Extraperitoneal Space: Anatomic and Radiologic Overview

Award:

Certificate of Merit

Poster No.:

C-2250

Congress:

ECR 2014

Type:

Educational Exhibit

Authors:

M. Horta , N. Neto , C. Couceiro , L. P. Martins ; Lisbon/PT,

1 1

Lisboa/PT

Keywords:

Education and training, Diagnostic procedure, MR, CT, Anatomy,

Abdomen

DOI:

10.1594/ecr2014/C-2250

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Page 1 of 37

Learning objectives
To describe and illustrate the imaging findings of extraperitoneal compartments and
fasciae and to understand the intercommunication between them as well as the pathways
of spread of extraperitoneal fluid collections.

Background
The extraperitoneal space is a potential space that surrounds the peritoneal cavity,
being defined by parietal peritoneum internally and by transversalis fascia posteroexternally (figure 1).
It is less developed in the anterior and lateral parts of the abdomen, while it is a large
compartment in the pelvis and especially in the posterior abdomen.
Its anatomic relationships with the visceral organs of the abdomen and pelvis give the
extraperitoneal space a great radiological importance.
Extraperitoneal effusions may result from a variety of infectious, neoplastic, inflammatory
and traumatic causes [1].
An accurate clinical diagnosis of extraperitoneal fluid collections is difficult because
sometimes they lack specific complaints and the area may not be accessible to
auscultation, palpations and percussion stages of the abdominal exam [2].
Moreover extraperitoneal tissues do not react as sharply to bacterial contamination as
does the peritoneal cavity [2].
A thorough knowledge of the extraperitoneal space is helpful for understanding the route
of spread of extraperitoneal fluid and gas collections, since they are conducted primarily
by fascial planes and planes of least resistance [1,2].

Page 2 of 37

Fig. 1: Diagram showing the anatomic limits of the extraperitoneal space and of the
retroperitoneum.
References: Horta M, Lisbon/Portugal
The retroperitoneal space is a huge compartment of the extraperitoneal space located
in the posterior abdomen, that lies posteriorly to the parietal peritoneum and anteriorly to
the transversalis fascia and the posterior abdominal wall (figure 1). It extends from the
diaphragm superiorly to the pelvis inferiorly [2,3]. Anteriorly, it is continuous with the root
of the small bowel mesentery and with the transverse mesocolon (figure 2) [2].

Page 3 of 37

Fig. 2: Illustration showing the contiguity of the retroperitoneal space (anterior

pararenal space) with the root of the mesentery (arrow) and the anterior pararenal
position of the ascending colon after the rotations and fusions of the dorsal mesentery
(arrowhead).
References: Horta M, Lisbon/Portugal
The renal fascia is a sheath of collagenous connective tissue that encapsulates the
kidneys, the adrenal glands and the perirenal fat. It is divided in an anterior layer (Gerota's
fascia) and in a posterior layer (also known as Zuckerkandl's fascia). These two layers
join in the lateral parts of the kidneys, behind the ascending and descending colon, to form
the lateroconal fascia, that then continues along the flank and fuses with the parietal
peritoneum (figure 3).

Page 4 of 37

Fig. 3: Diagram (A) and axial CT image (B) show the renal fascia, its anterior and
posterior layers, and its relation with lateroconal fascia.
References: Illustration: Horta M, Lisbon/Portugal. CT image: Department of
Radiology, Centro Hospitalar Lisboa Ocidental, Lisbon/Portugal.
The renal fascia conventionally divides the retroperitoneum into three distinct
compartments: the anterior pararenal space; the perirenal space and the posterior
pararenal space (figure 4) [2-5].

Fig. 4: Illustration showing the anterior pararenal space, the perirenal space, the
posterior pararenal space and their anatomical limits.
References: Horta M, Lisbon/Portugal
The anterior pararenal space is bounded anteriorly by posterior parietal peritoneum,
posteriorly by the anterior renal fascia and postero-externally by the lateroconal fascia
(figure 4).

