A rare twist after Ex-vivo RIRS: graft parenchymal urine leak in a living donor kidney

Retrograde intrarenal surgery (RIRS) is performed ex-vivo on donor kidneys prior to transplantation. Upto our knowledge, after the review of existing literature, this is the first reported case of graft parenchymal urine leakage following ex-vivo RIRS in a living donor kidney transplant. Parenchymal urine leaks following ex-vivo retrograde intrarenal surgery (RIRS) in donor kidneys are exceptionally rare. To the best of our knowledge, this represents the first reported case of graft parenchymal urine leakage following ex-vivo RIRS in a living donor kidney transplant. A 29-year-old man was transplanted with a donor kidney following removal of 5 mm upper pole calculus via ex-vivo RIRS. Postoperatively, the patient had bloody drain output, and re-exploration showed a capsular tear. The subsequent clear drain output was confirmed to be a parenchymal urine leak based on drain fluid creatinine concentration and CT urogram. The bleed was managed surgically, and the parenchymal urine leak was treated conservatively using prolonged drainage and double-J stenting. Graft function was stable. Irrigation pressure should be well-controlled during ex-vivo RIRS, and complications should be promptly diagnosed to save the graft function even with rare parenchymal urine leaks.