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CASE REPORT
Year : 2020  |  Volume : 36  |  Issue : 1  |  Page : 62-64
 

A novel approach to postrobot-assisted nephron-sparing surgery persistent urinary leak – Can we glue?


1 Department of Radio Diagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Urology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission09-Jul-2019
Date of Acceptance02-Nov-2019
Date of Web Publication2-Jan-2020

Correspondence Address:
Shantanu Tyagi
Department of Urology, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/iju.IJU_209_19

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   Abstract 

Urinary leak is a well known complication after partial nephrectomy. We describe a case of a persistent urinary leak after Robot assisted nephron sparing surgery that failed to resolve after conservative treatments and was subsequently managed with computed tomography (CT) guided percutaneous cynoacrylate glue injection.



How to cite this article:
Gorsi U, Kumar S, Tyagi S, Sharma A. A novel approach to postrobot-assisted nephron-sparing surgery persistent urinary leak – Can we glue?. Indian J Urol 2020;36:62-4

How to cite this URL:
Gorsi U, Kumar S, Tyagi S, Sharma A. A novel approach to postrobot-assisted nephron-sparing surgery persistent urinary leak – Can we glue?. Indian J Urol [serial online] 2020 [cited 2020 Jul 15];36:62-4. Available from: http://www.indianjurol.com/text.asp?2020/36/1/62/274689



   Introduction Top


Postoperative urine leak was the most commonly reported complication of open partial nephrectomy (PN), with an incidence of 17.4%,[1]. Various robotic PN series have reported generally low urinary leak rates, with a range of 0.6%–2.5%.[2] We describe the successful use of percutaneous cyanoacrylate glue to resolve urinary fistula postrobot-assisted nephron-sparing surgery (RA NSS) that failed to respond to conventional treatment.


   Case Report Top


A 51-year-old male was incidentally detected with a left renal mass during a routine health examination and imaging. On further evaluation, a 4.3 cm × 3.4 cm × 3.2 cm-enhancing lesion was localized to the mid-upper pole of the left kidney in the anterolateral cortex. After routine workup, the patient was planned for RA NSS for this cT1bN0M0 lesion, with a RENAL nephrometry score of 6a.

He underwent RA NSS under general anesthesia using the “da Vinci Si system” (Intuitive Surgical, Sunnyvale, CA, USA). The patient was in the right lateral position, and pneumoperitoneum created by a closed technique with a Veress needle. A 12-mm camera port was inserted 2 cm above the umbilicus in the midline. Two robotic ports along with one assistant port were inserted. Single renal vein and two renal arteries were identified at the hilum, and conventional clamping of both arteries and vein was done, with a warm ischemia time of 17 min. A pelvicalyceal system breach was detected intraoperatively, and renorrhaphy was done in three layers. The total operative time was 2 h.

On postoperative day 0 (POD0), drain output was 1400 ml, which gradually decreased to 600 ml/day on POD3. Drain fluid creatinine was 24.9 mg/dl. Ultrasonography showed no significant perirenal collection. A 4.8 Fr double-J (DJ) stent was placed. After 48 h of -DJ stent placement, drain output remained at 400 ml/day. RGP (Retrograde Pyelography) finding during DJ stent insertion showed contrast extravasation with no localization to the site of extravasation. Subsequently, the 4.8 Fr DJ stent was upgraded to 6 Fr, but drain output continued to be 400 ml/day. Computed tomography (CT) urography showed dehiscence of suture line with extravasation of contrast from a wedge-shaped defect in the mid-upper pole. Feasibility of percutaneous nephrostomy placement was assessed but deferred because of the scarcity of renal parenchyma around the wedge-shaped defect and extravasation site; moreover, no obvious connection with the PCS (Pelvicalyceal system) was seen on RGP. Since the urinary fistula was not responding to expectant management, we considered the following options:

  • Glue injection at the leak site
  • Angioinfarction of the upper half of the left kidney
  • Open repair of the renal defect
  • Left nephrectomy.


