Urologic complications in 1523 renal transplantations: The Baskent University experience

Interventional Treatment Methods for Ureteral Complications After Kidney Transplant: A Single-Center Experience

OBJECYIVES

Ureteral complications are one of the most common complications after kidney transplant. Although these complications have been treated surgically in the past, almost all can be successfully treated with interventional methods today. In this study, we assessed the interventional treatment of ureteral complications after kidney transplants performed in our center and the long-term results of these treatments.

MATERIALS AND METHODS

We performed a retrospective analysis of 2223 kidney transplant recipients seen between January 1, 2000, and May 1, 2020. Among these, 70 kidney transplant recipients who experienced ureteral leakage or ureteral obstruction in the early or late posttransplant period were included in the study. Complications within the first 2 months posttransplant were classified as early complications, whereas those occurring after 2 months were considered late complications. We treated all patients with interventional methods.

RESULTS

In review of patients, 44 patients were diagnosed with ureteral obstruction (22 patients were early obstruction, 22 were late obstruction) and 26 patients with ureteral anastomosis leakage. All patients with early and late ureteral obstruction were successfully treated with percutaneous methods. In the group of patients with ureteral leakage, all patients except 2 patients were treated with interventional methods. For 2 patients with ureteral leakage, surgical treatment was necessary because of persistent leakage despite percutaneous treatment methods.

CONCLUSIONS

Ureteral complications after kidney transplant can be successfully treated with interventional methods in experienced centers without the need for surgery.

Children Are Not Small Adults: Similarities and Differences in Renal Transplantation Between Adults and Pediatrics

Kidney transplantation is the treatment of choice for all patients with end-stage kidney disease, including pediatric patients. Graft survival in pediatrics was lagging behind adults, but now is comparable with the adult cohort. Although many of the protocols have been adopted from adults, there are issues unique to pediatrics that one should be aware of to take care of this population. These issues include recipient size consideration, increased incidence of viral infections, problems related to growth, common occurrence of underlying urological issues, and psychosocial issues. This article addresses the similarities and differences in renal transplantation, from preparing a patient for transplant, the transplant process, to post-transplant complications.

Dual Kidney Transplantation: Single-Center Experience

BACKGROUND

Dual and en bloc kidney transplantation are strategies used to mitigate the disparity between a reduced organ pool and an ever-increasing need for organ procurement. En bloc refers to the implantation of 2 kidneys from a pediatric donor, compensating for small renal mass, whereas dual expanded criteria donor (DECD) transplantation refers to older donors with grafts otherwise rejected for single transplant, including expanded. This study describes one center's experience with dual and en bloc transplantation.

METHODS

A retrospective cohort study of dual kidney transplants (en bloc and DECD) from 1990 through 2021. The analysis included demographic, clinical, and survival analysis.

RESULTS

Of 46 patients who underwent dual kidney transplantation, 17 (37 %) received en-bloc transplantation. The overall mean recipient age was 49.4 ± 13.9 years old, younger in the en-bloc subgroup (39.2 vs 59.8 years old, P < .01). The mean time on dialysis was 37 ± 25 months. Delayed graft function was present in 17.4 % and primary nonfunction in 6.4 %, all from the DECD group. The estimated glomerular filtration rates at 1 and 5 years were 76.7 ± 28.7 and 80.4 ± 24.8 mL/min/1.73 m2, lower in the DECD group (65.9 vs 88.7 mL/min/1.73 m2, P = 0.02). Eleven recipients lost their graft during the study period: 63.6% from death with a functioning graft, 27.3% due to chronic graft dysfunction (a mean of 76.3 months after transplantation), and 9.1% due to vascular complications. Subgroup comparison found no differences regarding cold ischemia time or length of hospitalization. Kaplan-Meier estimates, censored for death with a functioning graft, resulted in a mean graft survival of 21.3 ± 1.3 years, with survival rates of 93.5, 90.5, and 84.1% at 1, 5, and 10 years, respectively, without significant differences between subgroups.

CONCLUSIONS

Both DECD and en bloc strategies provide safe and effective options to further expand the use of otherwise rejected kidneys. Neither of the 2 techniques was superior to the other.

