Urinary fistulas after partial nephrectomy in renal cell carcinoma

Abstract

Urinary fistulas after partial nephrectomy are rare complications of this operation. There are various reasons for their development, prevention and treatment. This review analyzes the results of the cases' prevalence of urine leakage after partial nephrectomy with various approaches, occurrence's predictors of urinary fistulas, possible ways of their intraoperative prevention and treatment methods. The obtained data show that the size of tumors, their endophytic nature and proximity to the kidney pelvicalyceal system, as well as suturing of its defect, can be predictors of the development of urinary fistulas (UFs). Some authors point to the influence of long ischemia time and high blood loss on the occurrence of UFs. The main method of treating UFs is ureteral stenting or percutaneous drainage of the kidney pelvicalyceal system. For long-term persistent UFs, the method of choice can be simultaneous introduction of 2 stents, retrograde or percutaneous injection of fibrin glue, percutaneous cryoablation of the UFs.

A case of refractory urinary fistula after partial nephrectomy treated with additional partial nephrectomy for suspected isolated calix

“…In the review of Guliev, frequency of urinary fistula after partial nephrectomy was reported to be 0.25-17% [1]. He also reported that urinary fistula occurred less often in endoscopic surgery especially with robot assistance than in open surgery, of which he speculated attribution of patient selection, better visualization, and secure suture in robot surgery [1]. Most cases of urinary fistula are diagnosed by prolonged drainage and in minor cases the diagnosis is made after removal of perisurgical drainage [2,3].…”

“…Multiple related factors for urinary fistula after partial nephrectomy have been raised previously, including tumor size, endophyticity, proximity to the collecting system or sinus, intrarenal pelvis, RENAL nephrometry score, renorrhaphy, repair of the collecting system, blood loss, warm ischemic time, surgical time, severity of chronic kidney disease, surgeon's experience, and so on [1][2][3][4][5][6]. In the present case, the tumor was completely endophytic and large at 35 mm in diameter with a higher RENAL nephrometry score of nine, suggesting a higher risk of urinary fistula.…”

“…Many cases of urinary fistula will cure spontaneously, and primary interventions including drainage of urinoma, percutaneous nephrostomy, and ureteral stenting have been reported in 31-64% of the cases [1][2][3][4]. Although ureteral stent is frequently used to decrease the renal pelvic pressure, it is possible to worsen the urinary fistula by reflux at voiding or obstruction of the urethral catheter [3].…”

“…In cases of persistent urinary fistula, various approaches have been reported, including double stenting, primary closure of the fistula (fibrin adhesive, N-butylcyanoacrylate and fulguration), reconstructive surgery including calyceal infundibular dilation, cryoablation, transarterial embolization (TAE), and nephrectomy [1][2][3][7][8][9][10][11]. Meeks et al reported that 5 of 21 cases of urinary fistula after partial nephrectomy presented anatomical causes, including two cases of infundibular stenosis of calix with a duration of the fistula of more than five months [2].…”

“…Partial nephrectomy is the standard treatment for small renal cell carcinoma and its indication is extending to larger tumors for alleviation of the risk of chronic kidney disease, resulting in prolonged overall survival. Urinary fistula is one of the complications after partial nephrectomy, and in most cases it resolves conservatively or with minor interventions, including ureteral stenting and/or drainage of urinoma [1]. However, it occasionally persists and impairs quality of life with long hospitalization.…”