American Journal of Emergency Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Brief Report
Spontaneous ureteral rupture and review of the literature Guang-Heng Chen, MD a, Po-Jen Hsiao, MD a, 1, Yi-Huei Chang, MD a, Chi-Cheng Chen, MD a, Hsi-Chin Wu, MD a, b, Chi-Rei Yang, MD a, Kuo-Liang Chen, MD a, Eric Chieh-Lung Chou, MD a, b, Wen-Chi Chen, MD a, Chao-Hsiang Chang, MD a, b,⁎ a b
Department of Urology, China Medical University Hospital, Taichung, Taiwan School of Medicine, China Medical University, Taichung, Taiwan
a r t i c l e
i n f o
Article history: Received 16 February 2014 Received in revised form 18 March 2014 Accepted 21 March 2014 Available online xxxx
a b s t r a c t Introduction: Spontaneous ureteral rupture is defined as non-traumatic urinary leakage from the ureter. This is a diagnosis that, although uncommon, is important for emergency physicians to know about. The literature is relatively sparse. Materials and Methods: This was a retrospective review of patients who were diagnosed with spontaneous ureteral rupture. From 2006 to 2012, 18 patients were diagnosed by radiography (computed tomography or intravenous urogram) with spontaneous ureteral rupture. These cases all showed extravasation of the contrast outside the excretory system. We evaluated underlying causes, diagnostic and therapeutic procedures, and outcomes. Results: There were 9 men and 9 women with a median age of 59 years (range, 22-82 years). In 56% of patients, a ureteral stone was the cause; in 17% of, a ureteral stricture; in 1 patient, a ureteral tumor; and in the remaining 22%, no cause was identified. In 13 patients (72.2%), primary ureteroscopy to place D-J stents was performed. The average duration of ureteral catheter stenting was 21 days (range, 8-45 days). The other 5 patients (27.8%) were managed conservatively with antibiotic treatment and the outcome was good. Conclusions: Ureteral stones most commonly cause spontaneous ureteral rupture. In our experience, most patients received ureteroscopy and Double-J stenting. Conservative management with antibiotics also had good outcomes. Most patients had sudden onset of abdominal or flank pain. Spontaneous ureteral rupture should be kept in the differential diagnosis of patients with acute abdominal or flank pain in the emergency department. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Spontaneous ureteral rupture is defined as nontraumatic urinary leakage from the ureter. It is a rare condition and also a potential urologic emergency [1,2]. It is usually caused by ureteral obstruction by a calculus, stricture, or a tumor [3,4]. Till now, the reported cases were solitary and few in each hospital. The diagnosis was difficult initially because there were various symptoms. Management of spontaneous ureteral rupture is, therefore, not standardized. To our knowledge, our report has the largest case numbers in a single medical center, worldwide, until now. We report on 18 patients with spontaneous ureteral rupture and discuss clinical presentation, therapeutic procedures, and outcomes. 2. Materials and methods We performed a retrospective chart review on patients who were diagnosed with spontaneous ureteral rupture. From 2006 to 2012, 18 patients were diagnosed based on radiographic investigations such as ⁎ Corresponding author. E-mail address: [email protected] (C.-H. Chang). 1 Co-first author.