The Allium Ureteral Stent for the Treatment of Ureteral Complications Following Renal Transplantation-A Single-Center, Single-Surgeon Series

Ureteral complications such as urinary leak, ureteral necrosis or ureteral stenosis are common complications after renal transplantation with major short- and long-term issues, including graft impairment and graft loss. At present, there is no agreement on the optimal management of ureteral complications. The aim of the current study was to evaluate the safety and efficacy of the self-expanding, large-caliber Allium ureteral stent in patients with ureteral complications following renal transplantation. In this retrospective study, the electronic database of Charité University Hospital was screened for patients receiving the self-expandable Allium ureteral stent in the transplant ureter after kidney transplantation between January 2016 and March 2022. Descriptive statistics were used to describe the outcomes. There were six men and four women with a median age of 61 years (interquartile range, 55 to 68 years). Nine out of 10 patients had ureteric stenosis, which was diagnosed at a median of two years (interquartile range 10 months to 9 years) following renal transplantation. The median operating time was 49 min (interquartile range, 30 to 60 min). Endoscopic Allium stent placement was successful in all patients with ureteric stenosis. The median length of stay in the hospital was four days (interquartile range 2 to 7 days). Only one patient (#5) had a postoperative grade IIIb Clavien-Dindo complication. Patients had follow-ups every 3 months with ultrasound and serum creatinine. Dislocation of the Allium stent was seen in four patients; all occurred within three months. Ultimately, three patients required ureteric re-implantation, two of which had early dislocation of the stent. Six patients are managed with a permanent Allium stent. The median dwell time was 11 months (interquartile range 3 to 20 months) and maximum dwell time was 23 months. The overall success rate was 60% (6 out of 10). According to our data, the Allium stent represents a safe and minimally invasive option with a success rate of 60%. It might, therefore, represent an alternative to DJ stents, nephrostomies or immediate re-implantation. As all dislocations occurred within three months, frequent early postoperative follow-up is required.

Positive Effect of Platelet-Rich Plasma on Neoureterocystostomy in Rats: An Experimental Study

OBJECTIVES

Some of the most common problems after kidney transplant are urologic complications, including ureterocystoanastomosis leakage and stenosis with the development of severe renal graft complications. Isolated plasma contains active substances that cause the activation of various growth factors for the processes of tissue repair or regeneration, has an anti- inflammatory effect, activates angiogenesis, and reduces the risk of infectious complications. Platelet-rich plasma is actively used to stimulate bone regeneration, heal wounds and ulcers on the skin, enhance reconstruction of the larynx and trachea, and ameliorate urethral damage, among other uses. This study was developed to evaluate the positive effect of platelet-rich plasma on the healing process of an anastomotic wound in a model of ureterocystoanas-tomosis in rats.

MATERIAL AND METHODS

We randomized 14 Wistar albino male rats into 2 groups: group 1 included 7 rats that received platelet-rich plasma after ureterocystostomy; group 2 was the control group and included 7 rats that underwent ureterocystostomy without platelet-rich plasma. On postoperative day 7, all animals were euthanized, and the anastomosis area was resected for determination of the tissue hydroxyproline levels and histopathology examination.

RESULTS

Tissue hydroxyproline levels were 767 ± 62.9 μg/g in group 1 and 256 ± 28.0 μg/g in group 2. Tissue hydroxyproline levels were significantly higher in group 1 compared with group 2 (P < .05). There were no significant differences in epithelial damage, acute inflammation, or fibrosis between the tissue samples of both groups.

CONCLUSIONS

The results of this study show that the use of platelet-rich plasma during ureterocystostomy produces a positive effect. Our further research will be devoted to the use of autologous platelet-rich plasma in ureterocystostomy in big models.

Results of Haberal's Corner-Saving Ureteral Anastomosis Technique for Renal Transplantation: A Retrospective Study

BACKGROUND

Urological complications after renal transplantation (RT), including urine leaks, remain the most common type of surgical complications in the early post-transplant period. In this study we evaluated 324 consecutive RTs recipients in whom Haberal's corner-saving anastomosis technique was used for ureteroneocystostomy.

MATERIAL AND METHODS

Since January 2018, 461 RTs were performed at our center. Haberal's corner-saving anastomosis technique was used in 324 of these 461 RTs and the effectiveness of the technique was analyzed retrospectively. There were 115 female patients and 209 male patients, with a mean age of 42.1 ± 13.9 years. The most common etiology resulting in RT was hypertension among the recipients.

RESULTS

We observed 8 (2.4%) ureteral complications in 7 recipients as follows: ureteral stenosis in 2 recipients (0.6%), anastomotic leaks in 1 (0.3%), concomitant leak-stenosis in 1 (0.3%), and vesicoureteral reflux in 3 (0.9%). Six complications were treated with interventional radiological techniques and 2 were treated surgically. There was no graft and patient loss in the event of urological complications.

CONCLUSION

Because of the low complication rate, we believe that Haberal's corner-saving ureteral anastomosis technique is a safe method for performing a ureteroneocystostomy.

