Spontaneous, unriitting gross hematuria occurring one week after laparoscopic donor nephrectomy

CASE REPORT

Spontaneous, unriitting gross hematuria occurring one week after laparoscopic donor nephrectomy

Steve Y. Chung; Chris H. Chon; Christopher S. Ng; Gerhard J. Fuchs

Cedars-Sinai Medical Center, Endourology Institute, Los Angeles, California, USA

^{Correspondence}

ABSTRACT

Complications associated with the ureteral stump after nephrectomies rarely occur, especially after donor nephrectomies. The potential for the slippage of clips is a well-known event associated with vascular ligations. We report on the first case of clip slippage from the ureter and describe diagnosis and managient of the most extrie of morbid presentations.

Key words: kidney; laparoscopy; organ donation; nephrectomy; ureter; hematuria

INTRODUCTION

The laparoscopic donor nephrectomy (LDN) is ierging as a standard for living kidney procurient. Decreased donor morbidity has been well documented with no prior reports of ureteral complications. We report a case of spontaneous, unriitting gross hematuria from the ureteral stump occurring during convalescence after an uncomplicated LDN. Diagnostic and managient issues are discussed.

CASE REPORT

A healthy 23-year-old woman was discharged 2 days after an uneventful hand-assisted left LDN with ligation of the ureter using 2 titanium clips (Figure-1 A). One week later, she developed sudden onset gross hematuria and suprapubic pain. In the iergency department, a hematuria catheter was inserted and irrigated for many clots. Her hiatocrit was stable at 37% and urine culture was negative.

During 23-hour observation with catheter drainage, she had further episodes of gross hematuria requiring manual irrigation. She was subsequently taken to the operating room, and cystoscopy revealed blood clots in the left ureteral orifice. Sii-rigid ureteroscopy revealed bleeding without any identifiable source, and retrograde injection of contrast showed extravasation into the peritoneum (Figure-2 ). With a hiatocrit of 27%, she was immediately sent for angiogram, yet no active bleeder could be identified.

With persistent hematuria, the patient underwent a diagnostic exploratory laparoscopy. The approach utilized the previous umbilical and lateral port sites and one new port site. During inspection, it was evident that the titanium ureteral clips had fallen off, but no hiatoma, urinoma, or active intra-abdominal bleeding could be identified. The ureteral stump was eventually mobilized off the iliac vessels, and the proximal end was ligated with 2 Hi-o-lok clips (Weck Closure Systis, Research Triangle Park, NC) and wrapped with Surgicel (Figure-1 , ^B). A Foley catheter was left in place.

By postoperative day 1, the suprapubic pain had resolved, and Foley catheter was rioved. She was discharged the following day with clear, spontaneous urine output. At one-month follow-up, she denied any further episodes of gross hematuria.

COMMENTS

Morbidity associated with the ureteral stump after LDN is extriely rare. In a series of 738 consecutive living donor nephrectomies, Jacobs et al. reported no major or minor postoperative complications associated with the donors’ ureteral stumps (1).

Based on the intraoperative findings of this case, we concede that the titanium clips on the ureteral stump suddenly dislodged during convalescence, resulting in only antegrade ureteral bleeding. Clip slippage is a well-known occurrence, especially during ligation of vessels (2). However, slippage from the ureter has never been reported. Alternatives to titanium clips include locking clips, staplers, suture, cautery, and various vessel-sealing systis. We now ligate the ureter with plastic locking clips during laparoscopic nephrectomies.

In patients who present with delayed gross hematuria after any laparoscopic nephrectomy, bleeding from the ureteral stump should be considered. Failed conservative managient should be followed by cystoscopic localization and, if ureteral-stump bleeding is identified, laparoscopic exploration. Imaging studies such as computed tomography and angiography might be helpful in dionstrating a fluid collection or active bleeding, respectively; however, findings may also be equivocal, thus delaying definitive treatment.

Received: May 22, 2004

Accepted: June 30, 2004

• 1. Jacobs SC, Cho E, Foster C, Liao P, Bartlett ST: Laparoscopic donor nephrectomy: the University of Maryland 6-year experience. J Urol. 2004; 171: 47-51.
• 2. Carvi y Nievas MN, Hollerhage HG: Risk of intraoperative aneurysm clip slippage: a new experience with titanium clips. J Neurosurg. 2000; 92: 478-80.

Publication Dates

• Publication in this collection
  24 Nov 2004
• Date of issue
  Oct 2004

History

• Received
  22 May 2004
• Accepted
  30 June 2004