蔡仕傑1、顧明軒1, 2、黃志賢1, 2
Delayed Retroperitoneal Abscess with Cutaneous Fistula after Nephrectomy with Inferior Vena Cava Graft Reconstruction: A Case Report
Shi-Jie Tsai1, Ming-Hsuan Ku 1, 2, William J.S. Huang1, 2
1 Department of Urology, Taipei Veterans General Hospital,
2Department of Urology, College of Medicine and Shu-Tien Urological Science Research Center,
National Yang Ming Chiao Tung University, Taipei, Taiwan
Nephrectomy is the preferred therapeutic modality for non-functioning kidneys with nephrolithiasis and recurrent infections. However, the inflammation process will increase difficulty of surgery and may lead to vascular damage. Here we present a rare case of nephrectomy for a post-infection non-functioning kidney, which complicated with inferior vena cava (IVC) injury and repaired with vascular graft, but eventually developed retroperitoneal abscess with cutaneous fistula after three years.
This 73-year-old female patient had past history of hypertension and type 2 diabetes mellitus. She had right renal calculi history for nearly twenty years, and had received extracorporeal shock wave lithotripsy (ESWL) in 2004, open pyloplasty in 2004, and percutaneous nephrolithotomy (PCNL) twice in 2008 and 2013. She had experienced multiple urinary tract infection episodes, including right acute pyelonephritis in 2019. Abdomen computed tomography (CT) on 2019/04/26 disclosed residual right renal stones with size 2.2cm and right side hydronephrosis. Comprehensive renal function study showed near complete loss of renal plasma flow of right kidney. Therefore, under the impression of right non-function kidney with recurrent infection, she underwent right simple nephrectomy in flank position through retroperitoneal approach. Due to severe post-inflammation adhesion, IVC was transected during specimen retrieval, and then repaired with poly-tetra-flour-ethylene (PTFE) vascular graft. The estimated blood loss was 2800ml. The pathology of kidney reported chronic pyelonephritis. The post-operative recovery course was uneventful and she was discharged on postoperative day (POD) 8.
Three years after the nephrectomy surgery, she noticed occasionally right flank soreness and distention sensation. Then, purulent discharge was noted from previous right flank incision scar. Bedside wound debridement disclosed a deep tract to retroperitoneum at least 10 cm. Further abdomen CT showed heterogeneously enhancing cavitary lesion extending from right pararenal space involving IVC graft to cutaneous surface of right lateral abdominal wall, with internal tubular structure showing tram-tract enhancement, right pararenal abscess with cutaneous fistula formation considered. In addition, occluded vascular graft of IVC was also noted. Therefore, IVC graft removal with debridement of abscess was done on 2022/01/26 in supine position through transperitoneal approach. Severe adhesion with abscess formation in between right retroperitoneum, psoas muscle and IVC graft were noted during operation. The IVC graft was noted with necrotic change over the surrounding tissue. The fistula tract between right renal fossa and the skin was debrided and irrigated with saline thoroughly. Two Jackson-Pratt drains were placed at Morrison pouch, and wet dressing was applied to the wound of the cutaneous fistula tract. Culture of abscess tissue yielded Pseudomonas aeruginosa. After the surgery, we kept antibiotics course for two weeks and closed the fistula tract on POD 6. She was discharged on POD 13 without fever, flank pain, wound discharge or any signs of systemic infection.
Nephrectomy for kidneys with infection history are usually challenging. Due to the significant inflammatory process, the difficult dissection of the renal pedicle and adhesions to adjacent organs, makes this operation technically demanding. Whether transperitoneal or retroperitoneal approach is superior regarding open nephrectomy is inconclusive in literature. Transperitoneal approach had lower incidence of complications except for operative hypotension in a cohort of 450 cases  . On the other hand, Zhang et el. reported comparable complication rates between two different approaches . As for IVC injury during nephrectomy, McAllister et el. mentioned two cases in which the vena cava was transected during retroperitoneoscopic nephrectomy owing to lack of consistent landmarks through retroperitoneal approach . In contrast, transperitoneal approach has more direct route to the renal hilum, good exposure of the kidney, and better control of bleeding. Therefore, transperitoneal approach should be the preferred method in our case given her recurrent infection history.
Long-term safety and patency of IVC graft were well documented in the past. In 29 patients received IVC reconstruction due to malignancy, only two late graft occlusions occurred at 7.5 months and 6.3 years respectively . Hyams et al. also reported 94% acute patency rate of IVC graft in renal cell carcinoma cases . However, the combination of graft occlusion and infection are extremely rare. Most IVC graft were used in malignancy cases but not in infection. We could only postulate that pus spillage to PTFE graft during nephrectomy might be the cause of delayed graft infection and graft failure in our case. Biological instead of synthetic graft might provide superior infection control and long-term patency in such condition.
In conclusion, for nephrectomy of infected kidney with calculi conditions, surgical approach route should be carefully selected. Though the best choice varied between cases due to different anatomy and surgeon’s experience, we suggested transperitoneal approach given its better exposure and anatomical orientation. Furthermore, if vascular injury encountered and vascular graft reconstruction were needed, biological instead of synthetic graft should be considered to avoid delayed infection.