Is routine ureteral stenting cost-effective in renal transplantation?

External ureteric stent versus internal double J stent in kidney transplantation: a retrospective analysis on the incidence of urological complications and urinary tract infections

Introduction

Urologic complications (UCs) and urinary tract infections (UTIs) are common after kidney transplantation. Intraoperative stent placement at the vesicoureteric anastomosis reduces UC risk, but increases UTI risk.

Methods

In 2014 our stenting protocol changed from external ureteric stent (ES) to internal double J stent (DJ). We retrospectively studied the occurrence of UCs and UTIs in relation to ES or DJ in 697 kidney recipients.

Methods

An ES was used in 403 patients (57.8%), in 294 (42.2%) a DJ. ES was removed 7-12 days and DJ 3-4 weeks post-operative. Induction immunosuppression was the same in both groups. Primary outcomes at 6 months follow-up were UC (urinary leakage/ureter stenosis) and UTI; they were related to stenting procedure and clinical and transplant characteristics. The incidence of UCs was similar for ES (8.4%) and DJ (6.8%), p=0.389. ES use was a significant risk factor for UTI (OR 1.69 (1.15-2.50), p=0.008). Post-transplant hospitalization was significantly shorter in the DJ group. Despite more acute rejection episodes with ES (ES/DJ: 16.4%/6.1%, p<0.001), no clinical relevant differences in graft outcomes existed.

Discussion

A DJ is, compared to ES, associated with a lower incidence of UTIs and comparable occurrence of UCs and is therefore the preferred technique for stenting the vesicoureteric anastomosis.

Ureteric Trauma following Stent Removal in Kidney Transplant Recipient: A Unique Case of Prolonged Morbidity

A 52-year-old African-American male patient with end-stage renal disease due to hypertension underwent deceased donor kidney transplant procedure with no immediate complications. The postprocedure complications, interventions, and course were abstracted by chart review. The ureteric stent was removed with flexible cystoscopy on postoperative day (POD) 24. 24 hours later, the patient presented with abdominal pain and inability to urinate. An urgent ultrasound and noncontrast CT scan showed grade 4 hydronephrosis of the transplanted kidney. A percutaneous nephrostomy stent was placed for urinary diversion. A large ureteric hematoma filling the lumen of the mid to distal ureter was identified on the nephrostogram and was evacuated. A follow-up nephrostogram on POD 44 revealed a distal ureter stricture and persistent well-formed midureter filling defect. A repeat nephrostogram performed at POD 72 was done with stricture dilatation, internalization of stents, and removal of a percutaneous nephrostomy tube. The patient was maintained on antibiotics for UTI prophylaxis throughout the course.

Tubeless percutaneous nephrolithotomy (PCNL) for forgotten and retained stent in renal allograft recipient: an interesting case report and lessons learnt

Complications after renal allograft transplantation are not so uncommon. Most complications are related to graft rejection, immune-suppressive drug toxicity and the operative procedure. Stents are placed after a transplant to prevent urine leak at the site of ureteric reimplantation, to facilitate an early healing in immune-suppressed individuals and to prevent obstruction at the site of ureteral anastomosis. We report a case of a renal allograft recipient with a forgotten ureteral double J stent. where the stent remained in situ for more than 4 years and further complicated by encrustation and stone formation at both the bladder and renal pelvic ends. The stone over the bladder coil was removed by holmium laser cystolithotripsy while the encrusted renal pelvic coil was removed by percutaneous approach. This case is presented for its rarity and also to emphasise on the need for maintenance of a stent register in order to ensure avoidance of such preventable complications.

Implementing a Ureteric Magnetic Stent in the Kidney Transplant Setting: Report of 100 Consecutive Cases

BACKGROUND

Kidney transplantation (KT) is the treatment of choice for end-stage kidney disease. The double-J-stent has been used to prevent urological complications (UCs), but it requires cystoscopy extraction. The novel magnetic black star (MBS) stent provided with a customized retrieval device (9 or 15 Fr) has been developed to spare cystoscopy. Scope of the paper is to analyze MBS in 100 consecutive KTs.

