Complications chirurgicales de la transplantation rénale

The Effectiveness of Deflux® Treatment for Vesicoureteral Reflux Following Pediatric Renal Transplantation: A Single-Institution Challenging Experience

PURPOSE

To validate the effectiveness of Deflux® treatment for vesicoureteral reflux (VUR) following pediatric renal transplantation (RT), based on our single-institution experience.

METHOD

A retrospective study was conducted using the medical records of pediatric patients who underwent Deflux® treatment for VUR after RT from April 2008 to March 2022.

RESULTS

Sixty-eight pediatric patients underwent RT. VUR was subsequently detected in 22 (32 %) of these patients. Seven of the 22 patients (32 %) underwent Deflux® treatment to avoid renal dysfunction due to urinary infection (UTI). The median age at the time of RT was 4 years (range:2-12). All 7 patients had urinary UTIs before Deflux® treatment. The median estimated glomerular filtration rate (eGFR) before Deflux® treatment was 67 ml/min/1.73 m2 (range:42-138 ml/min/1.73 m2). After Deflux® treatment, VUR was downgraded in three cases (43 %). Four patients (57 %) experienced postoperative UTI, two of who underwent a second Deflux® treatment, one underwent submuscular tunnel reconstruction, and the other one experienced UTI without VUR after 1st Deflux® treatment but did not reoccur. All seven patients continued prophylactic medication after Deflux® treatment, without any history of recurrent UTIs during the observation period after treatment (median 37 months [range 7-86 months]). Furthermore, the eGFRs did not significantly decrease after Deflux® treatment (median eGFR 58 ml/min/1.73 m2 [range:33-99 ml/min/1.73 m2], p > 0.1).

CONCLUSION

Deflux® treatment for VUR after RT is technically challenging because the new ureteral orifice is ventrally anastomosed at the bladder. We believe our results indicate the possibility of reducing the frequency of UTIs and contributing to preservation of the renal function after RT.

TYPE OF STUDY

Retrospective Study.

LEVEL OF EVIDENCE

Level III.

Does STING failure affect short-term graft functions in renal transplant patients: a single-center study

PURPOSE

The aim of the present study was to evaluate outcomes of symptomatic VUR treatment in transplant patients, compare open and endoscopic approaches in terms of graft functions, success rates, complications and recurrent UTIs.

METHODS

67 patients who undergone only STING and STING followed redo UNC due to symptomatic VUR after kidney transplantation were included into the investigation. Patients who had lower urinary tract dysfunctions were excluded from the trial. For 67 patients, baseline and before final surgery and 3rd month creatinine and GFR levels were recorded. Twenty-six of those 67 patients had redo UNC due to failed STING. The data of those patients were compared with the remaining 41 patients who had only STING.

RESULTS

In both groups no statistically significant variations in serum creatinine and GFR levels were detected during follow-up (p > 0.05). Serum levels after STING and in the 3rd month of redo UNC were compared. Although variation was observed in serum creatinine levels and in GFR levels, was not statistically significant (p: 0.59 and p: 0.23). The success rate of STING was %61.1 in 67 patients, and was not significantly different when three VUR grade groups (Grade 3 n:17, Grade 4 n:24, Grade 5 n:36) were compared (p > 0.05).

CONCLUSION

The present study revealed that subureteral endoscopic injection is cost effective and safe for the first-line treatment due to its minimally invasive nature, does not cause delay which leads to deterioration of graft functions. Redo-UNC has acceptable morbidity and complication rates, should be considered when STING is failed.

Kidney transplantation from expanded criteria donors: an increased risk of urinary complications - the UriNary Complications Of Renal Transplant (UNyCORT) study

OBJECTIVES

To assess the impact of expanded criteria donors (ECD) on urinary complications in kidney transplantation.

PATIENTS AND METHODS

The UriNary Complications Of Renal Transplant (UNyCORT) is a cohort study based on the French prospective Données Informatisées et VAlidées en Transplantation/Computerized and VAlidated Data in Transplantation (DIVAT) cohort. Data were extracted between 1 January 2002 and 1 January 2018 with 1-year minimum follow-up, in relation to 44 pre- and postoperative variables. ECD status was included according to United Network for Organ Sharing (UNOS) definition. The primary outcome of the UNyCORT study was the association between the donor's ECD/standard criteria donors (SCD) status and urinary complications at 1 year in uni- and multivariate analysis. Sub-group analysis, stratified analysis on ECD/SCD donor's status and transplant failure analysis were then conducted.

