Refractory urinary fistula with infundibular stenosis after partial nephrectomy

A 71‐year‐old male patient who was diagnosed with renal cell carcinoma (cT1aN0M0) underwent a laparoscopic left partial nephrectomy. Because the bleeding could not be controlled, conversion to laparotomy was instigated. A ureteral stent was placed on confirmation of postoperative urine leakage from the drain, but the volume of drainage did not decrease. The findings of retrograde pyelography and computed tomography showed a urinary fistula resulting from isolated calyces caused by infundibular stenosis, for which transurethral dilatation for the stenosis was carried out. However, owing to the severity of stenosis, the guidewire was unable to achieve passage, and endoscopic dilatation was abandoned. Selective embolization of the left renal artery was then carried out. No drainage fluid was observed after embolization, and residual renal function of the left kidney was confirmed.     

Renal arteriovenous fistula after nephrectomy

Postnephrectomy renal arteriovenous fistulas are rare. An arteriovenous fistula of the right renal pedicle was discovered in a 37-year-old woman who had undergone nephrectomy for renal tuberculosis nine months previously, after she had complained of dyspnea and pain in the right flank. The fistula was confirmed on arteriograms. Proximal ligation of the artery and distal ligation of the vein were followed by an uneventful recovery. Twelve months later, the patient was asymptomatic. Even though complete excision of the fistula represents the ideal treatment of this type of lesion, simple ligation can provide good results when the size of the fistula contraindicates embolization.     

Percutaneous injection of fibrin glue for persistent nephrocutaneous fistula after partial nephrectomy

We report a case of persistent urinary leak of nearly 4 months' duration after open surgical partial nephrectomy. The urinary leak was refractory to ureteral stenting, urethral catheter placement, and ureteroscopic fulguration. Fibrin glue was injected percutaneously under fluoroscopic guidance into the nephrocutaneous fistula tract, which resulted in its prompt and complete resolution.     

Local recurrence of renal cell carcinoma that simulated multiple renal arteriovenous fistulas after laparoscopic partial nephrectomy: Report of a rare case

Herein we report a patient who was initially thought to have renal arteriovenous fistulas 3 months after laparoscopic partial nephrectomy for a small renal mass. After timely intervention using selective renal artery embolization, computed tomography 9 months post‐surgery showed persistent renal arteriovenous fistulas and nodular lesions in the perirenal fat. The patient then underwent radical nephrectomy, and histopathological examination showed underlying recurrent clear cell renal cell carcinoma invading the intraparenchymal arteries and veins, which was simulating multiple high‐flow renal arteriovenous fistulas.     

Indirect carotid cavernous fistula appeared after balloon embolization of direct CCF

Summary.  The authors describe a case of indirect carotid cavernous fistula (CCF) appearing five months after embolization for traumatic direct CCF, which was treated six months after the trauma. Long-term (six months) venous hypertension to the affected cavernous sinus due to direct CCF and cavernous sinus thrombosis following a balloon embolization were considered as an etiology of the de novo dural arteriovenous fistula. The recurrent symptoms of CCF are usually related to detached balloon disorder, but delayed recurrence may be caused by the de novo dural AVF, if the direct CCF was treated in the chronic state.     

Ureterocolonic fistula formation 12 years after a nephrectomy for renal tuberculosis with a staghorn stone

A postoperative ureterocolonic fistula is rare; only two cases have been reported in the past 38 years in the English medical literature. A 77-year-old female with left renal tuberculosis and staghorn stone received a nephrectomy and a 9-month course of antituberculous therapy. Twelve years later, she experienced repeated urinary tract infection and associated pneumaturia despite medical treatment. Cystoscopy revealed yellowish debris in the bladder, and a computed tomographic examination showed an air bubble in the bladder and a highly suspected fistula between the left ureteral stump and sigmoid colon. After a fistulectomy, she completely recovered, and follow-up urinalysis yielded normal results. This case report highlights this rare condition of urinary tract infection secondary to fistula formation from the ureteral stump even 12 years postoperatively. In addition, we compare different imaging techniques and hypothesize that a nephroureterectomy may be indicated for an inflammatory nonfunctioning kidney containing a staghorn stone.     

Delayed haemorrhage after laparoscopic partial nephrectomy: frequency and angiographic findings

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Delayed haemorrhage has not been well defined in the literature, clinical presentation has not been well described and treatment algorithms are lacking. From our experience we have shown that patients presenting with delayed bleeding after laparoscopic partial nephrectomy will need definitive rather than conservative treatment and angiographic findings demonstrate definitive lesions in all cases. Potential benefits include faster diagnosis and initiation of definitive treatment (angiography with embolization), avoiding repeat computed tomography imaging as it adds little in such patients and reducing need for prolonged hospitalization.