METHODS

We report a retrospective analysis of 100 consecutive KT performed between April 2015 and September 2018 using MBS (4.8 Fr, 15 cm) to protect Lich-Gregoir ureteroneocystotomy. MBS was removed 4 weeks after KT by either the 9 Fr (61 cases) or the 15 Fr (39 cases) retrieval device.

RESULTS

Intraoperative MBS insertion was straightforward in all cases, and its extraction was carried out in the outpatient setting in 93 patients. Extraction time was <30 seconds in 45 out of 61 patients (73.8%) and in 38 out of 39 patients (97.4%) using the 9 Fr and the 15 Fr retrieval device, respectively. In 15 patients, MBS removal took between 30 seconds and 3 minutes. Only 2 cases required extraction by cystoscopy. We observed 2 UC (ureteric leak and stenosis), 8 urinary tract infections, and 9 stent-related symptoms. 7 patients experienced distressing pain according to Visual Analog Scale for Pain.

CONCLUSIONS

In our cohort, MBS appeared to be safe and cost-effective. We advocate its routine implementation in KT because of an easy and comfortable extraction in the outpatient setting even by nondedicated staff, without detrimental impact on UC and urinary tract infection rates.

Does early removal of double J stents reduce urinary infection in living donor renal transplantation?

INTRODUCTION

Prophylactic use of double J (DJ) stents in recipients is highly accepted in renal transplantation. In this study, the association between the frequency of urologic complications (UC) and urinary tract infections (UTI), and the early or late removal of DJ stents was investigated.

MATERIAL AND METHODS

A total of 116 live-donor renal transplant patients were included in the study during a 4-year period, with a mean follow-up of 29.2 ±15.3 months. In all, DJ stents were used. All patients were clinically monitored for graft function by assessment of the complete blood count, renal biochemistry, urine analysis and blood drug level according to our follow-up protocol.

RESULTS

The patients were divided into 2 groups according to the time of their stent removal: group I (n = 44), removal within the first 14 days; and group II (n = 72), removal after 14 days. No urinary leaks were detected in either of the groups. Three patients suffered from anastomotic stricture (group I, n = 1; group II, n = 2). The rates of UTI were similar in groups I and II (13.6% vs. 16.6%, respectively, p = 0.79). The rate of UTI in women was found to be 3.8 times higher than in men.

CONCLUSIONS

The results of our study demonstrated that DJ stent removal within 14 days did not reduce the risk of UTI when compared to stent removal after 14 days. Similar effects on complication rates for ureteral stenting for these 2 removal periods were observed.

Benefits and Complications of Removing Ureteral Stent Based on the Elapsed Time After Renal Transplantation Surgery

Background

The most important surgical complications of renal transplantation are stenosis and obstruction of anastomosis of the ureter to the bladder. Although the routine use of the ureteral stents to prevent such complications seems rational, the optimal time to keep the ureteral stent is still controversial.

Objectives

This study presents the benefits and complications of removing the ureteral stent based on the elapsed time after the surgery.

Patients and Methods

All patients who underwent kidney transplantation between May 2011 and August 2014 in Modarres hospital, Tehran, Iran, were enrolled in the study. The patients were classified into three groups. The ureteral stent was removed 10, 20, and 30 days after the transplantation in these groups.

Results

A total of 529 patients underwent kidney transplant surgery in our center. Urologic complications among the three groups consisting of hydronephrosis, urinoma and collection did not have statistically significant differences.

Conclusions

Ureteral stent can be picked up with no increased risk of urologic complications at shorter intervals after the kidney transplantation surgery.

Early Stent Removal After Kidney Transplantation: Is it Possible?

Background

The most important surgical complications of renal transplantation are stenosis and obstruction of the ureterovesical anastomosis. Routine use of ureteral stents can prevent this complication, but the optimal time for ureteral stent use is still controversial.

Objectives

The purpose of this study is to compare the benefits and complications of early and delayed stent removal after surgery. Early ureteral stent removal can decrease some complications, such as urinary tract infections (UTIs), bladder irritation symptoms, persistent hematuria, and the risk of stent crusting; its benefits include easier stent removal and shorter hospitalization time.

