Spontaneous rupture of renal pelvis after renal transplantation.

Spontaneous rupture of the renal pelcis occurred in 4 cases following renul trunsplantation. The diagnosis ILUS difficult, and all 4 patients were septic clt the time of trmtnzent. Three ptients sumid, lmt presermtion of the transplant ~L’US pssihle 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 urinary fistula, requiring surgical exploration. In 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 ‘ s ~ , . , L l t : ) s r l I I t . ~ . l ~ . , [ C , ! l l ! [ . ’ d l [ ] 1 1 0 m q ~ 1 1 a c l , , [ , \ [ ~ ‘ 1 , f ” \ m 1 1 ” [ , a . i o [ c I r L I . ~ “ A ” [ 1 1 ” . > W l [ . ~ r u o ~ . ~ a . l r [ c l . , r l p l t ! ~ < ~ w q t ? & l ? L I ~ t ? . l [ , ~ ~ ~ S t w ~ l ? _ I [ ’ [ m ? . y : t l + . j ‘ ~ l I a r r l ~ c ~ ~ . l ] [ “ I V c ! s o u F h ? q 1 [ ! ~ l l l l T ~ l l l ~ ~ I [ $ ! \ \ . i [ p ’ _ l q , [ N ! . l l ! \ ~ ! s o l l ; i o . r d ‘ C . l , > . J ! ) o q l g l l ? . m l ‘ , r [ J s u . i \ s ! r [ j I [ ; l l t o r [ ~ [ y 3 y d J s [ , a z q t ? . l m , ~ S O J s r l t ? d . I o [ l ? L I ~ ~ “ “ ~ t l ~ o . l ~ s t ~ ~ i c [ _ I t : < “ l 1 0 r I o ! ) t : ) ! . l . l j [ K ” ‘ [ 1 1 1 0 . 1 ~ . > 5 L I t ~ . I [ “ I t ! [ m ! . I t : . \ , 3 . 1 \ 1 S L l ; i ! S p u e s L l l o ) t I L l l . i ~ y n . r ; C . l t ? L l ! . I l t A l p 1 ” r I o ~ ~ t ? ~ u ~ L L I l t . l ~ s L I ~ [ “ I \ ? ~ L l o ! ~ . ~ l l . l ~ s c [ o . s ! s o . r r , t L , l l c ~ . ; [ ~ i l l ‘ S ! , \ [ . x I [ l ? L I ‘ . l d l [ J t o w o ~ J ” ~ ~ [ I l ! v , [ , l t [ J U ! S . l O j . ) t : j ; i L l ! S O d S ~ [ , . X I d ‘ & , \ ? . I $ . i . I t ? L l ! . I l t . r x I d t t [ t : I 1 1 . I o l I ( [ t ! I I t ? L I ! . 1 1 1 3 D O . i [ [ l ? l l S l l ~ ~ s l u ~ ~ ~ u l ? ~ U O L l S T . . 1 . 1 1 ‘ l ( . , ! l [ . \ \ x > s o l [ ~ p I I t ? ~ 3 ~ ~ t ? l l l l t t ~ . l ~ , ) . l l ? s , > s t ? . ) J s o l l l J t ? l ( J [ ‘ * ‘ I ~ “ ” < ‘ H . ~ 3 d ~ C [ l I S S ! l [ . l I I 0 y o _ \ \ a \ ! ~ ! l l L J . ‘ [ ’ t ; S I I ! t : l l . l . ) . l ~ ~ [ . x ~ . I t ? S ’ H ‘ S C ’ [ L l ! J 3 ” j ‘ c [ l l S % ; ! I [ $ I 1 0 . ~ . l l l ~ l ! _ I ~ ~ $ q T , l [ J [ , a A \ a ! . w . l , , , ~ s l l o r ( s q ~ ‘ [ ~ ~ ~ ~ l l T > S ~ ‘ . I d l I A X [ , > \ l ’ I [ r l o ~ ~ l ! [ l K k ~ t I [ “ . 1 “ 1 . ‘ 5 A ’ [ _ 1 I I ! q a d [ l ” l A . l 1 [ ) ’ 3 t o s . m ~ d 1 t . 1 f ” s ~ . l o t k . I [ t ? _ l < Q . \ J s ~ ~ l l a r L r l t . , c ; p O J P J [ c [ ! s s o t I ~ o ! a s p : S ! L I o ~ s s ~ , . l d t l l r ~ o ~ l l l l L l l l l ~ 0 1 A l I p Y L I q t ? J L [ . 