Page 5 of 37

It can potentially be continuous across the midline and it extends from the dome of the
diaphragm to the pelvis, communicating with the posterior pararenal space below the
perirenal cone [6]. Anteriorly, it communicates with the root of the small bowel mesentery
and with the transverse mesocolon (figure 5) [2].
It contains structures that were developed in the embryologic dorsal mesentery and that
became secondarily retroperitoneal after mesentery rotations and fusions, such as the
ascending and descending colon, most of the pancreas (with exception of the tail that is
intraperitoneal) and the retroperitoneal portions of the duodenum (figure 2) [1,3,4].
Lesions of these organs are responsible for the high number of infections that occur in
this space, being the most common site of extraperitoneal infection. Effusions come from
perforating neoplasms, peptic ulcers, inflammatory conditions and trauma. Perforation of
an ascending retrocecal appendix can also lead to an abscess in this space. Bleeding
from the bare area of the liver and from the splenic and hepatic arteries has been seen
(figure 5) [2].

Fig. 5: A 84-year-old woman with pancreatitis. Axial contrast-enhanced CT scan (A

and B), show pancreatic fluid and inflammation extending from the pancreas in the
anterior pararenal space (APS), straddling the midline. Note its anterior communication

Page 6 of 37

with the root of small bowel mesentery (B, circle). Sagittal contrast-enhanced CT scan
(C and D), demonstrates de extension of the anterior pararenal, that reaches superiorly
the diaphragm (C, arrow). The perirenal and the posterior pararenal spaces are spared
(A-D).
References: Department of Radiology, Centro Hospitalar Lisboa Ocidental, Lisbon/
Portugal
The perirenal space is surrounded by the renal fascia and contains the kidneys, the
adrenal gland, the proximal ureter, fat and lymphatics (figures 6A-C).
It has the form of an inverted long tapered cone, caused by the ascent of the kidneys
from its pelvic location in early embryologic life to their adult position (figure 6D) [1,4].

Fig. 6: The perirenal space. Axial contrast-enhanced CT scan (A-C), show the
constituents and the anatomic limits of the perirenal space; adrenal glands (red circles);
kidneys (K); ureters (yellow circles); fat (F); Gerota's fascia (G); Zuckerkandl's fascia
(Z). Note the inverted long tapered cone appearance in sagittal contrast-enhanced CT
images (D,E).
References: Department of Radiology, Centro Hospitalar Lisboa Ocidental, Lisbon/
Portugal
There are inconsistencies in the literature whether the perirenal spaces have continuity
across midline [6].
According to Meyers, they do not communicate with each other. Internally, the thin
anterior renal fascia fuses with the connective tissue surrounding the great vessels and
the thicker Zuckerkandl's fascia joins the psoas and quadratus lomborum fascia (figure
7, arrows) [2]. On the other hand, studies conducted by Mindell et al., Thornton et al.
and Kneeland et al., demonstrated communication across midline between the perirenal
spaces [6-8]. This communication was shown at and below the level of the hila or superior
Page 7 of 37

mesenteric artery, since above this level the coeliac axis and the superior mesentery
artery prevent free communication [6-9].

Fig. 7: Non-contrast-enhanced axial CT scan of a fluid collection in the left perirenal

space and along the psoas muscle. CT demonstrates the accentuated renal fascial
planes, showing the anterior renal fascia blending with connective tissue surrounding
the great vessels and the posterior renal fascia joining the quadratus lomborum fascia
(arrows).
References: Department of Radiology, Centro Hospitalar Lisboa Ocidental, Lisbon/
Portugal
Inferiorly, there is also no consensus whether the inferior aspect of the renal cone is
closed (figure 6E). Some investigators support that it communicates freely with the pelvic
extraperitoneal spaces [6,7,9]. Others, suggest that anterior and posterior fascia fuse

Page 8 of 37

below the kidneys, preventing the extension of perirenal fluid collections to the pelvis, so
that the effusions stay confined within the perirenal space [2,9,10].
On the right side, over the right kidney and the adrenal gland, the anterior renal fascia
is deficient and the perirenal space abuts and opens to the bare area of the liver
[2,9,11]. Consequently, pathologic processes can extend upward into the bare area and
downward into the perirenal space (figure 8). On the left it opens towards the subphrenic
space [9,11].

