Glue ablation of a late-presentation urinary fistula after partial nephrectomy

Abstract

ABSTRACT. Urinary fistula is an acknowledged complication of partial nephrectomy. We describe a case of a urinary fistula that failed to respond to conventional treatment and the subsequent use of percutaneous HystoacrylH glue to achieve its resolution. Case reportA 57-year-old woman underwent an uncomplicated right lower pole partial nephrectomy for Fuhrman grade 3 pT1NxMx clear cell renal cell carcinoma, through a right loin 11th rib incision. At outpatient review meeting 1 month after discharge, she was well and reported only mild discomfort in the region of the wound. Renal CT after 1 year demonstrated no evidence of disease recurrence; however, a 10 cm diameter urinoma was identified anterior to the right kidney compressing the pelviureteric junction (PUJ) and upper ureter (Figure 1). Her renal function was normal.After multidisciplinary discussion, percutaneous drainage of the perinephric collection was performed, which resulted in continuous daily urine drainage of 20-100 ml that persisted for the next month, despite the added intervention of a right nephrostomy 2 weeks after drain insertion (Figure 2). The nephrostomy was deliberately placed through the point of leakage. A right retrograde pyelogram was performed and confirmed a lower pole urinary fistula and a PUJ obstruction. A right JJ ureteric stent was sited; however, urine drainage continued from the lower pole leak.As the urinary fistula had not responded to conventional management and nephrostomy was not a tolerable long-term option for the patient, the following options were considered:

Renal Cysts and Urinomas

“…There has also been a case reported in which a cyanoacrylate glue was percutaneously injected and used to close a persistent urine leak in a patient who was medically unfit for surgery. 89 This technique is interesting and bears further investigation.…”

Successful wound closure using fibrin glue for intractable neobladder‐urethral anastomosis leakage after radical cystectomy and neobladder reconstruction

“…In addition to local hemostasis, it is used to seal wounds and fistulas, and for nephroplasty, fixation of ureteral anastomosis, urethral skin, and bladder colon fistulas. 3,4 It has also been reported that transurethral injection of fibrin glue improved urinary leakage after partial nephrectomy. 5 The injected fibrin glue remains in a solid-state for approximately 24 h and then denatures into a gel state in approximately 5 days.…”

Gelatin sponge (Spongostan®) and N-butyl-2-cyanoacrylate: Utility on percutaneous treatment of persistent urinary leakage after partial nephrectomy. Case report and review of the literature

“…More recently the application of cyanoacrylate glues has been reported in different branches of surgery for endoscopic treatment of refractory bile leaks, gastroenteric fistulae, intracranial vascular malformations and also for the management of urinary fistulas. To our knowledge few cases in literature described the endoscopic utilization of cyanoacrylate in repairing UF after urological maneuvers and until now there are only 4 single cases reports of percutaneous successful utilization of cyanoacrylate glue in repairing UF after PN have been reported till date (5,6). In addition, two clinical case series: one of 13 cases in 9 years by Muto et al that reported the use of cyanoacrylate glue in repairing endoscopic percutaneous and endovaginal urinary fistula of various etiologies with a high success rate and few complications (7).…”