Managementul perioperatoriu multidisciplinar al polipectomiei histeroscopice la o pacientă cu transplant renal dependentă de dializă: prezentare de caz

Introduction

Advances in renal transplantation have substantially improved the survival and quality of life of patients with end-stage kidney disease (ESKD), resulting in an increasing number of women of reproductive and perimenopausal age requiring long-term gynecological care after transplantation⁽¹⁾. However, progressive chronic allograft dysfunction remains a major cause of graft failure, with many recipients eventually returning to maintenance hemodialysis despite continued immunosuppressive therapy⁽¹⁾. These patients frequently present with gynecological disorders such as abnormal uterine bleeding (AUB), uterine fibroids and endometrial polyps, necessitating surgical intervention under challenging medical circumstances⁽²⁾. Patients with advanced chronic kidney disease (CKD) and those receiving maintenance hemodialysis represent a unique perioperative population because of complex physiological alterations affecting multiple organ systems. Uremia is associated with platelet dysfunction, impaired hemostasis, anemia, electrolyte disturbances, metabolic acidosis, cardiovascular instability and altered pharmacokinetics of anesthetic agents, all of which contribute to increased perioperative morbidity and mortality. Furthermore, the coexistence of renal allograft dysfunction and long-term immunosuppressive therapy may increase the susceptibility to infection and delay wound healing, making perioperative optimization particularly important^(2,3). Hysteroscopic polypectomy is considered the standard minimally invasive treatment for symptomatic endometrial polyps and abnormal uterine bleeding, offering excellent visualization, minimal blood loss, rapid recovery and reduced postoperative morbidity compared with conventional surgical approaches⁽⁴⁾. Nevertheless, limited literature exists regarding the safety and perioperative management of hysteroscopic procedures in dialysis-dependent renal transplant recipients. Careful attention to the timing of dialysis, correction of electrolyte abnormalities, optimization of hemoglobin levels, continuation or modification of immunosuppressive medications, anesthetic planning and meticulous monitoring of intraoperative fluid balance are essential to minimize perioperative complications⁽⁵⁾. The successful management of medically complex patients increasingly relies on a multidisciplinary approach involving gynecologists, nephrologists, anesthesiologists and perioperative nursing teams. Such collaboration facilitates individualized risk assessment, optimization of medical comorbidities and coordinated perioperative care, thereby improving surgical safety and patient outcomes⁽⁵⁾. We report the successful perioperative multidisciplinary management of hysteroscopic polypectomy in a dialysis-dependent woman with renal allograft dysfunction nearly two decades after living-donor renal transplantation. This case highlights the importance of comprehensive preoperative optimization, continuation of appropriate immunosuppressive therapy, careful fluid management during hysteroscopy and coordinated multidisciplinary care in achieving favorable surgical outcomes in this high-risk patient population.

Case presentation

A woman with a history of end-stage kidney disease underwent a living-donor renal transplantation in 2005 and maintained satisfactory graft function for approximately 20 years. She was maintained on immunosuppressive therapy comprising tacrolimus and mycophenolate mofetil (MMF). In 2025, she developed progressive proteinuria suggestive of chronic renal allograft dysfunction. Despite conservative management, renal function progressively deteriorated, and maintenance hemodialysis was initiated in 2026 on a twice-weekly schedule while immunosuppressive therapy was continued. The patient had previously presented with symptomatic uterine fibroids causing abnormal uterine bleeding and underwent a laparoscopic myomectomy in 2023. The postoperative course was uneventful, with satisfactory symptomatic relief. In June 2026, she presented to the gynecology outpatient department with recurrent abnormal uterine bleeding. Clinical examination was unremarkable, except for vaginal bleeding. Transvaginal ultrasonography demonstrated an endometrial polyp (Figure 1), and hysteroscopic polypectomy was planned after comprehensive evaluation.

Owing to her dialysis-dependent status, renal allograft dysfunction and ongoing immunosuppressive therapy, the patient was considered to be at an increased perioperative risk, necessitating multidisciplinary management. Preoperative optimization was undertaken in close collaboration with the nephrology and anesthesia teams. Maintenance hemodialysis was performed one day before the planned procedure, to optimize intravascular volume, electrolyte balance and metabolic status. Tacrolimus and mycophenolate mofetil were continued without dose modification following nephrology consultation. Preoperative laboratory investigations revealed a hemoglobin concentration of 10.8 g/dL, serum creatinine of 4 mg/dL, serum potassium of 4.8 mmol/L and a normal platelet count. Following pre-anesthetic assessment, the patient was deemed fit to undergo surgery under short-duration intravenous sedation. Hysteroscopic polypectomy was performed using normal saline as the uterine distension medium. A total inflow of 2000 mL and outflow of 2000 mL were recorded, with no measurable fluid deficit. A solitary endometrial polyp was identified arising from the endometrial cavity, being completely excised using hysteroscopic instruments under direct visualization. The total operative time was approximately 10 minutes. Intraoperative blood loss was negligible, and no anesthetic or surgical complications occurred. The patient remained hemodynamically stable throughout the procedure. The postoperative period was uneventful. Oral intake was resumed as per institutional protocol, and the patient experienced no excessive vaginal bleeding, fluid overload, electrolyte disturbances or infectious complications. Maintenance hemodialysis was continued according to her routine schedule. Histopathological examination confirmed a benign endometrial polyp, with no evidence of hyperplasia or malignancy (Figure 2).