Fig. 8: Extension of a pneumoretroperitoneum to the bare area of the liver. Note the
contiguity between the right perirenal space and the bare area of the liver.
References: Department of Radiology, Centro Hospitalar Lisboa Ocidental, Lisbon/
Portugal
The perirenal space contains thin bridging septa that transverse the perirenal fat,
connecting the renal capsule to perirenal fascia and interconnecting its two layers (figure
9). Thickened fibrous lamellae may be an early sign of renal/perirenal disease and may
direct the spread of fluid, inflammation or neoplasms from the kidney to the perirenal
interfascial plane and vice versa [1,12].

Page 9 of 37

Fig. 9: Illustration showing the three types of perirenal bridging septa, those that arise
from the renal capsule and extend to the renal fascia, those that are only connect to the
renal capsule and those that interconnect the anterior and posterior renal fasciae. Axial
CT scan show thickened perinephric bridging septa in a patient with no pathology.
References: Illustration: Horta M, Lisbon/ Portugal. CT image: Department of
Radiology, Centro Hospitalar Lisboa Ocidental, Lisbon/Portugal
Small lymph nodes and a rich network of lymphatics can be found in the perirenal space.
They communicate with hilar and paraaortic lymph nodes as well as with transpleural and
transdiaphragmatic lymphatics, providing a route of spread for neoplasms to and from
the perirenal space [12].
Abscess due to renal infection, urinomas resulting from chronic disruption of the collecting
system and hematomas caused more frequently by trauma and neoplasms are the main
effusions encountered in this space [2].
The posterior pararenal space is a small space that only contains fat and no organs,
lying between the posterior renal fascia and the transversalis fascia (figure 10A) [2].
Inferiorly, below the renal cone, it merges with the anterior pararenal space,
communicating with the extraperitoneal compartments of the pelvis (figures 10C-E) [13].
The posterior pararenal space continues externally to the lateroconal fascia as the
properitoneal fat (figure 10A, orange arrow) [2,11]. Properitoneal fat is radiologically
visualized as the "flank stripe", being bound by lateroconal fascia internally and
transversalis fascia externally (figure 10A, PPF). Both posterior pararenal spaces can
potentially communicate via the properitoneal fat of the anterior abdominal wall [2,11].
At the level of the inferior aspect of the renal cone, when the anterior and posterior
pararenal spaces merge, the lateroconal fascia disappears so that the anterior pararenal
space stays in communication with the properitoneal fat (figure 10E) [2].

Page 10 of 37

The posterior renal fascia was shown to be divided at variable distance of the
posterolateral aspect of the kidneys in one thin anterior layer that continues with the
anterior perirenal fascia and in one thick posterior layer that continues with the lateroconal
fascia (figure 10B). Between these two layers a potential anatomic space exists that
communicates freely with the anterior pararenal space [2].

Fig. 10: Non-contrast-enhanced axial CT. Figure A shows the pararenal posterior
space (PPS), bounded by the transversalis fascia (TF) and the posterior renal fascia
(Z). Note its anatomic contiguity with the properitoneal fat (PPF, orange arrow), that is
bound by the lateroconal fascia (LCF) internally and the transversalis fascia externally.
The posterior renal fascia is shown to be divided in one layer that continues with the
anterior renal fascia and in one posterior layer that continues with LCF (B). Figures C-E
show the inferior extension of the PPS. At the inferior aspect of the renal cone the LCF
disappears (E).
References: Department of Radiology, Centro Hospitalar Lisboa Ocidental, Lisbon/
Portugal
The posterior renal space is a common site of hemorrhage from a ruptured abdominal
aneurysm as well as of spontaneous hemorrhage due to blood anticoagulation and blood
diathesis. Infection is not typically limited to this space, however effusions from spinal
osteomyelitis or from a perforated rectum or sigmoid may spread into this compartment
[2].

