Vol. 114, October
TttE JovRNAL oF UROLOGY
Copyright© 1975 by The Williams & Wilkins Co.
Printed in U.S.A.
OBSTRUCTIVE JAUNDICE COMPLICATING PYELOPLASTY J. E. PONTES
AND
J. M. PIERCE, JR.
From the Department of Urology, Wayne State University and Detroit General Hospital, Detroit, Michiian
ABSTRACT
The development of obstructive jaundice associated with the formation of a renal pseudocyst in 2 patients undergoing pyeloplasty on the right side is discussed. We emphasize the importance of proper drainage of the retroperitoneal area to prevent this complication. Jaundice following surgical procedures not related to the biliary tract is always challenging in diagnosis. This is especially true when no history of toxic causes or other medical conditions can be found. The recent report of a case of obstructive jaundice following pyeloplasty in a patient in whom a renal pseudocyst 1 developed prompted us to report the following cases. CASE REPORTS
Case 1. T. Q., a 16-year-old black boy, was admitted to the hospital with gross hematuria, following a slight back injury in a baseball game. Examination showed mild costovertebral tenderness and an excretory urogram (IVP) demonstrated a solitary right kidney with ureteropelvic junction obstruction. On the initial IVP there were also several clots in the renal pelvis. The patient remained stable and the bleeding subsequently subsided. A repeat IVP and retrograde pyelogram 10 days later confirmed the diagnosis (fig. 1, A). The patient underwent a right pyeloplasty (dismembered, unstented) without complications. Penrose drains were left at the retroperitoneal area. After the operation the patient experienced a drop in the urinary output and also in the drainage from the Penrose drain. The serum creatinine became elevated to 3.7 from normal preoperative values. An ileus developed and the boy had severe vomiting. Six days later cystoscopy and right ureteral catheterization were performed with some drop in the serum creatinine and improvement in renal function. However, because of continuous vomiting and paralytic ileus an upper gastrointestinal series was done and the patient was found to have a large retroperitoneal mass that was compressing the duodenum and the stomach (fig. 1, B). At that time the patient was noted to be jaundiced with a total bilirubin of 4.8 and an elevation of the direct bilirubin to 2.8. Serum glutamic pyruvic transaminase was 109, lactic dehydrogenase 350 and amylase 320. An exploraAccepted for publication April 4, 1975. Read at annual meeting of American Urological Association, Miami Beach, Florida, May 11-15, 1975.
tory laparotomy disclosed a large collection of urohemorrhagic fluid occupying the retroperitoneum compressing the duodenum, liver and pancreas. The urohemorrhagic fluid was drained and 2 Penrose drains were left in that area. Postoperatively, the ileus subsided and the liver functions returned to normal. Most of the urine drained initially via the Penrose drain but, subsequently, the patient started draining urine to the bladder. The Penrose drain was removed 2 weeks later and an IVP prior to the removal of the Penrose drains showed good function on the right side (fig. 1, C). The patient was discharged from the hospital in good condition. Case 2. D. K., a 20-year-old white man, was admitted to the hospital with gross hematuria following slight trauma in October 197:3. An IVP at that time showed bilateral ureteropelvic junction obstruction (fig. 2, A). The patient underwent a left pyeloplasty in December 197:3, with an uneventful postoperative course (fig. 2, R). He was readmitted to the hospital on ,June 9, 1974 for a right dismembered pyeloplasty, which was done 1 day after hospitalization. After the operation a moderate amount of drainage developed from the Penrose drain but decreased a few days later. By E days postoperatively the abdomen became distended, an ileus developed and the patient suffered severe vomiting, fever and became jaundiced. Bilirubin at that time was 4.5 with an increase in direct bilirubin to :l.7. Alkaline phosphatase was 95, serum glutamic oxaloacetic transaminase 175 and serum glutamic pyruvic transaminase 131 Serum creatinine was slightly elevated. A flat plate of the abdomen showed dilated loops of large and small bowel with a collection in the right upper quadrant of the abdomen. An IVP showed extravasation above the right kidney. Eight days after the original operation an exploration revealed a large collection of urine which was drained and a Saratoga pump was left in place. Postoperatively. the patient improved, liver functions returned to normal and an IVP a week later showed good ureteral filling (fig. 2, C). The pump drainage was disclmtinued 1 week later and the patient was discharged from the hospital in good condition.