RESULTS

Between 1 January 2002 and 1 January 2018, 10 279 kidney transplants in adult recipients were recorded within the DIVAT network. A total of 8559 (83.4%) donors were deceased donors and 1699 (16.6%) were living donors (LD). Among donation after circulatory death (DCD) donors, 224 (2.85%) were uncontrolled DCD and 93 (1.09%) were controlled DCD donors. A total of 3617 (43.9%) deceased donors were ECD. The overall urological complication rate was 16.26%. The donor's ECD status was significantly associated with an increased risk of urological complications at 1 year in multivariate analysis (odds ratio: 1.50, 95% CI 1.31-1.71; P < 0.001) and especially with stenosis and ureteric fistulae at 1 year. There is no association with LD, uncontrolled and controlled DCD. The placement of an endo-ureteric stent was beneficial in preventing urinary complications in all donors and particularly in ECD donors.

CONCLUSION

The donor's ECD status is associated with a higher likelihood of stenosis and ureteric fistulae at 1 year. Recipients of grafts from ECD donors should probably be considered for closer urological monitoring and systematic preventive measures.

The Efficiency and Safety of Endoscopic Treatment on Kidney-Transplanted Patients With Symptomatic Vesicoureteral Reflux in Native and Transplanted Renal Units

OBJECTIVES

To evaluate the outcome of endoscopic treatment of symptomatic vesicoureteral reflux (VUR) in patients with VUR in both transplanted and native renal units.

MATERIAL AND METHODS

Between January 2014 and December 2019, 23 transplanted patients with symptomatic VUR with reflux in both transplanted and native kidney were included in the study. All patients were patients with a history of kidney failure due to reflux nephropathy. A voiding cystourethrography was performed after at least 1 episode of acute glomerulo pyelonephritis or deterioration of the graft function. All patients underwent a urine culture and an ultrasonic evaluation preoperatively. A dextranomer/hyaluronic acid bulking agent was injected via endoscope by a rigid metal needle around a double J stent. Clinical success was defined as absent of febrile urinary tract infection during the follow-up period.

RESULTS

The procedure was applied in 52 effected renal units; of these, 27 were transplanted kidneys, and 25 were native kidneys. Overall clinical success was achieved in 69.6% (N = 16) of patients. The success rate after the first procedure was 52.2% (N = 12), whereas 17.3% (N = 4) achieved success after the second treatment. No intraoperative complications occurred throughout the endoscopic procedure. Minor postoperative complications included 2 (10%) cases of self-limiting episodes of hematuria that did not require intervention.

CONCLUSION

Endoscopic treatment of symptomatic VUR for both transplanted ureter and native ureter is a safe treatment in most of the patients. Therefore, endoscopic ureteral injection is a treatment modality with low morbidity that should be preferred to open surgery as first-line treatment in this subgroup of patients.

Endoscopic treatment of symptomatic VUR disease after the renal transplantation: analysis of 49 cases

BACKGROUND

To evaluate the outcome of endoscopic treatment for symptomatic vesicoureteral reflux (VUR) disease in renal transplantation patients and to determine the factors that were associated with the success rate of the treatment.

METHODS

A total of 121 symptomatic VUR diseases diagnosed between 2014 and 2018 in 3560 renal transplant patients. The results of 49 VUR cases that presented with febrile urinary tract infection (UTI) and were hospitalized for antibiotic treatment were included in the study. Reflux was detected by voiding cystourethrogram and treatment was performed by endoscopic Deflux® injection. The result of endoscopic treatment was evaluated clinically by 3 months periods.

RESULTS

The mean time between transplantation and endoscopic treatment was 59.6 (5-132) months, and the mean follow-up period after the endoscopic treatment was 14 (6-48) months, respectively. The success rate after the first injection was 59.1% (n = 29) and 67.3% (n = 33) after the second injection. One patient developed anuria, one patient febrile UTI and four patients developed minimal macroscopic hematuria after the procedure.