Page 11 of 37

Some authors describe a fourth space called the great vessel space, that contains the
aorta and inferior vena cava. It is bounded laterally by the perirenal space and extends
superiorly to the posterior mediastinum. Retroperitoneal fibrosis is usually confined to
this space [4].

Interfascial retroperitoneal planes

More recent studies documented the existence of interfascial retroperitoneal planes.
They demonstrated that the renal fascia was composed of multiple layers of variable
fused embryonic mesentery, originating potential spaces in the retroperitoneum that
could be recruited when a large amount of fluid developed rapidly, serving as pathways
for the spreading and decompression of various pathologic entities [1,4,5,14].
These potential spaces are the retromesenteric space, the retrorenal space, the
lateroconal plane and the combined interfascial plane [1,4,5].
The retromesenteric plane is located between the anterior pararenal space and the
perirenal space (figure 11) [12]. It is continuous across midline providing a major route
of contralateral retroperitoneal fluid spread [1,4,5].
On the right side it abuts the bare area of the liver and is contiguous with the liver hilum
through the subperitoneal space of the hepatoduodenal ligament. On the left it extends to
the dome of diaphragm, posterior to the esophagus and the phrenoesophageal ligament
[4,5].
Inferiorly, the retromesenteric plane extends to the pelvis along the anterior surface of
the psoas [1].
The retromesenteric plane communicates with the retrorenal and lateroconal interfascial
planes at the fascial trifurcation, which is another a potential space at the origin of the
lateroconal fascia where these three spaces meet each other (figure 11) [5].

Page 12 of 37

Fig. 11: Warfarin-induced haemorrhage in a 33-year-old man. Contrast-enhanced

axial CT shows haemorrhage in the anterior interfascial retromesenteric plane
(straight open arrow), in the posterior interfascial retrorenal plane (solid arrow) and
in the lateroconal interfascial plane (curved arrow). These three interfascial planes
communicate with each other at the fascial trifurcation (yellow circle). Collapsed
descending colon (arrowhead).
References: Department of Radiology, Centro Hospitalar Lisboa Ocidental, Lisbon/
Portugal
The retrorenal plane is the interfascial plane located between the perirenal space and
the posterior pararenal space (figure 11) [4,12]. It communicates with the great vessel
space which impedes their communication through midline [4,5]. Effusions from the

Page 13 of 37

anterior pararenal space and retromesenteric space may extend into the retrorenal space
(figure 11) [4,5].
The lateroconal interfascial plane is a potentially space between the layers of the
lateroconal fascia, that communicates with the retrorenal and retromesenteric planes at
the level of the fascial trifurcation (figure 11) [4,5,12].
The combined interfascial plane results from the inferior fusion of the retrorenal and
retromesenteric interfascial planes, posterior to the ascending and descending colon. It
continues inferiorly along the surface of the psoas into the mesorectal interfascial plane
or prevesical space (figure 12A) [5]. This plane allows the spread of effusions from the
abdominal retroperitoneum to the pelvic retroperitoneum and vice versa [4,5].

Fig. 12: Retroperitoneal fluid collections in a patient with necrotizing pancreatitis.