Patients and Methods

All patients who underwent kidney transplantation from May 2011 until March 2012 in Modarres Hospital were included in this study. We classified the patients into three groups, based on time of stent removal (10, 20, and 30 days after transplantation).

Results

Ninety-one patients were studied; urologic complications (hydroureteronephrosis and urinoma) in these three groups were analyzed and showed no statistical significant difference.

Conclusions

We can remove the ureteral stent earlier after kidney transplantation with no increase in the prevalence of surgical complications.

Internal or External Stenting of the Ureterovesical Anastomosis in Renal Transplantation

BACKGROUND

Stenting of the ureterovesical anastomosis reduces the incidence of urological complications (UCs) after renal transplantation, but there are multiple stenting techniques, and there is no consensus regarding which technique is preferred. The aim of this study was to compare an internal versus an external stenting technique on the incidence of UCs.

METHODS

This is a retrospective analysis of 419 deceased donor renal transplantations performed between January 2008 and December 2013. Until 2011, 183 patients received an external stent through the ureterovesical anastomosis placed by suprapubic bladder puncture (SP stent). From 2011, 236 recipients received an internal double-J (JJ) stent.

RESULTS

The rate of UC was 3.8% in JJ stents, compared to 9.3% in SP stents (p = 0.021). No difference in surgical ureter revision rate was observed between the groups (2.1 vs. 5.5%; p = 0.068). Urinary tract infection (UTI) rate and graft function were comparable between both groups.

CONCLUSIONS

Internal JJ stenting significantly decreased the incidence of UC compared to an external SP stent. There was no difference in surgical ureter revision rate, UTI or graft function.

Double-J Versus External Ureteral Stents in Kidney Transplantation: A Retrospective Analysis

Background:

Kidney transplantation has long been recognized as the best available therapy for end stage kidney disease.

Objectives:

This study aimed to compare outcomes of double-J versus percutaneous ureteral stent placement in renal transplantation.

Patients and Methods:

A retrospective analysis was performed on data of renal transplantations performed at our institution in a 12-month period. In this period, external and double-J stents were used in parallel. Length of hospital stay and stent-associated complications were evaluated.

Results:

In 76 kidney transplants, 43 external (group 1) and 33 double-J (group 2) urinary stents were used. No significant difference was observed in the number of urinary tract infections, ureteric stenosis or necrosis. The mean overall length of hospital stay was comparable in both groups (20.7 days in group 1 vs 19.3 days in group 2, P = 0.533). For patients without immunological complications, the hospital stay was significantly reduced using double-J stents (12.9 days in group 1, 10.8 days in group 2, P = 0.018). Leakage of the ureteroneocystostomy occurred in 6 out of 43 patients in group 1 (13.9%). No case of anastomotic insufficiency was observed in group 2 (P = 0.035). Macrohematuria was detected in 13 out of the 43 patients in group 1 (30.2%), compared to 3 out of 33 patients in group 2 (9.1%; P = 0.045).

Conclusions:

This nonrandomized comparison of stent types in kidney transplantation supports the use of prophylactic double-J stents in terms of decreased ureteric complications and reduced length of hospital stay.

The accuracy of transrectal ultrasound-guided biopsy for decision making in prostate cancer

Background:

The most important surgical complications of renal transplantation are stenosis and obstruction of anastomosis of the ureter to the bladder. Hence, routine use of ureteral stents to prevent such complications seems logical; however, the optimal time to remove the ureteral stent is still controversial.

Objectives:

The purpose of this study was to compare the benefits and complications of the early or delayed ureteral stent removal post-transplantation.

Patients and Methods:

All patients who underwent kidney transplantation in Modarres Hospital from May 2011 through March 2012 were recruited. The patients were allocated to three groups. Ureteral stent removed 10, 20, and 30 days after transplantation in groups one, two, and three, respectively.

