Treatment of renal transplant complications with a mesh hood fascial closure technique

Methods to prevent lymphocele after kidney transplantation: Seeking the optimal technique for avoiding a preventable complication

BACKGROUND

There are multiple methods for preventing lymphocele formation after kidney transplantation (KTx). However, lymphoceles still develop in up to one third of patients and the effectiveness of these different methods in preventing lymphocele is not well described. Here, we summarize the current strategies for preventing lymphocele after KTx.

METHODS

We conducted searches across several literature databases, including Medline (via PubMed), Web of Science, EMBASE, and Cochrane Central. Lymphocele formation after KTx was the outcome of interest. A random-effects model was applied to evaluate pooled estimates, which were presented as hazard ratios (HRs) and odds ratios (ORs), along with the random pooled estimate (ES), 95% confidence interval (95% CI), and P value. We calculated the pooled rate of lymphocele formation after KTx with the following preventive methods: LigaSure, haemostatic materials, prophylactic drainage, ligation, peritoneal fenestration, and bipolar cautery techniques.

RESULTS

The literature search retrieved 87 unique studies after excluding duplicates. Twenty papers reporting on 5445 patients were incorporated in the qualitative analysis. The pooled lymphocele rate was 3.0% (95% CI = 0.6-13.7) for the LigaSure method, 8.3% (95% CI = 6.4-10.7) for drainage, 9.2% (95% CI = 5.9-14.1) for haemostatic materials, 12.2% (95% CI = 9.2-16.1) for ligation, 14.4% (95% CI = 12.0-17.3) for peritoneal fenestration, and 20.5% (95% CI = 10.2-36.8) for bipolar sealing.

CONCLUSION

Despite preventive methods, the incidence of lymphocele following KTx remains high. The use of LigaSure appears to be the most effective method for preventing lymphocele. However, given the broad range of reported lymphocele rates and lack of control groups, further validation of these findings is necessary.

Abdominal wall complications after kidney transplantation: A clinical review

Introduction

Abdominal wall complications are common after kidney transplantation, and although they have a minor impact on patient and graft survival, they increase the patient's morbidity and may have an impact on quality of life. Abdominal wall complications have an overall incidence of 7.7–21%.

Methods

This review will explore the natural history of abdominal wall complications in the kidney transplant setting, with a special focus on wound dehiscence and incisional herni, with a particular emphasis on risk factors, clinical characteristics, and treatment.

Results

Many patient‐related risk factors have been suggested, including older age, obesity, and smoking, but kidney transplant recipients have an additional risk related to the use of immunosuppression. Wound dehiscence usually does not require surgical intervention. However, for deep dehiscence involving the fascial layer with concomitant infection, surgical treatment and/or negative pressure wound therapy may be required.

Conclusions

Incisional hernia (IH) may affect 1.1–18% of kidney transplant recipients. Most patients require surgical treatment, either open or laparoscopic. Mesh repair is considered the gold standard for the treatment of IH, since it is associated with a low rate of postoperative complications and an acceptable rate of recurrence. Biologic mesh could be an attractive alternative in patients with graft exposition or infection.

Renal Allograft Compartment Syndrome: A Case Report and Review of the Literature

Kidney transplantation is the treatment of choice for patients with ESRD. One rare complication after transplantation is the development of renal allograft compartment syndrome (RACS). We present a case of 1 patient who developed RACS due to compression of the transplant vein, which was then treated by salvaging the kidney transplant using urgent decompression surgery with mesh fascial closure. We postulate that this technique is safe and should be the treatment of choice for patients with RACS.

Imaging of Renal Transplant Complications throughout the Life of the Allograft: Comprehensive Multimodality Review

The kidney is the most commonly transplanted solid organ. Advances in surgical techniques, immunosuppression regimens, surveillance imaging, and histopathologic diagnosis of rejection have allowed prolonged graft survival times. However, the demand for kidneys continues to outgrow the available supply, and there are efforts to increase use of donor kidneys with moderate- or high-risk profiles. This highlights the importance of evaluating the renal transplant patient in the context of both donor and recipient risk factors. Radiologists play an integral role within the multidisciplinary team in care of the transplant patient at every stage of the transplant process. In the immediate postoperative period, duplex US is the modality of choice for evaluating the renal allograft. It is useful for establishing a baseline examination for comparison at future surveillance imaging. In the setting of allograft dysfunction, advanced imaging techniques including MRI or contrast-enhanced US may be useful for providing a more specific diagnosis and excluding nonrejection causes of renal dysfunction. When a pathologic diagnosis is deemed necessary to guide therapy, US-guided biopsy is a relatively low-risk, safe procedure. The range of complications of renal transplantation can be organized temporally in relation to the time since surgery and/or according to disease categories, including immunologic (rejection), surgical or iatrogenic, vascular, urinary, infectious, and neoplastic complications. The unique heterotopic location of the renal allograft in the iliac fossa predisposes it to a specific set of complications. As imaging features of infection or malignancy may be nonspecific, awareness of the patient's risk profile and time since transplantation can be used to assign the probability of a certain diagnosis and thus guide more specific diagnostic workup. It is critical to understand variations in vascular anatomy, surgical technique, and independent donor and recipient risk factors to make an accurate diagnosis and initiate appropriate treatment.^©RSNA, 2019.