No evidence for the need of a routine renal transplant ultrasound after elective transplant ureteric stent removal-A retrospective cohort study

Transplant ureteric stent insertion reduces the incidence of MUCs, but it is not known whether routine PSRGU is needed to detect unmasked MUCs. This study evaluated whether routine PSRGU in the pRTR is a useful tool to identify MUCs before they become clinically apparent. A retrospective analysis was undertaken of the clinical outcomes following elective stent removal from pediatric kidney-only transplant recipients at two London centers between 2012 and 2016. Our policy was to perform PSRGU either routinely or urgently if there were concerning symptoms or biochemical evidence of renal allograft dysfunction. Elective stent removal was performed in 86% (97 of 113 pRTR), and 75 (77%) of whom had routine PSRGU at a median (IQR) of 6 (2-8) days after stent removal. There were changes to management in 3 (4%) of pRTR with PSRGU identifying no MUC. Nineteen patients (25%) had urgent PSRGU, most commonly due to renal allograft dysfunction, at a median (IQR) of 5.5 (2.7-12.3) days after stent removal. Of these, two pRTR required ureteric intervention. For our current practice of removing transplant stents at 4-6 weeks post-transplantation, our study has found no evidence to support routine PSRGU after elective stent removal.

Post-renal transplant urolithiasis in children: an increasingly diagnosed complication: a retrospective cohort study

OBJECTIVE

Urolithiasis in renal transplant (RTx) recipients is a potential cause of allograft loss if obstruction is untreated. It is not clear if paediatric transplant recipients are following the global trend for increased prevalence of urolithiasis over time.

DESIGN/SETTING/PATIENTS

A retrospective chart review was undertaken to evaluate the frequency, risk factors and characteristics of post-RTx urolithiasis over two decades (1995-2016), in a tertiary Australian paediatric hospital.

RESULTS

Stones were diagnosed in 8 of 142 (5.6%) recipients, 6 of whom were transplanted in the latter decade. All patients were male, with a median age 4.9 years and median weight 11.8 kg. Presentation was with haematuria (n=4), pain (n=2), dysuria (n=2), stone passage (n=1) and asymptomatic (n=1). Time to presentation was bimodal; three stones were identified in the initial 3 months post RTx and the remainder after 31-53 months. Two stones were in association with retained suture material and two patients had recurrent urinary tract infections. The average stone size was 8.4 mm. Five stones were analysed; all contained calcium oxalate, three were mixed, including one with uric acid. Five (83.3%) children had hypercalciuria but none had hypercalcaemia. Cystolithotripsy was the the most common treatment (n=5), in combination with citrate supplementation. No graft was lost due to stones.

CONCLUSIONS

Calculi occur with increasing frequency after renal transplantation. Clinicians need a high index of suspicion as symptoms may be atypical in this population. The cause for the increased frequency of stones in transplant recipients is not clear but is in keeping with the increase seen in the general paediatric population.

An Update on Early Urological Complications in Kidney Transplantation: A National Cohort Study

<strong>BACKGROUND</strong> This study aimed to provide an update on the occurrence of early urological complications in living-donor and deceased-donor kidney transplantation (KTX). <strong>MATERIAL AND METHODS</strong> Data on all kidney transplant recipients in the Netherlands between January 2005 and December 2015 were retrieved from the prospectively collected Dutch National Organ Transplant Registry Database (NOTR). We assessed the incidence of major urological complications (MUCs) within 3 months after KTX, defined as urinary leakage and ureteral obstruction. Outcomes of living donor and deceased donor kidney transplants were compared. We performed regression analysis to identify predictive factors of urological complications and studied the influence of early urological complications on graft and patient survival. We performed an additional sub-study to explore the influence of preservation of the peri-ureteric connective tissue in living-donor KTX on the occurrence of urological complications. <strong>RESULTS</strong> Among 3329 kidney transplant recipients, urological complications occurred in 208 patients (6.2%) within 3 months after surgery. There were no significant differences in complication rates between recipients from living donors and deceased donors. Multiple regression analysis showed that older donor age and previous cardiac events of the recipient were predictors for the development of urological complications. Graft and patient survival were not affected by early MUCs. The additional sub-study showed that preservation of peri-ureteric tissue within living-donor KTX was not independently associated with urological complications. <strong>CONCLUSIONS</strong> Many living- and deceased-donor KTX recipients have early urological complications. MUCs did not affect long-term graft or patient survival.

Association of Double-J Stenting in Renal Transplant Patients With Urinary Tract Colonization and Infections in a Multidrug-resistant Microbe Endemic Nosocomial Environment

PURPOSE

We investigated the association of ureteral stenting after kidney transplantation with the development of urinary tract infections (UTIs) and/or urinary tract colonization, in a hospital environment considered endemic for multidrug resistant (MDR) Gram-negative Enterobacteriaceae.

METHODS

Seventy-five recipients of deceased donor grafts were divided in groups A and B. Group A (with subgroups A1 and A2) included 45 transplanted patients without urinary stenting, and group B 30 patients with stenting. Subgroup A1 consisted of 30 patients transplanted before 2006, and A2 of 15 patients transplanted after 2006, when MDR, mainly carbapenem-resistant, Enterobacteriaceae, frequency has risen in our hospital.