Results:

A total of 91 patients had undergone renal transplantation in our center. Ureteral stent was removed at 10, 20, and 30 days after surgery. Urologic complications among the three groups included hydronephrosis, urinoma, and collection around the graft; there was no statistically significant difference among study groups with regard to frequency of complications.

Conclusions:

We can remove the ureteral stent at shorter interval after renal transplantation with no increased risk of urologic complications.

Detection of medical errors in kidney transplantation: a pilot study comparing proactive clinician debriefings to a hospital-wide incident reporting system

BACKGROUND

Rates of medical errors and adverse events remain high for patients who undergo kidney transplantation; they are particularly vulnerable because of the complexity of their disease and the kidney transplantation procedure. Although institutional incident-reporting systems are used in hospitals around the country, they often fail to capture a substantial proportion of medical errors. The goal of this study was to assess the ability of a proactive, web-based clinician safety debriefing to augment the information about medical errors and adverse events obtained via traditional incident reporting systems.

METHODS

Debriefings were sent to all individuals listed on operating room personnel reports for kidney transplantation surgeries between April 2010 and April 2011, and incident reports were collected for the same time period. The World Health Organization International Classification for Patient Safety was used to classify all issues reported.

RESULTS

A total of 270 debriefings reported 334 patient safety issues (179 safety incidents, 155 contributing factors), and 57 incident reports reported 92 patient safety issues (56 safety incidents, 36 contributing factors). Compared with incident reports, more attending physicians completed the debriefings (32.0 vs 3.5%).

DISCUSSION

The use of a proactive, web-based debriefing to augment an incident reporting system in assessing safety risks in kidney transplantation demonstrated increased information, more perspectives of a single safety issue, and increased breadth of participants.

Resource utilization associated with procurement of transplantable organs from donors that do not meet OPTN eligible death criteria

BACKGROUND

The strategy of evaluating every donation opportunity warrants an investigation into the financial feasibility of this practice. The purpose of this investigation is to measure resource utilization required for procurement of transplantable organs in an organ procurement organization (OPO).

METHODS

Donors were stratified into those that met OPTN-defined eligible death criteria (ED donors, n=589) and those that did not (NED donors, n=703). Variable direct costs and time utilization by OPO staff for organ procurement were measured and amortized per organ transplanted using permutation methods and statistical bootstrapping/resampling approaches.

RESULTS

More organs per donor were procured (3.66±1.2 vs. 2.34±0.8, P<0.0001) and transplanted (3.51±1.2 vs. 2.08±0.8, P<0.0001) in ED donors compared with NED donors. The variable direct costs were significantly lower in the NED donors ($29,879.4±11590.1 vs. $19,019.6±7599.60, P<0.0001). In contrast, the amortized variable direct costs per organ transplanted were significantly higher in the NED donors ($8,414.5±138.29 vs. $9,272.04±344.56, P<0.0001). The ED donors where thoracic organ procurement occurred were 67% more expensive than in abdominal-only organ procurement. The total time allocated per donor was significantly shorter in the NED donors (91.2±44.9 hr vs. 86.8±78.6 hr, P=0.01). In contrast, the amortized time per organ transplanted was significantly longer in the NED donors (23.1±0.8 hr vs. 36.9±3.2 hr, P<0.001).

DISCUSSION

The variable direct costs and time allocated per organ transplanted is significantly higher in donors that do not meet the eligible death criteria.

Impact of ureteral length on urological complications and patient survival after kidney transplantation

BACKGROUND

Urologic complications are of the most important complications after kidney transplantation which increases mortality and morbidity significantly.

OBJECTIVES

We designed this study to evaluate the association between ureteral length and postoperative complications.

PATIENTS AND METHODS

We recorded the length of the transplanted ureter during the operation. Ureter-to-bladder anastomosis was performed using modified Lich-Gregoir method on the ureteral stent. Complications like urine leakage and increased creatinine were evaluated. We used both univariate and multivariate analyses and survival analysis according lengths of ureter. It means that the main variable is ureteral length and other variables are studied based on it.

