0022-534 7/90 /l 43 l -Cl 07$02.00 /0 THE ,JOURNP.L OF UROLOGY
Vol. 143, ,Js.nua:cy
Copyright (g 1990 by AMERICAN UROLOGlCAL ASSOC!A':'!ON, lNC.
Printed ir1 U.S.A.
Case Reports ACUTE LUIVl:BOSACRAL PLEXOPATHY IN DIABETIC WOMEN AFTER RENAL TRANSPLANTATION THOMAS R. HEFTY, KRISTINE A. NELSON, THOMAS R. HATCH
JOHN M. BARRY
From the Renal Transplant Program, The Oregon Health Sciences University, Portland, Oregon
Renal transplantation is an accepted treatment for patients with end stage renal disease from insulin-dependent diabetes mellitus. Acute lumbosacral plexopathy developed following renal transplantation in 4 female patients with insulin-dependent diabetes mellitus between January 1, 1981 and June 30, 1988. In all 4 patients the internal iliac artery was used for revascularization of the renal allograft with ligation of the anterior and posterior divisions. Within 24 hours of surgery they complained of ipsilateral buttock pain, numbness in the leg and weakness below the knee. This complication has not been observed in nondiabetic patients at our institution, nor in diabetic patients when the internal iliac artery was not used. However, lumbosacral plexopathy occurred in 4 of 27 (14.8%) female patients with insulin-dependent diabetes mellitus when the internal iliac artery was used (p less than 0.001). Age, duration of insulin-dependent diabetes mellitus, hypertension, cigarette smoking history and kidney donor were not significant predictors of this complication. This unusual and newly recognized complication appears to result from ischemia of the lumbosacral plexus following ligation of the internal iliac artery in patients with severe small vessel disease. (J. Ural., 143: 107-109, 1990) Renal transplantation has become a common treatment for patients with end stage renal disease from insulin-dependent diabetes mellitus. These patients are at increased risk for a number of cardiovascular and infectious complications.' We report 4 cases of an overlooked complication in this population. MATERIALS AND METHODS
Patients with insulin-dependent diabetes mellitus represented 24 % of the 785 kidney transplants performed at the Oregon Health Sciences University between January 1, 1981 and June 30, 1988. Records were available from 188 of these patients and they were reviewed for patient age, sex, duration of insulin-dependent diabetes me!litus, hypertension, cigarette smoking history, artery used, donor and neurological symptoms. The patients were based on sex and artery used. Statistical analysis was done with the chi-square and 1way analysis of variance methods. P values of <0.05 were considered significant. RESULTS
The results of the are presented in the table. The development of acute lumbosacral plexopathy was associated strongly with the use of the internal iliac artery (p <0.05) in all diabetic recipients and particularly in female recipients with insulin-dependent diabetes mellitus (p <0.001). Male recipients in whom the external iliac artery was used were older with a longer duration of insulin-dependent diabetes mellitus. Age, duration of insulin-dependent diabetes mellitus, hypertension, smoking history and kidney donor were not predictive of postoperative lumbosacral plexopathy. CASE REPORTS
Case 1. M. S., a 33-year-old white woman with insulindependent diabetes mellitus for 15 years, had the diabetic Accepted for publication August 23, 1989.
