Retrograde endoscopic assisted percutaneous treatment of urinary fistulas after partial nephrectomy

Background. Urinary fistulas (UFs) are one of the most significant complications after partial nephrectomy. Placement of an ureteral stent eliminates urine extravasation in the majority of patients. However, some of them have persistent UFs despite upper urinary tract drainage. Such cases require retrograde injection of fibrin glue into the renal cavity through a ureteroscope or via the percutaneous approach. Some authors reported cases of simultaneous use of 2 stents and percutaneous cryoablation of the fistula, but these techniques are rare and, therefore, it is problematic to evaluate their efficacy.Objective: to evaluate the results of the new treatment method for the elimination of persistent UFs using the retrograde endoscopic percutaneous approach.Materials and methods. This study included 5 patients (3 males and 3 females) with UFs developed after kidney resection. Mean age of the patients was 55.8 years. The tumor size was 2.5 to 4.8 cm; mean R.E.N.A.L. score was 7.8. All patients had earlier undergone minimally invasive partial nephrectomy; the time between surgery and UF development varied between 3 and 10 days. Four out of 5 patients had a large amount of discharge from their paranephral drainage system, examination of which confirmed high creatinine level. Patients underwent flexible ureteropyelography in the lithotomy position. During this procedure, we identified the damaged calyx and then performed percutaneous puncture targeting the distal end of the endoscope at this calyx, ensuring that the tip of the needle appeared in the paranephral cavity in front of the injured calyx. Using the flexible ureteroscope, we inserted the needle into the pelvis, dilated the puncture opening along the string, and installed a nephrostomy drainage system (12 Fr). Then the endoscope was removed and the ureter was additionally drained with a stent. The stent was removed after 8-10 days with subsequent antegrade pyelography. If there was no extravasation, the nephrostomy tube was removed and the patient was discharged from hospital to continue treatment in outpatient settings.Results. All patients with UFs resulting from partial nephrectomy was successfully operated on. No complications were registered. The mean surgery time was 45.0 ± 20.5 min (range: 40-65 min). Only two patients had some discharge from the fistula within 1 day after nephrostomy tube removal and it stopped without any additional interventions. Three patients had their fistula healed immediately. The treatment efficacy during the whole follow-up period of 18 ± 4 months (range: 6-26 months) was 100 %.Conclusion. Ureteral stenting ensures elimination of UFs in the majority of patients after partial nephrectomy. In individuals with persistent UFs, retrograde endoscopic percutaneous drainage of the pelvicalyceal system is the method of choice, because it allows rapid and effective treatment of UFs.

Urinary fistulas after partial nephrectomy in renal cell carcinoma

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.

P357 Long-term outcomes of biologic therapy in Crohn’s disease complicated with internal fistulizing disease: BIOSCOPE study from GETECCU

Background The prevalence of penetrating disease in Crohn’s disease (CD) increases progressively over time, and evidence on the medical treatment of this complication is limited. The aim of this study was to evaluate the efficacy of biologic agents in CD complicated with internal fistulising disease. Methods A retrospective analysis of all adult patients from the ENEIDA registry (>68,000 patients) with CD who received at least one biologic agent -anti-TNF, ustekinumab or vedolizumab- for penetrating disease was performed. Exclusion criteria comprised treatment for perianal disease, enterocutaneous, anastomotic or periostomal fistula tracts. The main outcomes were fistula-related surgery and fistula closure on cross-sectional imaging. Preestablished secondary outcomes included the rate of abdominal abscess, the need for percutaneous drainage, the changes in the number of fistula tracts, fistula closure rates, and the safety profile.The baseline characteristics were analyzed by means of descriptive statistics and were compared by non-parametric tests. Predictive factors associated with surgery and fistula closure were evaluated by a multivariable logistic regression and survival analyses. Results A total of 710 patients (median age 38 years [IQR, 28-48], 59% male, 55% L3) receiving 791 biologic treatments were included at 53 sites (701 anti-TNF, 71 ustekinumab, and 19 vedolizumab). Patients had a median of 1 (range 1-5) fistula tracts, 49% of them entero-enteric followed by entero-colic (28%). After a median follow-up of 59 months (IQR, 27-105), 244 patients (31%) required surgery due to internal fistulising complications after 8.5 months (IQR, 3-24). Patients with ileocolonic disease (OR 1.99 [1.22-3.23]), entero-urinary fistulas (OR 2.35 [1.17-4.73]), or with a stricture distal to the fistula (OR 2.1 [1.31-3.36]) showed a higher risk of surgery, with no differences between biologic drugs (Figure 1). Combination therapy reduced the risk of surgery (HR 0.58 [0.37-0.90]). Fistula closure was observed in 24% of patients after a median of 15 months (IQR, 7.5-27). Patients with a lower number of fistula tracts showed a higher probability of closure (OR 1.72 [1.09-2.7]). Conclusion A high proportion of patients with internal fistulizing CD benefit from biologic treatment after a median of 5 years. During this follow-up, around two thirds of patients are free of surgery and one in every four patients achieves fistula closure.

Winternitz. - For the treatment of vesicular fistulas. - (Ibid., No. 15)

The author places great hopes on a new way of treating difficult urinary fistulas, in which the wall of the bladder is separated from the wall of the uterus (or vagina), which creates significant mobility of the corresponding parts.

THE CASE OF THE OPERATION OF THE ENTEROCERVICAL FISTULA

Communications of various parts of the intestine with the genital area are relatively rare phenomena in gynecological practice; in any case, they are less common than urinary fistulas, which is understandable in view of the anatomical features of the pelvis. Infrequently and descriptions of individual cases of these fistulas. The case, which will be discussed here, is of some interest for its anatomical features, for the diagnostic difficulties encountered during its recognition and for those operational procedures that were applied here.

On the question of vesicoureteral fistulas and the description of five cases of this kind of fistula, which ended in full recovery

In the pathology of the female genital area, the correct and accurate recognition of urinary fistulas, as well as the improved surgical technique for the treatment of these sufferings in connection with antiseptics and the favorable outcomes of operations, undoubtedly belong to the second half of the 19th century.

Spontaneous appendico-renal fistula: clinical presentation and management of a previously unreported entity

Entero-urinary fistulas are uncommon in urological practice and may have widely varying aetiologies ranging from benign to malignant or iatrogenic in nature. All permutations of entero-urinary fistulas have been reported in the literature except an appendico-renal fistula. Here, we present one such case, presenting with urinary tract infections and perineal urethrocutaneous fistulae. He was ultimately diagnosed to have a spontaneous appendico-renal fistula as underlying pathology behind the symptoms.

Post-traumatic bilateral vesicocutaneous fistula of thighs treated with buccal mucosa graft urethroplasty and cyanoacrylate glue instillation: a novel treatment for management of a complicated fistula

Post-traumatic vesicocutaneous fistula (VCF) is a rare variant of urinary fistulas. These fistulas may externally communicate to abdomen, perineum, buttocks, scrotum or very rarely thigh. These fistulas usually develop at a variable time duration after trauma and are usually preceded with thigh swelling or abscess formation followed by spontaneous rupture. We, hereby, report a case of VCF of bilateral thighs with associated penobulbar urethral stricture after road traffic accident which was managed with dual modality of buccal mucosa graft urethroplasty surgery and cyanoacrylate glue injection in the fistulous tracts. To the best of our knowledge, this is first report of bilateral VCFs communicating externally to thighs. In literature, very few cases of VCFs of thigh are reported and are rarely managed with adhesive glue application.