,524
OBSTRUCTIVE JAUNDICE COMPLICATING PYELOPLASTY
525
Fie. 1
FtG. 2 DISCUSSION
Pararenal pseudocyst was initially described by Hawkins in 1834 in a child who died following a traumatic injury to the flank. The entity was created experimentally and extensively studied by Razzaboni in 1922. 2 Steps of the formation of the pseudocyst after renal injury were outlined in chronological detail and the pathological findings were revealed. This subject has been reviewed in its clinical aspect from time to time. 3- • The lesion was first described following pyeloplasty by Sauls and Nesbit. 5 Obstructive jaundice associated with renal pathology anatomically occurs only in relation to the right kidney and it has been the subject of sporadic reports in the literature. In 1948 Beirstein described a case of right hydronephrosis causing jaundice, 7 and J av ad pour and associates reported another case of a giant hydronephrosis on the right side of a horseshoe kidney.• The association of obstructive jaundice with a right renal
pseudocyst was first reported recently by Boltuch and Straffon in a case following a right pyeloplasty. 1 In their case , as in ours, jaundice appeared in the first postoperative week and the appearance paralleled the symptoms of pseudocyst formation. COMMENT
The appearance of jaundice following surgery raises a few possibilities: iatrogenic injury of the biliarv system. toxic jaundice owing to an anesthetic agent, hemolysis and /or hepatitis and so forth. The fact that in both of our patients jaundice subsided following drainage of the pseudocyst with the return of the other liver functions to normal points to the possibility that this was obstructive in nature from compression of the duodenum and common duct by the pararenal pseudocyst. With the recent improvement in surgical techniques there has been a tendency toward primary
t
526
PONTES AND PIERCE
closure of pyeloplasty without stents. The possible pitfalls of these procedures have been revealed recently by Crowell and Bard and their associates. 9 • '° Certainly, the causative factor illustrated in our 2 cases was improper drainage of the retroperitoneal space, either because of poor placement of the drain or subsequent mobilization during closure of the abdominal wall or early in the postoperative period. These cases serve to illustrate the importance of proper drainage in patients after a renal operation when an expected urinary leak is contemplated. REFERENCES
R. A.: Obstructive jaundice. Unusual complication of postoperative pararenal pseudocyst. Urology, 3: 759, 1974. 2. Razzaboni, G.: Ricerche sperimentali sulla pseudoidronefrosi. Arch. Ital. di Chir., 6: 365, 1922 2:3. 3. Crabtree, E. G.: Pararenal pseudo-hydronephrosis with report of three cases. Trans. Amer. Ass. 1. Boltuch, R. L. and Straffon,
Genito-Urin. Surg., 28: 9, 19:l5. 4. Pyrah, L. N. and Smiddy, F. G.: Pararenal pseudohydronephrosis: report of 2 cases. Brit. ,J. Urol., 25: 2:39, 195:3. 5. Sauls, C. L. and Nesbit, R. N.: Pararenal pseudocysts: a report of four cases. ,J. Urol., 87: 288, 1962. 6. Arnold, E. P.: Pararenal pseudocyst. Brit. J. Urol., 44: 40, 1972. 7. Beirstein, S. S.: Obstructive jaundice in a case of hydronephrosis. J. Urol., 59: 157, 1948. 8. Javadpour, N., Ireland, G. W., Hakin, A. A. and Bush, I. M.: Giant hydronephrosis in horseshoe kidney, presenting as right upper quadrant mass and jaundice. Chicago Med. Sch. Quart., 29: 37, 1970. 9. Crowell, B. H., Hewit. L. W. and York, W. N.: Experience with dismembered pyeloplasty: interesting complications. South. Med. ,J.,. 66: 237, 197:3. W. Bard. R. H. and Kirk. R. M.: Caution urged in unsplinted. unstented pyeloplasty. Urology, 3: 701, 1974.
