Outcome Analysis of Fornix Ruptures in 162 Consecutive Patients

Abstract

Background:

Fornix rupture is a potential urologic emergency. In most cases, ureteral stones represent the underlying cause. Management of a fornix rupture is not standardized.

Patients and Methods:

In a retrospective analysis, we investigated 162 patients who had received a diagnosis of fornix rupture between 1994 and 2005. In all patients, the diagnosis was based on radiographic investigations with application of contrast media. We evaluated the parameters' underlying cause, associated symptoms, diagnostic and therapeutic procedures, and outcome in patients with a fornix rupture.

Results:

There were 121 men and 41 women with a median age of 53 years (range 20–79 years). In 93.2% of patients, one or more symptoms were present at diagnosis. In 59.9% of cases, a ureteral stone was diagnosed; in 12.3%, the underlying cause was different; and in the remaining 27.8% of patients, no reason for a fornix rupture was found. In all patients, primary endoscopic therapy (96.3%) or insertion of a nephrostomy tube (3.7%) was performed. All patients had a bladder catheter inserted, and antibiotic treatment was given in 92% of patients. A renal or perirenal abscess or other secondary complications necessitating open operative revision did not develop in any patient. The retrospective manner is a limitation of our study. Comparison of subgroups may therefore be biased.

Conclusions:

Ureteral stones are the most frequent causes of a fornix rupture. With a low pressure system and antibiotic treatment, the outcome is excellent, and secondary complications can be effectively prevented. Parameters for conservative treatment are to be defined to reduce overtreatment of certain patients with a fornix rupture.

Introduction

F ornix rupture is a potential urologic emergency and isoften caused by obstructive uropathy.¹ The most frequent cause for obstruction is a ureteral stone.² In rare circumstances, tumor, blunt trauma, or other injuries, including those from endoscopy, may result in a fornix rupture.^3

–8 Intravenous urography (IVU) is associated with osmotic diuresis and may therefore also result in a fornix rupture.^9,10 In some series, the rate of fornix ruptures during IVU in patients with obstructive uropathy and associated renal colic reaches 18%.^11,12 Therefore, the intravenous application of contrast media during acute renal colic is regarded as a contraindication.

In patients with obstructive uropathy, there is often a sharp rise in intrapelvic pressure and the collecting system may rupture at its weakest location—the fornices.¹³ Calices of the upper and lower renal pole are mainly involved.¹⁴ One clinical sign of a fornix rupture is an immediate pain release. This is because of a rapid reduction of pressure within the collecting system from urine extravasation. Although urine is absorbed and the fornix rupture may heal spontaneously, “deobstruction” should be performed by an endoscopic approach in the majority of patients.¹³ Even with this therapeutic strategy, a fornix rupture can result in abscess formation, sepsis, retroperitoneal fibrosis, or even loss of kidney function or death.^{13,15

–20} Vice versa, 25% of patients with renal or perirenal abscess formation had ureteral obstruction from stones and/or a fornix rupture.^12,18
–20 Management of a fornix rupture, however, is not standardized.

We report the clinical parameters and outcome of 162 consecutive patients with a fornix rupture.

Patients and Methods

Between 1994 and 2005, a total of 162 patients with a fornix rupture were identified from our database (Table 1). There were 121 (74.7%) men and 41 (25.3%) women with a median age of 53 years (range 20–79 y). The fornix rupture was located on the right side in 68 (42%) patients and on the left side in 94 (58%) patients. In a retrospective manner, we investigated the parameters' underlying cause, associated symptoms, diagnostic and therapeutic procedures, and outcome.

Table 1.

