previously (three patients with enlargement of the prostate and ve patients with UTI and signs of urosepsis). One patient required secondary mechanical stone removal from the cystoureteric junction, one patient required SWL and the nal patient required URS, lithotripsy and stenting. Duration of hospitalization was an average of 7.6 2.1 days and 5.3 1.3 days for patients treated by options A and B, respectively. The double-J catheters remained for 30.9 4.6 and 10.2 2.8 days in patients treated according to options A and B, respectively (Table 2). No major early or late complications were reported.

1062

P Kalafatis et al.
Outcome of the treatment of 51 patients with fornix rupture by obstructive stone Option A (%) 9/22 (40.9) 6/22 (27.3) 4/22 (18.2) 3/22 (13.6) 13/22 (59.1) 4/12 (33.3) 7.6 2.1 30.9 4.6 2/22 (9.1) Option B (%) 27/29 (93.1) 1/29 (3.4) 1/29 (3.4) 0 (0.0) 2/29 (6.9) 1/27 (0.37) 5.3 1.3 10.2 2.8 1/29 (3.5) Overall (%) 36/51 (70.6) 7/51 (13.7) 5/51 (9.8) 3/51 (5.9) 15/51 (29.4) 5/39 (12.8) 6.4 1.7 20.3 3.7 3/51 (5.9)

Table 2 Variable

Primary successful outcome Delayed SWL Secondary URS and lithotripsy Secondary URS and stone extraction Total of secondary procedures required, regardless of stone location Secondary procedures required for stones of middle and distal ureter. Hospitalization (mean SD, days) Total stay of double-J stent (mean SD, days) Infection (minor) SWL, shock wave lithotripsy; URS, ureteroscopy.

Discussion
Diagnosis of FR is based primarily on the evaluation of the symptoms, plain X-ray of the abdomen, serial ultrasonography and CDDS evaluations of the kidneys. Serial ultrasonographic evaluation of the kidney and retroperitoneum has a high sensitivity in detecting even small quantities of uid extravasation in the peripelvic, perinephric or retroperitoneal areas, but is of low specicity when distinguishing urine extravasation from a hematoma or abscess. It is necessary to emphasize that during follow-up of FR, repeated ultrasonogrpahic evaluation, as well as a comparison of the data is essential. Furthermore, in certain cases, such as pregnancy, sonography is the only accepted way to diagnose kidney disease.19 Color duplex Doppler sonography, in addition to ultrasonography gives the dynamic aspect of the hydronephrosis. By following the degradation of RI and PI in the interlobular arteries of the diseased kidney and comparing the data to that of the healthy contralateral kidney, one may have indirectly useful information concerning the degree of the intrinsic pressure of the renal pelvis (Fig. 3). Pulsatility index and particularly RI values are signicantly elevated by acute hydronephrosis and are decreased by desobstruction.20 During the onset of FR, we observed decreases of RI and PI values (data on this topic are preliminary and not evaluated). This kind of information, added to that taken from serial ultrasonography and other imaging modalities give the physician the possibility to evolve a precise and dynamic idea of the forces acting during hydronephrosis and the onset of FR. Intravenous pyelogram is a very sensitive and specic method to conrm the diagnosis of FR. However, it is accused of provoking, or at least of increasing, extravasation due to the diuretic effect of the contrast

Fig. 3 Color duplex Doppler sonography of the interlobular arteries of a kidney with Fornix Rupture (FR). Mean RI (resistance index), mean pulsatility index and mean systolic to diastolic ratio of the arterial ow was estimated on the interlobular arteries of the upper, middle and lower kidney. High RI values were often registered (values of >0.70 are indicative of an acute obstruction). The mean inter-renal difference of RI (DRI) between the ipsilateral kidney with FR and contralateral healthy organ was <0.06. Taking into consideration that DRI values of 0.06 are accepted to be indicative of an acute obstruction, we believe that the onset of FR leads to a partial desobstruction of the pyelon which decrease the RI and the other arterial ow parameters.

media and is proposed to be eliminated from the rst line diagnostic options, as well as in the acute phase of renal colic.4,21,22 Computed tomography scans, as well as nonenhanced spiral CT scans, may assess renal obstruction and perinephric edema in a more sensitive and specic way than other, non-invasive, imaging modalities; however, perinephric edema due to acute obstruction is not synonymous with the extensive changes in perinephric space in ruptured fornix by ureter lithiasis.11,12 Furthermore, the combination of scout radiography of the abdo-

