Abstract
Identifying and localizing the site of post-renal transplantation urine leaks is important for patient management and treatment planning. Renal scintigraphy is a proven modality for confirming urine leaks after complicated post-renal transplantation. Routinely, renogram studies are performed with a clamped extraperitoneal drain. This results in the spread of radioactivity in the abdominal region, which makes localization of the leak site difficult in the planar images. Here we are trying to give an insight into minimalizing the accumulated urine volume by an unclamped extraperitoneal drain in order to precisely localize the site of the leak.
Keywords: Urine leak, Localisation, Unclamped drain, Radionuclide renography, SPECT
A 27-year-old male patient presented with a gradually increasing extraperitoneal drain output after a living donor renal transplantation. The renal output through the drain was satisfying (1400 ml/24 hours, post-operative day 7) and suggestive of preserved renal function. We performed a 99mTc L,L,-EC(L,L-Ethylene dicysteine) renography to confirm and localize the possible site of urine leak, as the findings of conventional modalities were unremarkable. The urinary bladder was catheterized, and the retroperitoneal drain remained unclamped throughout the procedure. Anterior renography image (Fig. 1A) shows a transplanted kidney in the right iliac fossa with focal abnormal radiotracer accumulation in the region of lower ureter superolateral to urinary bladder activity. These findings indicated the possibility of a urine leak (black arrow). To confirm the above findings, SPECT-CT images were acquired. It (Fig. 1B, C) showed focal radiotracer accumulation along the distal ureter approximately 2.5 cm proximal to the vesicoureteric junction (VUJ) in close proximity to metallic clips, consistent with the probable site of leak (white arrow). Considering the low volume leak, the patient was kept under observation. On follow-up, there was an increase in drain output, and therefore, re-exploration was planned for the repair of the leak site. Intra-operatively (Fig. 1D), no leak was identified at the usual site of VUJ (grey arrow) near the urinary bladder. However, during surgery, saline was injected through the upper ureter to assess the leak site. There was saline extravasation along the distal ureter (white arrow), confirming the leak site specified in the renogram study. The rent was repaired subsequently. The postoperative period was uneventful, with no extraperitoneal drainage output. The mechanism of the leak was probably due to ischemic necrosis involving lower third of the ureter.
Fig. 1.
Anterior renography image (A) showed a transplanted kidney in the right iliac fossa with focal abnormal radiotracer accumulation along the lower ureter just above the urinary bladder activity (black arrow). SPECT-CT images (B, C) revealed focal radiotracer accumulation at approximately 2.5 cm proximal to the vesicoureteric junction (white arrow). Intra-operatively (D), urinary leak (white arrow) was confirmed proximal to VUJ (grey arrow)
Urine leaks account for 2–6% of all the post-transplant complications. The incidence of urinary leaks post-transplantation has been declining recently. Early urine leaks within the first few days are considered to be due to technical construction errors, whereas late urine leaks are generally due to ureteral necrosis. If left unattended, it can cause significant morbidity, graft loss, or even mortality. Therefore, it is important to identify and localize the site accurately. Precise localization of the site of the urine leak preoperatively may increase the confidence of the surgeon during re-exploration surgery and help in planning the surgery in advance [1–3]. The role of a dynamic renogram in the evaluation of patients with post-renal transplant complications is well known. It is a non-invasive way to assess acute tubular necrosis, graft rejection, and urine leaks even before they are evident on other conventional imaging modalities. The use of SPECT-CT can further aid in the localization of urine leaks [4–10]. However, not much has been described in the literature about the significance of the clamping status of the drainage tube during the acquisition of a dynamic renogram. Some previous studies have shown evidence of extensive diffuse radiotracer activity in the pelvic floor, which may extend up to the scrotal sac [11] in a normal functioning kidney. This may obscure the possible site of leak. The present case demonstrates the importance of an unclamped drainage tube during renography by minimalizing the accumulated urine volume in order to localise the leak site. Along with SPECT-CT, it further increased the accuracy of detecting the site of the urine leak.
Acknowledgements
Not applicable.
Authors Contribution
Dr S.T. conceived the idea; Dr A.K M and Dr O.K. Yadav extracted the data and wrote the manuscript; Prof R.K. and Prof A.S.S. revised the manuscript; All authors read and approved the manuscript.
Funding
There are no source of funding.
Data Availability
Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
Declarations
Ethical Approval
This is an observational study. The AIIMS, JODHPUR Research Ethics Committee has confirmed that no ethical approval is required.
Consent for Publication
Not applicable.
Informed Consent
Not applicable.
Competing Interests
Dr Althaf K Majeed, Dr Om Kumar Yadav, Dr Sameer Taywade, Dr Rajesh Kumar and Dr Arjun Singh Sandhu declare that they have no competing interests.
Footnotes
Publisher’s Note
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Althaf K Majeed and Om Kumar Yadav contributed equally to this work.
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Data Availability Statement
Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.