Use of CT to reveal complications following laparoscopic partial nephrectomy

Clinical History

An otherwise healthy woman with no past medical history and incidentally discovered small renal cell carcinoma of the right kidney underwent laparoscopic partial nephrectomy.
Compared to the expected brief hospitalization, postoperative course was prolonged because of abdominal pain and progressive blood loss (nadir haemoglobin 11.5 g/dL), with stable vital signs.

Imaging Findings

Preoperatively, multidetector CT (Fig. 1) showed a vascularised 2.5 cm subcapsular round mass at the middle third of the right kidney, consistent with T1a stage renal cell carcinoma (RCC). The attending urologist indicated minimally invasive laparoscopic surgery.
Forty-eight hours after laparoscopic resection, urgent CT showed right-sided subcutaneous emphysema of the abdominal wall, moderate pneumoperitoneum and minimal pelvic haemoperitoneum, plus a sizeable hyperattenuating haematoma of the posterior pararenal space displacing the ipsilateral kidney medially. Additionally, pleural effusion and atelectatic/pneumonic consolidations were present at both lung bases.
Since CT excluded contrast extravasation indicating active bleeding, conservative in-hospital treatment was chosen, including repositioning of drainage tube. Follow-up unenhanced CT 5 days later showed persistent extensive right-sided subcutaneous emphysema, resolved pneumoperitoneum, and decreased posterior pararenal blood collection. The patient finally recovered and was discharged.

Discussion

During the last decade, widespread use of imaging resulted in increased incidental detection of small renal cell carcinomas (RCC). Meanwhile, improved surgical techniques and greater focus on minimizing functional impairment shifted the therapeutic approach from open nephrectomy towards minimally invasive nephron-sparing surgery. As a result, laparoscopic partial nephrectomy (LPN) currently represents the preferred treatment for T1a RCC, with superior results compared to open surgery in terms of renal function preservation and similar oncological outcomes (91-94% 5-year cancer-specific survival). Absolute indications for PN include tumours in solitary kidney, compromised renal function and hereditary disorders, which predispose to recurrent RCC. Furthermore, advantages of laparoscopic PN include reduced hospital stay, analgesics use and blood loss [1-3].
However, LPN is a challenging surgery which is most commonly performed transperitoneally rather than through a retroperitoneal route, with potentially serious complications particularly in elderly patients with comorbidities. Overall, adverse events after LPN occur in 15-23% of patients, including a majority (75% of cases) of minor occurrences (grades I-II according to the Clavien classification system). Major complications (grade III or higher) are reported in 6.2-9% of patients after LPN, a similar or slightly higher rate compared to open surgery (3-6.3%) despite favourable patient characteristics and lower tumour complexity [1-7].
After LPN, the spectrum of complications encompasses non-urological conditions such as ileus, cardiopulmonary problems (heart failure, venous thrombosis and pulmonary embolism, atelectasis/pneumonia, pleural effusion), renal failure, bleeding, collecting system injury, urinary infections and sepsis, wound infection and incisional hernias. According to some authors, tumour size and location may predict the perioperative outcome including risk of conversion to open surgery and postoperative function loss. Proximity to the renal sinus has the greatest association with overall complications and haemorrhage [4-9].
As this case exemplifies, postoperative haemorrhage represents one of the commonest and most feared occurrences after LPN, and transfusions are required in 5-21% of patients. Clinical suspicion of postoperative complications is usually based on postoperative pain, hypotension or blood loss, gross or persistent haematuria, clinical or laboratory signs of infection. Prompt use of multidetector CT allows efficient triage of iatrogenic complications after laparoscopic urologic surgery, including visualization of the site and extent of resection, identification or exclusion of haematomas in the perirenal and pararenal space, of contrast extravasation indicating active haemorrhage, and of urine leakage. Combination of laboratory and imaging data provides a consistent basis for correct therapeutic choice between conservative management, surgery, transarterial embolization, nephrostomy and/or ureteral stenting [2-6, 8-10].

Differential Diagnosis List

Final Diagnosis

Postoperative haemorrhagic complication after laparoscopic partial nephrectomy for renal carcinoma.

URL:	https://www.eurorad.org/case/12370
DOI:	10.1594/EURORAD/CASE.12370
ISSN:	1563-4086