RESULT

A total of 395 patients with the mean age of 37 years (range, 18 to 68 years) were enrolled in the study, twenty six graft lost during the follow-up period. The Mean age of recipients was 37 ± 13 years. Urinary stenosis was seen in 6 patients (1.5%) and urinary leakage in 4 (1%) patients. The complication rate was not significantly different between these groups (P = 0.67). We found that there were no significant difference among complication (P = 0.25), hospitalization (P = 0.31) and survival (P = 0.84) at 5.5 cm length cut off.

CONCLUSIONS

The length of transplanted ureter does not affect the postoperative urologic complications (including urinary fistula and ureter-to-bladder anastomosis stricture), and it seems that decreased rate of complication frequency during the recent years is due to technical improvement, surgeon's skillfulness and development in use of immunosuppressant's postoperatively.

Effect of ureteric stents on urological infection and graft function following renal transplantation

AIM: To compare urological infections in patients with or without stents following transplantation and to determine the effect of such infections on graft function.

METHODS: All 285 recipients of kidney transplantation at our centre between 2006 and 2010 were included in the study. Detailed information including stent use and transplant function was collected prospectively and analysed retrospectively. The diagnosis of urinary tract infection was made on the basis of compatible symptoms supported by urinalysis and/or microbiological culture. Graft function, estimated glomerular filtration rate and creatinine at 6 mo and 12 mo, immediate graft function and infection rates were compared between those with a stent or without a stent.

RESULTS: Overall, 196 (183 during initial procedure, 13 at reoperation) patients were stented following transplantation. The overall urine leak rate was 4.3% (12/277) with no difference between those with or without stents - 7/183 vs 5/102, P = 0.746. Overall, 54% (99/183) of stented patients developed a urological infection compared to 38.1% (32/84) of those without stents (P = 0.0151). All 18 major urological infections occurred in those with stents. The use of stent (Wald χ² = 5.505, P = 0.019) and diabetes mellitus (Wald χ² = 5.197, P = 0.023) were found to have significant influence on urological infection rates on multivariate analysis. There were no deaths or graft losses due to infection. Stenting was associated with poorer transplant function at 12 mo.

CONCLUSION: Stents increase the risks of urological infections and have a detrimental effect on early to medium term renal transplant function.

Stented ureterovesical anastomosis in renal transplantation: does it influence the rate of urinary tract infections?

Objective

Our objective was to evaluate the impact of routine use of double-J stents on the incidence of urinary tract infection after renal transplantation.

Methods

We conducted a retrospective-comparative single-centre study in 310 consecutive adult deceased donor kidney recipients transplanted from 2002 to 2006. Patients were divided in two groups, with or without urinary stent implantation. To evaluate the predictive factors for UTI, donor and recipients pre- and post-transplantation data were analysed. Early urological complications and renal function within 12 months of transplantation were included as well.

Results

A total of 157 patients were enrolled to a stent (ST) and 153 patients to a no-stent (NST) group. The rate of urinary tract infection at three months was similar between the two groups (43.3% ST vs. 40.1% NST, p = 0.65). Of the identified pathogens Enterococcus and Escherichia coli were the most common species. In multivariate analysis neither age nor immunosuppressive agents, BMI or diabetes seemed to have influence on the rate of UTI. When compared to males, females had a significantly higher risk for UTI (54.0% vs. 33.5%).

Conclusion

Prophylactic stenting of the ureterovesical anastomosis does not increase the risk of urinary tract infection in the early postoperative period.

Impact of early ureteric stent removal and cost-benefit analysis in kidney transplant recipients: results of a randomized controlled study

INTRODUCTION

Duration of retaining ureteric stent in kidney transplantation is still controversial. Our study aimed to compare healthcare expenditures in kidney transplant recipients with early or routine ureteric stent removal.

METHODS

This study was a post hoc analysis of data from a single-center parallel randomized controlled open-label study. Ninety patients who underwent kidney transplantation at a university-based hospital in Thailand from April 2010 to January 2011 were enrolled. Patients were randomized to early ureteric stent removal (8 days) or routine ureteric stent removal (15 days) after kidney transplantation. The costs of direct health care associated with kidney transplantation, urologic complication, and urinary tract infection (UTI) within the postoperative period among the 2 groups were compared.