CONCLUSIONS

Endoscopic treatment of symptomatic VUR in transplanted kidney is a safe and feasible procedure. The amount of bulking agent or duration between the transplantation and diagnosis of VUR does not have any impact on the success of the treatment. However, the younger age of the patients and the female gender seem to have a positive effect on the outcome of the procedure.

Efficiency and Safety of the Sting Operation on Kidney Transplanted Patients with Symptomatic Vesicoureteral Reflux and Neurogenic Bladder Dysfunction

PURPOSE

The study aimed to evaluate the feasibility and effectiveness of the endoscopic treatment in transplanted patients with neurogenic bladder who complained of symptomatic vesicoureteral reflux (VUR).

MATERIAL AND METHODS

Fifteen patients with VUR who were previously diagnosed with a neurogenic bladder were included in the study. The Lich-Gregoire technique was used for ureterovesical anastomosis during transplantation, and a double J stent was inserted routinely in the ureter to protect the anastomosis. The sting operation was performed under general anesthesia in the lithotomy position. A 4.8 Fr double J stent (Boston Scientific, Boston, MA) was inserted to prevent the risk of ureteral obstruction. Successful treatment was defined as absent acute glomerulopyelonephritis (AGPN) during follow-up and as absent VUR on radiological evaluation.

RESULTS

Clinical success was achieved in 6 of 10 patients (60%) who presented with recurrent febrile urinary tract infection (UTI) and in 4 of 6 (66%) patients who presented with gradually graft function deterioration. In 3 patients, the ureteral neo-orifice could not be localized during the operation owing to severe trabeculation of the bladder wall. The other 2 patients with a previous history of augmented bladder procedures had a hypotension attack during bladder filling; hence, the operation was stopped to prevent further complications. Two patients, whose clinical symptoms did not resolve after the sting procedure, accepted open ureteral reimplantation surgery.

CONCLUSION

Endoscopic management of the VUR in the transplant patients with neurogenic bladder function is safe and effective in at least half of the patients in a mid-term follow-up period.

Endoscopic Treatment for Post-Transplant Vesicoureteral Reflux

INTRODUCTION

Vesicoureteral reflux (VUR) is one of the most common ureteric complications after kidney transplantation that might cause symptomatic infections which deteriorate graft function. Surgical reimplantation has been the standard treatment; recently, endoscopic injection has been an alternative approach. We report our endoscopic treatment results and analyze the long-term outcome, even in patients with less optimal graft function.

MATERIALS AND METHODS

A total of 16 patients and 19 symptomatic VUR were diagnosed at mean time of 88.3 months after their transplantation. The distribution of VUR grade was 1, 2, 8, 6, and 2 for grade I to V, respectively, with a mean VUR grade of 3.26 according to their voiding cystourethrogram images. Endoscopic Deflux injections were performed by a single urologist via rigid cystoscope with a beveled needle system. They were followed monthly thereafter.

RESULT

The average number of admissions due to symptomatic urinary tract infection was 2.68/person, and the mean creatinine level before endoscopic treatment was 1.63 mg/dL. The amount of Deflux injection was 0.7 to 1.2 mL per affected ureter; the mean creatinine level after endoscopic treatment was 1.41 mg/dL. The eGFR remained stationary in both eGFR > 60 and eGFR < 60 mL/min groups with a clinical success rate of 75% in both groups.

CONCLUSION

Endoscopic dextranomer-hyaluronic acid injection is a safe and feasible treatment option for VUR after kidney transplantation. Our data showed its efficacy in recipients whose eGFR is less than 60 mL/min.

Symptomatic Venous Thromboembolism and Major Bleeding After Renal Transplantation: Should We Use Pharmacologic Thromboprophylaxis?

BACKGROUND

Venous thromboembolism (VTE) is a major health issue that may result in complications such as post-thrombotic syndrome, pulmonary hypertension, and death. Appropriate thromboprophylaxis in individuals undergoing kidney transplantation remains unclear. The aim of this study was to determine the prevalence of symptomatic VTE and major bleeding within 90 days after renal transplantation (RT).

METHODS

This was a retrospective study on consecutive patients undergoing RT at Hospital Privado Córdoba, Argentina, from January 1, 2006, to December 31, 2013. Exclusion criteria were age <18 years and combined organ transplantation. Pharmacologic or mechanical thromboprophylaxis was not used routinely. Symptomatic VTE and major bleeding were documented.

