Introduction

The patient was a 68-year-old man submitted to an open left radical nephrectomy for renal mass in September 2006. The pathologic examination revealed a renal cell carcinoma of 8.5 cm in maximum diameter located at the upper pole. In February 2007 he had been investigated with abdominal pelvic CT scan that showed a nodular image of about 23.5 mm located in the left renal bed next to the renal vessels. The mass appeared heterogeneous with a peripheral enhancement of the wall and irregular hyperdense internal areas (fig. 1). The lesion was interpreted in first hypothesis as local recurrence.

Figure 1. Abdominal pelvic CT scan showing a nodular image of about 23.5 mm located in left renal bed close to renal vessels.

In March 2007 the patient underwent laparoscopic transperitoneal surgical exploration. The intraoperative ultrasound (US) study showed a mass in the left renal bed with a homogeneous and mainly hyperechoic aspect of about 25 mm with no evidence of intralesional blood flow. Incision of the roof of the lesion revealed a thick wall associated with multiple serpentine fibers of textile (retained sponge). Curettage of the remaining textile fragments was performed and the lesion was removed with some difficulties because of the presence of an intense fibrotic reaction surrounding the renal vessels. The nodule excision was accomplished laparoscopically in a total operative time of 150 minutes. Blood loss was minimal and no intraoperative or perioperative complications occurred. The final pathologic examination revealed fibromuscular tissue with modest chronic flogosis associated with the presence of an amorphous material (hemostatic mesh partially absorbed).

Discussion

Textiloma is a foreign body unintentionally left in the body. Surgical sponges are the most frequently retained foreign bodies after surgery followed by gauzes and towels. ¹ A foreign body is usually detected with x-ray examination because of the presence of a radiopaque marker. Without markers retained sponges are more difficult to diagnose. Alternatively, a surgical sponge may be detected using US or computerized tomography (CT). ^2,4 US appearance may be widely different from hypoechoic to hyperechoic aspect with or without posterior shadow. ⁴ CT shows the heterogeneous appearance of the mass visible as pseudocystic lesion with partial calcification ³ or alternatively as low/high density mass. ^4,5

Figure 2. Final pathologic examination revealed a fibromuscular tissue with modest chronic flogosis associated with presence of an amorphous material (partially absorbed hemostatic mesh; 10x hematoxylin-eosin).

Oxidized regenerated cellulose was developed from wood pulp in 1960. It is used in vascular and general surgery as a local hemostatic agent and to control capillary bleeding. Due to its morphology it can be used everywhere as it can easily and rapidly adapt to any surface. Its maximal hemostatic effect seems to be achieved when it is applied dry. It decreases pH and generates an artificial brownish clot.

In the animal model oxidized cellulose is supposed to be reabsorbed within 3 months. ⁶ Peculiarity of this case is a suspected retroperitoneal tumor recurrence that was revealed to be a textiloma formed on an incompletely absorbed bolster of oxidized regenerated cellulose.

Its CT presentation was suggestive of a tumor recurrence with a hyperdense irregular aspect and a rim of contrast enhancement. This heterogeneous internal aspect may be related to a partial absorption of the hemostatic mesh while the peripheral rim of contrast enhancement could be present in the case of granulomatous reaction. ^7–9

Oxidized regenerated cellulose is a common hemostatic agent used in urological practice. A recent survey demonstrated wide use across the United States and Europe of parenchymal sutures over absorbable bolster of oxidized regenerated cellulose during laparoscopic partial nephrectomy. ¹⁰

To our knowledge no cases of suspected local recurrence are reported in the literature with the use of oxidized regenerated cellulose during partial nephrectomy. This case report must be considered in the future radiological followup of a patient who underwent partial nephrectomy with a bolstering technique.