http://informahealthcare.com/sju ISSN: 2168-1805 (print), 2168-1813 (electronic) Scand J Urol, 2015; Early Onlne: 1–2 DOI: 10.3109/21681805.2015.1040450
CASE REPORT
“Clip-strasse”: A novel complication following partial nephrectomy Andrew C Bayles1, Aftab Bhatti1, Ashok Sakthivel1, Geoffrey Naisby2 & Basavaraj Gowda1 Department of Urology, James Cook University Hospital, Middlesbrough, UK, and 2Department of Radiology, James Cook University Hospital, Middlesbrough, UK
Scandinavian Journal of Urology Downloaded from informahealthcare.com by Nyu Medical Center on 05/30/15 For personal use only.
1
Abstract
Key Words:
This report presents the case of a 63-year-old man who presented with recurrent visible haematuria and loin pain 18 months after open partial nephrectomy for renal cell carcinoma. A computed tomography urogram revealed three obstructing calculi in the mid- to distal ureter with hydronephrosis. Rigid ureteroscopy revealed three calcified objects in the pelvic ureter. These had the appearance of calcified WeckÒ clips. A laser was used to remove the calcification, confirming the presence of three Weck clips, which had been used for haemostasis during the partial nephrectomy. These were removed with graspers after balloon dilatation of the distal ureter. This phenomenon of multiple clips migrating with stone formation and obstruction of the ureter was named “clip-strasse”.
Complications, nephrectomy, partial
Introduction WeckÒ clips are polymer locking ligation systems that are used during partial nephrectomy. It is possible for clips on the cut surface of retained renal parenchyma to migrate into the collecting system. This report presents the case of a 63-year-old man who presented with recurrent visible haematuria and loin pain 18 months following open partial nephrectomy for renal cell carcinoma. A computed tomography (CT) urogram revealed three obstructing calculi in the mid- to distal ureter with hydronephrosis. The patient underwent rigid ureteroscopy, which revealed three calcified objects within the pelvic ureter. These had the appearance of calcified Weck clips. A laser was used to remove the calcification, confirming the presence of three Weck clips, which were removed with graspers after balloon dilatation of the distal ureter.
Case report A 63-year-old man had previously undergone a right open partial nephrectomy for a high-density 3.5 cm upper pole renal mass. Histology had revealed papillary renal cell carcinoma type II (pT3a). The procedure was uncomplicated. Weck clips had been used for haemostasis in the partial nephrectomy bed. Eighteen months later, under routine review, the patient complained of recurrent episodes of visible haematuria and had developed right loin pain. Midstream urine revealed red blood cells but no bacterial growth. A CT urogram was performed. This revealed no evidence of recurrence but did show three obstructing calcifications in the mid- to distal
History Received 29 October 2014 Revised 22 March 2015 Accepted 30 March 2015
right ureter with resultant hydroureteronephrosis and reduced perfusion of the right kidney (Figures 1 and 2). His serum creatinine had risen to 170 mol, with a drop in estimated glomerular filtration rate to 36 ml/min from a previous level of greater than 60 ml/min. Ureteroscopy was performed and the calcified objects were seen in the distal ureter (Figure 3). Appearances suggested that they were calcified Weck clips, and laser was used to clear the encrustation (Figure 4). This confirmed that they were indeed Weck clips, which were removed with graspers after balloon dilatation of the distal ureter. A ureteric stent was inserted and left for 2 weeks.
Discussion Partial nephrectomy is performed for small renal masses, allowing nephron sparing. It is recommended for low-stage (T1) renal cell carcinomas and gives comparable cancerspecific survival rates at 5 years to radical nephrectomy, with better quality of life scores [1]. Recognized complications include urine leakage and positive surgical margins. Weck clips are polymer locking ligation systems. They are used with sutures to compress the cut surface of the renal parenchyma during a partial nephrectomy and to secure SurgicelÒ bolsters, thereby reducing surface bleeding. Such clips lie outside the renal capsule and are unlikely to erode into the collecting system. Application of a Weck clip to an obvious vessel or infundibulum of the collecting system is an accepted step during excision of the tumour to reduce warm ischaemia time. Such clips on the cut surface of retained renal parenchyma can migrate into the collecting system, which is suspected to be the mechanism in this case.
Correspondence: Andrew C. Bayles, Department of Urology, James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, UK. E-mail: [email protected] Ó 2015 Informa Healthcare.
Scandinavian Journal of Urology Downloaded from informahealthcare.com by Nyu Medical Center on 05/30/15 For personal use only.