Patient Characteristics

Parameter	Result
No. patients	162
No. male/female patients	121/41
Median age (years, range)	53 (20–79)
No. right/left kidneys involved	68/94
No. patients with symptoms (%)	151 (93.2)
No. patients with pain (%)	146
No. patients with hematuria (%)	20
No. patients with emesis (%)	8
No. patients with elevated body temperature (%)	2
No. patients with weight loss (%)	1
No. patients without symptoms (%)	11 (6.8)
No. patients with known cause of fornix rupture (%)	117 (72.2)
No. patients with ureteral stones (%)	97 (59.9)
No. patients with other causes (%)	20 (12.3)
No. patients with unknown cause of fornix rupture (%)	45 (27.8)

In all patients, the diagnosis was based on radiographic investigations with application of contrast media. Fornix rupture was defined as any extravasation of contrast media. Radiographic investigations were either performed in the outpatient setting with referral of patients from urologists in private practice or as one of the first diagnostic procedures after hospital admission. At hospital admission, patients also had renal ultrasonography, a blood chemistry evaluation (at least full blood cell count, C-reactive protein [CRP], clotting parameters, creatinine level, and electrolytes) and urine tests (dipstick and urine culture). Basic care included check of vital signs and body temperature.

According to the policy of our department, a low pressure system was realized as the first therapeutic step in all patients with a fornix rupture. For this purpose, primary endoscopic therapy was undertaken in 156 (96.3%) patients, and a percutaneous nephrostomy tube was inserted in the remaining 6 (3.7%) patients. The type of endoscopic treatment (sole insertion of a ureteral stent, ureteroscopy with or without lithotripsy and/or removal of fragments) and type of ureteral stent (Double J (DJ) stent vs mono J [MJ] stent) were performed according to the patient's condition and the urologist's preference. Also, all patients had a bladder catheter inserted, and 149 (92%) patients were treated with antibiotics. Most patients also received intravenous fluids and analgesics.

Monitoring during hospital stay included split urine outputs (via bladder catheter, MJ stent, or nephrostomy tube, if applicable) ultrasonography, blood chemistry evaluation, urine test, and radiographic investigations according to the individual patient situation. Additional therapeutic procedures were performed according to the patient's individual condition.

Results

Underlying cause of fornix rupture

In 97 (59.9%) patients, a ureteral stone was diagnosed as the underlying cause of fornix rupture (Table 1).

In 20 (12.3%) patients, the underlying causes were different: 8 patients with and 7 patients without a ureteral stone demonstrated a fornix rupture after retrograde pyelography. Three patients had a fornix rupture from a renal contusion, one after antegrade pyelography via nephrostomy tube, and one because of nephritis.

The underlying cause of fornix rupture remained unclear in 45 (27.8%) patients. These patients, however, presented with flank pain, and 17/45 patients had a positive history for stones. Therefore, a spontaneous stone passage can be anticipated in the majority of these patients.

Of 105 patients with a ureteral stone (in 97 patients this was the underlying cause for fornix rupture and in 8 patients with a ureteral stone, retrograde pyelography resulted in a fornix rupture), 21 (13%) patients had a stone in the proximal part of the ureter, 12 (7.4%) patients in the mid part, and 72 (43.2%) patients in the distal part of the ureter (Table 1).

Symptoms

In 151 (93.2%) patients, one or more symptoms were present at the time of diagnosis (Table 1). Pain was reported by 146 patients. Hematuria was present in 20, emesis in 8, and elevated body temperature in 2 patients. One patient reported weight loss.

Diagnostic procedures

In all patients, the diagnosis of fornix rupture was based on radiographic investigations with application of contrast media. The radiographic investigation included IVU and/or retrograde or antegrade pyelography and/or CT of the abdomen.

All patients had blood chemistry evaluation (Table 2). Before therapy, 54.3% of patients had leukocytosis (defined as 10/nL or more), and 61.5% of patients demonstrated elevated CRP levels (defined as 6 mg/L or more).

Table 2.

Clinical Parameters

Parameter	Result
Rate of patients with fever during hospital stay (%)	27.2
Rate of patients with leukocytosis before therapy (%)	54.3
Rate of patients with elevated CRP before therapy (%)	61.5
Median duration of antibiotic therapy (days, range)	7 (1–33)
Median bladder catheter time (days, range)	6 (1–30)
Median hospital stay (days, range)	7 (1–36)
Median stent time (days, range)	25 (3–154)

CRP = C-reactive protein.

Urinalysis was performed in 157 (96.6%) patients. In 72.6% of patients, the urine culture was negative, and in 27.4%, it was positive (≤10⁴ bacteria in 19.7% and ≥10⁵ bacteria in 7.7% of cases). In 33.3% of patients with leukocytosis, the urine culture was positive, compared with 26.4% of patients without leucocytosis (Table 2).