abdominal intravenous urography (Fig. 1) and computed tomography (CT) (Fig. 2) with application of contrast media. These cases all showed extravasation of the contrast outside the excretory system. We evaluated the parameters including underlying causes, diagnostic and therapeutic procedures, and outcomes. 3. Results There were 9 men and 9 women with a median age of 59 years (range, 22-82 years) (Table). In 10 patients (55.6%), a ureteral stone was diagnosed; in 3 patients (16.7%), the underlying cause was ureteral stricture, and in 1 patient (5.6%), the cause was a ureteral tumor. In the remaining 4 patients (22.2%), no reason for a ureteral rupture was found. Twelve patients (66.7%) presented with a chief complaint of sudden onset flank pain. In the remaining 6 patients (33.3%), abdominal pain was the chief complaint. In 13 patients (72.2%), primary ureteroscopy to place double J (D-J) stents was performed. In those patients undergoing ureteroscopy, 10 were caused by ureteral stones, and 3 had ureteral stricture. The average duration of ureteral catheter stenting was 21 days (range, 8-45 days). Neither flank pain nor fever developed after removal of the ureteral stents. The other 5 patients (27.8%) were managed
http://dx.doi.org/10.1016/j.ajem.2014.03.034 0735-6757/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Chen G-H, et al, Spontaneous ureteral rupture and review of the literature, Am J Emerg Med (2014), http://dx.doi. org/10.1016/j.ajem.2014.03.034
2
G-H. Chen et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx Table Patient demographics and results Mean patient age, y (range) No. of patients by sex (%) Male Female Etiology (%) Stone Stricture Tumor Unknown Treatment (%) URS and D-J stent Support care Mean hospital days (±SD) Mean hospital days (±SD) Mean stone size (mm) Upper Lower
59.2 (22-82) 9 (50) 9 (50) 10 (55.6) 3 (16.7) 1 (5.6) 4 (22.2) 13 (72.2) 5 (27.8) 7.1 ± 7.4 21.1 ± 12.0 4.4 × 3.4 7.5 × 3.3 2.3 × 2.2
Values are expressed as mean ± SD.
The average ureteral stone size was 4.4 × 3.4 mm. The size of proximal ureteral stones seemed larger than distal ureteral stones (7.5 × 5.3 vs 2.3 × 2.2 mm) (Table). 4. Discussion
Fig. 1. Intravenous pyelography showed contrast extravasation.
conservatively with antibiotic treatment, and the outcome was good. The average duration of hospitalization was 7.1 days (range, 2-22 days). Among the 10 patients with stones, 6 patients had distal ureteral stone, and the other 4 patients had proximal ureteral stones.
Fig. 2. Computed tomography showed a dilated left renal pelvis with contrast extravasation.
Ureteral rupture may be spontaneous or posttraumatic. Spontaneous ureteral rupture is a rare condition, and ureteral calculi are the most frequent causes [1-5], which is consistent with the findings of our study. In addition, tumors [4,6], enlarged lymph nodes, retroperitoneal fibrosis [7], pregnancy [8], bladder outlet obstruction [9-11], and connective tissue disease [12] were also reported to be responsible for the problem. In some cases, the cause is unknown [13,14]. Akpinar et al [11] gathered 91 cases from published literature in 2002 and divided these patients into 5 main groups based on the etiology. These groups are stone disease (65), tumor (10), connective tissue disease (10), high-dose corticosteroid treatment (5), other causes (6), and unknown (5). Management of the spontaneous ureteral rupture is not standardized because few systemic reports are available now [3-5]. In our series, primary ureteroscopy to set double ureteral stents was successfully performed in 13 patients (72.2% without complication). The average duration of D-J ureteral stenting was 21 days (range, 8-45 days). All our patients had good outcomes with a mean follow-up of 12.5 months (range, 0-52). Therefore, minimally invasive procedures or conservative care offer excellent results, and several case reports confirm this [1-5]. Starvodimos et al reported on five patients managed successfully with a D-J ureteral stent insertion under fluoroscopy [13]. Csata et al [15] reported 2 patients with spontaneous ureteral rupture cured by conservative therapy. Akpinar et al [11] successfully managed 1 patient by a D-J stent, 1 patient with acute urinary retention by urethral catheterization, and 2 patients by conservative therapy. A recent retrospective study by Gershman et al [4] with 108 patients who were identified with the CT diagnosis of renal “forniceal” or “calyceal” rupture showed that the distal calculi in the ureter had a higher rate of spontaneous ureteral rupture than proximal stones (24.3% vs 76.7%). One possibility would be that smaller distal stones create higher intraureteral pressures than larger proximal stones because of the greater length of obstructed ureter and the smaller diameter of the distal ureter. Spontaneous ureteral rupture often produces symptoms such as sudden onset severe abdominal and flank pain associated with nausea and vomiting. In our study, most of the patients had acute flank pain (66.7%), and some presented as acute abdominal pain (33.3%). Ultrasound may detect fluid collections in the perinephric or retroperitoneal areas, but we recommend contrasted CT to confirm
Please cite this article as: Chen G-H, et al, Spontaneous ureteral rupture and review of the literature, Am J Emerg Med (2014), http://dx.doi. org/10.1016/j.ajem.2014.03.034
G-H. Chen et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
the diagnosis. Because ureteral rupture can cause serious results, spontaneous ureteral rupture should be kept in mind in patients with acute abdominal pain at the emergency department [1,2]. The limitations of this study are its retrospective design, singlecenter experience, and small case number. We are not able to show comparative efficacy of stenting vs conservative care because this is not a randomized study and the case numbers are too small. 5. Conclusions Spontaneous ureteral rupture is uncommon. Obstructing ureteral stones are the most common cause (N50%), but no definitive cause was found in almost a quarter of patients. Stenting for obstructive causes and conservative care for other causes seem to be reasonable options for management. In patients with acute abdominal or flank pain, this diagnosis warrants consideration so that appropriate imaging and treatment can be done in an expeditious manner. References [1] Ay D, Yencilek E, Celikmen MF, Akkas M, Ekci B. Spontaneous rupture of ureter: an unusual cause of acute abdominal pain. Am J Emerg Med 2012;30(2):390.e1–2. [2] Lien WC, Chen WJ, Wang HP, Liu KL, Hsu CC. Spontaneous urinary extravasation: an overlooked cause of acute abdomen in ED. Am J Emerg Med 2006;24(3):347–9. [3] Doehn C, Fiola L, Peter M, Jocham D. Outcome analysis of fornix ruptures in 162 consecutive patients. J Endourol 2010;24(11):1869–73.
3
[4] Gershman B, Kulkarni N, Sahani DV, Eisner BH. Causes of renal forniceal rupture. BJU Int 2011;108(11):1909–11 [discussion 12]. [5] Diaz ES, Buenrostro FG. Renal pelvis spontaneous rupture secondary to ureteral lithiasis. Case report and bibliographic review. Arch Esp Urol 2011;64(7):640–2. [6] Cormio G, Cormio L, Di Gesu G, Loverro G, Selvaggi L. Calyceal rupture and perirenal urinoma as a presenting sign of recurrent ovarian cancer. Gynecol Oncol 2001;83(2):415–7. [7] Sakai Y. A case of idiopathic retroperitoneal fibrosis with renal subcapsular urinoma resolved by steroid therapy. Hinyokika Kiyo 1999;45(4):249–51. [8] Satoh S, Okuma A, Fujita Y, Tamaka M, Nakano H. Spontaneous rupture of the renal pelvis during pregnancy: a case report and review of the literature. Am J Perinatol 2002;19(4):189–95. [9] Lin D-Y, Fang Y-C, Huang D-Y, Lin S-P. Spontaneous Rupture of the Ureter Secondary to Urolithiasis and Extravasation of Calyceal Fornix due to Acute Urinary Bladder Distension: four cases report. Chin J Radiol 2004;29:269–75. [10] Choi SK, Lee S, Kim S, et al. A rare case of upper ureter rupture: ureteral perforation caused by urinary retention. Korean J Urol 2012;53(2):131–3. [11] Akpinar H, Kural AR, Tufek I, et al. Spontaneous ureteral rupture: is immediate surgical intervention always necessary? Presentation of four cases and review of the literature. J Endourol 2002;16(3):179–83. [12] Huang KH, Hsieh SC, Huang CY, Chen SC, Chen J. Dermatomyositis associated with bilateral ureteral spontaneous rupture. J Formos Med Assoc 2007;106 (3):251–4. [13] Stravodimos K, Adamakis I, Koutalellis G, et al. Spontaneous perforation of the ureter: clinical presentation and endourologic management. J Endourol 2008;22 (3):479–84. [14] Huri E, Ayyildiz A, Nuhoglu B, Germiyanoglu C. Spontaneous rupture and emergency repairment of the renal pelvis. Int Urol Nephrol 2007;39 (2):413–5. [15] Csata S, Repassy D, Weninger T, Tamas G. Spontaneous (renal) pelvic rupture. Two cases cured by conservative therapy. Int Urol Nephrol 1998;30(1):19–24.
