Indian Journal of Urology
CASE REPORT
Year
: 2003  |  Volume : 20  |  Issue : 1  |  Page : 67--68

Calyceal-cutaneous fistula - an unusual complication in a series of 1020 renal transplantations


Shailesh A Shah1, Prakash Ranka1, Sharad Dodiya1, Manish Visnagra1, Rajesh Jain1, Sajni Khemchandani1, HL Trivedi2,  
1 Department of Urology, Institute of Kidney Diseases and Research Centre and Institute of Transplantation Sciences, BJ Medical College and Hospital Campus, Ahmedabad, India
2 Department of Nephrology, Institute of Kidney Diseases and Research Centre and Institute of Transplantation Sciences, BJ Medical College and Hospital Campus, Ahmedabad, India

Correspondence Address:
Shailesh A Shah
Kidney Line Health Care, 1st Floor, Harikrupa Towers, Near Govt. Ladies Hostel, Behind Gujarat College, Ellisbridge, Ahmedabad - 380 006
India




How to cite this article:
Shah SA, Ranka P, Dodiya S, Visnagra M, Jain R, Khemchandani S, Trivedi H L. Calyceal-cutaneous fistula - an unusual complication in a series of 1020 renal transplantations .Indian J Urol 2003;20:67-68


How to cite this URL:
Shah SA, Ranka P, Dodiya S, Visnagra M, Jain R, Khemchandani S, Trivedi H L. Calyceal-cutaneous fistula - an unusual complication in a series of 1020 renal transplantations . Indian J Urol [serial online] 2003 [cited 2020 Sep 23 ];20:67-68
Available from: http://www.indianjurol.com/text.asp?2003/20/1/67/37133


Full Text

 Case Report



A 22-year-old male, diagnosed as a case of Alport's syn­drome with end stage renal disease underwent renal trans­plantation in June 2002. The donor had bilateral single renal arteries with early division on both sides. Left donor nephrectomy was performed. During bench dissection the lower polar division of the renal artery was accidentally injured and was repaired using 6/0 prolene suture. The renal artery was anastomosed end to side with the exter­nal iliac artery. Following release of the clamps the graft functioned well. Double J (DJ) stent was placed and extravesical ureteroneocystostomy was done. During the first postoperative week the patient developed acute tubu­lar necrosis and was managed with intermittent hemodialysis. Perigraft drain was 50 ml on the first day, re­duced to 10 ml by the 5 th day and was nil thereafter. The drain tube was removed on the 17 th day. Repeat ultrasonog­raphy on the 4 th week revealed a hemorrhagic collection near the upper pole and a subcapsular hematoma which were drained by open exploration. The healing of the wound was delayed. The DJ stent was removed after 7 weeks. In the 8" week, there was a watery discharge from the lower part of the wound which was confirmed as uri­nary tract. Color doppler study followed by selective re­nal angiography revealed normal flow in the main renal artery but no flow in the lower polar division of the artery. Exploration was done within 24 hours. The lower pole of the graft (about 25%) was infracted [Figure 1]. Lower polar partial nephrectomy was performed and the repair was re­inforced by an omental patch. Distal obstruction and leak were ruled out. Nephrostogram was performed 6 weeks after surgery [Figure 2] and the nephrostomy tube was re­moved DJ stent was removed 3 months later. At 4 months' follow-up his urine output was in the range of 3 to 5 liters/ 24 hours and serum creatinine stabilized at 1.1 mg%. This was our first case of calyceal-cutaneous fistula (CF) in a series of 1020 consecutive renal transplant operations.

 Comments



CF is a serious sequelae of renal transplantation occurring in approximately 3% of allografts. The urinary leak is usually secondary to infarction due to ligation of polar vessels or damage during retrieval or bench surgery. When more than 10% of the renal mass is infracted the necrotic process penetrates to a calyx and it leads to CF. Early in­tervention is mandatory to avoid wound infection and sys­temic infection which could be fatal. In a series of 1000 consecutive renal transplant operations there was one CF due to thrombosis of a lower pole artery and consequent infarction of the lower pole of the kidney. [1] This patient died of septicemia due to infection. Goldman et al (1976) [2] reported 8 CF following renal transplantation and only one patient had successful partial resection and closure of fistula with a muscular graft. But attempts at surgical cor­rection of fistulae were unsuccessful in the rest with ulti­mate loss of 7 of 8 kidneys and death of 3 patients. In our patient we anticipated leak and therefore the drain tube and DJ stent were kept for a prolonged period. But the fistula developed late in the post transplant period. How­ever, immediate exploration and repair with omental patch salvaged the graft and the patient. In a series of 543 renal transplants, 6 patients suffered a post transplant renal seg­mental infarct and developed CF between 9 and 17 days. [3] They were treated by partial (25 to 40%) transplant ne­phrectomy, followed by closure and tissue coverage. They pointed out that transplanted kidneys could tolerate fur­ther intrinsic injury.

References

1Mundy AR, Podesta ML, Bewick M, Rudge CJ, Ellis FG. The urological complications of 1000 renal transplants. J Urol 1981: 53: 397-402.
2Goldman MH, Burleson RL, Tilney NL, Vineyard GC, Wilson RE. Calyceal cutaneous fistulae in renal transplant patients. Ann Surg 1976;184:679.
3Gutierrez-Calzada JL, Ramos-Titos J, Gonzalez-Bonilla JA, Garcia­Vaquero AS, Martin-Morales A, Burgos-Rodriquez R. Calyceal fis­tula formation following renal transplantation : Management with partial nephrectomy and ureteral replacement. J Urol 1995; 153: 612-614.