Minimally invasive management of urinary fistula following robot-assisted partial nephrectomy: Case report

Abstract

Urinary fistulas are a known complication that can occur after partial nephrectomy, potentially causing considerable morbidity if not properly treated. The present study examines the case of a 71-year-old male patient who developed a urinary fistula six months following a robot-assisted partial nephrectomy. Initial efforts to address the fistula through the placement of a double pigtail ureteral stent proved ineffective. Subsequent interventional radiology procedures successfully achieved fistula closure by administering adhesive fibrin directly within the fistulous tract. This case highlights the importance of a multidisciplinary approach in handling post-surgical complications like urinary fistulas.

1 Introduction

Urinary fistulas represent a recognized complication following partial nephrectomy, leading to significant morbidity if not managed appropriately. The incidence of urinary fistulas after partial nephrectomy varies from 0.5 % to 17.4 %, depending on multiple factors. Notably, the incidence is higher following open surgical approaches compared to laparoscopic or robotic techniques. Although this difference may be due to selection bias, as larger and more complex partial nephrectomies are usually done with an open approach, laparoscopic and robotic surgery offer better visibility, greater precision, and more delicate tissue handling. Several risk factors significantly correlate with an increased likelihood of urinary fistula formation following partial nephrectomy. These factors include tumor size, endophytic nature, ischemia time, repair of the collecting system, renal nephrometry score, and proximity to the urinary collecting system. Tumor size, often indicative of advanced disease, has been consistently associated with a higher risk of urinary fistula formation due to its potential to compromise the integrity of surrounding tissues and structures. Similarly, the endophytic growth pattern of tumors, characterized by their inward growth into the renal parenchyma, poses challenges during surgical excision, increasing the risk of inadvertent injury to the urinary collecting system. Furthermore, the meticulous repair of the collecting system following tumor resection is crucial in preventing postoperative urinary leakage. Renal nephrometry scoring systems serve as valuable predictive tools in assessing the likelihood of urinary fistula formation preoperatively, guiding surgical planning and risk stratification. Acknowledging and mitigating these risk factors through meticulous surgical techniques, careful patient selection, and preoperative planning are imperative to minimize the occurrence of urinary fistulas and optimize patient outcomes following partial nephrectomy. , , , , The management of urinary leaks post-partial nephrectomy is varied and lacks a consensus on treatment approaches. Various methods, such as the use of gelatin sponges, fibrin adhesive, and endoscopic treatments, have been utilized.

2 Case report

A 71-year-old man underwent a robot-assisted partial nephrectomy in 2022 at Azienda sanitaria territoriale Pesaro-Urbino, Italy, to treat a 5 cm mass located at the upper pole of his left kidney (7a according to the RENAL Nephrometry Score). Following appropriate preoperative preparation, the mass was enucleated with a clamp of renal artery of 21 minutes. Care was taken to close the renal wound meticulously using absorbable sutures and covered with sealing matrix (made by human fibrinogen and thrombin), and perirenal fat. Post-surgery, pathological analysis of the surgical specimens revealed stage pT1a, grade 2 renal cell carcinoma (RCC). The patient recovered well, with the temporary drainage tube removed on the fourth postoperative day, and he was discharged on the fifth day. However, six months later, was re-admitted with fever and elevated inflammatory markers, she had no history of urinary stones and did not report any recent trauma. CT urography showed a 8 cm perirenal collection at the upper pole of the left kidney, with contrast leakage from the upper calyx into the perirenal space. Subsequent retrograde pyelography confirmed the presence of a urinary fistula between the urinoma and the upper urinary calyx ( Fig. 1 ). To address this complication, a retrograde double pig-tail stent was inserted in the collecting system and percutaneous US drainage was positioned by interventional radiologist in the perirenal collection. Cultural examination of urine and drainage fluid yielded negative results. However, at the one-month follow-up, the urinary fistula persisted. Along with the interventional radiologist, despite the non-dilatated collection system a US guided percutaneous access into the lower calyx was obtained with a vascular introducer sheat. After confirming the presence of the fistula from the upper calyx with contrast injection, a catheterization of the fistula was obtained with a Bern catheter and a microcatheter (Progreate 2.7 F Terumo). Adhesive fibrin, a solution comprising frozen aprotinin and thrombin-calcium chloride, was then introduced via the microcatheter in the fistula, following a sudden closure of the fistula, as indicated by the urogram ( Fig. 2 ). The percutaneous nephrostomy was left with the distal tip within the upper calyx group after the procedure along with the double pig-tail stent, in order to optimize the drainage of the entire collecting system of the kidney. After three days, a pyelography control showed no contrast leakage in the upper calyx, which remained absent on subsequent controls at nine days and after a further 15-day period. With the urinary fistula resolved, the percutaneous drainage and nephrostomy were removed, while the double pig-tail stent remained. A final pyelography conducted one month after nephrostomy removal confirmed the sustained absence of the urinary fistula, prompting the decision to remove the double pig-tail ureteral stent ( Fig. 3 ).