Calyceal-cutaneous Fistulae in Renal Transplant Patients MITCHELL H. GOLDMAN, M.D.,* RICHARD L. BURLESON, M.D.,t NICHOLAS L. TILNEY, M.D., GORDON C. VINEYARD, M.D., RICHARD E. WILSON, M.D.

Calyceal-cutaneous fistula is a serious sequela of renal transplantaFrom the Department of Surgery, tion occurring in approximately 3% of allografts. This complicaPeter Bent Brigham Hospital, tion occurred in 12% of allografts with multiple renal arteries. A Boston, Massachusetts localized area of poor parenchymal perfusion involving less than one-eighth of the kidney was noted at the time of transplantation in only one-third of the kidneys developing fistulae. Attempts at surgical correction of the fistulae in the presence of serious wound and urinary tract sepsis were usually unsuccessful, with the warm ischemia time, presence of an area of decreased ultimate loss of 7 of 8 kidneys and the death of 3 patients from perfusion or parenchymal infarct documented intrasepsis. One individual underwent successful partial resection and operatively, occurrence of calyceal-cutaneous fistula closure of the fistula with a muscular graft and survives with ade- and subsequent clinical course, the type and number of quate function. This experience would suggest that if an initial aggressive surgical attempt at repairing a calyceal-cutaneous corrective procedures and allograft and patient survival. The records of two patients with calyceal fistula occurring fistula fails, transplant nephrectomy should be performed.

prior to this period of review were also included in the T HE COMMONLY OCCURRING urologic complications of renal transplantation, ureteric anastomotic failure resulting from stricture or infarction, have been reported in detail.2'510'2'5-1 Calyceal-cutaneous fistula is an unusual postoperative complication often caused by local or segmental infarction of renal parenchyma occurring predominately in kidneys with multiple arteries."3'6'9 This report details the experience at the Peter Bent Brigham Hospital with eight calyceal-cutaneous fistulae developing following renal transplantation.

Material and Methods The hospital records of all patients receiving renal allografts between January, 1970 and July, 1974 were reviewed. The following data were tabulated for each allograft: number of arteries, type of arterial anastomosis, Naval Medical Research Institute. National Naval Medical Center. Bethesda. Maryland 20014. Present address: Department of Surgery. Upstate Medical Center, 750 East Adams Street. Syracuse. New York 13210. This work was supported in part by grants from the USPHS and the Avalon and Hartford Foundations.

series.4 Results

Calyceal-cutaneous fistula developed in 6 of 239 allografts, an incidence of 2.6% (Table 1). Four of the involved kidneys were taken from cadaver donors and two from living related donors. Multiple vessels or early division of the main renal artery occurred in 50 kidneys. An area of poor perfusion or a distinct site of infarction of renal parenchyma involving less than one-eighth of the kidney was noted at operation in 18 grafts (38%). Of the 6 kidneys developing calyceal-cutaneous fistulae, all had multiple renal arteries, one had ligation of a small polar vessel, and two had a localized area of parenchymal infarct. Thus, 12% of the kidneys with multiple vessels, and 11% with segmental infarction or hypoperfusion, developed a fistula. Anastomosis of all non-polar vessels in a standard endto-end or end-to-side fashion with the hypogastric or external iliac arteries was felt to be satisfactory at the time of transplantation. However, the time needed for revascularization was prolonged in 5 of the 6 involved kidneys as compared to the average time for vascular

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December 1'976

TABLE 1. Caly eal-Ciitaneous Fistiilta Afler Renatil Tranilspltianttltion

Patient Number I 2 3 4 5 6 7

Source

No. of Vessels

C C C LR

2 E.T.* 2

C

2 2 2 4

LR C LR

8t

No. of Vessels Anastomosed

Ligated Polar Vessel

2 1 1 1 2 2 1 2

0 0 Upper 0 0 0 Upper

E.B.2

Upper

Infarct at Op. Posterior 0 1/8 of kidney 0 0 0 Less than 1/8 of kidney Less than 1/10 of kidney

Location of Eventual Infarct

Uirete-al Complication

Mid portion Lower pole Upper Lateral 1/2 of kidney Lower Latercal lower 1/2 of kidney Upper

