Retroperitoneal Urinoma Spontaneously Drained in the Scrotum Repaired with Gracilis Muscle Flap: A Case Report

Aim. To report a unique case of retroperitoneal urinoma extending to the scrotum through the spermatic cord and successfully treated with nephrostomy, drainage, and gracilis muscle flap. 1. Case Report A 66-year-old male patient was referred to us from the medical oncology department for a scrotal wound with purulent discharge. On physical examination, he presented with severe asthenia, abdominal pain, cushingoid aspect, tender abdomen mostly on lower quadrants, and reddened, swollen scrotum with foul smelling ？cm defect. The wound presented pus and haematic discharge and exposed spermatic cord and testis (Figure 1). After culture samples were taken, the wound was debrided, irrigated with saline solution, and packed with gauzes. Figure 1: Perineal wound. Patient’s urologic history had started two months earlier, when during oncological followup for metastatic prostate cancer, a CT scan showed a 15？mm left ureteral stone causing hydronephrosis (Figures 2(a) and 2(b)). He was scheduled for left laser ureteral lithotripsy and double J stent positioning. The first procedure was only partially successful, and a second-look procedure was scheduled 4 weeks later. Figure 2: (a) Abdomen CT scan: left ureteral stone. (b) Abdomen CT scan: left hydronephrosis. Before the latter, he started external beam radiotherapeutic treatment for D11-L1 bone metastases, and after 9？Gy in 3 fractions, he developed the scrotal abscess. His therapy included daily oral intake of 8？mg of Dexamethasone, infusion of 66？mg of Taxoter twice a month, and monthly infusion of 4？mg of Zoledronic acid. Blood gas showed normal pH and hyperglycemia confirmed by laboratory (793？mg/dL). Blood tests showed also hyponatremia (127？mEq/L), normal renal function (creatinine 0.81？mg/dL), Hb 10.9？g/dL, Hct 34.3%, WBCs 7.730/uL, PLTs 173.000/uL, and a normal coagulation pattern. Peripheral venous access and transurethral catheter were inserted. Insulin drip, intravenous rehydration with 2000？cc of Normo Saline, and empiric antibiotic therapy with Clindamycin 600？mg and Ceftazidime 1？g every 8 hours were administrated. Abdominal CT-scan showed (Figure 3) in the distal part of left ureter a 13？mm stone with a well-positioned double J stent and a 12？cm urinoma anterior to iliopsoas muscle as for ureteral leakage according to increased attenuation of urinoma in delayed imaging. The urinoma extended from the ileopsoas muscle through spermatic funicle and drained in the scrotum. Figure 3: Abdomen CT scan: left urinoma, left ureteral stone, and left double J stent. Left percutaneous nephrostomy and abdominal