1 o o t I . I 0 p u t ? L I o ! p d x u J O . ‘ [ “ . I “ L [ L ‘ S , > S 1 ? . 3 . l l l O L I ! [ ‘ ~ ~ ~ ‘ J g t ? s t ? . k \ _ I ~ J ~ U n , ) I i $ ~ O L I p I I t ? s ! . y , , d [ t ? i i . x l d L ( J i l ( . \ \ , f O L I o y x l t ~ [ t i s < ~ 0 1 1 c ; I . m r p J l N [ ‘ t l ~ ; i ~ . l o . l l ? [ l m t ~ . \ t ? p . , . \ ~ g s J : , j J l l s ‘ ; ! r l o ~ ~ t ~ ~ r n : [ d s L I t ? . l ~ ~ s o L l S . i l ? [ > a . \ t f 0 4 . I l l O ] s n l o ~ c I l l r . ~ s J O ~ ~ l W ( ’ a r p [ , t ? r [ s . I o L I o [ ~ [ 1 d ~ “ [ ~ . l d L l ! _ U [ L l l O . I J s h u p q [ , ~ ~ , \ ! n x I o r I ” \ s $ L I a ! g t ? ! t l E ; J V L [ $ p 1 : j , “ [ J * ‘ S ! \ [ , K i [ t ? r I . x l X [ J L I ! M O H [ “ “ ‘ [ ‘ [ . i . l t ? [ [ ~ t I t ? ! . ~ a s e ~ . l s a [ , . i l : r l l s a . I l t s s , , . I c l . J ~ . \ [ “ c l l ? . l ~ L l ~ L @ L [ S d l ? L ( . I < , d z ‘ l l o ! ~ . J l I l l ~ [ t : ~ ~ ~ ~ . I o . ~ o [ a . i t I 9 L [ J $ 1 : . i . I , > ~ . l l ! < 3 S . l 2 . \ s t l l ? . l ~ . 3 1 ( ) . l t : ~ l . l l I o ~ ~ . x x s q 1 O L I b . l t : [ l t . , g . I l ? ‘ I L I ! [ “ I ’ ? 3 ! . \ [ . K I [ ‘ ? l I ‘ . l , l L [ J 4 ” L I o ~ ~ o a s s q ~ O L I S l ? . \ \ a . I a L [ J p r r r . i [ t l d r l s [ , O O [ ‘ [ i . l t ! , ~ ! t h ! . ~ r p p t : S l ? L [ S ! . \ [ < > d [ \ ! U & l a , r p J 3 1 1 ! S ‘ q q ! [ r I t t S ! s ! r [ J * 3 ! , \ [ a t l [ l ? U ‘ _ I , , t p 0 3 . i [ t I d t t s [ X ” ‘ [ ‘ [ a q j I [ ~ ! . \ 1 ~ ~ . ~ r I . m p ~ ~ L l ! S l ? . 4 1 a . I d l [ J J l ? L [ J a ( [ p [ l t o _ ” . i . I o a r { ~ . l ~ L [ ~ o L I ~ , ‘ i [ a . ~ ! ~ J a d s o l ~ a . l ~ L I a L L r t l m p 0 1 ~ [ c [ ~ s s o d t l I ! “ ; ! S ! l [ J 1 ~ s , > . l t t s s A I d . J ! . \ [ a t l l ? . r ~ L l ~ L [ ; i ! l [ ~ r I ~ y : t I a l p [ m : p . \ J x a . I t I s ; : . 1 \ r l c l ! J J L r I l , J ~ r l t q t l S L I l ? . I J [ 1 x 1 1 _ “ “ ’ ‘ ~ u a ~ t I ! m [ m : . 1 0 U 0 [ ’ S U ! [ ( [ ! S A l [ $ L I a a M ~ ; , c [ r p ~ t ! u I a c I . & @ ? L [ 2 ; t ! S B . M . A I a l [ ~ d S I l l ? . ~ 2 g x h : U ~ l ? J [ 1 . i U r o p w t [ t I a U p r r n S q ~ t I [ \ ! “ < I ) _ 1 a l p p . l ~ l ? d r > . l . c q [ , a . M o [ [ o f [ m a ~ s ! L I ! L L l [ ~ t : , ) . 