Please cite this article as: Chen G-H, et al, Spontaneous ureteral rupture and review of the literature, Am J Emerg Med (2014), http://dx.doi. org/10.1016/j.ajem.2014.03.034
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Brief Report
Spontaneous ureteral rupture and review of the literature Guang-Heng Chen, MD a, Po-Jen Hsiao, MD a, 1, Yi-Huei Chang, MD a, Chi-Cheng Chen, MD a, Hsi-Chin Wu, MD a, b, Chi-Rei Yang, MD a, Kuo-Liang Chen, MD a, Eric Chieh-Lung Chou, MD a, b, Wen-Chi Chen, MD a, Chao-Hsiang Chang, MD a, b,⁎ a b
Department of Urology, China Medical University Hospital, Taichung, Taiwan School of Medicine, China Medical University, Taichung, Taiwan
a r t i c l e
i n f o
Article history: Received 16 February 2014 Received in revised form 18 March 2014 Accepted 21 March 2014 Available online xxxx
a b s t r a c t Introduction: Spontaneous ureteral rupture is defined as non-traumatic urinary leakage from the ureter. This is a diagnosis that, although uncommon, is important for emergency physicians to know about. The literature is relatively sparse. Materials and Methods: This was a retrospective review of patients who were diagnosed with spontaneous ureteral rupture. From 2006 to 2012, 18 patients were diagnosed by radiography (computed tomography or intravenous urogram) with spontaneous ureteral rupture. These cases all showed extravasation of the contrast outside the excretory system. We evaluated underlying causes, diagnostic and therapeutic procedures, and outcomes. Results: There were 9 men and 9 women with a median age of 59 years (range, 22-82 years). In 56% of patients, a ureteral stone was the cause; in 17% of, a ureteral stricture; in 1 patient, a ureteral tumor; and in the remaining 22%, no cause was identified. In 13 patients (72.2%), primary ureteroscopy to place D-J stents was performed. The average duration of ureteral catheter stenting was 21 days (range, 8-45 days). The other 5 patients (27.8%) were managed conservatively with antibiotic treatment and the outcome was good. Conclusions: Ureteral stones most commonly cause spontaneous ureteral rupture. In our experience, most patients received ureteroscopy and Double-J stenting. Conservative management with antibiotics also had good outcomes. Most patients had sudden onset of abdominal or flank pain. Spontaneous ureteral rupture should be kept in the differential diagnosis of patients with acute abdominal or flank pain in the emergency department. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Spontaneous ureteral rupture is defined as nontraumatic urinary leakage from the ureter. It is a rare condition and also a potential urologic emergency [1,2]. It is usually caused by ureteral obstruction by a calculus, stricture, or a tumor [3,4]. Till now, the reported cases were solitary and few in each hospital. The diagnosis was difficult initially because there were various symptoms. Management of spontaneous ureteral rupture is, therefore, not standardized. To our knowledge, our report has the largest case numbers in a single medical center, worldwide, until now. We report on 18 patients with spontaneous ureteral rupture and discuss clinical presentation, therapeutic procedures, and outcomes. 2. Materials and methods We performed a retrospective chart review on patients who were diagnosed with spontaneous ureteral rupture. From 2006 to 2012, 18 patients were diagnosed based on radiographic investigations such as ⁎ Corresponding author. E-mail address: [email protected] (C.-H. Chang). 1 Co-first author.
