Yildiz, Baris D.
From the Ankara Numune Teaching Hospital, General Surgery Clinic, Sihhiye, Ankara, Turkey.
Submitted for consideration December 23, 2013; accepted for publication in revised form February 20, 2014.
Disclosures: Baris D. Yildiz collected data, analyzed data, and wrote the article. Patient had given her informed consent for this publication.
Reprint Requests: Baris D. Yildiz, MD, Ankara Numune Teaching Hospital, General Surgery Clinic, Selanik cad 29/2 Kizilay, 06650 Ankara, Turkey. Email: email@example.com.
Thousands of patients with renal disease are on waiting lists for kidney transplant. Survival and quality of life on hemodialysis are much lower than that after renal transplantation. Renal allografts are extremely valuable and worth saving at all costs. Many complications can be seen after organ transplants on short and long term as rejection, vascular compromise, and infection. There are various reports on partial nephrectomy after renal transplant secondary to de novo masses in the renal allograft. Here, we present a case where we used radiofrequency bipolar sealer for partial nephrectomy for necrotic abscess of the renal allograft. We successfully saved the allograft with partial nephrectomy despite parenchymal infection and necrosis.
There are approximately 20,000 patients with end-stage renal disease waiting for a renal allograft in Turkey. The majority of kidney transplants in Turkey are living related transplantations secondary to cultural factors that adversely affect cadaveric organ donations. It is a well-known fact that survival and quality of life on hemodialysis are much lower than that after renal transplantation (RTx).1 These factors render renal allografts extremely valuable and worth saving at all costs in Turkish population. There are various reports on partial nephrectomy after RTx secondary to de novo masses in the allograft.2 Radiofrequency ablation was also used for the same purpose.3
Here, we present a case where we used radiofrequency bipolar sealer (RBS) (Aquamantys®; Medtronic, Minneapolis, MN) for partial nephrectomy for necrotic abscess of the renal allograft.
A 59-year-old female presented to the emergency department with high fever. There was a skin fistula draining pus over an incision scar for RTx. The kidney graft was from a living relative donor (her sister), and the procedure was performed in another center 2 years ago. She reported that the oozing started 2 months ago and she did not have any prior complaints before that time. She had received intravenous (iv) antibiotics (moxifloxacin 400 mg bid iv) without any improvement in another center before presenting to our center. At physical examination, there was a 0.5 cm opening on the incision scar of RTx with actively draining purulent fluid. A Doppler sonography of the kidney allograft was ordered and revealed 6 cm necrotic abscess cavity on the superior aspect of kidney parenchyma with decreased segmentary arterial flows. There was also a suspicion about a foreign body overlying the kidney. A noncontrast computed tomography confirmed the presence of the foreign body along with the abscess (Figure 1).
At the initial presentation, the patient’s urea level was 46 mg/dl, creatinine level was 1.1 mg/dl, and leukocyte count was 14,000 103/μl (82.5% neutrophils, 8.8% lymphocytes, and 8.4% monocytes). Her urine output was 60 ml/hr. She had 38.7°C fever, but the rest of vital signs were normal. She was taking tacrolimus 1 mg twice daily, mycophenolate mofetil 1 g twice daily, and 5 mg prednisolone daily. Tacrolimus blood levels were within normal limits (17.8 ng/ml [normal range: 5–20 ng/ml]).
The clinical picture and its risks were discussed with the patient and the family and they did not consent for any intervention involving the allograft. Surgical exploration was undertaken using the previous incision for RTx and the foreign body was found to be a surgical sponge placed over the kidney allograft 2 years ago during RTx (Figure 2). The surgical sponge was taken out and vacuum-assisted closure (VAC) was applied on the on the open wound to facilitate continuous drainage from deeper tissues as the allograft was kept in place. The bacterial cultures during first surgery revealed Enterococcus species and the reports of blood cultures were negative. The patient’s antibiotics were changed to linezolid 2 × 600 mg iv and meropenem 2 × 1 g iv. Vacuum-assisted closure was changed on regular basis, but there was not any improvement either of the wound or fever although she was on antibiotics. On the 25th day of admission, the patient started to have abdominal pain and rebound tenderness. Abdominal sonography revealed massive free fluid inside the abdomen, and Doppler and computed tomography (Figure 1) showed the same sized necrotic mass in the allograft with no change in arterial or venous flow. At this time, the patient’s creatinine level was 1.6 mg/dl, urea level was 70 mg/dl, and she was producing approximately 40 ml/hr of urine. Surgical exploration of the allograft was undertaken using the same incision as the first surgery. It was seen that the upper pole and most of the middle part of the allograft was replaced with necrotic abscess (Figure 3). There was a point in contact with the lower part of peritoneum where the abscess drained to the peritoneal cavity. Using RBS, the necrotic part was excised (Figures 3 and 4). Two segmental arteries were encountered during resection that were controlled successfully with RBS without sutures. After all necrotic debris and abscess were evacuated, and hemostasis was further achieved on the parenchyma and other surfaces with RBS. We did not need to clamp the renal artery to induce warm ischemia, and estimated blood loss during the procedure was 20 ml. The parenchymal transection with the help of bipolar sealer took 28 min.
After excision of the necrosis, a midline laparotomy was done for exploration of the abdomen, which showed massive purulent fluid. There was not any source other than the allograft abscess to explain the intra-abdominal fluid, which was washed out with saline. The patient’s postoperative course was uneventful. She was continued with the same antibiotic regimen as the first surgery and was discharged home on 37th day after admission. Her creatinine level dropped back to 1.1 mg/dl at postoperative day 5 and it was 1.0 mg/dl at first month follow-up. She was producing 40–50 ml/hr of urine at follow-up.
Other than electrocautery, techniques using different energy sources were defined for partial allograft nephrectomy including microwave tissue coagulator4 and radiofrequency.5 To our knowledge, our patient is the first case depicting the use of RBS for partial nephrectomy for necrotic abscess of a renal allograft. Radiofrequency bipolar sealer proved to be a reliable tool for partial nephrectomy both for dissection and for achieving hemostasis. Radiofrequency bipolar sealer works by combining a bipolar electrosurgical generator with a rotary peristaltic pump to provide simultaneous delivery of radiofrequency energy and saline. The saline cools the tissue as it is treated and evenly conducts the energy into the tissue to seal blood vessels. The thermal effect shrinks the collagen in the walls of small arteries, and this results in the cessation of bleeding from these vessels. The saline cools the tissue surface and prevents the tissue temperature from exceeding 100°C.6 Radiofrequency bipolar sealer was proved to be useful for hepatic resection7 and orthopedic surgery.8
Our starting point when considering RBS was its efficiency in parenchymal dissection and hemostasis in liver surgery. Our case points out that the same may be applicable for kidney parenchymal transaction, but this has to be verified with more cases. In our case, the kidney was affected by long-lasting pyelonephritis with abscess formation. This could have obliterated the parenchymal vascular structures, decreasing bleeding during RBS transection.
To our knowledge, this is the first case reported in medical literature using RBS in partial nephrectomy for necrotic abscess of the renal allograft. Infected renal allografts can be saved successfully with partial nephrectomy using radiofrequency sealer. A mass inside the allograft should not be the only indication for partial nephrectomy. In the face of scarcity of organs for transplant, new technologies should be used to salvage the allograft.
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partial nephrectomy; renal transplantation; radiofrequency