Contrasted-enhanced sagittal CT and contrasted-enhanced axial CT at the level of
the lower poles of kidneys show fluid collections in the left retromesenteric plane
(open arrows) and in the left retrorenal plane (solid arrows). These two planes fuse
to form a single multilaminar fascia, the combined interfascial plane ( A, solid lines),
that allows the spread of effusions from the abdominal retroperitoneum to the pelvic
retroperitoneum.
References: Department of Radiology, Centro Hospitalar Lisboa Ocidental, Lisbon/
Portugal

Page 14 of 37

Images for this section:

Fig. 1: Diagram showing the anatomic limits of the extraperitoneal space and of the
retroperitoneum.

Page 15 of 37

Fig. 2: Illustration showing the contiguity of the retroperitoneal space (anterior pararenal
space) with the root of the mesentery (arrow) and the anterior pararenal position of the
ascending colon after the rotations and fusions of the dorsal mesentery (arrowhead).

Fig. 3: Diagram (A) and axial CT image (B) show the renal fascia, its anterior and posterior
layers, and its relation with lateroconal fascia.

Page 16 of 37

Fig. 4: Illustration showing the anterior pararenal space, the perirenal space, the posterior
pararenal space and their anatomical limits.

Fig. 5: A 84-year-old woman with pancreatitis. Axial contrast-enhanced CT scan (A and

B), show pancreatic fluid and inflammation extending from the pancreas in the anterior
pararenal space (APS), straddling the midline. Note its anterior communication with the
root of small bowel mesentery (B, circle). Sagittal contrast-enhanced CT scan (C and
D), demonstrates de extension of the anterior pararenal, that reaches superiorly the
diaphragm (C, arrow). The perirenal and the posterior pararenal spaces are spared (A-D).

Page 17 of 37

Fig. 6: The perirenal space. Axial contrast-enhanced CT scan (A-C), show the
constituents and the anatomic limits of the perirenal space; adrenal glands (red circles);
kidneys (K); ureters (yellow circles); fat (F); Gerota's fascia (G); Zuckerkandl's fascia
(Z). Note the inverted long tapered cone appearance in sagittal contrast-enhanced CT
images (D,E).

Page 18 of 37

Fig. 7: Non-contrast-enhanced axial CT scan of a fluid collection in the left perirenal space
and along the psoas muscle. CT demonstrates the accentuated renal fascial planes,
showing the anterior renal fascia blending with connective tissue surrounding the great
vessels and the posterior renal fascia joining the quadratus lomborum fascia (arrows).

Page 19 of 37

Fig. 8: Extension of a pneumoretroperitoneum to the bare area of the liver. Note the
contiguity between the right perirenal space and the bare area of the liver.

Fig. 9: Illustration showing the three types of perirenal bridging septa, those that arise
from the renal capsule and extend to the renal fascia, those that are only connect to the
renal capsule and those that interconnect the anterior and posterior renal fasciae. Axial
CT scan show thickened perinephric bridging septa in a patient with no pathology.

Page 20 of 37

Fig. 10: Non-contrast-enhanced axial CT. Figure A shows the pararenal posterior space
(PPS), bounded by the transversalis fascia (TF) and the posterior renal fascia (Z). Note
its anatomic contiguity with the properitoneal fat (PPF, orange arrow), that is bound by the
lateroconal fascia (LCF) internally and the transversalis fascia externally. The posterior
renal fascia is shown to be divided in one layer that continues with the anterior renal fascia
and in one posterior layer that continues with LCF (B). Figures C-E show the inferior
extension of the PPS. At the inferior aspect of the renal cone the LCF disappears (E).

Page 21 of 37

Fig. 11: Warfarin-induced haemorrhage in a 33-year-old man. Contrast-enhanced axial

CT shows haemorrhage in the anterior interfascial retromesenteric plane (straight open
arrow), in the posterior interfascial retrorenal plane (solid arrow) and in the lateroconal
interfascial plane (curved arrow). These three interfascial planes communicate with each
other at the fascial trifurcation (yellow circle). Collapsed descending colon (arrowhead).

Page 22 of 37

Fig. 12: Retroperitoneal fluid collections in a patient with necrotizing pancreatitis.