OBJECTIVES

? To determine the frequency of delayed postoperative haemorrhage requiring selective angioembolization (SAE) after laparoscopic partial nephrectomy (LPN). ? To describe the clinical presentation and characterize the angiographic findings encountered in this setting.

PATIENTS AND METHODS

? Prospective data from 640 LPNs performed between August 1993 and May 2009 were retrospectively analyzed, from which patients with delayed postoperative haemorrhage (defined as ‘gross haematuria ≥7 days postoperatively that persists for more than 24 h’) and requiring SAE were identified. ? Clinicopathological, preoperative and perioperative factors were reviewed. ? Selective catheterization and angiography of the renal artery was performed for persistent gross haematuria and for haemodynamic instability associated with a significant drop in haematocrit level. ? Arteries feeding the bleeding site were identified and embolized with endovascular coils.

RESULTS

? Patients presented with delayed haemorrhage between 7 and 30 days after surgery. SAE was required in 13 patients (2%) for delayed postoperative bleeding. ? Of the 640 LPNs, 68 (10.6%) were performed without hilar occlusion (‘off‐clamp’) of whom one (1.5%) had a delayed haemorrhage, which was successfully embolized. ? For patients with and without delayed haemorrhage after LPN, the mean tumour size was 2.7 cm and 3.3 cm (P= 0.31), the mean warm ischaemia time was 28.2 min and 14.3 min (P < 0.001), and the mean estimated blood loss 403.8 mL and 308.2 mL (P= 0.26), respectively. ? Percutaneous angiography showed renal artery pseudoaneurysm in 10 patients and arterial contrast extravasation in three patients, two of whom also had an arteriovenous fistula. ? Following embolization, creatinine levels remained stable in all patients.

CONCLUSIONS

? Clinically significant delayed postoperative bleeding after LPN occurs in a small percentage of patients. ? Angiography will accurately make the diagnosis of RAP or AVF and SAE is safe and effective procedure that allows for preservation of renal function.     

Percutaneous endoscopic management of persistent urine leak after partial nephrectomy

PURPOSE: As nephron-sparing surgery becomes more commonly used for the management of renal masses, the incidence of complications unique to this procedure will increase. Urine leak after partial nephrectomy (PN) is a common occurrence that can be difficult to manage if conservative measures fail. We describe our approach for persistent urine leaks after PN. PATIENTS AND METHODS: Two patients presented with urine leaks after PN. After an upper-pole heminephrectomy, fever developed in the first patient. CT showed an intra-abdominal fluid collection, and percutaneous drainage confirmed a urine leak with persistently high outputs from an upper-pole calix. Conservative management, including ureteral stent, Foley catheter, and percutaneous nephrostomy (PCN) drainage failed. The calix was then directly accessed percutaneously, dilated to 30F, and a 22F nephrostomy tube was placed through the tract into the renal pelvis. The urine leak quickly resolved. The second patient had a lower pole heminephrectomy, and a urine leak with nephrocutaneous fistula from the posterior aspect of the upper-pole remnant developed. Again, conservative measures failed before percutaneous endoscopy. The PCN tract was dilated to 30F, and 3 weeks later the leaking calix was fulgurated through the tract with a flexible ureteroscope. RESULTS: Both patients had complete resolution of urine leaks, stable creatinine levels, and required no further intervention. CONCLUSIONS: Urine leak after PN remains a complex problem if conservative measures are unsuccessful. We describe a novel technique to percutaneously manage persistent urine leak after PN through a minimally invasive approach.     

Effective treatment of empyema with bronchopleural fistula after esophagectomy by endobronchial embolization using endobronchial Watanabe Spigots

IntroductionEmpyema and bronchopleural fistula are well known complications after thoracic surgery. We report a case of refractory air leakage of bronchopleural fistula in a patient with empyema that was successfully treated by endobronchial embolization using Endobronchial Watanabe Spigots (EWSs).Presentation of caseA 71-year-old man underwent esophagectomy for primary esophageal cancer. A right empyema with bronchopleural fistula (BPF) developed four months after surgery. Right thoracic drainage tube was inserted. Although the empyema was treated by drainage and anti-biotics therapy, the air leakage was apparent. The chest computed tomography (CT) scan revealed that the bronchopleural fistula existed in the segment 6 and 10. Endobronchial embolization was performed to the responsible bronchus using EWSs. After the EWSs of middle and large sizes were inserted into the B⁶c and B¹⁰b + c, the air leakage was stopped. The thoracic tube of drainage was removed after endobronchial embolization. Complications due to the EWSs insertion were not observed, and the patient was discharged.DiscussionThe management of BPF has evolved over the years. Surgical approach is frequently needed to control the BPF, though endobronchial embolization is effective in closing the BPF in some patients. In our case, EWSs of middle and large size were useful to control air leakage. We safely retried the 2nd endoboronchial embolization using the EWS. The patient had no complication after insertion the EWS again.ConclusionEndobronchial embolization using EWSs was an effective treatment of an empyema with bronchopleural fistula after esophagectomy.     

