A 63-year-old man was admitted to local hospital with chief complaint of defecation difficulty for one week. Colonoscopy after enema suggests rectal neoplasm and pathological examination confirmed rectal adenocarcinoma. One day after colonoscopy, sigmoid colostomy was emergently performed in this patient because of colonic perforation. The patient then came to our hospital to consult for further treatment. Colonoscopy in our hospital showed that ulcerative neoplasm located 8 cm from the anal verge invaded about two-thirds of the circumferential intestinal wall and pathological examination showed mucinous adenocarcinoma with mucinous component and few signet-ring cells. Clinically suspected LLNM on the right side was considered based on contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) (Figure 1), then he was planned to administer nCRT. After two courses chemotherapy of XELOX (Oxaliplatin infusion + capecitabine taken orally) and radiotherapy with 50.4 Gy (28 fractions) accompanied by oral capecitabine in total, the sizes of both the primary tumor and lymph nodes decreased (partial response: PR) (Figure 2).
Curative radical resection was performed 6–8 weeks after the completion of radiotherapy. After the multi-disciplinary team evaluation, laparoscopic abdominoperineal resection (APR) with right LLND was suggested. During the operation, an extended radical surgery for rectal cancer was performed to remove of the suspiciously invaded the right seminal vesicle gland and the right pelvic nerve. After completion of the TME procedure, LLND was performed according to our previously reported method[5]. Briefly, LLND began by isolating the ureter, hypogastric nerve, and pelvic nerves from the pelvic sidewall. Thereafter, the dissection of lymph nodes was initiated in the area around the common iliac artery, around the common iliac artery, internal iliac artery, and obturator space. Because LLNM most frequently occurs around the distal internal iliac vessels, LLND with the combined vesical artery resection may simplify the procedure and bring on more secure en bloc dissection of metastatic lateral lymph node adjacent to the vessels. Thus, for this case, the anterior trunk of right internal iliac artery was ligated, leaving only the superior gluteal artery during LLND. The patient was discharged on 7th after surgery without immediate postoperative complications and voiding dysfunction. Next, he underwent four cycles chemotherapy of XELOX and no recurrence was found during regular follow-up after surgery.
However, one month after the second surgery, the patient presented to our outpatient clinic with chief complaints of frequent micturition, urgency of urination and intermittent fever. These symptoms improved after the treatment of antibiotics but recurred since then. Five months after the second surgery, the patient was readmitted to our hospital with chief complaints of fluid drained from the perineal wound. Physical examination showed that perineum was distended with tenderness and no signs of peritoneal irritation were observed. And clear fluid drained from a fistula about 2mm in size located at the upper part of perineal wound. Contrast-enhanced CT revealed there was encapsulated effusion in pelvic cavity, which involved bladder and right lower ureter. Moreover, there was hydronephrosis in the upper part of right ureter and renal pelvis, right lower ureteral stricture was found and the perfusion of right kidney was decreased. Due to apparent pelvic effusion, fistula enlargement and placement of drainage tube through the perineal fistula were performed. The amount of fluid reached about 850 ml on the first day after drainage tube placement. Biochemical results of drainage fluid showed creatinine 918umol/L, uric acid 1092umol/L, urea 41.6mmol/L, serum cystatin C determination 0.23mg/L, estimated glomerular filtration rate 4.78ml/min/1.73m2. Moreover, computed tomography urography (CTU) showed that the fistula between the right pelvic segment of the ureter and the encapsulated effusion area was formed, the right pelvic segment of ureter in the surgical area was unclear and dilatation of ureter was found above that part of ureter and the perfusion of the right kidney was decreased (Figure 3A). These results suggested the possibility of a right pelvic ureteral fistula. Therefore, cystoscopic double-J ureteral stent insertion was performed. The postoperative course was uneventful, and the patient was discharged on postoperative day 4. The patient had been carrying drainage tubes and double-J ureteral stent since discharge, and no pelvic effusion or fever occurred.
However, five months after the ureteral stent insertion, the pelvic drainage tube was accidentally removed by the patient, followed by massive pelvic effusion and persistent fever. Enhanced ureteral CT revealed formation of right pelvic ureteral fistula and pelvic encapsulated effusion (Figure 3B). After the failure of replacement of the drainage tube through perineum, a laparoscopic ureteral reimplantation (vesicoureteric anastomosis) was performed and a new ureteral stent was placed after the ureteral leakage was identified in the right lower ureter (Figure 4). During the follow-up period, enhanced ureteral CT showed no leakage of contrast medium (Figure 5) and no pelvic effusion and fever were found in this patient with normal urinary function.