Contrasted-enhanced sagittal CT and contrasted-enhanced axial CT at the level of the
lower poles of kidneys show fluid collections in the left retromesenteric plane (open
arrows) and in the left retrorenal plane (solid arrows). These two planes fuse to form a
single multilaminar fascia, the combined interfascial plane ( A, solid lines), that allows the
spread of effusions from the abdominal retroperitoneum to the pelvic retroperitoneum.

Page 23 of 37

Findings and procedure details

Pancreatitis
The absence of a capsule around the pancreas allows easy access to pancreatic
enzymes to spread to multiple anatomic compartments around the pancreas when acute
inflammation occurs.
Fluid collections are commonly present in the anterior pararenal space, in the interfascial
planes, in the lesser sac and in the subperitoneal spaces of transverse mesocolon and
of the small bowel mesentery [1,5].
Since the pancreas is mostly located in the anterior pararenal space, the involvement of
this retroperitoneal space is typical (figure 5). However, bilateral spread is usually only
seen in advanced stages of fulminant necrotizing pancreatitis [2].
Pancreatic effusions commonly infiltrate the anterior interfascial retromesenteric plane
and extend to the contiguous retrorenal interfascial plane (figure 13). Involvement of the
lateroconal plane is sometimes seen. They may spread inferiorly along the combined
interfascial plane to the pelvic retroperitoneal spaces [1,5].
The classical clinical sign of Grey-Turner (subcutaneous discoloration of the
costovertebral angle) is caused by the spread of pancreatic effusion to the retrorenal
interfascial plane. From this space it reaches the subcutaneous tissues of the posterior
abdominal wall areas of anatomic weakness (the Grynfeltt and Petit triangles) through a
cleft between the medial border of the posterior pararenal space and the lateral border
of quadratus lomborum fat pad [1,2,4].

Page 24 of 37

Fig. 13: Necrotizing pancreatitis in a 75-year-old woman. Contrast-enhanced CT

scan (A-D) show bilateral spread of pancreatic effusion within the retromesenteric
interfascial planes (open arrows), dissecting posteriorly into the left retrorenal space
(solid arrows; yellow line). The right retromesenteric plane communicates with the liver
hilum through the subperitoneal space of the hepatoduodenal ligament (yellow circle).
Note the extension of the left retromesenteric plane and the retrorenal plane to left
hemidiaphragm (orange circle).
References: Department of Radiology, Centro Hospitalar Lisboa Ocidental, Lisbon/
Portugal
Ruptured abdominal aortic aneurysms
The most common CT finding indicating rupture of an abdominal aortic aneurysm is a
retroperitoneal hematoma [15]. Bleeding from a ruptured aortic aneurysm may extend
into the pararenal spaces, the perirenal space or the psoas muscle [15].
Most commonly they bleed posteriorly and are circumscribed by the psoas space [5].
Frequently, bleeding extends to the posterior pararenal space or into the retrorenal plane
that is usually involved due to its medial relation to the great vessel space[2,5].The

Page 25 of 37

combined interfascial plane can be dissected upward and downward by haemorrhage

[5] (figure 14).

Fig. 14: Rupture of abdominal aortic aneurysm is a 73-year-old man. Axial

contrast-enhanced CT images (A,B) and sagittal contrast-enhanced CT image
(C) demonstrate a large ruptured abdominal aortic aneurysm with a prominent
retroperitoneal haemorrhage. Haemorrhage is predominantly located in the left anterior
retromesenteric space, crossing the midline. The hematoma also extends to the left
retrorenal space, to the left combined interfascial plane and to a lesser extent, to the
bridges of the perirenal space (B,C).
References: Department of Radiology, Centro Hospitalar Lisboa Ocidental, Lisbon/
Portugal
Perirenal hematoma
Both subcapsular and perirenal hematomas can be caused by trauma or by lesions of
the kidneys and of their blood vessels [2]. They can spread into the adjacent interfascial
planes along the perinephric bridging septa (figure 15) [1].

