Giant calyceal diverticulum diagnosed in pregnancy: A case report of successful percutaneous catheter management during pregnancy and robot-assisted calyceal diverticulectomy after delivery

Abstract

We report our experience with a pregnant patient with a giant calyceal diverticulum—a very rare presentation. A 30-year-old pregnant woman was referred to our department with left flank pain at 7 weeks of gestation. Ultrasonography and computed tomography showed a giant cystic lesion on the left kidney. Single-puncture drainage was performed, but when fluid immediately reaccumulated, a percutaneous catheter was placed. We suspected a fistula between the cystic lesion and renal pelvis. After delivery, we made a definitive diagnosis of a calyceal diverticulum and successfully performed robot-assisted calyceal diverticulectomy.

Highlights

•

・This case reports a rare instance of huge calyceal diverticulum in a pregnant woman.
•

・She was appropriately managed during pregnancy with a percutaneous catheter.
•

・After delivery, she underwent curative robot-assisted surgery.
•

・There is no evidence of recurrence 5 months after surgery.

1 Introduction

Calyceal diverticulum (CD) is a rare congenital malformation of the urinary tract, consisting of a cystic lesion that communicates with the renal pelvis and having an incidence of approximately 0.21%–0.4 %. ^, When it is symptomatic, aggressive therapeutic intervention may be required. Herein, we report our experience with a patient who had a very rare presentation: a giant CD diagnosed during pregnancy. She was managed appropriately with a percutaneous catheter during pregnancy and definitively treated with robotic surgery after delivery with a good outcome.

2 Case presentation

A 30-year-old nulliparous woman at 7 weeks of gestation was referred to our department with left flank pain, abdominal distention, and anorexia. About 2 years prior, an asymptomatic cystic lesion of the left kidney, about 5 cm in size, was noted at another hospital but was not evaluated further. Ultrasonography revealed a cystic lesion measuring 18 × 15 cm on the left kidney, which was thought to be a simple renal cyst ( Fig. 1 A). We performed single-puncture drainage and removed 1500 mL of yellowish clear fluid. However, only a few days later, the patient reported severe abdominal distension, and ultrasonography revealed fluid reaccumulation to the same volume as before the puncture.

We placed a 6-Fr pigtail catheter into the lesion and performed plain computed tomography (CT), which revealed findings consistent with a simple renal cyst ( Fig. 1 B). However, assessment of the drained fluid revealed a high creatinine level (29.37 mg/dL), and a urinary fistula was suspected. Because of the potential impact on the fetus, the plan was to avoid iodinated contrast imaging and to continue percutaneous catheter management until delivery. Eventually, the catheter was changed to a 10-Fr balloon catheter. To accomplish this, we injected approximately 100 mL of saline through the 6-Fr pigtail catheter into the diverticulum to allow visualization by abdominal ultrasonography. A guidewire was inserted, a dilator was used to expand the tract, and the original catheter was replaced with a 10-Fr balloon catheter. The guidewire, dilator, and balloon catheter were all well visualized and were safely exchanged without the need for contrast imaging. The balloon catheter was changed every 3 weeks using the same technique, allowing for safe management until delivery. The patient underwent successful vaginal delivery at 37 weeks and 1 day of gestation.

After delivery, the catheter continued to drain urine at a rate of more than 1000 mL/day. Contrast-enhanced CT and retrograde pyelography revealed a cystic lesion communicating with the renal calyx through a small fistula ( Fig. 1 C and D). At this point, we diagnosed a CD and performed robot-assisted calyceal diverticulectomy using the da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA). The port placement is shown in Fig. 2 A. Excision of the diverticular wall revealed a fistula that appeared to be a diverticular orifice ( Figs. 2B and 3 A, B). The fistula was closed by continuous suturing using 4-0 poliglecaprone (Monocryl) in a watertight fashion ( Fig. 3 C). The diverticular lumen was cauterized using monopolar soft coagulation, and the fistula closure was sealed using a tissue adhesive sheet (TachoSil; CSL Behring Japan, Tokyo, Japan) ( Fig. 3 D and E). Finally, we performed renorrhaphy with the sliding-clip technique using a V-Loc wound closure device with a 2-0 suture (Covidien™, Mansfield, MA, USA) ( Fig. 3 F). A 6-Fr double-J ureteral stent was placed immediately after surgery and removed 8 weeks after surgery.