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Journal of Postgraduate Medicine, Vol. 56, No. 1, January-March, 2010, pp. 26-27 Commentary Subcapsular nephrectomy Aslan G Department of Urology, Dokuz Eylul University School of Medicine, 35340, Inciralti, Izmir, Turkey Correspondence Address: Department of Urology, Dokuz Eylul University School of Medicine, 35340, Inciralti, Izmir, Turkey, aslang@deu.edu.tr Code Number: jp10008 This issue of the journal carries an interesting case report demonstrating a rare complication of subcapsular nephrectomy. [1] Missed kidney tissue at the hilar region during difficult subcapsular nephrectomy is not rare. However, the presence of urine-producing amount of kidney tissue is really rare. The case report will be of interest to the readers of the journal and could be informative to surgeons performing pre-transplant nephrectomy. Surgery for infected or previously operated kidney is usually difficult due to severe perinephric adhesions. At times, subcapsular nephrectomy may be the only choice to remove the kidney successfully without injury to the surrounding structures. Although it is obviously more difficult in technique, surgeons must be aware and capable of surgical alternatives and perform when needed. Complications of subcapsular nephrectomy are mainly related to bleeding while separating the parenchyma or performing hilar dissection. To our knowledge, this is the first report of urine-producing residual kidney tissue remnant and it raises attention regarding the pitfalls of subcapsular nephrectomy. Technically, a longitudinal incision is made over the convex border of the kidney and the capsule peeled off from the parenchyma until the renal hilum. When the surgeon comes down to the hilus, several branches of the renal vessels are encountered and it is mostly difficult to skeletonize them separately from the fatty or dense adhesive hilar tissues and to divide properly. At this time, placing clamps to the renal vessels en bloc, cutting the pedicle is usually done. When visualization is poor, this way of blind clamping may lead to some part of thin parenchyma tissues adhering to the bulky clamped pedicle. Urinary fistula formation in the postoperative period is mainly dependent on the amount of parenchymal tissue left between the clamps. Usually, a small portion of the parenchyma is included in the pedicle with no problem in the postoperative period. Prolonged drainage consistent with urinary biochemical properties should attract the surgeon′s attention to the complication described by the authors. Rarely, an open proximal ureteral stump due to improper ligation of the ureter (which goes unnoticed) within bulky retroperitoneal fatty tissue could also be a reason. The authors were able to insert a pigtail catheter into the collecting system which aided diagnosis, but use of intravenous injection or oral dye agents could also have helped in reaching the diagnosis of urinary fistula. I do not agree with the authors′ statement that injection of dyeing agents into the collecting system at the first operation could have prevented such a complication. Discoloration of operation field would be a significant disadvantage even after the pedicle was cut. While dissecting dense adhesions close to the hilum unintentional entry into the calyces could occur even you see these structures dyed. Trying to create better exposure for the anatomical landmarks and separating the renal pedicle to an adequate thickness could be achieved depending on the level of surgical experience with infected kidney. Moreover, difficulties of the second operation for total excision of residual tissue should not be underestimated. If there is low-volume drainage, and in cases where infection is not a major concern, as it is in pretransplant surgery, angioembolisation should be considered as an important alternative to surgery where available. I congratulate the authors for managing such a rare complication successfully and sharing their experience with us which could obviously be a significant contribution to the learning of the surgical fraternity. References
Copyright 2010 - Journal of Postgraduate Medicine |
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