Introduction and Background

Most ureteral injuries occur by iatrogenic trauma.^1,2 Ureteral injury during partial nephrectomy is an uncommon iatrogenic lesion, but there is a higher risk of injury with lower pole and medially located tumors.¹

Many ureteral injuries go unrecognized at the time of surgery. In fact, of all recognized iatrogenic ureteral injuries, 50% to 70% are not recognized acutely, resulting in further complications.^1,2

Ureteral injury at the time of partial nephrectomy may be successfully treated with ureteral stent placement; however, in some cases more complex procedures may be required.¹

Our aim is to show resolution of a urinary leak after laparoscopic partial nephrectomy with the placement of an Allium® stent.

Case Report

In our center, a 49-year-old male patient with a 20-year history of smoking was assessed after presenting with gross hematuria.

A computerized tomography (CT) with contrast demonstrated a 6 cm lower pole right renal mass with central necrosis. The opposite kidney was normal. Laparoscopic right partial nephrectomy was performed, and during the procedure a proximal ureteral injury occurred due to an incision with cold cutting scissors. This was repaired with spatulation and an end-to-end tension-free ureteral anastomosis over a 6Fr internal ureteral stent. The pathology demonstrated a renal cell carcinoma ISUP 2 with clear surgical margins.

Sixty days after surgery, a retrograde pyelogram was performed at the time of ureteral stent removal to evaluate the site of ureteral injury, and a urinary fistula was evidenced with contrast leak (fig. 1).

Given the findings, an Allium ureteral stent was placed with cystoscopically under fluoroscopic control.

Six months after placement, the Allium stent was removed and semirigid ureteroscopy was conducted using a 7.5Fr ureteroscope. Access to the upper urinary tract was easily achieved, and the Allium stent was removed with grasping forceps. Retrograde pyelography demonstrated no contrast leak, and the patient was discharged from hospital 6 hours postprocedure.

A CT with contrast performed 3 months after Allium removal and demonstrated no calcification, extravasation or hydronephrosis.

Six months after stent removal the patient is clinically well with no urinary leak recurrence.

Discussion and Literature Review

Figure 1. Retrograde pyelography showing proximal ureter contrast leak.

Figure 2. Allium stent placed in right ureter.

Figure 3. No contrast extravasation on CT scan.

Allium stents are designed for temporary use in urology with the concept of rebuilding a normal epithelium with resultant healing and improved drainage.³ The stent is composed of nitinol and coated with a co-polymer, which reduces the rate of encrustation. In order to overcome migration, stents are connected to an anchor, which significantly reduces the risk of migration and helps at the time of stent removal.³

The Allium ureteral stent was originally designed for the treatment of ureteral strictures, caused by any etiology, with a wide range of stricture lengths.³ Successful experience with this device has encouraged use of the stent in other pathologies such as urinary fistula.⁴

Prolonged urinary leakage at the site of a previous anastomosis is the most common acute genitourinary complication after repair of ureteral injuries.¹ The incidence of complications after repair of the iatrogenically injured ureter is not well reported, but there are data regarding complication rates after repair of traumatic ureteral injuries; this rate is approximately 25%.⁵

As is well documented in trauma literature, delayed recognition of any traumatic injury leads to an increased complication rate,¹ including urinoma formation, urosepsis and a more complicated subsequent repair.⁵

Bahouth et al have reported the use of Allium stents to treat benign and malignant ureteral strictures and urinary fistulae. They documented feasible, safe and effective results with stents placed in 107 ureters. A total of 21 patients died of their primary disease carrying the stent. Stent migration was seen in 11 patients within 8 months after its insertion, and these stents were removed. In 4 patients with early stent migration, the stents were replaced. In 18 patients, the stents were removed as planned after 1 year of indwelling time, and these patients were asymptomatic in a followup period of up to 59 months.

The Allium stent represents an important tool that may allow effective treatment for postoperative urinary fistulae. In our case, a 6-month period of stenting resulted in resolution of the fistula and ureteral healing without obstruction or stricture formation.⁶