RESULTS

Seventy-four patients (58% living donor) fulfilled the randomized criteria (early removal, n = 37; routine removal, n = 37). By intention-to-treat analysis, incidence of UTI in early stent removal was less than the routine stent removal group (15/37, 40.5% vs 27/37, 72.9%; P = .004). Urologic complication showed no significant difference between the early and routine groups (4/37 vs 2/37; P = .39). The cost-benefit analysis of early over routine stent removal was 2390 United States dollars (USD) per patient (11,182 vs 8792 USD). Presence of UTI significantly increase the hospitalization cost of 5131 USD per patient (mean cost = 12,209 vs 7078 USD; P < .001).

CONCLUSION

UTI in the early post-kidney transplantation period increases healthcare cost. Early ureteric stent removal can reduce UTI and reduce hospitalization cost. This approach shows cost-benefit in the early management of kidney transplant recipients.

Routine short-term ureteral stent in living donor renal transplantation: introduction of a simple stent removal technique without using anesthesia and cystoscope

OBJECTIVE

We evaluated routine short-time insertion of ureteral stent in living donor renal transplant at a single center. It was easy to remove the stent without cystoscopy and anesthesia.

MATERIALS AND METHODS

Between October 2007 and July 2010, a single surgeon performed 76 living donor renal transplantations at one institute. All recipients underwent extravesical ureteroneocystostomy with a 2-0 silk suture passed through the venting side hole of the double-J stent into the bladder; a quadruple knot prevented the suture's slippage or distraction from the stent. After removal of the indwelling catheter at 5 days posttransplantation, the 2-0 silk passed with the urinary stream within 72 hours. The double-J stent was removed at 7 to 10 (mean 8.4) days after kidney transplantation by pulling the 2-0 silk out of the urethral orifice without anesthesia or cystoscopy.

RESULTS

There was only one case of stenosis, which was resolved by surgery. No patient developed urinary leakage. There were three episodes of urinary tract infection in 70 patients during first 6 months' follow-up.

CONCLUSIONS

Routine short-term stenting is a safe and effective technique in living donor renal transplantation. Removal of the stent is feasible without cystoscopy or anesthesia.

Transplant ureter should be stented routinely

Vesicoureteric complications present early after transplantation and contribute to patient morbidity, graft loss and mortality. Ureteral stenting provides a decrease in ureteroneocystostomy anastomotic complications following renal transplantation. There should be prophylactic stent insertion with endoscopic removal at a designated time post transplantation. With the addition of antibiotic prophylaxis post transplantation, ureteric stenting does not increase the rate of urinary tact infections. There is no significant increase in cost for stenting during transplantation in comparison to management of major ureteric complications. Routine stenting causes significant cost-saving per year and prevents anastomotic complications. It is wise to stent the transplant ureter routinely.

[Should ureteral catheterization be systematically used in kidney transplants?]

OBJECTIVE

To assess if the systematic use of double J ureteral catheters in ureteroneocystostomies of kidney transplants reduces the rate of complications.

MATERIALS AND METHODS

Non-randomized prospective, comparative study of parallel groups in 194 kidney transplants. We established two equal groups, 111 patients with double J catheter and another of 83 catheter-free patients. We studied the incidence of complications between both groups by means of a univariate comparative study (X2 test)and a multivariate analysis (logistic regression).

RESULTS

In the catheter group, the overall complications appeared in 22.2% as opposed to 43.3% of the catheter-free group (p=0.04). Depending on the ureteral transplant, complications appeared in 38.12% of the Paquin type reimplantation as opposed to the 20.3% in Lich-Gregoir (p=0.09). There was evidence of 1 (0.9%) urinary fistula in the catheter group as opposed to 5 (6%) in the catheter-free group (p=0.08), and 3 (2.7%) ureterovesical anastomosis stricture in the group with catheter against 7 (8.4%) of the catheter-free group (p=0.13). The multivariate analysis showed that not using the catheter increases the risk of suffering complications related to reimplantation (OR: 2.55; IC 95%, 1.37-4.75). The risk of fistula increased significantly when a catheter was not placed (OR 9.19, IC 95%, 1.01-84.7). There were no differences between the two groups as regards urinary tract infections; there were 3 (2.7%) in the catheter group and 1 (1.2%) in the catheter-free group (p=0,63).