RESULTS

A total of 511 RTs were performed; 62 patients received combined organ transplantation, and 8 patients (1.5%) were lost to follow-up. Overall, follow-up was completed on 441 patients, 4 (0.9%) of whom developed deep venous thrombosis and 14 (3%) of whom died. The most frequent causes of death were septic shock and severe hemorrhage. Duration of surgery >4 hours (P = .006) and a history of VTE (P < .001) were associated with VTE. Twenty-three patients (5.2%) had major bleeding, 2 (0.4%) died from bleeding complications, and 17 (3.85%) required a reoperation to control bleeding.

CONCLUSIONS

This study shows a low prevalence of symptomatic VTE in patients undergoing RT despite not having used thromboprophylaxis routinely. Major bleeding was significant, and despite the high risk of VTE assigned by the Caprini score, which suggests pharmacologic prophylaxis, our data raise questions about the appropriate prophylaxis for these patients.

Late Allograft Renal Vein Thrombosis Treated With Anticoagulation Alone: A Case Report

BACKGROUND

Allograft renal vein thrombosis is a rare complication of kidney transplantation. Most cases occur in the first 2 weeks after transplantation, but there are cases described many years after the transplant surgery. Allograft loss is the usual outcome.

METHODS

We present a case of a renal transplant recipient with allograft renal vein thrombosis associated with deep venous thrombosis of a lower limb, 9 years after transplantation. He was successfully treated with anticoagulation alone, with recovery of allograft function.

RESULTS

The patient was given unfractioned heparin and elastic compression stockings. Five days later, the patient recovered diuresis and hemodialysis treatment was discontinued. Doppler ultrasound was done and revealed partial re-permeabilization of allograft renal vein, with maximal velocity of 15 cm/s. After 30 months of follow-up, the patient was maintained on oral anticoagulation with warfarin, and no thromboembolic or hemorrhagic events were documented. The patient's serum creatinine was stable, between 1.6 and 1.8 mg/dL.

CONCLUSIONS

Our patient demonstrated that anticoagulation alone and dialytic support might be able to promote total recovery of allograft function after renal vein thrombosis.

Comparison of Surgical Correction Techniques for Post-Renal Transplantation Vesicoureteral Reflux

BACKGROUND

Symptomatic urinary tract infection (UTI) after renal transplantation (RT) is an important morbidity in transplant recipients and may cause pyelonephritis and sepsis. Surgical correction of high-grade vesicoureteral reflux (VUR) after RT is suggested, performing ureteral reimplantation or pyelo-ureteral/uretero-ureteral anastomosis. Recently, extravesical seromuscular tunnel lengthening techniques have been reported with favorable results and low complication rates.

METHODS

We retrospectively reviewed the charts of 38 patients with post-transplantation VUR who underwent reflux correction surgery. Patient characteristics were analyzed to compare our extravesical seromuscular tunnel lengthening technique with uretero-ureteral and pyelo-ureteral anastomosis techniques.

RESULTS

Twenty patients were treated with the extravesical approach (group I) and 18 patients by pyelo-ureteral or uretero-ureteral anastomosis with the use of native ureter (group II). Mean operative time was significantly shorter in group I than in group II (64.8 vs 110.1 min; P < .05), and mean duration of hospital stay after the operation also was shorter in group I (1.5 vs 5.1 d; P < .05). We determined persistent VUR in postoperative voiding cystouretrography in 2 patients (10%) in group I, but there was regression in VUR grades of all of the patients. There was no significant difference in postoperative number of UTI episodes and serum creatinine levels between the 2 groups.

CONCLUSIONS

Extravesical seromuscular tunnel lengthening is an effective and safe technique for post-transplantation VUR management.

Rigenera protocol in the treatment of surgical wound dehiscence

The effective management of post-operative wounds is important to prevent potential complications such as surgical-site infections and wound dehiscence. The purpose of this study was to treat wound dehiscence in elderly patients who were subjected to orthopaedic surgical interventions. The dehisced wounds were treated with autologous micro-grafts obtained using a promising CE-certified medical device called Rigeneracons. This instrument is a biological disruptor of human tissues able to specifically select progenitor cells that, as already reported in previous studies, maintain high cell viability but mainly have a high regenerative potential, allowing the repair of damaged tissues. Autologous micro-grafts obtained by Rigeneracons are ready to use and can be applied alone or in combination with biological scaffolds directly on the injured area. We observed in our patients a complete remission of dehisced wounds, on average, after 30 days from micro-grafts application and a total wound re-epithelialisation after 1 year from the surgical intervention. In conclusion, although we reported only three patients, autologous micro-grafts can be considered a promising approach for the treatment of dehisced wounds, improving the wound-healing process and in general the patient's quality of life without using other dressings.