TttE JovRNAL oF UROLOGY
Copyright© 1975 by The Williams & Wilkins Co.
Printed in U.S.A.
OBSTRUCTIVE JAUNDICE COMPLICATING PYELOPLASTY J. E. PONTES
AND
J. M. PIERCE, JR.
From the Department of Urology, Wayne State University and Detroit General Hospital, Detroit, Michiian
ABSTRACT
The development of obstructive jaundice associated with the formation of a renal pseudocyst in 2 patients undergoing pyeloplasty on the right side is discussed. We emphasize the importance of proper drainage of the retroperitoneal area to prevent this complication. Jaundice following surgical procedures not related to the biliary tract is always challenging in diagnosis. This is especially true when no history of toxic causes or other medical conditions can be found. The recent report of a case of obstructive jaundice following pyeloplasty in a patient in whom a renal pseudocyst 1 developed prompted us to report the following cases. CASE REPORTS
Case 1. T. Q., a 16-year-old black boy, was admitted to the hospital with gross hematuria, following a slight back injury in a baseball game. Examination showed mild costovertebral tenderness and an excretory urogram (IVP) demonstrated a solitary right kidney with ureteropelvic junction obstruction. On the initial IVP there were also several clots in the renal pelvis. The patient remained stable and the bleeding subsequently subsided. A repeat IVP and retrograde pyelogram 10 days later confirmed the diagnosis (fig. 1, A). The patient underwent a right pyeloplasty (dismembered, unstented) without complications. Penrose drains were left at the retroperitoneal area. After the operation the patient experienced a drop in the urinary output and also in the drainage from the Penrose drain. The serum creatinine became elevated to 3.7 from normal preoperative values. An ileus developed and the boy had severe vomiting. Six days later cystoscopy and right ureteral catheterization were performed with some drop in the serum creatinine and improvement in renal function. However, because of continuous vomiting and paralytic ileus an upper gastrointestinal series was done and the patient was found to have a large retroperitoneal mass that was compressing the duodenum and the stomach (fig. 1, B). At that time the patient was noted to be jaundiced with a total bilirubin of 4.8 and an elevation of the direct bilirubin to 2.8. Serum glutamic pyruvic transaminase was 109, lactic dehydrogenase 350 and amylase 320. An exploraAccepted for publication April 4, 1975. Read at annual meeting of American Urological Association, Miami Beach, Florida, May 11-15, 1975.
tory laparotomy disclosed a large collection of urohemorrhagic fluid occupying the retroperitoneum compressing the duodenum, liver and pancreas. The urohemorrhagic fluid was drained and 2 Penrose drains were left in that area. Postoperatively, the ileus subsided and the liver functions returned to normal. Most of the urine drained initially via the Penrose drain but, subsequently, the patient started draining urine to the bladder. The Penrose drain was removed 2 weeks later and an IVP prior to the removal of the Penrose drains showed good function on the right side (fig. 1, C). The patient was discharged from the hospital in good condition. Case 2. D. K., a 20-year-old white man, was admitted to the hospital with gross hematuria following slight trauma in October 197:3. An IVP at that time showed bilateral ureteropelvic junction obstruction (fig. 2, A). The patient underwent a left pyeloplasty in December 197:3, with an uneventful postoperative course (fig. 2, R). He was readmitted to the hospital on ,June 9, 1974 for a right dismembered pyeloplasty, which was done 1 day after hospitalization. After the operation a moderate amount of drainage developed from the Penrose drain but decreased a few days later. By E days postoperatively the abdomen became distended, an ileus developed and the patient suffered severe vomiting, fever and became jaundiced. Bilirubin at that time was 4.5 with an increase in direct bilirubin to :l.7. Alkaline phosphatase was 95, serum glutamic oxaloacetic transaminase 175 and serum glutamic pyruvic transaminase 131 Serum creatinine was slightly elevated. A flat plate of the abdomen showed dilated loops of large and small bowel with a collection in the right upper quadrant of the abdomen. An IVP showed extravasation above the right kidney. Eight days after the original operation an exploration revealed a large collection of urine which was drained and a Saratoga pump was left in place. Postoperatively. the patient improved, liver functions returned to normal and an IVP a week later showed good ureteral filling (fig. 2, C). The pump drainage was disclmtinued 1 week later and the patient was discharged from the hospital in good condition.