After multidisciplinary discussion, a consensus was made to glue the defect percutaneously. On POD14 under local anesthesia and CT guidance, beta-cyanoacrylate glue was injected with a 23G spinal needle over the wedge-shaped defect at the upper mid-pole of the left kidney [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d. Cyanoacrylate: lipiodol mixture (50:50) 6 ml was used. Postprocedure, glue cast was noted in the defect, upper pole calyx, and perinephric space. Drain output decreased to 10 ml/day on postprocedure day 1 and ceased completely on day 2. Subsequently, the drain was removed on the 3rd day, with ultrasonography the next day showing no perinephric collection. DJ stent was removed, and subsequently, the patient was discharged on postprocedure day 5 in stable condition. Follow-up imaging at 1 month showed no perinephric collection [Figure 1]e. The artifact was observed in the region of the wedge-shaped defect at the left kidney, consistent with lipiodol-cyanoacrylate glue. At 18-month follow-up, the patient remained afebrile throughout with stable renal function.
Figure 1: (a-d) Computed tomography imaging in axial section showing wedge-shaped defect at the upper mid-pole of the left kidney with glue (beta-cyanoacrylate:lipiodol mixture [50:50]: 6 ml) injection using a 23G spinal needle. (e) Follow-up axial computed tomography imaging at 1 month showing no perinephric collection

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   Discussion Top


Stroup et al.[2] compared the outcomes following various approaches for PN and reported urinary leak rates of 9.8%, 3%, and 3.2% for open, laparoscopic, and robotic assistance, respectively. Endoscopic ureteric stent placement with percutaneous drainage are feasible treatment modalities for urinary leak, with up to 46 days as median resolution time.[3] Though Meeks et al.[4] recently reported fulguration of a leaking calyces post-PN using flexible ureteroscope after conventional measures had failed, we believe that the least traumatic modality, in this case, would be by radiological interventions. Breda et al.[5] described the role of hemostatic agents and glues during minimally invasive nephron-sparing surgery including fibrin-gel, cyanoacrylate glue, gelatin-matrix thrombin, oxidized regenerated cellulose, bovine- albumin or combinations of these. Sellie et al.[6] in their series of five cases reported management of calyceal fistulae following open, laparoscopic and robotic removal of renal masses, pelvic fistula after orthotopic ileal neobladder and leakage of ureterosigmoidostomy using a retrograde endoscopic approach for renal calyces, while a descending percutaneous approach for the pelvic fistula Cryoablation has also been described by Ward et al.[7] for managing persistent urine leakage postrobot-assisted PN done for ureteral duplication with a nonfunctional upper pole. However, the reason for choosing this modality was to ablate the residual functioning tissue rather than extravasation from the collecting system. After reviewing the previous literature, we report the first case of a persistent urinary fistula in immediatepostoperative period after RA NSS that was managed successfully with percutaneous CT-guided cyanoacrylate glue instillation with no procedure-related complications.


   Conclusion Top


Glue ablation for post-RA NSS urinary fistula is a safe and effective modality.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

 
   References Top

1.
Siegel R, Ma J, Zou Z, Jemal A. Cancer statistics, 2014. CA Cancer J Clin 2014;64:9-29.  Back to cited text no. 1
    
2.
Stroup SP, Palazzi K, Kopp RP, Mehrazin R, Santomauro M, Cohen SA. RENAL nephrometry score is associated with operative approach for partial nephrectomy and urine leak. Urology 2012;80:151-6.  Back to cited text no. 2
    
3.
Polascik TJ, Pound CR, Meng MV, Partin AW, Marshall FF. Partial nephrectomy: Technique, complications and pathological findings. J Urol 1995;154:1312-8.  Back to cited text no. 3
    
4.
Meeks JJ, Smith ND, Lesani OA, Nadler RB. Percutaneous endoscopic management of persistent urine leak after partial nephrectomy. J Endourol 2008;22:485-8.  Back to cited text no. 4
    
5.
Breda A, Stepanian SV, Lam JS, Liao JC, Gill IS, Colombo JR, et al. Use of haemostatic agents and glues during laparoscopic partial nephrectomy: A multi-institutional survey from the United States and Europe of 1347 cases. Eur Urol 2007;52:798-803.  Back to cited text no. 5
    
6.
Selli C, De Maria M, Manica M, Turri FM, Manassero F. Minimally invasive treatment of urinary fistulas using N-butyl-2-cyanoacrylate: A valid first line option. BMC Urol 2013;13:55.  Back to cited text no. 6
    
7.
Ward TJ, Ahmed O, Chung BI, Sze DY, Hwang GL. Percutaneous cryoablation for successful treatment of a persistent urine leak after robotic-assisted partial nephrectomy. J Vasc Interv Radiol 2015;26:1867-70.  Back to cited text no. 7
    


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