Infarction I nfarction

Upper

Str-ictul-e

Infarction

E.T.. Early Trifurcation. E.B., Early Bifurcation. Previously reported.'

anastomosis in allografts with single or multiple vessels. Three patients in the series developed a ureteral stricture or leak and a fourth sustained an associated bladder fistula in the early post-transplant period. Diabetes mellitus occurred in two recipients secondary to steroid therapy and was present in one prior to transplantation. Sepsis was a major sequela of fistula formation. All 6 patients in the group developed both wound and urinary tract infections. The majority of calyceal-cutaneous fistulae were treated initially by resection of the infarcted parenchyma, primary closure and nephrostomy (Table 2). The fistula recurred and persisted despite several attempts at closure in 3 of 4 patients undergoing such an initial corrective procedure. In a single individual, successful resection of a longitudinal infarct of renal parenchyma and closure with a muscular graft was achieved. She remains asymptomatic TABLE 2. Resialts of Replair of Calceal-Ciatanemo s Fistisla in Transplant Pautiens Patient Number

Primary Treatment

No. of Operations

6

Debridement, closure, nephrostomy Resection, closure. nephrostomy Nephrectomy Resection, closure with muscle graft, nephrostomy Resection, closure with muscle graft, nephrostomy Nephrectomy

7

Nephrostomy

2

8

Nephrostomy

3

1 2

3 4

5

4 4

I

2

6

I

with stable function one year- later. Another patient underwent 6 attempts at fistula closure resulting in prolonged hospitalization before nephrectomy and retr-ansplantation. The inability to achieve closur-e was explained on pathological examination of the fistulous tract which revealed epithelialization with transitional cell epithelium. One patient died of septic complications directly related to his fistula. Both individuals with a calyceal-cutaneous fistula reported previously from this hospital, received allografts with multiple vessels and had a polar artery ligated at surgery with an infarct noted at the time of transplantation.4 One kidney was taken from a cadaver donor, the other from a living related donor. Concomitant ureteral structure developed in one and urinary and wound sepsis occurred in both. Steroid related diabetes mellitus developed in one patient. Nephrostomy alone was the primary surgical therapy in both patients and both died with irreversible sepsis.

Discussion

Calyceal-cutaneous fistula is a rare complication following renal transplantation which may appear late in the post-transplant period.' It frequently develops secondary Nephrectomy to anastomosis of multiple renal arteries or ligation of a polar vessel, and often occurs in a kidney with an area Died from sepsis of poor parenchymal perfusion noted at the time of transplantation.1 In the present series, ligation of an upper Chronic hemodialysis polar vessel led to calyceal-cutaneous fistula in three Functioning allograft instances. Since all of the infarcts leading to fistula formation involved less than one-eighth of the renal parenchyma, Nephrectomy and reit is no means clear that the size of infarct noted at the by transplantation time of transplantation can be correlated with the subseChronic hemodialysis, quent occurrence of calyceal-cutaneous fistula. Although retransplantation a localized site of parenchymal ischemia does not always portend the development of a calyceal-cutaneous fistula, Died from sepsis its presence is of some prognostic value. The occurrence Died from sepsis of a parenchymal infarct at transplantation associated Results

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CALYCEAL-CUTANEOUS FISTULAE

with postoperative scrotal and labial swelling, a perinephric mass or wound drainage should alert the physician to the possibility of a calyceal fistula. The calyceal fistulae were associated with ureteral complications in 4 instances in this study. Ureteral infarction and stricture have been attributed to poor perfusion of the ureteral vessels either due to compromise of blood supply during harvesting of the graft or from rejection, and occur more frequently in kidneys with multiple renal arteries.4' 1 Ligation of lower polar vessels may put the ureteric blood supply especially at risk. The more frequent occurrence of calyceal fistulae among cadaver allografts suggests the greater use of cadaver kidneys with multiple renal arteries compared with similar kidneys from living related donors, which may have been screened by preoperative arteriograms. Cadaver kidneys with multiple vessels and areas of poor perfusion apparent during the period of preservation should generally be excluded from the transplantation.7 Reanastomosis of the accessory vessels is not sufficient to prevent calycealcutaneous fistulae, since irreversible necrosis usually occurs in a non-perfused area during the period of preservation. As noted in this series, the most critical factor in the management of a calyceal fistula is the presence or development of perinephric sepsis. Placement of a nephrostomy in these patients increases the threat of prolonged infection. Multiple operative procedures, high dose steroid treatment for rejection, immunosuppressive drugs and the occurrence of diabetes mellitus during the posttransplant period are factors which increase the susceptibility of the patient to infection and mitigate against its eradication.8 Disseminated bacterial or fungal overgrowth documented in 3 patients and suspected in a fourth patient in our group was presumably secondary to chronic antibiotic therapy. Surgical management of the fistula by resection of nonviable renal parenchyma and nephrostomy drainage, or a nephrostomy alone, is almost invariably unsuccessful, and may lead to prolonged hospital course and appreciable mortality. Successful management of calyceal fistulae by resection of infarcted parenchyma and primary

