Conservative treatment of persistent calyceal fistula after tumor excision. Case report and clinical remarks

Abstract Nowadays, ultrasounds allow to discover accidentally a large number of renal small tumors. So, radical nephrectomy, which years ago was considered as the gold standard, is rarely required. Today, nephron sparing surgery is often prescribed for renal masses smaller than 4 cm. Its most frequent complication is calyceal fistula. It can be prevented exploring carefully the surgical surface, and suturing any opening. It can heal over within a few days or some weeks, so it can be a trouble for both the patient and the surgeon. A complete urinary drainage, obtained with an ureteral stent and an open bladder catheter, helps heal. Recently, it has become common practice to spread synthetic or biological tissue sealants over the surgical surface, to improve hemostasis. These surgical glues have also been used to repair calyceal openings, with conflicting results. We performed left renal tumor excision (3.5 x 3 cm) in a 72-years-old man, during temporary renal artery occlusion with surface hypothermia. We placed intraoperatively an ureteral stent. The visual examination of the surgical cavity did not reveal any calyceal opening. We electrocauterized it and stuffed it with FloSeal. Surgical edges were free from illness. After 5 days urinary leakage from the drainage tube increased. Pyelography showed a calyceal fistula. A further stent was placed, with no results. Bladder catheter was kept open for about 2 months. Urinary leakage stopped 34 days after surgery. Urinary leakage increased when the catheter was removed, and stopped only after many days of complete urinary drainage. The conservative treatment of a calyceal fistula must be considered a still effective therapy, also in difficult cases, provided that a complete and long-lasting urinary drainage is carried out.