1 9 . \ \ S ? h l . I [ ~ a . \ ~ s s ~ ~ . l t l d t t s o L I l ~ L L I L L l ~ ; o s a s o p . M O [ ~ , i [ ~ L l m h J s c [ l r ~ ‘ [ h x l , , . \ ~ , . I S l I ‘ L \ S ! S d X s ‘ ~ L I + l ? d a r p [ , L l V ~ L l . n t ~ . l [ 1 I [ J ! M . i [ ! . I l ? . I o t I r I l a ~ s t ? . n l I o ! s s r x l d d l r s o l I l t L L I L L I [ ‘ l l J ! S U ’ J j f ” [ S t ? M . i . X I p p I “ Y J p U t ? ‘ a . Z ? d S [ l ! . ~ t I O ) ! r a d O ~ ~ a 1 A L p $ 0 & h ? U ! t ? . I p a ‘ 2 ~ s U ~ ~ s J [ [ I ! . \ \ [ , . ~ ~ l : T > . I J s t 1 . u “ H & o & ~ . ~ s o ! J d a s q $ ~ \ p a ~ r r a s a . r t I o s [ t ? ( e x t z ? ; ~ ) ~ r l x 3 ! ~ l ? d q ~ . l t l o , J a t [ L ‘ s ~ s c l a s 9 \ ~ s s a . r ~ o . l d t o [ , a ! [ , ~ t I a g t ? d s ! q J : [ ~ a l t u ~ ~ U o . , I I o I c s r ) ~ ~ i d l l s o t 1 l I z I I 1 1 1 I [ “ I F ‘ [ m I . I o p ~ c I . i r r I o ~ s o [ ~ . i t I 1 1 ~ , > , ~ l ~ [ t i I I ! q . > [ w . \ \ ~ L l l ? [ c k r I l ? _ I ~ i L , j ( c ; a w ] ) ~ L I < > ! g t x I 1 I I ] i . I , > \ O . N . l St~\.~~r;tl ~~r~thors ha\-e also ~ddrc~sstd the topic of’ rlriliar\, fishllas after renal transI~l;iiltation.“~” Infcy+ion: poor healing in the immunosuppressed 11041 . mrtl cmws iii teclrnicpes of liail,esting 01 traiisl)l;tn tutioil iiw lwlie\.rd to lw rcsponsil~le 1‘01. niost ~‘;i4t’s. \‘ascular insufficiency and Ilrc~ttwl ilc’c’rosi4 is an aid result in many cases. S\.iiiptoins a~itl signs are 1 arid. hut ;I mass o\.t7l\iiig tllrl kidnc\. mid ~vound tlrainagc are oftrl11 swn. Earl! diagnosis and prompt inhtitrltioll of’ tlitxrap!. is vinphasized l,,. all kiiltllors. Depending on the clinical circuinstancrh, tlirrapy may Iw ncphrectomy, drainage and rqxiir. or o\~wr\~ation. Spontaileo~ls rripture of‘ the renal pelvis dtci rt‘id transpl;“it~itioii has lwwi inentioned ml) three times in the litcrature.‘~‘~x The diagnosis mxs iil;ide onl) after considvral)le urinar!~ vstra\ asation l~atl rcslllted in a flucttunt imss. Treatment consistccl of successful repair, attempted wpnir follomwl 1)~ nephrectoiny, and transplmt nrphrectom~~. The authors believed tliat tlie rllptllre \I’;I~ seconchy to olxjtruction of the nleteroiieoc\,stostom)in 1 case and to erosion of an iidcctd liwiatomti in another. 01ir tluta sllggest that this coinplication, while 11ii1tsuiil. is inore cornnion than previoilsl!, :tppreciatd (4 c’ases in Yjk5). The diagnosis is ofien delayed, and as ;i conseqiiencc’ the patient \vill of‘tw show. signs of systemic sepsis. Aclecpatra del~ritleinent and tensionless reapproximation of tht ~-cd pel\‘is is not al\va)x fwsihle. Transplant nephrectom~is the treatment of choice in most cases. However, the clinical condition of each patient is different, and an occasional graft niu)~ he sal\xged if the patient is clinically ~rell or if tll? dvgrcv of histocoinpatibility is such that imiiiunosilpl~r~ssion can 1x2 drainaticall~~ rdiicecl. Vrology Section Box 03 Uni\~ersity Hospital 14X5 E. Ann Street Ann Arbor. Michigan 48103 (DR. KONNAK)