2 A. C. Bayles et al.
Scand J Urol, 2015; Early Online: 1–2
Figure 3. Ureteroscopic image of a calcified Weck clip in the ureter.
Figure 1. Axial computed tomography showing Weck clips on the periphery of the kidney postoperatively.
Figure 4. Image of Weck clips removed from the ureter after using a laser to clear the calcification.
Figure 2. Sagittal computed tomography showing a calcified Weck clip in the distal ureter.
Although the 10 mm Weck clip is only 2 mm wide in a locked state, some ureters may not allow straightforward retrieval. Ureteric dilatation may therefore be required. The curvature of the limbs in the locked position and the locking mechanism of the Weck clip may drag the ureteric wall, risking ureteric injury, or become stuck during retrieval. Holmium laser, which is very good for breaking stones and cutting the wires of a trapped stone retrieval basket, is less useful in dealing with plastic clips. With an energy output of 20 W, the laser melts the clip at the point of contact and leaves an indentation but does not fracture the clip. It is very useful to clean the encrustation, thereby exposing the clip for easier retrieval. In this case, all three clips had migrated down to the pelvic ureter and only the distal 3–4 cm of the ureter required dilatation. There have been case reports of single clips migrating into the collecting system following robot-assisted partial nephrectomy with subsequent stone formation [2] and reports
of a single clip migrating into the ureter after partial nephrectomy [3,4], but this is the first report of multiple clips migrating with stone formation and obstruction of the ureter. Given the similarity to multiple stone fragments following extracorporeal shock wave lithotripsy, it has been labelled “clipstrasse”. Declaration of interest: All authors declare that there are no conflicts of interest.
References [1] Llungberg B, Bensalah K, Bex A, Canfield S, et al. Renal Cell Carcinoma EAU Guidelines. Available from http://uroweb.org/ guideline/renal-cell-carcinoma/. [2] Lee Z, Reilly CE, Moore BW, Mydlo JW, Lee DI, Eun DD. Stone formation from nonabsorbable clip migration into the collecting system after robot-assisted partial nephrectomy. Case Rep Urol 2014;2014:397427. [3] Park KS, Sim YJ, Jung H. Migration of a Hem-o-lok clip to the ureter following laparoscopic partial nephrectomy presenting with lower urinary tract symptoms. Int Neurourol J 2013;17:90–2. [4] Massoud WA. Spontaneous migration of a surgical clip following partial nephrectomy. Urol J 2011;8:153–4.
CASE REPORT
“Clip-strasse”: A novel complication following partial nephrectomy Andrew C Bayles1, Aftab Bhatti1, Ashok Sakthivel1, Geoffrey Naisby2 & Basavaraj Gowda1 Department of Urology, James Cook University Hospital, Middlesbrough, UK, and 2Department of Radiology, James Cook University Hospital, Middlesbrough, UK
Scandinavian Journal of Urology Downloaded from informahealthcare.com by Nyu Medical Center on 05/30/15 For personal use only.
1
Abstract
Key Words:
This report presents the case of a 63-year-old man who presented with recurrent visible haematuria and loin pain 18 months after open partial nephrectomy for renal cell carcinoma. A computed tomography urogram revealed three obstructing calculi in the mid- to distal ureter with hydronephrosis. Rigid ureteroscopy revealed three calcified objects in the pelvic ureter. These had the appearance of calcified WeckÒ clips. A laser was used to remove the calcification, confirming the presence of three Weck clips, which had been used for haemostasis during the partial nephrectomy. These were removed with graspers after balloon dilatation of the distal ureter. This phenomenon of multiple clips migrating with stone formation and obstruction of the ureter was named “clip-strasse”.
Complications, nephrectomy, partial
Introduction WeckÒ clips are polymer locking ligation systems that are used during partial nephrectomy. It is possible for clips on the cut surface of retained renal parenchyma to migrate into the collecting system. This report presents the case of a 63-year-old man who presented with recurrent visible haematuria and loin pain 18 months following open partial nephrectomy for renal cell carcinoma. A computed tomography (CT) urogram revealed three obstructing calculi in the mid- to distal ureter with hydronephrosis. The patient underwent rigid ureteroscopy, which revealed three calcified objects within the pelvic ureter. These had the appearance of calcified Weck clips. A laser was used to remove the calcification, confirming the presence of three Weck clips, which were removed with graspers after balloon dilatation of the distal ureter.
