Prolonged Urinary Leakage After Partial Nephrectomy: A Novel Management Pathway

Prolonged postoperative urine leakage due to a calyceal diverticulum mimicking a renal cyst: A case report and literature review

Background

The calyceal diverticulum is a rare cystic cavity that communicates with the collecting system via a narrow neck or infundibulum. In clinical practice, part of the calyceal diverticula is difficult to differentiate from simple renal cysts even after contrast-enhanced CT. To date, there have been few kinds of literature works on the diagnosis and treatment of calyceal diverticulum combined with renal pelvis dilatation, especially concerning the treatment of prolonged postoperative urine leakage.

Case description

A 53-year-old woman with calyceal diverticulum and renal pelvis dilatation mimicking a simple renal cyst suffered urine leakage after receiving laparoscopic unroofing of the renal cyst. A persistent urine leakage was observed immediately after surgery, with about 200 ml of drainage fluid per day. We first attempted to place a double-J ureteral stent and indwell a catheter. After failing that, conservative treatment was performed. The core idea of the conservative treatment is retaining the drainage tube for more than 1 month, then clamping the drainage tube for 1 week, and finally removing the drainage tube. By 3 weeks of follow-up, the urine leakage disappeared, and the CT scan showed hydronephrosis of the right kidney without perirenal exudation and the lower pole cyst of the right kidney shrank significantly.

Conclusion

This case, we reported here, is to attract the attention of clinicians. Renal cysts should exclude the possibility of the calyceal diverticulum. If urine leakage is inevitable after surgical treatment, our conservative treatment strategy is also an alternative method.

Systematic review on active treatment for urinary fistula after partial nephrectomy

INTRODUCTION

Urinary fistula is expected to become more frequent in urological practice as a result of expanding indication of partial nephrectomy given it's oncological results equivalent to those of radical nephrectomy but at a lower risk of progression to chronic kidney disease, lower cardiovascular morbidity, and overall mortality.

OBJECTIVES

Review and compare different techniques of contemporary active management for urinary fistula after partial nephrectomy.

METHODS

A systematic literature search on the MEDLINE database was conducted in March 2020, combining the terms: "urine leak", "urine leakage", "urinary leak" and "urinary fistula", with: "partial nephrectomy", "nephron sparing surgery" and "renal sparing surgery". This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Only articles related to active treatment were eligible. Abstracts in English and Spanish from the last two decades were screened. No restriction based on study design nor the length of follow-up.

PRIMARY OUTCOMES

1) Leak resolution rate 2) Time course of leak resolution and 3) Number of interventions needed for resolution.

RESULTS

Multiple studies were found. There were no randomized controlled trials. Urinary fistula can be solved in many ways with active treatment, with a high success rate (97.5%), an average of 1.4 intervention-per-patients and a mean time for leak resolution of 11 days (median of 3 days).

CONCLUSION

There is a high risk of bias due to the study's methodology. There is a broad range of effective alternatives and various approaches to solve urinary fistula in an appropriate timing.

Percutaneous Obliteration of Urinary Leakage after Partial Nephrectomy Using N-Butyl-Cyanoacrylate Obliteration of the Urinoma with or without Coil Embolization of the Fistula Tract

PURPOSE

To retrospectively evaluate the safety and efficacy of the percutaneous obliteration of urinary leakage after partial nephrectomy (PN) using coils and N-butyl-cyanoacrylate (NBCA).

MATERIALS AND METHODS

Data of 10 consecutive patients who underwent percutaneous obliteration of urinary leakage after PN using coil and NBCA between February 2016 and May 2018 were retrospectively reviewed. A urinary fistulography was performed via the drainage catheter. If the fistulous tract was clearly visualized, super-selective embolization of the fistulous tract with coils and urinoma cavity sealing with NBCA was performed. In cases where the fistulous tract could not be clearly visualized, only urinoma cavity sealing was performed. Outcomes and complications were assessed by reviewing medical records and computed tomography (CT).