Primary therapeutic procedures

All patients were admitted to the hospital. One patient left the hospital 1 day after admission for private reasons.

After diagnostic procedures, achievement of a low pressure system was the main focus of primary therapy. In all patients, primary endoscopic therapy (96.3%) or insertion of a nephrostomy tube (3.7%) was performed (Table 3). In 79 patients, a ureteral stent was placed without further manipulations. In 38 patients, ureteroscopy was performed without further therapy. In 36 patients, ureteroscopy with stone removal was performed, and in 3 patients, ureteroscopy with ultrasound or laser lithotripsy and removal of the fragments was performed. Of 156 patients who underwent such endoscopic procedure, 65 patients received a DJ ureteral stent and 91 patients an MJ ureteral stent. The remaining 6 patients had a nephrostomy tube inserted. In addition, all patients had a bladder catheter, and 92% of patients received antibiotic therapy for a median of 7 days (range 1–33 d) (Table 3).

Table 3.

Therapeutic Procedures

Parameter	Result
Primary therapeutic procedure
No. patients with sole ureteral stent (%)	79 (48.8)
No. patients with ureteroscopy without further manipulations (%)	38 (23.4)
No. patients with ureteroscopy with stone removal or lithotripsy (%)	39 (24.1)
No. patients with percutaneous nephrostomy (%)	6 (3.7)
Additional therapeutic procedures
No. patients with one additional procedure (%)	98 (60.5)
Removal of ureteral stent or nephrostomy tube	98
No. patients with two additional procedures (%)	36 (22.2)
Change and later removal of ureteral stent	17
Removal of ureteral stent and SWL	15
Insertion of ureteral stent and later removal	3
Ureteroscopy and removal of ureteral stent	1
No. patients with three additional procedures (%)	26 (16.1)
Change and removal of ureteral stent and SWL	12
Ureteroscopy, change and removal of ureteral stent	6
SWL (2×) and removal of ureteral stent	4
Ureteroscopy, change and removal of ureteral stent	3
SWL, ureteroscopy, and removal of ureteral stent	1
No. patients with four additional procedures (%)	2 (1.2)
Reposition of ureteral stent, ureteroscopy, change and removal of ureteral stent	1
Change of ureteral stent, SWL (2×), removal of ureteral stent	1

SWL = shockwave lithotripsy.

Outcome

In all patients, additional therapeutic procedures, such as removal of the ureteral stent or nephrostomy tube, ureteroscopy with stone removal or stone lithotripsy with or without removal of fragments, reposition of a ureteral stone, change of ureteral stent, or shockwave lithotripsy were performed. One, two, three, and four additional therapeutic procedures were applied in 98 patients, 36 patients, 26 patients, and 2 patients, respectively (Table 3).

Fever developed in 44 (27.2%) patients (defined as body temperature of 38°C or higher) during the hospital stay (Table 2). Fever was not related to the therapeutic procedure. Fever developed in patients with sole insertion of a ureteral stent, patients with ureteroscopy but without further manipulations, and patients with ureteroscopy and stone removal or lithotripsy in 27.8%, 26.3% and 19.4%, respectively.

Median bladder catheter time was 6 days (range 1–24 d) (Table 2). Median hospital stay of all patients was 7 days (range 1–36 d). Median hospital stay was 6 days (range 1–30 d) in patients without fever compared with 10 days (range 2–36 days) in patients with fever. Median stent time was 25 days (range 3–154 days) (Table 2).

A renal or perirenal abscess did not develop in any patient. None of the patients needed open operative interventions for the underlying cause of fornix rupture or for secondary complications. There was no death within 30 days of diagnosis or otherwise related to fornix rupture.

Discussion

Fornix rupture is a potential urologic emergency caused by ureteral stones in most cases.^1,2

We identified 162 patients with fornix rupture from our database. All patients were admitted to the hospital followed by specific diagnostic procedures. In all patients with a fornix rupture, a low pressure system was realized as the first therapeutic step. In addition, 92% of patients were treated with antibiotics. With this strategy, the outcome was excellent. A renal or perirenal abscess did not develop in any patient; none of the patients needed open surgery or died from secondary complications.