Prevention of fluid effusion in kidney transplantation with the use of hemostatic biomaterials

BACKGROUND

Fluid effusion (blood, lymph, or urine) in kidney transplantation may give rise to several complications, directly, such as hematoma, seroma, lymphocele, and/or urinoma, or consequently, such as increased infection risk, longer hospital stay, graft compression--with or without functional impairment--and necessity of further hospitalizations. The aim of this study was to evaluate effectiveness of hemostatic biomaterials in prevention of fluid effusions, especially lymphocele in kidney transplant patients.

METHODS

We selected 40 patients who underwent kidney transplantation from 2009 to 2012 in which we used hemostatic biomaterials, and compared their results with those of other transplant patients from our center in which we did not used these biomaterials. Evaluated parameters were: fluid effusion, graft function, quality and quantity of drainage, blood count, and operative time.

RESULTS

There was no difference in operative time. The incidence of complications on which biomaterials can have a role decreased; particularly, we observed a reduction from 24.21% to 7.5% of fluid effusions (lymphocele). There was no evidence of complications due to biomaterials.

CONCLUSIONS

Hemostasis is important in surgery, and in kidney transplantations lymphostasis also has a significant role. In addition to the traditional hemostatic methods, recently some biomaterials, with the purpose of providing atraumatic hemostasis, were added. In our experience they are easy to use, and their use has proved to be effective for both hemostasis and lymphostasis with consequent reduction of fluid effusions.

Recipient and donor risk factors for surgical complications following kidney transplantation

OBJECTIVE

The aim of this study was to evaluate recipient and donor risk factors that are related to surgical complications after renal transplantation.

MATERIAL AND METHODS

In total, 419 kidney transplantations were analysed with regard to the influence of recipient and donor risk factors on the main postoperative surgical complications.

RESULTS

The mean follow-up for the entire group was 72.8 months (± 54.2 SD). Vascular complications were independently associated with donor age; and urological complications with recipient age >65 years and cyclosporine rather than tacrolimus therapy. Wound complications were independently associated with recipient age, preoperative dialysis time, recipient body mass index (BMI) and cyclosporine rather than tacrolimus therapy. Collections were independently associated with retransplantation, type 2 diabetes mellitus and wound complications. Overall surgical complications were associated with donor age and delayed graft function. In terms of severity, grade I complications were independently associated with recipient age and surgical revision, grade II with recipient age >50 years, grade III with recipient BMI, and grade IV with donor age.

CONCLUSIONS

Recipient characteristics are the primary determinants of wound, urological and minor (Clavien grades I, II and III) complications; however, graft or donor characteristics are the primary risk factors for vascular, overall and major (Clavien grade IV) surgical complications.

A novel surgical technique for management of vesicoureteral reflux following kidney transplantation: prospective study of 12 cases

The incidence of vesicoureteral reflux (VUR) varies between 10% and 80% of transplanted kidneys. In cases of failure of endoscopic treatment or recurrent urinary tract infections, surgical correction is proposed by ureteral reimplantation or pyeloureteral anastomosis using the native ureter. The aim of this study was to assess the results of a technique that increases the submucosal length of the ureter without a ureterovesical reimplantation. We treated 12 patients with VUR in the transplanted kidney by open surgery. Retrograde cystography showed resolution of reflux in all the patients. Our technique has the advantage of avoiding ureteral dissection thereby avoiding its devascularization and no invasion of the bladder mucosa.

Testicular torsion after pediatric kidney transplantation

Kidney transplantation has become the treatment of choice for children with end-stage renal disease and offers recipients an excellent quality of life. Following kidney transplantation several types of medical and surgical complications can arise. In this report, a testicular torsion occurring on the sixth day after pediatric kidney transplantation is described. It remains unclear whether this unusual complication should be regarded as coincidental or as a direct consequence of the transplantation.