,524
OBSTRUCTIVE JAUNDICE COMPLICATING PYELOPLASTY
525
Fie. 1
FtG. 2 DISCUSSION
Pararenal pseudocyst was initially described by Hawkins in 1834 in a child who died following a traumatic injury to the flank. The entity was created experimentally and extensively studied by Razzaboni in 1922. 2 Steps of the formation of the pseudocyst after renal injury were outlined in chronological detail and the pathological findings were revealed. This subject has been reviewed in its clinical aspect from time to time. 3- • The lesion was first described following pyeloplasty by Sauls and Nesbit. 5 Obstructive jaundice associated with renal pathology anatomically occurs only in relation to the right kidney and it has been the subject of sporadic reports in the literature. In 1948 Beirstein described a case of right hydronephrosis causing jaundice, 7 and J av ad pour and associates reported another case of a giant hydronephrosis on the right side of a horseshoe kidney.• The association of obstructive jaundice with a right renal
pseudocyst was first reported recently by Boltuch and Straffon in a case following a right pyeloplasty. 1 In their case , as in ours, jaundice appeared in the first postoperative week and the appearance paralleled the symptoms of pseudocyst formation. COMMENT
The appearance of jaundice following surgery raises a few possibilities: iatrogenic injury of the biliarv system. toxic jaundice owing to an anesthetic agent, hemolysis and /or hepatitis and so forth. The fact that in both of our patients jaundice subsided following drainage of the pseudocyst with the return of the other liver functions to normal points to the possibility that this was obstructive in nature from compression of the duodenum and common duct by the pararenal pseudocyst. With the recent improvement in surgical techniques there has been a tendency toward primary
t
526
PONTES AND PIERCE
closure of pyeloplasty without stents. The possible pitfalls of these procedures have been revealed recently by Crowell and Bard and their associates. 9 • '° Certainly, the causative factor illustrated in our 2 cases was improper drainage of the retroperitoneal space, either because of poor placement of the drain or subsequent mobilization during closure of the abdominal wall or early in the postoperative period. These cases serve to illustrate the importance of proper drainage in patients after a renal operation when an expected urinary leak is contemplated. REFERENCES
R. A.: Obstructive jaundice. Unusual complication of postoperative pararenal pseudocyst. Urology, 3: 759, 1974. 2. Razzaboni, G.: Ricerche sperimentali sulla pseudoidronefrosi. Arch. Ital. di Chir., 6: 365, 1922 2:3. 3. Crabtree, E. G.: Pararenal pseudo-hydronephrosis with report of three cases. Trans. Amer. Ass. 1. Boltuch, R. L. and Straffon,
Genito-Urin. Surg., 28: 9, 19:l5. 4. Pyrah, L. N. and Smiddy, F. G.: Pararenal pseudohydronephrosis: report of 2 cases. Brit. ,J. Urol., 25: 2:39, 195:3. 5. Sauls, C. L. and Nesbit, R. N.: Pararenal pseudocysts: a report of four cases. ,J. Urol., 87: 288, 1962. 6. Arnold, E. P.: Pararenal pseudocyst. Brit. J. Urol., 44: 40, 1972. 7. Beirstein, S. S.: Obstructive jaundice in a case of hydronephrosis. J. Urol., 59: 157, 1948. 8. Javadpour, N., Ireland, G. W., Hakin, A. A. and Bush, I. M.: Giant hydronephrosis in horseshoe kidney, presenting as right upper quadrant mass and jaundice. Chicago Med. Sch. Quart., 29: 37, 1970. 9. Crowell, B. H., Hewit. L. W. and York, W. N.: Experience with dismembered pyeloplasty: interesting complications. South. Med. ,J.,. 66: 237, 197:3. W. Bard. R. H. and Kirk. R. M.: Caution urged in unsplinted. unstented pyeloplasty. Urology, 3: 701, 1974.