Case report A 63-year-old man had previously undergone a right open partial nephrectomy for a high-density 3.5 cm upper pole renal mass. Histology had revealed papillary renal cell carcinoma type II (pT3a). The procedure was uncomplicated. Weck clips had been used for haemostasis in the partial nephrectomy bed. Eighteen months later, under routine review, the patient complained of recurrent episodes of visible haematuria and had developed right loin pain. Midstream urine revealed red blood cells but no bacterial growth. A CT urogram was performed. This revealed no evidence of recurrence but did show three obstructing calcifications in the mid- to distal
History Received 29 October 2014 Revised 22 March 2015 Accepted 30 March 2015
right ureter with resultant hydroureteronephrosis and reduced perfusion of the right kidney (Figures 1 and 2). His serum creatinine had risen to 170 mol, with a drop in estimated glomerular filtration rate to 36 ml/min from a previous level of greater than 60 ml/min. Ureteroscopy was performed and the calcified objects were seen in the distal ureter (Figure 3). Appearances suggested that they were calcified Weck clips, and laser was used to clear the encrustation (Figure 4). This confirmed that they were indeed Weck clips, which were removed with graspers after balloon dilatation of the distal ureter. A ureteric stent was inserted and left for 2 weeks.
Discussion Partial nephrectomy is performed for small renal masses, allowing nephron sparing. It is recommended for low-stage (T1) renal cell carcinomas and gives comparable cancerspecific survival rates at 5 years to radical nephrectomy, with better quality of life scores [1]. Recognized complications include urine leakage and positive surgical margins. Weck clips are polymer locking ligation systems. They are used with sutures to compress the cut surface of the renal parenchyma during a partial nephrectomy and to secure SurgicelÒ bolsters, thereby reducing surface bleeding. Such clips lie outside the renal capsule and are unlikely to erode into the collecting system. Application of a Weck clip to an obvious vessel or infundibulum of the collecting system is an accepted step during excision of the tumour to reduce warm ischaemia time. Such clips on the cut surface of retained renal parenchyma can migrate into the collecting system, which is suspected to be the mechanism in this case.
Correspondence: Andrew C. Bayles, Department of Urology, James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, UK. E-mail: [email protected] Ó 2015 Informa Healthcare.
Scandinavian Journal of Urology Downloaded from informahealthcare.com by Nyu Medical Center on 05/30/15 For personal use only.
2 A. C. Bayles et al.
Scand J Urol, 2015; Early Online: 1–2
Figure 3. Ureteroscopic image of a calcified Weck clip in the ureter.
Figure 1. Axial computed tomography showing Weck clips on the periphery of the kidney postoperatively.
Figure 4. Image of Weck clips removed from the ureter after using a laser to clear the calcification.
Figure 2. Sagittal computed tomography showing a calcified Weck clip in the distal ureter.
Although the 10 mm Weck clip is only 2 mm wide in a locked state, some ureters may not allow straightforward retrieval. Ureteric dilatation may therefore be required. The curvature of the limbs in the locked position and the locking mechanism of the Weck clip may drag the ureteric wall, risking ureteric injury, or become stuck during retrieval. Holmium laser, which is very good for breaking stones and cutting the wires of a trapped stone retrieval basket, is less useful in dealing with plastic clips. With an energy output of 20 W, the laser melts the clip at the point of contact and leaves an indentation but does not fracture the clip. It is very useful to clean the encrustation, thereby exposing the clip for easier retrieval. In this case, all three clips had migrated down to the pelvic ureter and only the distal 3–4 cm of the ureter required dilatation. There have been case reports of single clips migrating into the collecting system following robot-assisted partial nephrectomy with subsequent stone formation [2] and reports
of a single clip migrating into the ureter after partial nephrectomy [3,4], but this is the first report of multiple clips migrating with stone formation and obstruction of the ureter. Given the similarity to multiple stone fragments following extracorporeal shock wave lithotripsy, it has been labelled “clipstrasse”. Declaration of interest: All authors declare that there are no conflicts of interest.
References [1] Llungberg B, Bensalah K, Bex A, Canfield S, et al. Renal Cell Carcinoma EAU Guidelines. Available from http://uroweb.org/ guideline/renal-cell-carcinoma/. [2] Lee Z, Reilly CE, Moore BW, Mydlo JW, Lee DI, Eun DD. Stone formation from nonabsorbable clip migration into the collecting system after robot-assisted partial nephrectomy. Case Rep Urol 2014;2014:397427. [3] Park KS, Sim YJ, Jung H. Migration of a Hem-o-lok clip to the ureter following laparoscopic partial nephrectomy presenting with lower urinary tract symptoms. Int Neurourol J 2013;17:90–2. [4] Massoud WA. Spontaneous migration of a surgical clip following partial nephrectomy. Urol J 2011;8:153–4.