外伤性颈动脉海绵窦瘘的血管内栓塞治疗

目的 比较不同方法治疗外伤性颈动脉海绵窦瘘的临床效果。方法 治疗中应用球囊导管,复杂的5例使用了胶及弹簧圈等栓塞材料。结果 10例成功闭塞瘘口且保留载瘤动脉通畅,2例闭塞载瘤动脉．结论 外伤性颈动脉海绵窦瘘应首选血管内栓塞治疗。有时瘘口太小,弹簧圈也是有效方法。     

Transarterial detachable coil embolization combined with ipsilateral intermittent carotid oppression for traumatic carotid-cavernous fistula with small fistula

One case of traumatic carotid-cavernous fistula (TCCF) with small fistula treated by transarterial detachable coil embolization was reported. The intermittent ipsilateral carotid compression was used to identify the final blocking of the residual fistula. The follow-up digital subtraction angiography showed that the TCCF was cured finally. From this case, we conclude that this method may be an effective way to treat TCCF with small fistula.     

肾动静脉瘘的血管造影诊断与超选择性栓塞治疗(附19例报告)

目的总结肾动静脉瘘的诊治经验,提高肾动静脉瘘的诊治效果。方法回顾性分析我院19例肾动静脉瘘患者诊治的临床资料。结果19例肾动静脉瘘患者经肾动脉造影明确诊断,并行超选择性肾动脉栓塞治疗,全部治愈。随访5个月至3年,无症状复发。结论选择性肾动脉造影和栓塞术是诊治肾动静脉瘘的重要方法。     

Haemostatic partial nephrectomy using bipolar radiofrequency ablation

OBJECTIVE: To determine whether an electrode array with a bipolar radiofrequency ablation (RFA) energy source can be used to perform a haemostatic partial nephrectomy by simultaneously ablating and coagulating renal tissue. MATERIALS AND METHODS: Lower-pole partial nephrectomy was performed in 12 porcine kidneys using a bipolar RFA system. Intraoperative ultrasonography was used to identify and avoid the collecting system. Tissues were positioned between opposing electrodes and tissue impedance monitored using a proprietary feedback and control algorithm. Ablation time and power, lesion width and length, and tissue thickness were recorded. The kidneys were assessed in vivo to show haemostasis of the remaining renal unit. Collecting system integrity was assessed with methylene blue injection, and the resected tissue analysed histologically. RESULTS: Partial nephrectomies were successful in all 12 porcine kidneys; the mean nephrectomy specimen was 3.2 x 2.6 cm. The total ablation time (sem) per lesion was 211 (15) s and the mean power was 23 W. Methylene blue injection showed an intact collecting system in 11 of the 12 kidneys, and haematoxylin and eosin staining showed a mean zone of necrosis of 9 mm at the resection margin. Ultrasonography revealed flow to the remaining kidneys after RFA and the in vivo assessment of haemostasis revealed no abnormal bleeding or haemorrhage from the kidneys. CONCLUSIONS: Applying bipolar RF energy to an electrode array can enable transmural excision of renal parenchyma in vivo in a bloodless fashion without collecting system injury.     

Chyluria after partial nephrectomy: A rare but considerable complication

An 82‐year‐old male patient underwent open left lower‐pole partial nephrectomy with a microwave tissue coagulator (Microtaze). Pathological findings showed clear cell renal cell carcinoma, pT1a, Fuhrman grade 2 with negative margins. Then 2 years later, he presented with urinary retention. His urine appeared cloudy and milky only after meals, but appeared normal at other times. He was diagnosed with chyluria after partial nephrectomy. Endoscopic sclerotherapy with silver nitrate was carried out, because his serum albumin decreased to 3.4 g/dL within 3 months. He had an uneventful postoperative course. His chyluria completely disappeared and has not recurred for 11 months. Although chyluria after nephrectomy is very rare, there is a possibility that the frequency of chyluria after partial nephrectomy might increase, because the number of partial nephrectomies continues to increase worldwide. We herein summarize this rare surgical complication and discuss the effectiveness of endoscopic sclerotherapy as a therapeutic tool.