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URINE LEAK AFTER A PARTIAL NEPHRECTOMY
Authored By: Bennett Greenspan and Andrew Homb.
Patient: 63 year old male
History:

63 year old man who underwent a left partial nephrectomy for renal cell carcinoma approximately 8 days ago and now presents with abdominal pain, fever. and an elevated white blood cell count.

 

Figure 1

Figure 2

Figure 3

 

Findings and Impression?

 

CT Urogram (same day) 

 

Figure 4

Figure 5

 

Next step in Management?

 

Ureteral stent placed by urology, (same day)

 

Percutaneous Fluid Collection Drianage, (one day later) 

 

Figure 6

Image Size:[small][as-submitted]

Fig. 1
Renal Scintigraphy Flow (Initial Study)

Fig. 2
Renal Scintigraphy Function (Initial Study)

Fig. 3
Renal Scintigraphy Post Void (Initial Study)

Fig. 4
CT urogram (same day as the initial study)

Fig. 5
CT urogram (same day as the initial study)

Fig. 6
Percutaneous Fluid Collection Drainage (1 day after the initial study)

Fig. 7
Renal Scintigraphy Flow (2 months after the initial study)

Fig. 8
Renal Scintigraphy Function (2 months after the initial study)

Fig. 9
Renal Scintigraphy Post Void (2 months after the initial study)
Image Size:[small][as-submitted]

Findings:

Renal Scintigraphy

 

RADIOPHARMACEUTICAL: 7.5 mCi Tc-99m MAG3 i.v.

 

There is left-sided extrarenal activity present, consistent with a urine leak. The extrarenal activity is first visualized at the medial aspect of the lower pole the left kidney and increases in size over time. At the conclusion of the exam, extrarenal activity is present projecting over the lower pole and inferior to the left kidney.

 

At the conclusion of the study, there is a mild amount of retained activity in the left renal collecting system with substantial clearance of activity from the cortex. There is minimal residual activity in the right renal collecting system at the end of the exam.

 

There is normal renal function

 

CT Urogram

 

Status post partial left nephrectomy with urine leak from a left inferior pole calyx into a large adjacent fluid collection, which appears contiguous with a pelvic fluid collection. Although the excreted/leak contrast is not seen throughout the fluid collections, their contiguity suggests they are all from a urinoma.

 

Percutaneous Fluid Collection Drainage

 

Successful percutaneous drainage of a large intra abdominal fluid collection with placement of a 12 French Mac Lock pigtail catheter.

 

DDx:

Urine leak/Urinoma (+/- infection)

 

Other post surgical complications (All unlikely to cause an abnormal collection of radiotracer on renal scintigraphy):

 

Hematoma

 

Abcess

 

Lymphocele

Diagnosis: Left-sided urine leak with formation of a urinoma following a partial left nephrectomy for renal cell cancer.
General Discussion:

Follow up:

 

Renal Scintigraphy (2 months after the initial study)

 

Figure 7

Figure 8

Figure 9

 

RADIOPHARMACEUTICAL: 8.28 mCi Tc-99m MAG3 i.v.

 

Interval resolution of a left kidney lower pole urine leak.

Specific Discussion:

Full History:

 

63 year old man who underwent a left partial nephrectomy for renal cell carcinoma approximately 8 days ago and now presents with abdominal pain, fever. and an elevated white blood cell count.

 

Discussion: Incidence, Risk Factors, and Management of Urine Leaks After Partial Nephrectomy

 

Nephron sparing surgery via either open or laproscopic techniques has been increasingly used for small lesions (< 4cm) and select medium sized lesions (< 7 cm) and provides multiple benefits including superior renal function outcomes and equivalent oncological outcomes; however, as the complexity and number procedures increases complications such as renal leaks will likely increase.

 

Meeks et al. retrospectively reviewed 127 consecutive patient who underwent either open (70 patients) or laproscopic (57 patients)partial nephrectomies.  21 patients (13.3%) developed a urine leak (drain output consistent with urine greater than 48 hours surgery), 10.5% after laproscopic and 18.5% after open partial nephrectomies. Risk factors included: increased tumor size, endophytic lesions (>60% of the mass deep to the renal surface), and repair of the collecting system defects during inital surgery.  The median duration of the urine leak was 20 days.  Most resolved with prolonged drainage (61%) or replacement of a ureteral stent (38%); however, 2 patients (1%) required percutaneous nephrostomy placement with open repair. All leaks persisting for greater than 30 days required stent replacement, with the stents remaining in place for a median of 53 days. 

 

 

 

 

References: Meeks et al. "Risk Factors and Management of Urine Leaks after Partial Nephrectomy"  J Urol 2008; 180, 2375-2378.
Comments:
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Additional Details:

Case Number: 245525Owner(s): Bennett Greenspan and Andrew HombLast Updated: 02-07-2013
Anatomy: Genitourinary (GU)   Pathology: Iatrogenic
Modality: CT, Nuc MedAccess Level: Readable by all users, writable by NucMed Certifiers
Keywords: rsnm

Case has been viewed 31 times.
Certified by Bennett Greenspan on 08-26-2011

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