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CASE REPORT

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RESORBABLE CLIP MIGRATION IN THE COLLECTINGSYSTEM AFTER LAPAROSCOPIC PARTIAL NEPHRECTOMY

MEREDITH MILLER, JAMES KYLE ANDERSON, MARGARET S. PEARLE, AND JEFFREY A. CADEDDU

ABSTRACTcomplication is reported in which Lapra-Ty absorbable suture clips (Ethicon EndoSurgery) migrated fromlaparoscopic partial nephrectomy bed into the collecting system, causing renal colic. During surgery

erformed with hilar occlusion, visual inspection did not reveal collecting system entry. Transected vesselsere oversewn with absorbable suture secured with Lapra-Tys. Absorbable bolsters were placed in thearenchymal bed, and compression sutures secured with Lapra-Tys were placed through the renal capsule.ix weeks postoperatively, the patient developed ipsilateral renal colic, and computed tomography demon-trated several 3-mm opacities within the ureter. After 2 weeks of conservative management, he spontane-usly passed several Lapra-Ty clips. UROLOGY 67: 845.e7–845.e8, 2006. © 2006 Elsevier Inc.

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aparoscopic partial nephrectomy with hilar oc-clusion has become an accepted technique for the

anagement of select renal tumors. Given the con-traints of warm ischemia, the laparoscopic surgeonust excise the mass and achieve good hemostasis inrelatively short period. A popular alternative to

ime-consuming conventional knot tying for secur-ng sutures is the use of two Lapra-Tys (Ethicon En-oSurgery, Cincinnati, Ohio).1 We describe a case inhich a Lapra-Ty migrated from the tumor excisioned into the collecting system after a laparoscopicartial nephrectomy.

CASE REPORT

A 47-year-old man with a history of nephrolithi-sis was found to have a 2-cm mesophytic rightenal mass upon computed tomography (CT) scanuring workup for diverticulitis. He chose to un-ergo a laparoscopic partial nephrectomy. Visualnspection did not reveal collecting system viola-ion, though indigo carmine was not administered.urgical bed hemostasis was achieved by oversew-ng large vessels with 2-0 Vicryl (Ethicon) suturelipped with Lapra-Tys at both ends. The paren-

rom the Department of Urology, University of Texas Southwest-rn Medical Center, Dallas, Texas

Address for correspondence: Jeffrey A. Cadeddu, M.D., Depart-ent of Urology, University of Texas Southwestern Medical Cen-

er, 5323 Harry Hines Boulevard, Dallas, TX 75390-9110. E-ail: jeffrey.cadeddu@utsouthwestern.eduSubmitted: June 1, 2005, accepted (with revisions): October 5,

W005

2006 ELSEVIER INC.LL RIGHTS RESERVED

hymal bed was then filled with Floseal (Baxterealthcare, Deerfield, Ill) and covered by oxidized

ellulose bolsters. The bolsters were then com-ressed with 0 Vicryl sutures placed through theenal capsule and again secured with Lapra-Tys.The postoperative course was uncomplicated untilweeks later, when the patient developed right loweruadrant pain radiating to his right flank, as well asausea and vomiting. An abdominal CT scan demon-trated a 3-mm right ureteral opacity with moderateydroureteronephrosis, as well as multiple additionalmall opacities bordering and within the partial ne-hrectomy site (Fig. 1). He also had small nonob-tructing stones in his left kidney that had beenbserved in his preoperative imaging. The diagno-is of right ureteral stone was made, and the patientas managed conservatively with hydration, nar-

otic analgesia, and instructions to strain his urine.wo weeks later, several fragments were passed,nd it was immediately obvious that these frag-ents were Lapra-Ty clips and not calculi (Fig. 2).o stone analysis was performed. Subsequent im-

ging showed no further calcifications in the rightollecting system, although three calcificationsere noted in the right renal parenchyma at the sitef his tumor resection, and the small stones notedn the left kidney remained unchanged.

COMMENT

To date, urinary passage of Lapra-Ty suture clipsas not been reported after partial nephrectomy.

ithin the general surgical literature, several groups

0090-4295/06/$32.00doi:10.1016/j.urology.2005.10.009 845.e7

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ave reported clips from laparoscopic cholecystec-omies migrating into the common bile duct andcting as a nidus for stone formation.2 These re-orts prompted the use of absorbable clips to avoidhis complication. Furthermore, within the uro-ogic literature, it has been reported that surgicallips and even absorbable gastrointestinal staplesan act as a nidus for stone formation when inontact with urine.3Lapra-Ty suture clips are made of polydioxanone

nd are designed to degrade as the ester bonds areydrolyzed. Degradation begins after approxi-ately 90 days, with the hydrolyzed polymer ex-

IGURE 1. Abdominal CT scan demonstrating opaci-ies seen within partial nephrectomy surgical defect.

reted in the urine. In this case, before the La- E

45.e8

ra-Ty clips could be hydrolyzed, they eroded intohe collecting system, which likely had been un-nowingly transected during the resection. Thisxperience suggests that the surgeon must care-ully assess whether the collecting system has beeniolated at the time of laparoscopic partial ne-hrectomy and that care should be taken to avoidlacing a Lapra-Ty in proximity to the renal col-ecting system. In addition, shortly after surgeryapra-Ty suture clips remain dense and can appearimilar to renal calculi on CT scan.

REFERENCES1. Orvieto MA, Chien GW, Lavan B, et al: Eliminating knot

ying during warm ischemia time for laparoscopic partial ne-hrectomy. J Urol 172: 2292–2295, 2004.2. Dell’Abate P: Choledocholithiasis caused by migration

f a surgical clip after video laparoscopic cholecystectomy. Japaroendosc Adv Surg Tech A 13: 203–204, 2003.3. Groneau E, and Panek J: Reflux of a staple after Kock

ouch urinary diversion: A nidus for renal stone formation. J

IGURE 2. Lapra-Ty clips that were spontaneouslyassed by patient. Width of clip � 4 mm.

ndourol 18: 481–482, 2004.

UROLOGY 67 (4), 2006