RESULTS

In 7 (70%) patients who showed obvious urinary fistulous tract, coil embolization of the urinary fistulous tract, followed by sealing of the urinoma cavity with NBCA, was performed. Obliteration of the urinoma without coil embolization of the fistula tract was performed in 3 patients (30%) in whom a distinct fistulous tract could not be visualized. The median number of treatment sessions required to achieve clinical success was 1 (range, 1-5). Four patients underwent multiple repeated procedure with successful results. All patients showed gradual decrease in size or complete disappearance of urinoma on follow-up CT without evidence of urinary leakage during the follow-up period (mean, 44.6 weeks; range, 11-117 weeks). There were no procedure-related complications.

CONCLUSIONS

Percutaneous obliteration of urinary leakage after PN using coils and NBCA is safe and effective.

Massive Dilation of the Ureter: An Endoscopic Management of Persistent Urinary Leak After Partial Nephrectomy

Introduction: The incidence of urinary leakage is increased as nephron sparing surgery becomes more used for the management of small renal masses. We present an endourologic approach in a patient with a persistent urinary leak after partial nephrectomy by placing two synchronous ureteral stents to improve drainage and avoid further potential surgery.

Patients and Method: A 39-year-old patient presented with a urine leak on the fifth postoperative day after an open partial nephrectomy. Initially, the leakage was managed with a placement of a 6F Double-J stent. However, due to persistence of leakage after a month, two ureteral stents (a 6F Double-J stent and a 14F endopyelotomy stent) were placed. With this maneuver, the ureter was dilated to 20F and a bladder catheter was placed to complete the drainage.

Results: At 3 weeks, a CT urography was performed, which showed complete resolution of the urinary leakage compared with previous examination. The stents were removed the following day and the patient required no further intervention. The follow-up examination was continued for 24 months without any symptom of the patient and any sign of leak recurrence.

Conclusion: Endoscopic approach to urinary leak after partial nephrectomy obtaining high ureteral gauge can be a good alternative, avoiding more aggressive surgical approaches.

Does Ureteral Catheter Insertion Decrease the Risk of Urinary Leakage After Partial Nephrectomy in Patients With Renal Cell Carcinoma?

INTRODUCTION

We aimed to evaluate the impact of preoperative ureteral catheter insertion on urinary leakage after partial nephrectomy (PN) in patients with renal cell carcinoma.

METHODS

We reviewed the data of 893 patients with renal cell carcinoma who underwent PN and divided them according to ureteral catheter placement. The impact of ureteral catheter placement on postoperative urinary leakage was evaluated by using multivariate analysis.

RESULTS

Ureteral catheters were inserted in 397 (44.5%) patients. Patients with ureteral catheter insertion had larger tumors (2.4 vs. 2.6 cm; P = .031); however, the RENAL nephrometry scores were comparable (P = .131). Robotic PN was more common in patients with ureteral catheters (11.1 vs. 53.9%; P < .001). Urinary leakage did not differ according to ureteral catheter placement (3.4 vs. 3.5%; P = .936). Although tumor size (P = .002), ureteral catheter insertion (P < .001), and operative methods (P < .001) were significantly different according to surgeons, the rate of urinary leakage was similar (surgeon A: 4.0%, surgeon B: 4.6%, surgeon C: 1.5%, others: 2.9%; P = .294). In multivariate analysis of preoperative variables, age and RENAL nephrometry scores were associated with urinary leakage. In multivariate analysis of preoperative and intraoperative variables, the operative method, collecting system status, and intraoperative transfusion, but not ureteral catheter insertion, were related to urinary leakage.

CONCLUSIONS

Ureteral catheter insertion does not appear to reduce the risk of urinary leakage after PN, and visibility during PN with meticulous bleeding control is important in preventing urinary leakage after PN.

[Conservative management of upper tract urinary fistulae using ureteral trans-vesico-parietal stent]

OBJECTIVES

Ureteral stents and ureteral catheters externalized through the urethra are not ideal solutions to manage complicated upper urinary tract fistulae. We sought an effective method of drainage, minimally invasive, reproducible allowing a rapid patient's discharge.