Retroperitoneal Compartment Syndrome in Renal Transplantation: How to Salvage the Graft?

OBJECTIVE

Early allograft dysfunction may be caused by several technical factors including vascular complications such as thrombosis, kinking, or extrinsic compression. Renal allograft compartment syndrome (RACS) is an unrecognized cause of early allograft dysfunction. This complication is characterized by increased pressure of the iliac fossa that reduces the blood supply to the graft with a potentially devastating consequence. The main objective when recognizing this condition is to create a tension-free muscle closure. Many approaches have been proposed involving mesh such as the mesh hood fascial closure technique.^1-4 PATIENT AND METHODS: We describe in the video an RACS during an operation. The recipient is a 23-year-old young man with a body mass index of 22, with renal failure secondary to chronic reflux. Past history of failure to peritoneal dialysis currently on hemodialysis. He received a living donor's kidney. After performing a standard anastomosis, his urine output was brisk. The fascia was then closed with no force, at which point he stopped making urine. A RACS was suspected; intraoperative examination and ultrasound showed no flow in the graft, with no signs of kinking. Immediately, reexploration was performed, showing the graft with abnormal color and turgor. After relieving the pressure, the graft returned to normal. The closure was redone with a large ellipsoid piece of polypropylene mesh draped loosely and without tension over the graft.

RESULTS

A Doppler ultrasound, after the skin closure was performed, showed good flow, and the postoperative course was unremarkable. There was minimal bulking in the right iliac area, making it cosmetically acceptable.

CONCLUSION

RACS could be associated with a lack of compliance in the retroperitoneal cavity.⁵ The RACS required a prompt intervention. The timely suspicion is a watershed in the prognosis of this rare pathology. We propose that mesh hood fascial closure is easy, effective, and a safe method to treat these complications.

Risk factors for renal allograft compartment syndrome

Renal allograft compartment syndrome (RACS) is graft dysfunction secondary to intracompartment hypertension. The purpose of this study was to identify risk factors for RACS. We reviewed 7 cases of established RACS and all intra-abdominal placements of the kidney in order to include potential RACS. We also studied early graft losses in order to rule out a missed RACS. We compared the allograft length and width, recipient height, weight, body mass index, aberrant vessels, site of incision, and side of kidney with the remainder of the cohort as potential predictors of RACS. Among 538 transplants, 40 met the criteria for actual RACS or potential RACS. We uncovered 7 cases of RACS. Only kidney length and width were statistically significant (P = 0.041 and 0.004, respectively). The width was associated with a higher odds ratio than was length (2.315 versus 1.61). Increased allograft length and width should be considered as a potential risk for RACS.

Abdominal compartment syndrome: an underrated complication in pediatric kidney transplantation

The transplantation of a large kidney in small children can lead to many complications, including an underrated complication known as abdominal compartment syndrome (ACS), which is defined as intra-abdominal pressure (IAP)≥20 mm Hg with dysfunction of at least one thoracoabdominal organ. Presenting signs of ACS include firm tense abdomen, increased peak inspiratory pressures, oliguria, and hypotension. Between June 1, 1985, and September 30, 2013, our center performed 420 kidney transplants (deceased/living related donors: 381/39) in 314 pediatric recipients (female/male: 147/167). ACS occurred in 9 pediatric patients (weight<15 kg) who received a large kidney from adult donors. In 1 case, the patient underwent abdominal decompression with re-exploration and closure with mesh in the immediate postoperative period. In a second case, the patient developed a significant respiratory compromise with hemodynamic instability necessitating catecholamines, sedation, and assisted ventilation. For small children transplanted with a large kidney, an early diagnosis of ACS represents a critical step. From 2005 we have measured IAP during transplantation via urinary bladder pressure, and immediately after wound closure we use intraoperative and postoperative duplex sonography to value flow dynamics changes. We recommend that bladder pressure should be routinely checked in small pediatric kidney recipients who are transplanted with a large graft.

Immediate postoperative sonography of renal transplants: vascular findings and outcomes

OBJECTIVE

The purpose of this study was to determine the frequency and types of significant vascular findings on bedside sonography immediately after renal transplantation and which abnormalities would suggest a benefit from early surgical revision.

MATERIALS AND METHODS

Five hundred seventy-five renal transplant sonograms obtained within 4 hours of surgery were retrospectively reviewed for major vascular abnormalities: lack of renal artery (RA) or renal vein (RV) flow, elevated peak systolic velocity (PSV)>300 cm/s, parvus tardus waveforms, and markedly decreased or no color parenchymal flow. Clinical outcomes of abnormal cases were reviewed, including reoperations and percutaneous interventions.