abdominal intravenous urography (Fig. 1) and computed tomography (CT) (Fig. 2) with application of contrast media. These cases all showed extravasation of the contrast outside the excretory system. We evaluated the parameters including underlying causes, diagnostic and therapeutic procedures, and outcomes. 3. Results There were 9 men and 9 women with a median age of 59 years (range, 22-82 years) (Table). In 10 patients (55.6%), a ureteral stone was diagnosed; in 3 patients (16.7%), the underlying cause was ureteral stricture, and in 1 patient (5.6%), the cause was a ureteral tumor. In the remaining 4 patients (22.2%), no reason for a ureteral rupture was found. Twelve patients (66.7%) presented with a chief complaint of sudden onset flank pain. In the remaining 6 patients (33.3%), abdominal pain was the chief complaint. In 13 patients (72.2%), primary ureteroscopy to place double J (D-J) stents was performed. In those patients undergoing ureteroscopy, 10 were caused by ureteral stones, and 3 had ureteral stricture. The average duration of ureteral catheter stenting was 21 days (range, 8-45 days). Neither flank pain nor fever developed after removal of the ureteral stents. The other 5 patients (27.8%) were managed
http://dx.doi.org/10.1016/j.ajem.2014.03.034 0735-6757/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Chen G-H, et al, Spontaneous ureteral rupture and review of the literature, Am J Emerg Med (2014), http://dx.doi. org/10.1016/j.ajem.2014.03.034
2
G-H. Chen et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx Table Patient demographics and results Mean patient age, y (range) No. of patients by sex (%) Male Female Etiology (%) Stone Stricture Tumor Unknown Treatment (%) URS and D-J stent Support care Mean hospital days (±SD) Mean hospital days (±SD) Mean stone size (mm) Upper Lower
59.2 (22-82) 9 (50) 9 (50) 10 (55.6) 3 (16.7) 1 (5.6) 4 (22.2) 13 (72.2) 5 (27.8) 7.1 ± 7.4 21.1 ± 12.0 4.4 × 3.4 7.5 × 3.3 2.3 × 2.2
Values are expressed as mean ± SD.
The average ureteral stone size was 4.4 × 3.4 mm. The size of proximal ureteral stones seemed larger than distal ureteral stones (7.5 × 5.3 vs 2.3 × 2.2 mm) (Table). 4. Discussion
Fig. 1. Intravenous pyelography showed contrast extravasation.
conservatively with antibiotic treatment, and the outcome was good. The average duration of hospitalization was 7.1 days (range, 2-22 days). Among the 10 patients with stones, 6 patients had distal ureteral stone, and the other 4 patients had proximal ureteral stones.
Fig. 2. Computed tomography showed a dilated left renal pelvis with contrast extravasation.
Ureteral rupture may be spontaneous or posttraumatic. Spontaneous ureteral rupture is a rare condition, and ureteral calculi are the most frequent causes [1-5], which is consistent with the findings of our study. In addition, tumors [4,6], enlarged lymph nodes, retroperitoneal fibrosis [7], pregnancy [8], bladder outlet obstruction [9-11], and connective tissue disease [12] were also reported to be responsible for the problem. In some cases, the cause is unknown [13,14]. Akpinar et al [11] gathered 91 cases from published literature in 2002 and divided these patients into 5 main groups based on the etiology. These groups are stone disease (65), tumor (10), connective tissue disease (10), high-dose corticosteroid treatment (5), other causes (6), and unknown (5). Management of the spontaneous ureteral rupture is not standardized because few systemic reports are available now [3-5]. In our series, primary ureteroscopy to set double ureteral stents was successfully performed in 13 patients (72.2% without complication). The average duration of D-J ureteral stenting was 21 days (range, 8-45 days). All our patients had good outcomes with a mean follow-up of 12.5 months (range, 0-52). Therefore, minimally invasive procedures or conservative care offer excellent results, and several case reports confirm this [1-5]. Starvodimos et al reported on five patients managed successfully with a D-J ureteral stent insertion under fluoroscopy [13]. Csata et al [15] reported 2 patients with spontaneous ureteral rupture cured by conservative therapy. Akpinar et al [11] successfully managed 1 patient by a D-J stent, 1 patient with acute urinary retention by urethral catheterization, and 2 patients by conservative therapy. A recent retrospective study by Gershman et al [4] with 108 patients who were identified with the CT diagnosis of renal “forniceal” or “calyceal” rupture showed that the distal calculi in the ureter had a higher rate of spontaneous ureteral rupture than proximal stones (24.3% vs 76.7%). One possibility would be that smaller distal stones create higher intraureteral pressures than larger proximal stones because of the greater length of obstructed ureter and the smaller diameter of the distal ureter. Spontaneous ureteral rupture often produces symptoms such as sudden onset severe abdominal and flank pain associated with nausea and vomiting. In our study, most of the patients had acute flank pain (66.7%), and some presented as acute abdominal pain (33.3%). Ultrasound may detect fluid collections in the perinephric or retroperitoneal areas, but we recommend contrasted CT to confirm
