An asymptomatic 62-year-old patient was admitted to the urology department following the incidental discovery of a mass on the lower pole of the right kidney. His past medical history included midline hernia repair in 2000 and type 2 diabetes since 2010.
The CT urogram study showed a 3 cm mass on the lower pole of a pelvic located right kidney. The arterial supply to the right kidney was delivered by one main artery and one upper polar artery originating from the aorta, the venous return drained through one main renal vein into the vena cava.
The patient case was assessed in a multidisciplinary concertation meeting that recommended the patient to undergo an open partial nephrectomy. The surgery went without any incident. The bleeding was estimated at 100 cc and cold ischemia time was 24 min. Post-operative care was simple.
Histopathology study identified the tumor as a grade 2 of Fuhrman classification clear cell renal cell carcinoma measuring 3,2 cm. The lesion was contained within a pseudocapsule without surrounding fat invasion. It was classified as pT1a of the American Joint Committee on Cancer (AJCC) TNM system.
A month after discharge, the patient is admitted to the emergency department complaining of chills and diarrhea for 8 days. Upon examination, the patient was slightly dehydrated but hemodynamically stable. The blood workout found a high C-reactive protein at 76 mg/L and an elevated creatinine at 127 mg/L for an estimated glomerular filtration rate at 52 mL/min per 1.73 m2 using MDRD formula. The abdominal ultrasound found a 40-mm fluid collection near the lower pole of the right kidney. This prompted us to prescribe an abdominal CT-scan that found no sign of mesenteric ischemia but confirmed the presence of a 40-mm pararenal urinoma. Seeing no improvement in the patient symptomatology, he underwent a colonoscopy that was normal.
The patient received fluids, antalgics and symptomatic treatment that improved his symptoms. He was discharged days later with a follow-up abdominal CT-scan.
A month later, the patient was seen at a follow-up visit with the result of the abdominal CT-scan that showed a renocolic fistula (Fig. 1).
A second colonoscopy was performed showing the colic orifice of the renocolic fistula at 25 cm from anal margin.
The decision of the multidisciplinary concertation meeting was to perform a right total nephrectomy with partial colectomy. Upon exploration, a renocolic fistula surrounded by inflammatory tissue was found. The surgery went well. A draining tube was left for 24 h (Fig. 2).
Histopathology study identified the fistula surrounded by areas of steatonecrosis and angiogenesis without any malignant characteristics. Resection margins were clear.