CONCLUSIONS

The placement of a double J catheter reduces complications related to ureteral reimplantation without increasing the morbidity associated with their use.

Effectiveness of a 5-day external stenting protocol on urological complications after renal transplantation

Background

Ureteral stents are successful in reducing urological complications after renal transplantation. However, the optimal duration and method of stenting have not yet been clarified. The objective of the present study was to investigate the frequency of urological complications when a 5-day external stented ureterocystostomy protocol was followed.

Methods

A single-center nonrandomized analysis of 392 kidney transplantations between June 2003 and June 2007 was conducted. From July 2005 all 196 renal transplant recipients received a 5-day external stented ureterocystostomy. A urological complication was defined as any cause leading to the placement of a percutaneous nephrostomy catheter and/or surgical revision of the ureterocystostomy.

Results

In the non-stented group, 21 of the 196 patients (10.7%) developed a urological complication compared to 13 patients (6.6%) in the stented group (p = 0.151). In the stented group, 2 of the 66 recipients of a living donor transplant (3.0%) developed a urological complication compared to 8 of the 59 recipients (13.6%) in the non-stented group (P = 0.030). Eleven of 130 recipients of a deceased donor transplant (8.5%) in the stented group developed a urological complication, compared to 13 of the 137 recipients (9.5%) in the non-stented group (P = 0.769). The surgical revision rate of the stented and the non-stented group was 5/13 39% and 6/21 29%, respectively.

Conclusions

A 5-day routine external stent protocol is efficacious in living donor renal transplantation in preventing early postoperative ureter obstruction, but this stenting period seems inadequate for deceased donor renal transplantation.

Effects of ureteral stent on urologic complications in renal transplant recipients: a retrospective study

The aim of the present study was to analyze the effects of ureteral stents used in renal transplantation on urologic as well as other complications. Cases of renal transplants from living or deceased donors performed in our hospital were retrospectively evaluated. The effects of the routine use of ureteral stents on postoperative complications were investigated. All outcomes and complications encountered during the postoperative follow-up were recorded. The Lich-Gregoire technique, which is a method of extravesical ureteroneocystostomy, was performed on all patients. One hundred and twenty-two patients underwent renal transplantation between 2001 and 2007 in our hospital. Stents were placed routinely in all patients. Leakage was observed in one patient, and one patient developed an obstruction; however, none of the patients developed an infection. A lymphocele developed in one patient. All urologic complications were treated without major morbidity. Graft loss did not occur. Complications following urinary anastomosis have a high rate of morbidity in renal transplantation. Ureteral stenting in renal transplant recipients prevents early urologic complications. The data generated in the current study were compared to the literature.

Case mix, quality and high-cost kidney transplant patients

A better understanding of high-cost kidney transplant patients would be useful for informing value-based purchasing strategies by payers. This retrospective cohort study was based on the Medicare Provider Analysis and Review (MEDPAR) files from 2003 to 2006. The focus of this analysis was high-cost kidney transplant patients (patients that qualified for Medicare outlier payments and 30-day readmission payments). Using regression techniques, we explored relationships between high-cost kidney transplant patients, center-specific case mix, and center quality. Among 43 393 kidney transplants in Medicare recipients, 35.2% were categorized as high-cost patients. These payments represented 20% of total Medicare payments for kidney transplantation and exceeded $200 million over the study period. Case mix was associated with these payments and was an important factor underlying variation in hospital payments high-cost patients. Hospital quality was also a strong determinant of future Medicare payments for high-cost patients. Compared to high-quality centers, low-quality centers cost Medicare an additional $1185 per kidney transplant. Payments for high-cost patients represent a significant proportion of the total costs of kidney transplant surgical care. Quality improvement may be an important strategy for reducing the costs of kidney transplantation.