Ureteroscopic treatment for stone-causing fornix rupture

1063

men and serial utrasonography of the kidney and retroperitoneum yielded comparable results with no clinically signicant misdiagnoses and, therefore, can be used as an alternative when CT resources are limited. Additionally, ultrasonography is more accessible to the urologist, particularly given that CT is not always available as a 24-h service at all institutions.23 Ultrasonography also has several advantages, as it is simple to perform real-time, non-invasive, does not involve exposure to ionizing radiation, is relatively inexpensive and less time consuming than other imaging procedures. In the Department of Urology at the General Hospital of Rhodos Island, serial ultrasonography and CDDS is available to the urologist for immediate and repeatable assessment of FR and markedly improves diagnostic condence. According to the majority of the related literature the management of obstructive stones with FR, is conservative and recovery is most often uneventful,11,24,25 although Chapman et al. insist that 10% of perirenal abscesses are delayed complications of FR.26,27 In the present series, 40.7% of patients were treated conservatively with no early or late complications. However, in many cases, interventional treatment was required due to the patients clinical condition, the persistence of the obstruction and extravasation or the presence of complications, such as urinoma or abscess.26,28,29 Interventional treatment with ureteral stenting alone reduces hydronephrosis and urine extravasation by pushing back the stone to the pyelon, or even by passing the obstructing stone of the ureter. This method resolves the acute phase, but it usually (59.1% in the present series) requires secondary auxiliary interventions, such as SWL or URS, lithotripsy and instrumental maneuvers, which prolong the hospital stay and morbidity.6,8,22 In cases of UTI or sepsis, endoscopic maneuvers basically consist of gentle desobstruction of the ureter by stenting alone, preferably with a ureter catheter, and sufcient antibiotic covering is indispensable in all cases. The use of optical bers and the reduction of the outer diameter while preserving a wide working channel in the ureteroscopes minimized the invasiveness of ureteroscopy. Flexible ureterorenoscopes of small calibers reduce the disadvantages of rigid and semirigid instruments. Endoureteric treatment of urinary tract calculi is accepted to be efcient and safe and it is the recommended approach for stones requiring surgical intervention.1517,28 Following this tendency, URS for obstructive stones with FR has become an attractive option among urologists and has tended to overturn the opinion that ureteroscopic desobstruction provokes an expansion of

extravasation and increases the risk of complication.11,14 The routine insertion of a double-J ureteric stent after ureteroscopic stone fragmentation signicantly reduced morbidity and hospitalization.15,17,26 We started to introduce the use of URS in the treatment of obstructive stones with FR around 1988. In the beginning, our attempts were reserved exclusively for FR with stones located in the distal ureter, but this has now been extended to calculi of the middle and, occasionally, of the proximal ureter. In accordance with Jeronim et al.,29 instrument introduction must be performed careful and without dilatation of the ureteral orice and the stone fragmentation energy must be controlled. Another important point during the procedure is to maintain a low ow rate of irrigating uid in order to avoid uid back-ow to the kidney and an increase of extravasation. The irrigation remains in hands of the assistant, who is responsible for maintaining (under video endoscopy) a good visualization of the stone and low intraluminal pressures, keeping the uid in-ow to a minimum. (A very useful device for manually assisted uid irrigation is Irri-Flo II; ACMI). Also, we believe that during the insertion of the URS up to the stone, the possibility of the irrigating uid overcoming the stone is very low, as long as the stone is impacted. It requires high pressure to mobilize the stone and analogous quantities to provoke an extravasation increase.1,24 The critical phase for urine extravasation begins with the onset of lithotripsy energy and stone fragmentation. This is the moment that requires high coordination of the working team in order to avoid prolonged maneuvers with an associated increase to the risk of complication. Ureteroscopy, combined with other ancillary endoureteric maneuvers and ureter stenting, is a safe procedure in the treatment of lithiasis-obstructed ureter with FR, but requires an experienced urologist and a coordinated working team. In the present series, we did not observe an increase of urine extravasation during URS, due to maintained low-pressure conditions and the high reabsorption capability of the retroperitoneal fatty tissue.25

Conclusions
In our opinion, ultrasonography and CDDS are essential when diagnosing and staging obstructive stones with FR. In the case of obstructive stones with FR, sole stenting of the ureter does not always lead to a successful outcome. Secondary ureteroscopic stone fragmentation or delayed SWL may be required in attempt to solve the obstruction and its cause.