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closure, or closure with a muscular and omental graft in the absence of sepsis has been reported,3'9 although only one patient in this series was successfully treated in this fashion. From this experience we would recommend early and aggressive exploration and primary closure of uninfected calyceal-cutaneous fistulae. If initial attempts at closure fail, or if sepsis supervenes at any time after transplantation, allograft nephrectomy is indicated without further attempts at repair. References 1. Anderson, E. E., Glenn, J. F., Seigler, H. F., and Stickel, D. L.: Urologic Complications in Renal Transplantation. J. Urol., 107: 187, 1972. 2. Fjeldborg, 0. and Kim, C. H.: Ureteral Complications in Human Renal Transplantation. Urol. Int., 27:417, 1972. 3. Fox, M. D. and Tottenham, M.D.: Urinary Fistula from Segmental Infarction in a Transplanted Kidney: Recovery Following Surgical Repair. Br. J. Urol., 44:336, 1972. 4. Hricko, G. M., Birtch, A. G., Bennett, A. H.. and Wilson, R. E.: Factors Responsible for Urinary Fistula in the Renal Transplant Recipient. Ann. Surg., 178:609, 1973. 5. MacKinnon, K. J., Oliver, J. A., Morehouse, D. D., and Taguchi, Y.: Cadaver Renal Transplantation. J. Urol., 99:486, 1968. 6. McLean, L. D., MacKinnon, N. G., Inglis, F. G., and Dossetor, J. B.: When Should Allografts Be Removed? Arch. Surg., 99:269, 1969. 7. Moore, T. C., English, T. S., and Berne, T. V.: Machine preservation of 302 Human Cadaver Kidneys for Transplantation. Surg. Gynecol. Obstet. 138:239, 1974. 8. Moore, T. C. and Hume, D. M.: Hazard in Clinical Renal Transplantation. Ann. Surg., 170:1, 1969. 9. O'Donoghue, E. P. N., Chisholm, G. D., and Shackman, R.: Urinary Fistulae After Renal Transplantation. Br. J. Urol., 45:28, 1973. 10. Palmer, J. M., Kountz, S. L., Swenson, R. S., et al.: Urinary Tract Morbidity in Renal Transplantation. Arch. Surg., 98:352, 1969. 11. Robertshaw, G. E., Madge, G. E., and Kauffman, H. M.: Ureteral Pathology in Treated and Untreated Renal Homografts. Surg. Forum, 17:236, 1966. 12. Salaman, J. R., Calne, R. Y., Pena, J., et al.: Surgical Aspects of Clinical Renal Transplantation. Br. J. Surg., 56:413, 1969. 13. Starzl, T. E., Groth, C. G., Putnam, C. W., et al.: Urological Complications in 216 Human Recipients of Renal Transplants. Ann. Surg., 172:1, 1970. 14. Weil, R. E., Simmons, R. L., Lillehei, R. C., et al.: Prevention of Urological Complications After Kidney Transplantation. Ann. Surg. 174:154, 1971. 15. Williams, G., Birtch, A. G., Wilson, R. E., et al.: Urological Complications of Renal Transplantation. Br. J. Urol.,42:21, 1970.

Calyceal-cutaneous fistulae in renal transplant patients.

Calyceal-cutaneous Fistulae in Renal Transplant Patients MITCHELL H. GOLDMAN, M.D.,* RICHARD L. BURLESON, M.D.,t NICHOLAS L. TILNEY, M.D., GORDON C. V...
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