Page 26 of 37

Fig. 15: Subcapsular and perirenal left hematoma caused by a stab wound. Contrastenhanced axial CT scan (A-C) and contrast-enhanced sagittal images (C,D) depict a
subcapsular and perinephric left renal hematoma. Note the thickened perirenal bridging
septa (small arrows) serving as conduit for the spread of fluid to the retrorenal plane
and to the anterior renal fascia (open arrow).
References: Department of Radiology, Centro Hospitalar Lisboa Ocidental, Lisbon/
Portugal
Perirenal abscess
The majority of perirenal abscess are usually a sequela of an acute pyelonephritis [2].
They may also originate from infection of a pre-existing hematoma or urinoma [16].
Perforation of the renal capsule leads to the involvement of the perirenal space. On CT
a fluid collection with a thick enhancing wall is usually seen within the renal parenchyma
and within the perirenal space. Intralesional gas may be present (figure 16) [16].

Page 27 of 37

Fig. 16: Perirenal abscess in a 82-year-old man. Contrast-enhanced axial CT scan (AC) and non-contrast-enhanced sagittal CT images (D,E) show a large collection with
thickened enhancing wall that distends the perirenal space and extends into the psoas
compartment (solid arrows). Note the thickened anterior renal fascia (open arrow) and
the involvement of the posterior pararenal space (orange arrowhead).
References: Department of Radiology, Centro Hospitalar Lisboa Ocidental, Lisbon/
Portugal
Pneumoretroperitoneum
Causes of a pneumoretroperitoneum include traumatic and non-traumatic hollow viscera
rupture, emphysematous infections and residual air from retroperitoneal surgery [17]. As
shown previously, fascial compartments and interfascial planes can direct the spread
of gas and fluid from the extraperitoneal pelvic compartments to the extraperitoneal
abdominal compartments and vice versa. Air in the pelvic extraperitoneal space can get
off through the properitoneal fat, that is in contiguity with the posterior pararenal space
and by the combined interfascial plane, that communicates with the pelvic retroperitoneal
perivesical and presacral spaces (figure 17) [17].

Page 28 of 37

Fig. 17: Extraperitoneal air in a 83-year-old woman with a iatrogenic perforation of the
sigmoid. Axial CT scan obtained without intravenous contrast material (A-D) depicts
gas within the presacral space (red arrow) and within the perirectal space (yellow
arrow) dissecting into the prevesical space (green arrow). Cephalad extension of
the gas through the combined interfascial plane is demonstrated (C, circle and line;
D). The pneumoretroperitoneum penetrates into the perirenal space and into the
retromesenteric interfascial plane (D, blue arrow). Note the presence of gas in the
posterior pararenal space and in the extraperitoneal anterolateral abdominal wall (white
arrow).
References: Department of Radiology, Centro Hospitalar Lisboa Ocidental, Lisbon/
Portugal
Spontaneous retroperitoneal warfarin-induced haemorrhage

Page 29 of 37

Spontaneous retroperitoneal haemorrhage is defined as the presence of bleeding from a

non traumatic and non iatrogenic cause without any underlying retroperitoneal pathology
[18].
Haemorrhage associated with anticoagulation and bleeding diathesis commonly involves
body wall muscle compartments, such as the ileopsoas muscle (figure 18) [19].
The patient typically presents with lower extremity pain and paraesthesia in the territories
of the lumbar plexus [18].
Perirenal and posterior pararenal spaces hematomas are not rare [2,19].

Fig. 18: 77-year-old woman with a retroperitoneal warfarin-induced hematoma.