Kalafatis and colleagues¹ published a series of 86 patients with fornix rupture from ureteral stones. They, however, analyzed only those 51 patients who underwent endoscopic therapy.¹ Compared with the series by Kalafatis and coworkers,¹ there were more men in our series (74.7% vs 58.8%), and our patients were older (median 53 years vs mean 44.3 years). In both series, the left kidney was affected more often (58% in our series vs 58.8%), and ureteral stones were the most often detected causes of fornix ruptures (59.9% in our series, probably plus some patients with unclear underlying cause vs 100%). Ureteral stones were predominantly located in the distal part of the ureter (68.6% vs 54.9%) followed by the proximal part (20% vs 23.5%). In accordance with other publications, underlying causes for fornix rupture, such as trauma or tumor, were also rare in our series.^3

–8

According to the policy of our department, a low pressure system was realized as the first therapeutic step in all patients with a fornix rupture. We believe that active therapy is justified by the fact that a relevant number of patients had a positive urine culture (27.4%). Also, at initial presentation, more than half of the patients had systemic signs of infection such as leukocytosis (54.3%) and/or elevated CRP level (61.5%). Therefore, it is not surprising that even with our policy, fever developed in 27.2% of patients after primary therapy.

Otherwise, we cannot exclude that some patients may have undergone overtreatment. Prospective data in the literature are lacking, however, and the report by Kalafatis and associates¹ is the only series in the last 20 years.

Kalafatis and colleagues¹ treated 35/81 (41%) patients in a conservative manner—ie, bed rest, intravenous fluid, and antibiotics. They concluded that conservative therapy can be applied in certain patients with fornix rupture. Outcome data of these patients were not reported, however. Based on our data on urine cultures, blood chemistry evaluation, and fever after therapeutic procedures, we believe that even in “uncomplicated patients” as defined at the time of hospital admission, secondary complications may occur.

These secondary complications, such as abscess formation, sepsis, retroperitoneal fibrosis, or even loss of kidney function or death, have been frequently described in the literature.^{13,15

–20} For instance, a renal or perirenal abscess may develop in patients with fornix rupture. Renal and perirenal abscesses are potentially lethal.^18,20 In one study, 65 patients with a renal abscess (n = 16), perirenal abscess (n = 33), or mixed abscess (n = 16) were analyzed.²⁰ Ureteral obstruction was the underlying cause in 7/65 (11%) patients. Despite different therapeutic strategies (operative intervention in 31% patients with a renal abscess and 90% of patients with a perirenal abscess), 5/65 (6%) patients died. The authors concluded that early and correct diagnosis is most important in patients with a renal or perirenal abscess.²⁰

The main criteria for endoscopic therapy in terms of sole insertion of a ureteral stent in the series by Kalafatis and coworkers¹ were abdominal pain, elevated body temperature, signs of sepsis, stone size >5 mm, stone location in the proximal ureter, gravidity, or increasing urine extravasation regardless of the degree of hydronephrosis. In contrast, primary ureteroscopy was applied in patients without hydronephrosis, stone size <10 mm, stone localization in the mid or distal ureter, in women, and in patients with increasing urine extravasation.¹

Our criteria for sole insertion of a ureteral stent vs ureteroscopy without or with stone removal are based on the patient's condition (eg, relevant comorbidity), signs of systemic infection (eg, leukocytosis, elevated CRP level), and stone size and location. Based on our results, we now tend to perform primary ureteroscopy (compared with sole insertion of a ureteral stent) in more patients. Also, we now prefer the insertion of a DJ ureteral stent (compared with an MJ ureteral stent) in more patients.

We believe that our results—even in the absence of a group of “untreated patients” for comparison—allow the following recommendations:

A low pressure system should be established as the first therapeutic step in most patients with a fornix rupture. Most patients should also receive a ureteral stent and a bladder catheter. The insertion of an MJ ureteral stent can be restricted to severe cases (such as single kidneys, large extravasation, significant bacteriuria), because MJ ureteral stent therapy necessitates bed rest and is associated with prolonged hospital stay and other disadvantages. Endoscopic therapy of the underlying causes during the same session can be performed in easy cases of fornix rupture.