Please cite this article as: Chen G-H, et al, Spontaneous ureteral rupture and review of the literature, Am J Emerg Med (2014), http://dx.doi. org/10.1016/j.ajem.2014.03.034
G-H. Chen et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
the diagnosis. Because ureteral rupture can cause serious results, spontaneous ureteral rupture should be kept in mind in patients with acute abdominal pain at the emergency department [1,2]. The limitations of this study are its retrospective design, singlecenter experience, and small case number. We are not able to show comparative efficacy of stenting vs conservative care because this is not a randomized study and the case numbers are too small. 5. Conclusions Spontaneous ureteral rupture is uncommon. Obstructing ureteral stones are the most common cause (N50%), but no definitive cause was found in almost a quarter of patients. Stenting for obstructive causes and conservative care for other causes seem to be reasonable options for management. In patients with acute abdominal or flank pain, this diagnosis warrants consideration so that appropriate imaging and treatment can be done in an expeditious manner. References [1] Ay D, Yencilek E, Celikmen MF, Akkas M, Ekci B. Spontaneous rupture of ureter: an unusual cause of acute abdominal pain. Am J Emerg Med 2012;30(2):390.e1–2. [2] Lien WC, Chen WJ, Wang HP, Liu KL, Hsu CC. Spontaneous urinary extravasation: an overlooked cause of acute abdomen in ED. Am J Emerg Med 2006;24(3):347–9. [3] Doehn C, Fiola L, Peter M, Jocham D. Outcome analysis of fornix ruptures in 162 consecutive patients. J Endourol 2010;24(11):1869–73.
3
[4] Gershman B, Kulkarni N, Sahani DV, Eisner BH. Causes of renal forniceal rupture. BJU Int 2011;108(11):1909–11 [discussion 12]. [5] Diaz ES, Buenrostro FG. Renal pelvis spontaneous rupture secondary to ureteral lithiasis. Case report and bibliographic review. Arch Esp Urol 2011;64(7):640–2. [6] Cormio G, Cormio L, Di Gesu G, Loverro G, Selvaggi L. Calyceal rupture and perirenal urinoma as a presenting sign of recurrent ovarian cancer. Gynecol Oncol 2001;83(2):415–7. [7] Sakai Y. A case of idiopathic retroperitoneal fibrosis with renal subcapsular urinoma resolved by steroid therapy. Hinyokika Kiyo 1999;45(4):249–51. [8] Satoh S, Okuma A, Fujita Y, Tamaka M, Nakano H. Spontaneous rupture of the renal pelvis during pregnancy: a case report and review of the literature. Am J Perinatol 2002;19(4):189–95. [9] Lin D-Y, Fang Y-C, Huang D-Y, Lin S-P. Spontaneous Rupture of the Ureter Secondary to Urolithiasis and Extravasation of Calyceal Fornix due to Acute Urinary Bladder Distension: four cases report. Chin J Radiol 2004;29:269–75. [10] Choi SK, Lee S, Kim S, et al. A rare case of upper ureter rupture: ureteral perforation caused by urinary retention. Korean J Urol 2012;53(2):131–3. [11] Akpinar H, Kural AR, Tufek I, et al. Spontaneous ureteral rupture: is immediate surgical intervention always necessary? Presentation of four cases and review of the literature. J Endourol 2002;16(3):179–83. [12] Huang KH, Hsieh SC, Huang CY, Chen SC, Chen J. Dermatomyositis associated with bilateral ureteral spontaneous rupture. J Formos Med Assoc 2007;106 (3):251–4. [13] Stravodimos K, Adamakis I, Koutalellis G, et al. Spontaneous perforation of the ureter: clinical presentation and endourologic management. J Endourol 2008;22 (3):479–84. [14] Huri E, Ayyildiz A, Nuhoglu B, Germiyanoglu C. Spontaneous rupture and emergency repairment of the renal pelvis. Int Urol Nephrol 2007;39 (2):413–5. [15] Csata S, Repassy D, Weninger T, Tamas G. Spontaneous (renal) pelvic rupture. Two cases cured by conservative therapy. Int Urol Nephrol 1998;30(1):19–24.
Please cite this article as: Chen G-H, et al, Spontaneous ureteral rupture and review of the literature, Am J Emerg Med (2014), http://dx.doi. org/10.1016/j.ajem.2014.03.034
