Negative Pressure Therapy May Delay Resolution of Urinary Leaks

Abstract

We read with interest the case report titled 'Negative Pressure Wound Therapy used to Heal Urinary Fistula Wounds Following Renal Transplantation into an Ileal Conduit' (1). We have employed negative pressure therapy (NPT) in over 100 renal transplant recipients with excellent results. However, we recently encountered an unusual case of a slow healing ureteral anastomosis in a patient managed with NPT.A 56-year-old man underwent kidney transplantation and subsequently developed a perinephric collection. After wound exploration and debridement, NPT was initiated. A screening renal scan was performed which was consistent with acute tubular necrosis with no evidence of leak. One week later, an analysis of the drainage fluid was consistent with urine. A repeat renal scan confirmed the diagnosis of a new urine leak. A urinary catheter was placed. An abdominal X-ray confirmed proper positioning of the double-J ureteral stent. After a week of conservative management, the leak persisted. At this point, we discontinued the NPT. Five days later, a nuclear scan confirmed complete resolution.The presence of fistulas is a known relative contraindication to NPT. We believe the NPT slowed healing of the neocystoureterostomy perhaps leading to the development of a urine leak. We also believe that the continued use of the NPT delayed the eventual resolution of this leak. We understand that this anecdote may be only an association, not definitive proof that NPT may slow healing of a neocystoureterostomy. Nevertheless, we maintain that NPT should be employed with caution in patients who may be at risk for urinary complications.

Abdominal wall complications following renal transplantation in adult recipients – factors associated with interventional management in one unit

“…In this study, we found that our recipients required NPWT for a longer duration than has been previously described (median 35 days, range 16–119 days). Similar published case series to date however, only describe the use of NPWT for superficial wound dehiscence and infection [9, 10, 36], whereas we commonly use NPWT for not only superficial dehiscence and infection but also as an adjunct to operative intervention after complete fascial dehiscence. In addition, our recipients who required NPWT had a median time to healing of 73 days, which was longer than patients not requiring NPWT at 29 days.…”

“…The second case series describes two cases where NPWT was similarly used to manage wounds with superficial dehiscence after renal transplant followed by secondary wound closure at day 14 and day 21 respectively [10]. Three others case reports have described the use of NPWT for the management of either urine leaks or lymphoceles [34–36], and one as a prophylactic measure onto a clean surgical incision [37]. The infrequent use of NPWT, which in our centre was required in 2% of the recipients, may be a factor in the relative under reporting of the use of this modality in renal transplant recipients and hence why there is a lack of data on efficacy.…”

Surgical site infection prevention and management in immunocompromised patients: a systematic review of the literature

“…NPWT was successfully used to treat wound complications (ranging from wound dehiscence to urine leak). Conflicting results exist regarding the use of NPWT in post-KT urinary leak [ 44 , 45 ]. Pre-emptive NPWT was applied in a series of 9 patients undergoing KT: no SSI or other postoperative wound complication were observed [ 46 ].…”

Systematic review of the negative pressure wound therapy in kidney transplant recipients

“…The renal function was restored in both patients leading to 141 µmol/L and 75 µmol/L of serum creatinine, respectively, at the end of 3 mo[28]. On the other hand, Ortiz et al[27], had negative experience of NPWT in a KT recipient with peri-renal collection and wound infection. They concluded that NPWT had encouraged and prolonged urine leak, which had healed after 5 d of discontinuation of NPWT[27].…”

“…On the other hand, Ortiz et al[27], had negative experience of NPWT in a KT recipient with peri-renal collection and wound infection. They concluded that NPWT had encouraged and prolonged urine leak, which had healed after 5 d of discontinuation of NPWT[27]. Iesari et al[36] had applied VAC device in a KT patient who had developed spontaneous rupture of urinary bladder due to gangrenous cystitis and extensive wound dehiscence associated with multidrug resistant Acinetobacter baumanni infection.…”