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Spontaneous rupture of renal pelvis after renal transplantation
SPONTANEOUS
RUPTURE
OF RENAL PELVIS
AFTER RENAL TRANSPLANTATION
BARRY
A. KOGAN,
JOHN
W. KONNAK,
ROBERT DARRELL From the Universitv
M.D. h1.D.
J. MACGREGOR, A. CAMPBELL,
M.D. JR., hl. D.
Sections of Urology and General Surgery, of Michigan Medical Center, Ann Arbor,
Department Michigan
of Surgery,
ABSTRACT - Spontaneous rupture of the renal pelcis occurred in 4 cases following renul trunsplantation. The diagnosis ILUSdifficult, and all 4 patients were septic clt the time of trmtnzent. Three ptients sumid, lmt presermtion of the transplant ~L’USpssihle in only 1 cast. The cause is uncertuin lmt inq Iw relntecl to functionul ot!utruction or wsculur insufficiency.
Urinart extravasation occurred in 31 of 585 renal transplants performed at the Univrersity of Michigan Medical Center. and of these, 4 suffered spontaneous rupture of the renal pelvis. Previously, this complication has been reported only rarely, therefore, a review of the diagnosis, treatment, outcome, and possible origin of this complication appeared warranted. Our experience is contrasted with that reported for spontaneous rupture of the renal pelvis in the general population and that reported for urinary fist&s after renal transplantation. Material
and
Methods
Table I is a summary of the clinical data in our 4 cases. Extravasation from the renal pelvis occurred in I cadaver and 3 liv~ing related recipients. It developed from five to forty-six days l>ost-transplant and was noted in patients who had undergone ureteroureterost~m~, transvesical ureteroneoc)~stostomy, and external ureteroneoqstostomy using the techniques described by Freier ct al. ’ The exxt diagnosis was not made preoper:rtiv.ely in any ewe’. Treatment was transplant nephrectomy in 2 cases, repair arid drainage of the renul pelvis in I, and pyelostomy in the fourth. Although 3 patients survived, graft preserv-ation was possible in only 1 exe.
Comment The diagnosis of rupture of the renal pelvis was elusive in all 3 cases, as evidenced by the delay of from six to thirty-five days from onset of symptoms until treatment. In 2 cases a wound infection was the initial abnormality noted. Later this developed into an obvious uriIn nary fistula, requiring surgical exploration. the other 2 patients acute peritonitis developed as a result of transperitoneal rupture of an infected ririnoma. Again, surgical exploration was required. Despite the use of excretory ur_ograI~liy, ultlasonograph~~, and nuclear scanning, the site of extravasation was not identified preoperatively in any case. Retrograde pyelography is difficult after ureteroneocystostomy especially when an external ureteroneocystostomy technique is used. Antegrade pyelography is not performed safely unless the renal pelvis is dilated. Dilatation was not present in any of the cases and is unlikely after rupture. Diagnosis is dependent on a high index of suspicion. When clinical judgment suggests 0perativ.e intervention, a careful inspection of the renal pelvis should be included. All the patients in the group under consideration were ill at the time of presentation. In 2 cases (Cases 1 and 4). the septic status of the patient required that transplant nephrectomy be
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RUPTURE
OF RENAL PELVIS
AFTER RENAL TRANSPLANTATION
BARRY
A. KOGAN,
JOHN
W. KONNAK,
ROBERT DARRELL From the Universitv
M.D. h1.D.
J. MACGREGOR, A. CAMPBELL,
M.D. JR., hl. D.
Sections of Urology and General Surgery, of Michigan Medical Center, Ann Arbor,
Department Michigan
of Surgery,
ABSTRACT - Spontaneous rupture of the renal pelcis occurred in 4 cases following renul trunsplantation. The diagnosis ILUSdifficult, and all 4 patients were septic clt the time of trmtnzent. Three ptients sumid, lmt presermtion of the transplant ~L’USpssihle in only 1 cast. The cause is uncertuin lmt inq Iw relntecl to functionul ot!utruction or wsculur insufficiency.
Urinart extravasation occurred in 31 of 585 renal transplants performed at the Univrersity of Michigan Medical Center. and of these, 4 suffered spontaneous rupture of the renal pelvis. Previously, this complication has been reported only rarely, therefore, a review of the diagnosis, treatment, outcome, and possible origin of this complication appeared warranted. Our experience is contrasted with that reported for spontaneous rupture of the renal pelvis in the general population and that reported for urinary fist&s after renal transplantation. Material
and
Methods
Table I is a summary of the clinical data in our 4 cases. Extravasation from the renal pelvis occurred in I cadaver and 3 liv~ing related recipients. It developed from five to forty-six days l>ost-transplant and was noted in patients who had undergone ureteroureterost~m~, transvesical ureteroneoc)~stostomy, and external ureteroneoqstostomy using the techniques described by Freier ct al. ’ The exxt diagnosis was not made preoper:rtiv.ely in any ewe’. Treatment was transplant nephrectomy in 2 cases, repair arid drainage of the renul pelvis in I, and pyelostomy in the fourth. Although 3 patients survived, graft preserv-ation was possible in only 1 exe.
Comment The diagnosis of rupture of the renal pelvis was elusive in all 3 cases, as evidenced by the delay of from six to thirty-five days from onset of symptoms until treatment. In 2 cases a wound infection was the initial abnormality noted. Later this developed into an obvious uriIn nary fistula, requiring surgical exploration. the other 2 patients acute peritonitis developed as a result of transperitoneal rupture of an infected ririnoma. Again, surgical exploration was required. Despite the use of excretory ur_ograI~liy, ultlasonograph~~, and nuclear scanning, the site of extravasation was not identified preoperatively in any case. Retrograde pyelography is difficult after ureteroneocystostomy especially when an external ureteroneocystostomy technique is used. Antegrade pyelography is not performed safely unless the renal pelvis is dilated. Dilatation was not present in any of the cases and is unlikely after rupture. Diagnosis is dependent on a high index of suspicion. When clinical judgment suggests 0perativ.e intervention, a careful inspection of the renal pelvis should be included. All the patients in the group under consideration were ill at the time of presentation. In 2 cases (Cases 1 and 4). the septic status of the patient required that transplant nephrectomy be
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