Most patients with a fornix rupture should receive antibiotic therapy. Certain patients, however, may not require interventional therapy, including endoscopy, stent placement, bladder catheter insertion, and antibiotic therapy. We speculate that patients without ureteral stones (as a sign of spontaneous passage), without systemic signs of infection, without fever, and patients without a perirenal fluid collection may be such candidates.

Conclusions

Ureteral stones are the most frequent causes of a fornix rupture. With a low pressure system and antibiotic treatment, the outcome is excellent. A renal or perirenal abscess did not develop in any patient, and none of the patients needed open surgery or died from secondary complications. Parameters for conservative treatment are to be defined to reduce overtreatment of certain patients with a fornix rupture.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

References

Kalafatis

, Zougkas

, Petas

. Primary ureteroscopic treatment for obstructive ureteral stone-causing fornix rupture. Int J Urol, 2004; 11:1058–1064.

O'Boyle

, Porter

. Obstructive nephropathy: Causes and management. Eur Urol Curric Urol 5.3, 1999; 36:1–11.

Twersky

, Twersky

, Phillips

, Coppersmith

. Peripelvic extravasation, urinoma formation and tumor obstruction of the ureter. J Urol, 1976; 116:305–307.

Tosch

, Becker-Gaab

, Hahn

. Extravasation of contrast media in the excretory urogram. (Ger) Digitale Bilddiagn, 1984; 4:112–117.

Rose

, Ragosin

, LaRosa

, Drago

. Pyelosinus extravasation and urinoma associated with malignancy. Computed tomography demonstration. Urology, 1988; 31:349–353.

Cass

, Lee

, Smith

. Perirenal extravasation with blunt trauma from rupture of a calyceal fornix. J Trauma, 1993; 35:20–22.

Goldman

, Rawal

, Sandler

, Hertz

. Spontaneous pyelosinus extravasation in blunt abdominal trauma: Radiographic findings and treatment implications. Emerg Radiol, 1998; 5:65–69.

Bannowsky

, Melchior

, Horst Cv

et al. The iatrogenic fornix rupture after endoscopic extraction of an ureteral stone via ureterorenoscopy. (Ger) Aktuelle Urol, 2003; 34:488–490.

Traumann

, Holsten

, Berndt

. Extravasation from fornix rupture during infusion urography. (Ger) Fortschr Geb Rontgenstr Nuklearmed, 1972; 117:429–433.

10.

Eggerath

, Friedrichs

. Evaluation of spontaneous renal extravasation of contrast media in the excretory urogram. (Ger) Radiologe, 1985; 25:224–229.

11.

Schwartz

, Caine

, Hermann

, Bitterman

. Spontaneous renal extravasation during intravenous urography. Am J Roentgenol Radium Ther Nucl Med, 1966; 98:27–40.

12.

Chapman

, Gonzalez

, Diokno

. Significance of urinary extravasation during renal colic. Urology, 1987; 30:541–545.

13.

Breun

, Csapo

, Sigel

. Fornix rupture—a review of pathophysiology and clinical aspects. (Ger) Urologe A, 1989; 28:329–333.

14.

Anderhuber

, Reimann

. Pyelorenal reflux. I. Actual and presumed routes. (Ger) Morphol Med, 1982; 2:109–122.

15.

Harrow

. Unusual renal peripelvic extravasation requiring operative drainage. J Urol, 1969; 102:564–566.

16.

Altwein

. Nierenverlust nach Fornixruptur. Akt Urol, 1983; 14:99–100.

17.

Wang

, Schur

, Wang

. Ruptured fornix demonstrated during abscess drainage. Urology, 1998; 52:321–321.

18.

Meng

, Mario

, McAninch

. Current treatment and outcomes of perinephric abscesses. J Urol, 2002; 168:1337–1340.

19.

Shu

, Green

, Orihuela

. Renal and perirenal abscesses in patients with otherwise anatomically normal urinary tracts. J Urol, 2004; 172:148–150.

20.

Coelho

, Schneider-Monteiro

, Mesquita

et al. Renal and perinephric abscesses: Analysis of 65 consecutive cases. World J Surg, 2007; 31:431–436.