At follow-up, the patient reported complete resolution of abnormal uterine bleeding, and she remained clinically stable, without procedure-related complications.

Discussion

The increasing longevity of renal transplant recipients has resulted in a growing number of women presenting with benign gynecological disorders that require surgical intervention during the course of chronic kidney disease (CKD) or following renal allograft dysfunction⁽⁴⁾. However, evidence describing the perioperative management of minimally invasive gynecological procedures in dialysis-dependent renal transplant recipients remains limited. This case demonstrates that hysteroscopic polypectomy can be safely performed in carefully selected patients, when meticulous preoperative optimization and multidisciplinary collaboration are employed. Patients receiving maintenance hemodialysis present unique perioperative challenges. Uremia contributes to qualitative platelet dysfunction despite normal platelet counts, increasing the risk of perioperative bleeding, while chronic anemia, electrolyte disturbances, impaired cardiovascular reserve and altered drug pharmacokinetics further increase the anesthetic risk⁽⁵⁾. Although our patient had a normal platelet count and acceptable serum potassium concentration, these laboratory parameters alone do not eliminate the increased perioperative risk associated with advanced CKD. Consequently, comprehensive optimization rather than reliance on isolated laboratory values is essential before elective surgery. The timing of dialysis before surgery is an important determinant of perioperative safety. Current recommendations advocate performing hemodialysis within 24 hours before elective surgery to optimize fluid balance, correct electrolyte abnormalities, reduce uremic toxin burden, and minimize the anticoagulant effects associated with dialysis^(5-7). In the present case, dialysis was performed one day before surgery, resulting in satisfactory biochemical parameters and an uncomplicated intraoperative and postoperative course. This highlights the importance of close coordination between nephrologists and surgeons during perioperative planning. Another important consideration is the management of immunosuppressive therapy. Abrupt interruption of calcineurin inhibitors or antiproliferative agents may predispose to immunological complications, whereas continuation may increase susceptibility to infection and impair wound healing⁽⁸⁾. Following consultation with the nephrology team, tacrolimus and mycophenolate mofetil were continued throughout the perioperative period, reflecting an individualized, multidisciplinary approach that balanced graft preservation with surgical safety. Fluid management during hysteroscopy deserves particular attention in dialysis-dependent patients because excessive absorption of distension media may precipitate pulmonary edema, electrolyte disturbances or cardiovascular compromise. Continuous monitoring of inflow, outflow and fluid deficit is therefore mandatory during hysteroscopic procedures⁽⁹⁾. In this patient, normal saline was selected as the distension medium, with a recorded inflow and outflow of 2 L each, resulting in no measurable fluid deficit. Combined with the short operative duration of 10 minutes and negligible blood loss, these factors likely contributed to the favorable perioperative outcome. Minimally invasive gynecological surgery offers several advantages over conventional surgery in medically complex patients, including reduced tissue trauma, lower blood loss, shorter operative time, decreased postoperative pain, and earlier recovery^(10,11). Although these benefits are well established in the general population, published reports involving dialysis-dependent renal transplant recipients remain scarce. This case adds to the growing body of evidence supporting the feasibility of hysteroscopic management in this high-risk cohort when evidence-based perioperative protocols are followed.

Conclusions

This case emphasizes that successful surgical outcomes in dialysis-dependent women with renal allograft dysfunction depend not only on surgical expertise, but also on comprehensive multidisciplinary perioperative management. Appropriate timing of dialysis, continuation of individualized immunosuppressive therapy, careful anesthetic assessment, meticulous intraoperative fluid monitoring and close collaboration among gynecologists, nephrologists and anesthesiologists are essential to minimize the perioperative complications and optimize the patient outcomes.

Corresponding author: Smit Bharat Solanki E-mail: drsmitbharat@gmail.com

Conflict of interests: none declared.

Financial support: none declared.

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