1064

P Kalafatis et al.
duplex Doppler ultrasonography in renal colic. Eur. Urol. 2002; 41: 7180. Mitty HA. CT for diagnosis and management of urinary extravasation. Am. J. Roentgenol. 1980; 134: 497501. Illya C, Boridy MD, Akira Kawashima MD et al. Acute ureterolithiasis. Nonenhanced helical CT ndings of perinephric edema for prediction of degree of ureteral obstruction. Radiology 1999; 2133: 6637. Flueckiger R, Gunst M. Fornixruptur. Ein Beitrag zur Differentialdiagnose des Acuten Abdomens. Helv. Chir. Acta. 1989; 56: 3614. [in German] Breun H, Csapo Z, Sigel A. Fornix-Ruptur- Ueberpruefung der Pathologie und der Klinik. Urologe A 1989; 28: 32933. [in German] Marberger M, Hofbauer J, Tuerk Ch, Hobart K, Albrecht W. Management of ureteric stones. Eur. Urol. 1994; 25: 26572. Kostakopoulos A, Sofras F, Karagiannis A, Kranidis A, Dimopoulos C. Ureterolithotripsy. Report of 1,000 cases Br. J. Urol. 1989; 63: 2434. Puppo P, Ricciotti G, Bozzo W, Introini C. Primary endoscopic treatment of ureteric calculi. Eur. Urol. 1999; 36: 4852. Petas A, Baruxis G, Kalafatis P. Rupture of the fornix renalis during kidney colic due to ureter calculus. Hellenic Urol. 1999; 11: 5762. Sung Su Hwang MD, Young Ha Park MD, Choong Bum Lee MD, Youn Ju Jung MD. Spomtaneous rupture of hydronephrotic kidney during pregnancy: Value of serial sonography. J. Clin. Ultrasound 2000; 28: 35860. Murphy ME, Tublin ME. Understanding the Doppler RI. impact of renal arterial distensibility on the RI in a hydronephrotic ex vivo rabbit kidney model. J. Ultrasound Med. 2000; 19: 303314. Gillenwater J. Hydronephrosis. In: Gillenwater JY, Grayhack JT, Howards SS, Mitchell ME (eds) Adults and Pediatric Urology, 2nd edn. Mosby-Year Book, St Louis, 1991, 789813. Holsten DR. Fornix rupture of the kidney as a complication of infusion pyelography. Roentgenblatter 1973; 26: 4479. Catalano O, Nunziata A, Siani FAA. Suspected ureteral colic. Primary helical CT versus S elective helical CT after unenhanced radiography and sonograohy Am. J. Roendgenol. 2002; 178: 37987. OBoyle P, Porter T. Obstructive nephropathy. Causes and management. Eur. Urol. 1999; 36: 16575. Matthews LA, Smith EM, Spirnak JP. Non operative treatment of major blunt renal lacerations with urinary extravasation. J. Urol. 1997; 157: 20568. Chapman JP, Gonzalez J, Diokno AC. Signicance of urinary extravasation during renal colic. Urology 1987; 30: 5415. Cass AS, Lee JY, Smith CS. Perirenal extravasation with blunt trauma from rupture of a calyceal fornix. J. Trauma 1993; 35: 2022. Haas CA, Reigle MD, Selzman AA, Elder JS, Spirnak JP. Use of ureteral stents in the management of major renal trauma with urinary extravasation: is there a role? J. Endourol. 1998; 12: 5459. Jeromin L, Sosnowski M. Ureteroscopy in the treatment of ureteral stones: Over 10 years experience. Eur. Urol. 1998; 34: 3449.

Stenting of the lithiasis-obstructed ureter is the best option for the acute phase of an infected or septic FR. Primary ureteroscopic lithotripsy and stone extraction, combined with ureter stenting, is a reliable, efcient, and safe method to treat denitely obstructive stones associated with FR. In these cases, the use of adequate small-caliber, semirigid and exible ureterorenoscopes in experienced hands is required. Primary ureteroscopic management may offer a quick and safe therapeutic alternative for distal and middle ureteral stones causing FR. Furthermore, in comparison to other therapeutic options, primary ureteroscopic management is associated with less hospitalization and lower morbidity.

11 12

13 14 15 16

Acknowledgments
We would like to thank Fotis Kalafatis and Marinos Kalafatis for their technical assistance.

17 18 19

References
1 Phagavan BS, Wenk RE, Dutta D. Pathways of urinary backow in obstructive uropathy. Demonstration by pigmented gelatin injection and Tamm-Horsfall Uromucoprotein markers. Hum. Pathol. 1979; 10: 66983. 2 Green N, Fingerhut AG, French S. Mechanism of renovascular backow: a pathophysiologic study. Radiology 1969; 92: 5316. 3 Friedenberg RM, Moorehouse H, Gade M. Urinomas secondary to pyelosinus backow. Urol. Radiol. 1983; 5: 239. 4 Becopoulos T, Likurinas M, Pliotas G. Spontaneous rupture of the ureter during high dose urography. Br. J. Urol. 1979; 51: 51. 5 Verdu Martinez M, Napal Lecumberri S, Kilani Elsmari S, Monsalve Rodroguez M, Gomez Cisneros SC, Garcia Alonso J. Spontaneous extravasation of urine at the pyelo-caliceal level. Spontaneous urinomas. Arch. Esp. Urol. 1993; 46: 4951. 6 Kettlewell M, Walker M, Dudley N, De Souza B. Spontaneous extravasation of urine secondary to ureteric obstruction. Br. J. Urol. 1973; 45: 814. 7 Paajanen H, Kettunen J, Tainio H, Jauhiainen K. Spontaneous peripelvic extravasation of urine as a cause of acute abdomen. Scand. J. Urol. Nephrol. 1993; 27: 333 6. 8 Bertolotto M, Perrone R, Rimondini A. Kidney obstruction. potential use of ultrasonography and Doppler color ultrasonography. Arch. Ital. Urol. Androl. 2000; 72: 12734. 9 Mostbeck GH, Zontsich T, Turetschek K. Ultrasound of the kidney: obstruction and medical diseases. Eur. Radiol. 2001; 11: 187889. 10 Geavlete P, Georgescu D, Cauni V, Nita G. Value of

20

21

22 23

24 25 26 27 28

29