PATIENTS AND METHODS

Between November 2013 and February 2015, an ureteral stent was exteriorized in trans-vesico-parietal by an endoscopic and percutaneous access in patients with complicated upper urinary tract fistulae. Monitoring of tolerance, complications and urinary fistula healing was performed.

RESULTS

Nine consecutive patients had an ureteral stent exteriorized in trans-vesico-parietal to manage complicated upper urinary tract fistulae. There was no failure in introducing the catheter, or postoperative complication. Catheters were left in place on average 36.1days (24-55). The patients were able to return home with the catheter in place in 77.8% of cases. The tolerance of the catheter was good. All fistulae were able to be treated conservatively at the end of the drainage period.

CONCLUSION

Trans-vesico-parietal ureteral catheters enable efficient and reproducible conservative treatment of upper tract urinary fistulae regardless of their cause.

LEVEL OF EVIDENCE

5.

Off-Clamp Renal Tumourectomy by Retroperitoneoscopy in Posterior Renal Tumours of Medium Complexity (Padua score 8-9)

BACKGROUND

The guidelines recommend partial surgery for T1 renal tumours. Various aspects of this surgery have evolved in recent years, including the clamping method and duration, enucleation, the retroperitoneoscopic approach and the use of 3mm ports. We present our initial series on laparoscopic renal tumourectomy by retroperitoneoscopy (LRTR) and analyse our learning curve and use of 3-mm instrumentation.

MATERIAL AND METHODS

From January 2011 to January 2015, we performed LRTR on 50 patients with posterior or convex T1 renal tumours. After 10 cases, the technique changed to off-clamp, and 11 cases were subsequently performed with 3mm instrumentation.

RESULTS

The mean tumour size was 34.36 mm (14-62), with a mean PADUA score of 8.42 (5-12). The mean operative time was 163.1 minutes (75-300), and the mean warm ischaemia time was 4.21 minutes (0-28). The main renal artery was not clamped in 41 (82%) patients, and no vessel (zero ischaemia) was clamped in 39 (78%) patients. Seven cases had positive margins (6 focal). Eleven LRTRs were performed with 3mm instrumentation, with shorter surgical times, less intraoperative bleeding and shorter hospital stays.

CONCLUSIONS

Retroperitoneoscopy coupled with enucleation enables the extirpation without clamping of posterior renal tumours, with a relatively short learning curve. The 3-mm material enables the technique to be performed, although in our experience it has resulted in a higher rate of positive surgical margins.

Chemical and Mineralogical Analysis of Ureteral Stent Encrustation and Associated Risk Factors

OBJECTIVE

To assess the burden and chemical and mineralogical composition of stent coating at both stent ends, with evaluation of associated risk factors.

MATERIALS AND METHODS

A total of 40 consecutive patients submitted to ureteral-stent removal were considered. Stents were previously positioned for both urolithiasis and during the management of other urologic diseases and/or procedures. Mean indwelling time was 59.2 ± 7.5 days.

ANALYTICAL PROCEDURES

Encrustations were submitted to chemical-mineralogical analysis as well as to their quantification. Quantification was achieved by measuring the weight of stent fragments before and after oxidative acid treatment to dissolve the deposited (both organic and inorganic) material. The analytical solution obtained by acid attack was used to acquire information on calcium and magnesium content with atomic-absorption spectroscopy. X-ray diffraction was used to determine the mineralogy of encrustations for a group of stent samples characterized by relatively high amounts of deposited material.

RESULTS

The composition of encrustations at the proximal coil reflected the composition of stones in patients with urolithiasis. Whewellite was the more common encrustant. In a regression model, the variable mostly related to the burden of proximal encrustation was urolithiasis (P = .04), especially in frequent stone formers. At the distal coil, higher degrees of encrustation were related to urinary tract infection (P = .012) and patient's aging (P = .05), thus suggesting a possible association with a bladder outlet dysfunction.

CONCLUSION

The present study highlighted some variables related to stent encrustation and seems to be the first one analyzing separately the two coils. Our outcomes suggest that the so-obtained risk factors have to be considered when positioning a ureteral stent.