complications of retinopathy and peripheral neuropathy, and she had been on hemodialysis for 4 months. The patient had been treated for hypertension for 2 years and she had smoked 1 pack of cigarettes a day for 15 years. On April 19, 1981 she underwent cadaver kidney transplantation using the right internal iliac artery with ligation of the anterior and posterior divisions. On postoperative day 1 the patient complained of right buttock and leg aching with weakness on walking. Neurology consultation revealed a normal motor examination of the left leg but weakness of plantar-flexion (3/5), absent dorsiflexion (0/5), and weak toe extension and flexion (1/5) were noted on the right l.eg. Pelvic ultrasound showed no perinephric fluid collection. Mild improvement in motor function was noted during the next several weeks. Electromyography documented a sciatic nerve injury with denervation of the tibialis anterior, gastrocnemius and vastus medialis muscles. The patient died 8 weeks postoperatively of disseminated cytomegalovirus infection. a white woman with insulin-dependCase 2. I. ent diabetes mellitus for 20 years, had diabetic retinopathy and peripheral neuropathy, and she had been on continuous ambulatory peritoneal dialysis for 2 months. The patient had been treated for 5 years for hypertension and she had smoked 1 pack of cigarettes a day for 15 years. On August 28, 1986 cadaver kidney transplantation was performed in the left iliac fossa using the internal iliac artery with ligation of the anterior and posterior divisions. A small endarterectomy for soft plaque was done. On postoperative day 1 the patient complained of weakness and sensory loss in the buttock and leg. A neurology consultation documented normal cranial nerves, upper extremities and right leg but the left leg motor examination showed no motor function below the knee (0/5). The numbness improved within several weeks but after 2 years the left leg has not completely regained normal strength. Case 3. M. N., a 47-year-old white woman with insulindependent diabetes mellitus for 23 years, had been on hemo-
HEFTY AND ASSOCIATES
Results in 188 diabetic patients Age Sex-No.-(yrs.)
F-46-37.1 M-41-36.2 M-74-40.2t
Duration Insulin-Dependent Diabetes Mellitus (yrs.)
% Cadaveric Donor
% Lumbosacral Plexopathy
Internal iliac External iliac Internal iliac External iliac
* p <0.001. t p <0.05.
dialysis for 18 months. She had been treated for hypertension for 3 years and she had no history of cigarette smoking. On March 19, 1987 cadaver kidney transplantation was performed using the left internal iliac artery. The anterior and posterior divisions were ligated and a soft plaque was trimmed. On postoperative day 1 the patient complained of left hip and left buttock pain with numbness of the entire left leg and inability to move the toes. Within the next 5 days the pain and numbness markedly improved. When she was discharged from the hospital the left dorsiflexion and plantar-flexion were still impaired (2/ 5). The patient was fitted for a brace that she used for 3 months, after which she had achieved complete recovery. Case 4. D. A., a 34-year-old white woman, had insulindependent diabetes mellitus for 17 years with diabetic retinopathy, coronary artery disease, peripheral vascular disease and severe gastroparesis. She had been on continuous ambulatory peritoneal dialysis for 13 months. The patient had been treated
Right common iliac artery
Obliterated umbilical, obturator
Inferior gluteal, pudenda!
FIG. 1. Usual branching of internal iliac artery. Branch of inferior gluteal artery supplies sciatic nerve.
FIG. 2. A, method of ligation of distal branches of internal iliac artery performed in all 4 cases. B, more proximal ligation of internal iliac artery may allow additional collateral flow into inferior gluteal branch.
for hypertension for 2 years and she had smoked 1 pack of cigarettes a day for 17 years. On June 21, 1988 endarterectomy and living related donor kidney transplant were performed using the right internal iliac artery with ligation of the anterior and posterior divisions. The evening of surgery the patient complained of right buttock pain, leg pain, numbness and decreased strength of the right leg below the knee. Neurological examination revealed absent motor activity below the right knee. Electromyography confirmed a plexus lesion with involvement of the tibialis anterior and gastrocnemius muscles. Ultrasound showed no perinephric collection. The buttock numbness had resolved 2 months postoperatively but dorsiflexion and plantar-flexion remained absent (0/5). The patient is able to ambulate with assistance. DISCUSSION