RESULTS

Thirty-two (5.6%) patients underwent repeat surgery within the first week, 16 for nonvascular causes. Forty-seven (8.2%) patients had positive sonography findings. In 16 patients, sonography impacted the decision for reoperation, with 14 confirmed vascular diagnoses: compartment syndrome (n=7), RV thrombosis (n=3), RA thrombosis (n=1), RA and RV thromboses (n=2), and vascular steal (n=1). All were salvaged except the three RV thromboses. Two patients had no vascular abnormality at surgery. All 16 had markedly decreased color flow and varying abnormalities of PSV and waveforms. Outcomes of the remaining 31 cases were infarct (n=1), renal or iliac artery stenoses eventually requiring stents (n=4), and normalized (n=26). These 26 had elevated PSV with normal or near-normal color flow. Unpaired Student t tests showed no significant difference in PSV between patients requiring surgery or stents and those who normalized (p=0.34).

CONCLUSION

Immediate postoperative sonography has a spectrum of vascular findings, of which markedly decreased color flow is most likely to benefit from immediate reoperation.

Use of intraperitoneal ePTFE Gore dual-mesh plus in a giant incisional hernia after kidney transplantation: a case report

We evaluated the incidence of and predisposing factors for an incisional hernia after kidney transplantation. Numerous techniques have been used to repair postoperative fascial dehiscences or simple incisional hernias, but no clear treatment exists for giant hernias. Our aim was to obtain (1) a safe procedure to repair a large abdominal defect and reinforce the surrounding, fragile zones and (2) a simple, rapid technique to reduce the operative time. Herein we have described the surgical repair of a giant incisional hernia using intraperitoneal Gore ePTFE dual-mesh plus (Gore-Tex; W. L. Gore, Flagstaff, Ariz, USA) in a 55-year-old man status-post renal transplantation. Total necrosis of distal graft ureter had caused a giant urinoma. The patient was reexplored on day 2 posttransplantation with a primary fascial approximation. Thirty days after transplantation we discovered a large incisional hernia and performed a repair. No drain was used. The patient continued immunosuppressive therapy (cyclosporine, mycophenolate mofetil, prednisolone) and was discharged on postoperative day 4 with no complications. An ultrasonographic follow-up at 1 year revealed the prosthesis to be correctly positioned. Incisional hernia is not rare after renal transplantation but the real incidence is unknown. Immunosuppressive therapy, prolonged pretransplantation dialysis, obesity, and diabetes are probably the major causes of incisional hernias in these patients. Surgical complications of renal transplantation surgery, such as wound hematoma, urinoma, and lymphocele, are the most important predisposing factors for an incisional hernia. The use of intraperitoneal ePTFE dual-mesh is feasible, safe, and easy to repair a large incisional hernia in a kidney transplant patient.

Page kidney as a rare cause of hypertension: case report and review of the literature

Page kidney occurs by extrinsic compression of the renal parenchyma from a hematoma or a mass, leading to activation of the renin-angiotensin-aldosterone system and resulting in systemic hypertension. There have been about 100 cases of Page phenomenon reported in the literature. A review of cases published prior to 1991 revealed that football and nonsports-related trauma were the most common causes of Page kidney. Thereafter, 28 cases have been reported in the literature, including our case report presented here. These recent cases show that the etiology of Page kidney has shifted, perhaps because of the procedure-oriented current practice of medicine and the increased frequency of kidney transplant biopsies. In addition, management options have evolved, given the more frequent use of medications that block the renin-angiotensin-aldosterone system and the availability of less invasive procedures. Page kidney should be considered in the differential diagnosis of secondary hypertension.

Acute Page kidney following renal allograft biopsy: a complication requiring early recognition and treatment

The acute Page kidney phenomenon occurs as a consequence of external compression of the renal parenchyma leading to renal ischemia and hypertension. Between January 2000 and September 2007, 550 kidney transplants and 518 ultrasound-guided kidney biopsies were performed. During that time, four recipients developed acute oligo-anuria following ultrasound-guided allograft biopsy. Emergent doppler-ultrasounds were performed demonstrating absence of diastolic flow as well as a sub-capsular hematoma of the kidney. Prompt surgical exploration with allograft capsulotomy was performed in all cases. Immediately after capsulotomy, intraoperative Doppler study demonstrated robust return of diastolic flow. Three patients maintained good graft function, and one kidney was lost due to acute antibody-mediated rejection. We conclude that postbiopsy anuria associated with a subcapsular hematoma and acute absence of diastolic flow on doppler ultrasound should be considered pathognomonic of APK. All renal transplant specialists should be able to recognize this complication, because immediate surgical decompression can salvage the allograft.