Percutaneous Transrenal Application of Fibrin Sealant for Refractory Urinary Leak After Gunshot Wound

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Percutaneous Transrenal Application of Fibrin Sealant for Refractory Urinary Leak After Gunshot Wound
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  PERCUTANEOUS TRANSRENAL APPLICATION OF FIBRIN SEALANTFOR REFRACTORY URINARY LEAK AFTER GUNSHOT WOUND STEVEN M. BAUGHMAN, ALLEN F. MOREY,* , † PETER H.  VAN  GEERTRUYDEN,MARTIN G. RADVANY, AMY E. BENSON  AND  JOHN P. FOLEY   From the Urology and Interventional Radiology Services, Brooke Army Medical Center, San Antonio, Texas K  EY   W ORDS : fibrin tissue adhesive; ascites; wounds, gunshot; kidney We report a novel percutaneous transrenal application of fibrin sealant for control of refractory urinary leakage afterpenetrating trauma. CASE REPORT  A 63-year-old male presented to the emergency depart-ment with an abdominal gunshot wound. Immediate laparot-omy was performed, where a splenic injury, jejunal lacera-tion and nonexpanding left retroperitoneal hematoma wereidentified. Intraoperative excretory urography demonstratedan obscured left renal contour. Left renal exploration re- vealed an anterior upper pole defect with significant blastinjury. After debridement renal reconstruction was per-formed with gelatin sponge bolsters and a Penrose drain wasplaced superolaterally to the kidney.On postoperative day 3 perirenal drainage increased to 1 l.Retrograde pyelography showed left superior forniceal ex-travasation prompting ureteral stent placement. An addi-tional percutaneous perinephric drain was placed after ab-dominal computerized tomography demonstrated a largeperirenal fluid collection. The urethral Foley catheter wasleft indwelling.Persistent copious perirenal urinary drainage promptedrepeat abdominal exploration and renorrhaphy with omentalflap on postoperative day 18. However, perirenal leakagepersisted, and percutaneous nephrostomy was initiated 12days later, on postoperative day 30. Despite maximal en-dourological treatment, urinary leakage persisted and percu-taneous transrenal application of fibrin sealant was at-tempted in lieu of nephrectomy.On postoperative day 37, with the patient under generalanesthesia, the area of extravasation was identified in theupper renal pole (fig. 1). A 0.035-inch angled guidewire waspositioned across the parenchymal defect under fluoroscopicguidance. A 5Fr open-ended ureteral catheter was used tomeasure the exact distance from the skin to the point of urinary leak (20 cm). A 6Fr Magnum-Z-Cath (Horizon Med-ical Products, Inc, Manchester, Georgia) double lumen pe-ripherally inserted central catheter (PICC) was tailored to 25cm and passed over a 0.018-inch guidewire for use as theconduit for fibrin sealant application (fig. 2). Contrast fluo-roscopy confirmed precise placement across the fornicealleak. Fibrin sealant (5 cc) was injected during withdrawal of the PICC line, sealing the leaking renal tract. A 20Fr Counciltip catheter was introduced into the renal pelvis tract as anephrostomy after appropriate dilation.The perinephric drain subsequently drained less than 10 ccfluid during the next 48 hours. Computerized tomography onpostoperative day 39 revealed complete absence of perirenalfluid collection. The perinephric drain was removed and thepatient was discharged home the following day (day 40).  Accepted for publication March 21, 2003.* Financial interest and/or other relationship with Haemacure andPfizer.† Corresponding author: Urology Service, Brooke Army MedicalCenter, 3851 Roger Brooke Dr., Fort Sam Houston, Texas 78234.F IG . 2. Transrenal percutaneous placement of PICC catheteracross renal defect (arrow) is accomplished under fluoroscopic guid-ance. Arrowheads indicate direction of PICC withdrawal during in- jection of fibrin sealant. Perirenal drain is coiled above left kidney.F IG . 1. Refractory caliceal leak 37 days after abdominal gunshotwound (arrow). 0022-5347/03/1702-0522/0 Vol. 170, 522–523, August 2003T HE  J OURNAL OF  U ROLOGY   ®   Printed in U.S.A. Copyright © 2003 by A  MERICAN  U ROLOGICAL  A  SSOCIATION  DOI: 10.1097/01.ju.0000074976.94470.11 522  DISCUSSION Persistent urinary leak secondary to renal trauma usuallyresolves with conservative management and occasional per-cutaneous drainage. In our patient the urinary leak persisteddespite maximal conservative treatments. Failure of thesemaneuvers resulted in attempted percutaneous transrenalapplication of fibrin sealant to resolve the leak.Percutaneous instillation of fibrin sealant has proved suc-cessful in a variety of challenging nonurological applications,such as refractory cerebrospinal fluid and air leaks. 1 – 3 To ourknowledge this case represents the first percutaneous transrenalapplicationoffibrinsealant.ThedoublelumenPICClineappearsto be well suited for deep percutaneous sealant administration. REFERENCES 1. Patel, M. R., Louie, W. and Rachlin, J.: Postoperative cerebro-spinal fluid leaks of the lumbosacral spine: managementwith percutaneous fibrin glue. AJNR Am J Neuroradiol,  17: 495, 19962. Joho, S., Asanoi, H., Sakabe, M., Nakagawa, K., Kameyama, T.,Hirai, T. et al: Long-term usefulness of percutaneous intra-pericardial fibrin-glue fixation therapy for oozing type of left ventricular free wall rupture: a case report. Circ J,  66:  705,20023. Samuels, L. E., Shaw, P. M. and Blaum, L. C.: Percutaneoustechnique for management of persistent airspace with pro-longed air leak using fibrin glue. Chest,  109:  1653, 1996PERCUTANEOUS TRANSRENAL FIBRIN FOR REFRACTORY URINARY LEAK   523
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