Acute lumbosacral plexopathy has not been reported previously as a complication of renal transplantation. Ligation of the internal iliac artery usually is well tolerated because multiple sources of collateral blood flow are available, including the contralateral vesical arteries, the inferior mesenteric, medial femoral circumflex, lateral sacral and iliac circumflex arteries. A branch of the internal iliac artery, via the inferior gluteal artery, supplies arterial blood to the sciatic nerve (fig. 1). The sciatic nerve is derived from lumbar roots 4-5 and sacral roots 1-3. Complete loss of the sciatic nerve results in paralysis of all muscles below the knee. Cisplatin, alone or in combination with other drugs, has been reported to cause acute lumbosacral plexopathy when infused into the internal iliac artery,2 which is believed to be secondary to chemotherapy-induced injury to small vessels with nerve infarction. Compression neuropathy of the lateral femoral cutaneous and femoral nerves also has been reported following renal transplantation,3 which has been attributed to sustained pressure on the nerve from self-retaining retractors. No evidence of sciatic nerve injury was found in that report. All procedures at our institution are done using a ring self-retaining retractor (Smith ring, Bookwalter) and care is taken to avoid downward pressure on the iliopsoas muscle because of the underlying femoral nerve. If the lumbosacral plexus lesions seen in our diabetic patients were due to self-retaining retractors we would expect to see such cases when the internal iliac artery is not used (p <0.05). During the interval reviewed intermittent claudication was seen in 2 diabetic men after use of the internal iliac artery for renal allograft revascularization. They complained of ipsilateral buttock and thigh aching with walking and no symptoms at rest. These patients did not have a lumbosacral plexus lesion since there were no parethesias, no symptoms at rest and no muscle weakness. Ischemic mononeuropathy multiplex may be seen in diabetic patients• but the relationship to surgery and artery used makes this an unlikely explanation for our 4 cases. It is unclear why women with diabetes would be more prone to this complication than men. Pelvic angiography was available in 2 cases and
ACGTE LUivlBOSACRAL PLEXOPATHY IPJ DIABETIC V!Ol\rfEI'..J AFTER RE0JAL TRAl~SPLAl~TA?I01~
revealed extensive arteriosclerotic disease in case 4 but not in case 2. Endarterectomy of the internal iliac artery was done in cases 2, 3 and 4. In cases 2 and 3 soft plaque was found after dividing the artery and it was easily removed. Case 4 did not have a usable common or external iliac artery and endarterectomy was required to make the internal iliac artery acceptable for transplantation. Donor and recipient arterial anatomy often makes use of the internal iliac artery preferable to the external iliac or common iliac arteries. Extensive disease of the common or external iliac artery may be present and use of these vessels may embarrass the arterial circulation to the leg. Excess arterial length in a donor kidney with 2 renal arteries on an aortic patch may best be handled by use of the internal iliac artery producing a smooth curve to the renal arteries. Conversely, a long internal iliac artery can compensate for a short renal artery allowing a satisfactory anastomosis. However, in the presence of diabetes mellitus with extensive small vessel disease ligation of the internal iliac artery may occasionally produce permanent neurological injury from ischemia. All 4 of our cases had the branches of the internal iliac artery ligated as shown in figure
2, A. Although this technique is well tolerated at our institution by most diabetic and all nondiabetic renal transplant recipients, the incidence of acute lumbosacral plexopathy is 14.8% in female diabetics. If the internal iliac artery must be used in this group, ligating the internal iliac artery more proximally as shown in figure 2, B may prevent this complication by leaving additional collateral flow to the inferior gluteal artery via the umbilical, obturator and superior gluteal branches. REFERENCES 1. Najarian, J. S., Sutherland, D. E. R., Simmons, R. L., Howard, R.
J., Kjellstrand, C. M., Ramsay, R. C., Goetz, F. C., Fryd, D. S. and Sommer, B. G.: Ten year experience with renal transplantation in juvenile onset diabetics. Ann. Surg., 190: 487, 1979. 2. Castellanos, A. M., Glass, J.P. and Yung, W. K. A.: Regional nerve injury after intra-arterial chemotherapy. Neurology, 37: 834, 1987. 3. Vaziri, N. D., Barnes, J., Mirahmadi, K., Ehrlich, R. and Rosen, S. M.: Compression neuropathy subsequent to renal transplantation. Urology, 7: 145, 1976. 4. Raff, M. C., Sangalang, V. and Asbury, A. K.: Ischemic mononeuropathy multiplex associated with diabetes mellitus. Arch. Neurol., 18: 487, 1968.