Nephrocutaneous Fistula After Percutaneous Nephrolithotomy

Abstract

Background: Nephrocutaneous fistula (NF) is a rare pathologic condition in urology practice. Xanthogranulomatous pyelonephritis and renal tuberculosis are the two common causes of this pathologic condition. Another rare cause of NF is surgery. Percutaneous nephrolithotomy is standard treatment for >2 cm renal stones. However, this surgery can be associated with surgical complications in long-term follow-up. NF is a rare complication of percutaneous renal surgery.

Case Presentation: In this study, we present a 31-year-old man with continuous urine leakage at the nephrolithotomy scar during 11 months, starting from 1 month after surgery. Final confirmation is NF and could be treated with nephrectomy.

Conclusion: Surgical treatment such as nephrectomy is essential for non- or low functioning kidney with fistula formation. Patients must be informed about this complication.

Introduction and Background

Although percutaneous nephrolithotomy (PCNL) was defined for surgical treatment of the renal stones in 1970, high rates of complications may occur with PCNL. Pain, fever, urinary tract infection, and renal colic are minor complications. The most common major complications are septicemia and severe bleeding that require blood transfusion. Nephrocutaneous fistula (NF) after PCNL is a rare complication. Treatment options are conservative management such as observation, ureteral stenting, and percutaneous drainage. We present a case of NF developing after PCNL and treated with nephrectomy.

Case Presentation

A 31-year-old man presented with continuous urine leakage from a nephrolithotomy scar for 11 months. The patient was treated with open right kidney surgery for nephrolithiasis 10 years previously and PCNL 1 year earlier. Laboratory tests and urinalysis were unremarkable. The fistula was 1 × 1.5 cm size in the posterior area and was located in the percutaneous access tract without muscle involved and not associated with the open surgery incision (Fig. 1). CT showed the fistulous tract (Fig. 2) without hydronephrosis or ureteral stone that excluded obstruction. Fistulogram confirmed communication with the right kidney (Fig. 3). Renal dynamic scan suggested low function (8%) of the right kidney. The patient had laparoscopic right nephrectomy, but the right kidney anatomy was not normal, had adhesions to surrounding tissues, but no signs of infection. Vascular structures were also not identified and the procedure was converted to open surgery. Pathologic examination reported chronic pyelonephritis with stone formation. The patient was discharged 7 days after the operation and had no complaint during 3 months follow-up.

FIG. 1.

Fistulous tract of the skin that is located in posterior area.

FIG. 2.

Image of the fistula in CT.

FIG. 3.

Fistulogram showed the fistulous tract between kidney and skin.

Discussion and Literature Review

NF is an unusual complication of renal stones. These fistulas can occur as a result of chronic diseases such as xanthogranulomatous pyelonephritis, renal tuberculosis, chronic stone disease, post-trauma, or surgery. Fistulas between the kidney and adjacent organs such as colon, lung, and pleura are more common than fistulas from the kidney to the skin. The most common cause of NF is xanthogranulomatous pyelonephritis, followed by tuberculosis of the kidney. Fistula formation after surgery is the next leading cause of this pathologic condition. Our patient underwent percutaneous renal surgery 1 year before, and NF formation occurred 1 month after the surgery.

Although PCNL has a high success rate of 90%, complication rates for this surgery are ∼83%.¹ A new classification (modified Clavien) was reported and urinary extravasation (7.2%) is a grade 3 complication, which means it requires surgical, endoscopic, or radiologic intervention. Unfortunately, single organ dysfunction is a grade 4a complication¹ and our patient underwent nephrectomy because of the nonfunctioning kidney. Tefekli et al.¹ reported the complications of PCNL, four patients (0.4%) were treated with nephrectomy for nonfunctioning kidney, and NF was not reported. Oner and colleagues.² investigated a large patient group (1750 patients) who underwent PCNL and there was also no case of NF in this series. In the literature, authors have analyzed the complications of NF after PCNL, but there are few reports. Miranda et al.³ reported a case with NF who was treated with fibrin glue application. But the NF was diagnosed in the postoperative period at 7 days. We do not agree with Miranda about the diagnosis and we think that urinary extravasation is the correct diagnosis. Maheshwari and Shah⁴ reported NF after PCNL presenting with tuberculosis and the patients were treated with antitubercular treatment. Our patient had no history of tuberculosis; preoperative laboratory tests and pathologic examination revealed no evidence of tuberculosis. To the best of our knowledge, this is the first case of the NF after PCNL in the literature.

Conclusion

NF is a rare disorder in daily urology practice. This complication can occur after percutaneous renal surgery, physicians should keep this complication in mind and patients must be informed about this complication.

Abbreviations Used

CT

computed tomography

NF

nephrocutaneous fistula

PCNL

percutaneous nephrolithotomy

Disclosure Statement

No competing financial interests exist.

Cite this article as: Caliskan S, Sungur M (2019) Nephrocutaneous fistula after percutaneous nephrolithotomy, Journal of Endourology Case Reports 5:3, 137–138, DOI: 10.1089/cren.2019.0027.