Axial CT scan obtained with intravenous contrast material (A-F) depicts an extensive
hematoma along the psoas compartment (yellow asterisks), that extends to the
posterior renal space and a large hematoma in the anterior pararenal space (purple
asterisks). Note the presence of hydronephrosis caused by the compression of the
perirenal space (open arrow). Thickened bridging septa are seen providing a conduit
for the spread of fluid into the perirenal space (small arrows).
References: Department of Radiology, Centro Hospitalar Lisboa Ocidental, Lisbon/
Portugal
Images for this section:

Page 30 of 37

Fig. 13: Necrotizing pancreatitis in a 75-year-old woman. Contrast-enhanced CT scan

(A-D) show bilateral spread of pancreatic effusion within the retromesenteric interfascial
planes (open arrows), dissecting posteriorly into the left retrorenal space (solid arrows;
yellow line). The right retromesenteric plane communicates with the liver hilum through
the subperitoneal space of the hepatoduodenal ligament (yellow circle). Note the
extension of the left retromesenteric plane and the retrorenal plane to left hemidiaphragm
(orange circle).

Fig. 14: Rupture of abdominal aortic aneurysm is a 73-year-old man. Axial contrastenhanced CT images (A,B) and sagittal contrast-enhanced CT image (C) demonstrate a

Page 31 of 37

large ruptured abdominal aortic aneurysm with a prominent retroperitoneal haemorrhage.

Haemorrhage is predominantly located in the left anterior retromesenteric space,
crossing the midline. The hematoma also extends to the left retrorenal space, to the left
combined interfascial plane and to a lesser extent, to the bridges of the perirenal space
(B,C).

Fig. 15: Subcapsular and perirenal left hematoma caused by a stab wound. Contrastenhanced axial CT scan (A-C) and contrast-enhanced sagittal images (C,D) depict a
subcapsular and perinephric left renal hematoma. Note the thickened perirenal bridging
septa (small arrows) serving as conduit for the spread of fluid to the retrorenal plane and
to the anterior renal fascia (open arrow).

Page 32 of 37

Fig. 16: Perirenal abscess in a 82-year-old man. Contrast-enhanced axial CT scan (AC) and non-contrast-enhanced sagittal CT images (D,E) show a large collection with
thickened enhancing wall that distends the perirenal space and extends into the psoas
compartment (solid arrows). Note the thickened anterior renal fascia (open arrow) and
the involvement of the posterior pararenal space (orange arrowhead).

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Fig. 17: Extraperitoneal air in a 83-year-old woman with a iatrogenic perforation of the
sigmoid. Axial CT scan obtained without intravenous contrast material (A-D) depicts gas
within the presacral space (red arrow) and within the perirectal space (yellow arrow)
dissecting into the prevesical space (green arrow). Cephalad extension of the gas
through the combined interfascial plane is demonstrated (C, circle and line; D). The
pneumoretroperitoneum penetrates into the perirenal space and into the retromesenteric
interfascial plane (D, blue arrow). Note the presence of gas in the posterior pararenal
space and in the extraperitoneal anterolateral abdominal wall (white arrow).

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Fig. 18: 77-year-old woman with a retroperitoneal warfarin-induced hematoma. Axial CT

scan obtained with intravenous contrast material (A-F) depicts an extensive hematoma
along the psoas compartment (yellow asterisks), that extends to the posterior renal
space and a large hematoma in the anterior pararenal space (purple asterisks). Note the
presence of hydronephrosis caused by the compression of the perirenal space (open
arrow). Thickened bridging septa are seen providing a conduit for the spread of fluid into
the perirenal space (small arrows).

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Conclusion
The introduction of cross-sectional imaging was essential to understand and to study the
extraperitoneal space anatomy and the extent of extraperitoneal disease.
The recognition of the anatomic relationships of the extraperitoneal space is important to
accurate CT diagnosis and analysis of extraperitoneal pathologic processes.

Personal information
Mariana Horta
Department of Radiology
Centro Hospitalar Lisboa Ocidental
Estrada do Forte do Alto do Duque 1449-005 Lisboa
Portugal

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