Bolster material granuloma masquerading as recurrent renal cell carcinoma following partial nephrectomy

Can near-infrared imaging distinguish a gelatin-based matrix granuloma from a malignancy in a kidney?

Aim: Differentiating granulomas from cancerous tissue poses a significant challenge in upper urinary tract surgery. We present the case of a 62-year-old male with a gelatin-based matrix (SurgifloTM) granuloma in the kidney following renal cyst decortication eight years earlier.Methods: Contrast-enhanced abdominal tomography revealed a Bosniak type-4 cyst at the previous operation site. The patient underwent laparoscopic partial nephrectomy with near-infrared imaging.Results: The lesion presented as hypofluorescent relative to normal kidney tissue. Histopathological examination revealed a foreign body granuloma due to unabsorbed Surgiflo.Conclusion: The fluorescence pattern could not distinguish a Surgiflo granuloma from a malignant lesion of the kidney.

Pre-gerotal fat patch-A novel alternative to haemostatic agents during partial nephrectomy

Objective

This study aimed to determine if using a pre-gerotal fat patch at open partial nephrectomy (PN) as a haemostatic bolster is a viable alternative to using synthetic haemostatic agents.

Materials and methods

Human Research Ethics Committee approval was obtained for audit of a prospectively kept database from July 2012 to July 2021, which followed outcomes of patients who received a low-tension pre-gerotal fat patch renorrhaphy at open PN. Patient demographics, intraoperative measures, histological outcomes and post-operative complications were analysed. Using a retroperitoneal approach, the peritoneum was mobilised and a vascularised pedicle of pre-gerotal fat was rotated in the direction of the kidney. Routine definition of the hilum, clamping of the hilar vessels and dissection of mass followed. After watertight closure and haemostasis, the harvested pre-gerotal fat patch was placed over the defect and secured using low-tension renorrhaphy. Two-layer closure of the abdominal wall with placement of a drain was routine.

Results

A total of 55 patients underwent open PN. Mean age was 60.4 (35-77) years. There were 38 men and 17 women, and 32 right and 23 left PNs. Mean mass size was 31.9 mm (10-95 mm) and collecting system was breached in 36.5% of cases. One patient (1.9%) suffered a Clavien-Dindo IIIb complication requiring return to theatre and transfusion due to a bleed from an intercostal artery. There were no renal bed bleeds, urine leaks or urine fistulas detected. Mean intraoperative blood loss was 355 mL (50-1500 mL) and mean post-operative creatinine increased by 10.7 μmol/L (51-172 μmol/L). Mean follow up was 40.2 (4-109) months.

Conclusion

Utilisation of an anatomical pre-gerotal fat patch to provide pressure at the renorrhaphy site during open PN is an effective technique to assist with surgical haemostasis. This simple technique avoids the costs of haemostatic agents, whilst adding minimal operating time to procedures.

Surgicel® Granuloma Mimicking Recurrent Thyroid Tumor After Thyroidectomy: A Case Report and Literature Review

Oxidized regenerated cellulose, commonly known by the brand name Surgicel®, is a hemostatic agent widely used in various surgical procedures. While it is generally considered safe and effective, there have been reports of complications associated with its use, including the formation of pseudotumoral lesions. This article presents a case of a patient who developed a Surgicel® granuloma in the thyroid bed, mimicking a recurrent tumor. Surgicel® is known to cause a chronic inflammatory reaction, leading to foreign body giant cell formation and fibroblastic proliferation. Fine-needle aspiration (FNA) cytology is a valuable diagnostic tool for identifying pseudotumoral lesions caused by oxidized cellulose. The characteristic appearance of oxidized cellulose fragments and the presence of a granulomatous reaction can help distinguish these lesions from tumor recurrence or abscesses. To prevent Surgicel® granuloma, it is recommended to use the minimal amount necessary to achieve hemostasis. It is also important to document its use in the operative report. In cases where a recurrent mass lesion is suspected postoperatively, a comprehensive medical history, imaging studies, and FNA are essential for accurate diagnosis and management. This case report highlights the importance of considering Surgicel®-induced granuloma in the differential diagnosis of recurrent thyroid-bed tumors. A correct diagnosis can help avoid unnecessary aggressive interventions, particularly in cancer patients.

Surgical margin follow-up after nephron-sparing surgery: the possible role of CEUS

PURPOSE

To evaluate the possible role of CEUS in the management of patients who underwent nephron-sparing surgery (NSS) and presented questionable findings on the surgical margins at the CECT follow-up exam.

METHODS

In our retro-prospective study, we included 952 patients with small renal masses (SRMs) treated with NSS between 2012 and 2015 and followed with CECT for at least 3 years at Careggi University Hospital. Twenty-two of them presented solid masses on the site of surgery with questionable enhancement at CECT and were further studied with CEUS. This examination was followed by a quantitative analysis of the enhancement pattern.

RESULTS

Out of the 22 masses, 18 were considered possible granulomas, presenting slow wash-in and low enhancement peaks compared to the surrounding parenchyma and persistent delayed wash-out at CEUS. Four lesions presented a suspicious malignant enhancement pattern, with rapid wash-in, high peak and rapid wash-out. In accordance with instructions from the urologist, the first group of 18 patients was strictly monitored, revealing that the mass dimensions and enhancement pattern were stable for at least 3 years of follow-up, while the other 4 patients underwent a second intervention and their masses were confirmed as tumor recurrence at the histopathological evaluation.

CONCLUSIONS

CEUS can play a key role in the surgical margin follow-up after NSS when a suspicious enhancing mass is detected by CECT, giving an accurate depiction of the enhancement pattern and thus helping the clinician in the management of the patient.

Practical Suggestions for Prevention of Complications Arising from Oxidized Cellulose Retention: A Case Report and Review of the Literature

BACKGROUND Bleeding is a major intraoperative complication during surgical procedures. When conventional methods such as ligature and diathermocoagulation are ineffective for bleeding management, hemostatic agents should be used. Oxidized cellulose is one of the major hemostatic agents used worldwide. Oxidized cellulose is often left in situ after hemostasis because of its high level of reabsorption that lasts up to 8 weeks. However, 38 cases of retaining-associated complications are reported in the literature. CASE REPORT A 51-year-old male patient presented in our emergency department with acute abdominal pain, nausea, and vomiting. The patient had been admitted in our department for laparoscopic cholecystectomy for acute cholecystitis 25 months previously. Abdominal ultrasound and CT scan showed the presence of a cystic circular mass, with homogeneous fluid content, close to the surgical clips of the previous surgery, resembling a "neogallbladder". Laparoscopic abdominal exploration and drainage were performed. Histological examination reported protein-based amorphous material with rare lymphocytes and macrophages. Culturing was negative for bacterial growth. The patient was discharged uneventfully on the 4 th postoperative day. The primary surgical report was evaluated with evidence of application of Gelita-Cel ® Standard for hemostatic purposes. Results of 12-month follow-up were normal. CONCLUSIONS Herein, we report the first case of a complication associated with the use of Gelita-Cel ® Standard. We reviewed the literature to better define the purpose and limits of oxidized cellulose use as a hemostatic agent. Despite the fundamental role of oxidized cellulose as a hemostatic agent, we provide some practical suggestions to prevent the reported severe complications and surgical overtreatments.