RESULTS

The incidence and the number of UTIs per patient were significantly higher in patients without stenting compared to those with stenting. (Group A: 32/45 vs group B: 9/30, P < .001, and group A: 2.86 ± 0.43 vs group B: 0.6 ± 0.19, P < .01 respectively). Patients without stenting tended to have a higher frequency of recurrent UTIs compared to those with stenting (group A: 16/45 vs group B: 4/30, P < .05). Asymptomatic bacteriuria was more frequent in the patients with stent (group A: 8/45 vs group B: 14/30, P < .05). Further sub-comparison of the A1 and A2 subgroups with group B did not change the statistical results.

CONCLUSIONS

There is no clinically significant association of ureteral stenting after kidney transplantation with the high frequency of MDR Gram-negative bacteria in our hospital.

Imaging non-vascular complications of renal transplantation

In patients with end-stage renal disease, the treatment of choice for most patients is renal transplantation. Complications that occur after kidney transplant can be broadly divided into vascular and non-vascular categories. Non-vascular complications can further be divided into surgical and medical categories. When evaluating renal transplant imaging, it is helpful to consider the occurrence of complications in a timeline from time of surgery. Ultrasound is often the first modality used for evaluation of renal transplants particularly in the early postoperative period. Contrast-enhanced ultrasound can be a helpful adjunct in evaluating certain complications such as hematoma, rejection, and infection. Computed tomography (CT) is also helpful in accurately diagnosing complications. Surgical complications include perinephric fluid collections (hematoma, urinoma from urine leak, abscess, and lymphocele), urinary obstruction, and incisional fluid collections and hernias. One major category of medical complications that affect the renal parenchyma includes rejection (hyperacute, acute, and chronic), delayed graft function, acute tubular necrosis (ATN), and nephrotoxicity. Infection, renal calculi, and neoplasms such as post-transplant lymphoproliferative disease are medical complications that occur after renal transplantation. It is important for radiologists to be aware of the ultrasound and CT findings of the surgical and medical complications after renal transplant for prompt identification and treatment.

Early urological complications after kidney transplantation: An overview

Urological complications, especially urine leaks, remain the most common type of surgical complication in the early post-transplant period. Despite major advances in the field of transplantation, a small minority of kidney transplants are still being lost due to urological problems. Many of these complications can be traced back to the time of retrieval and implantation. Serial ultrasound examination of the transplanted graft in the early post-operative period is of key importance for early detection. The prognosis is generally excellent if recognized and managed in a timely fashion. The purpose of this narrative review is to discuss the different presentations, compare various ureterovesical anastomosis techniques and provide a basic overview for the management of post-transplant urological complications.

Urologic Evaluation and Management of Pediatric Kidney Transplant Patients

Urologic causes of end-stage renal disease are estimated between 25% and 40% of causes. The goal of renal transplantation in chronic kidney disease patients is to provide renal replacement therapy with less morbidity, better quality of life, and improved overall survival compared with dialysis. A patient's urologic history can be a significant source of problems related to infections, recurrence of disease, and surgical complications. Many of the urologic risks are modifiable. Proper evaluation and management can mitigate the potential problems after transplantation, and these patients with complex urologic problems are seen to have similar graft function outcomes.

Tubular vesicopyelostomy for the management of types 2 and 3 (long-segment) ureteric stenosis after kidney transplantation

Late ureteral stenosis following kidney transplantation needs immediate correction in order to protect allograft function and requires a complicated surgical procedure. In this study, we present the long-term results of tubular bladder reconfiguration and cystopyelostomy (tubular vesicopyelostomy), an innovative and practical procedure for the management of long-segment ureteric stenosis (types 2 and 3) after transplantation. Between 2002 and 2017, 722 kidney transplant patients were monitored at the University of Medical Sciences, Bozyaka Organ Transplantation and Research Center. Twenty-eight of these patients underwent tubular vesicopyelostomy operation; 17 male and 11 female patients with a mean age of 45.6 ± 10.5 years. Time to surgical intervention for urinary tract obstruction was 122.5 ± 114.7 months. The mean serum creatinine values previous to and 3 days following the tubular vesicopyelostomy operation were 3.46 ± 1.5 mg/dL and 1.75 ± 0.7 mg/dL, respectively (p < 0.0001). Within a mean follow-up period of 55.1 ± 40.9 months, functional grafts were recorded in 22 patients with a mean serum creatinine value of 1.92 ± 0.8 mg/dL. Only one patient developed anastomotic stenosis after the tubular vesicopyelostomy procedure, giving an overall success rate for tubular vesicopyelostomy of 96.4%. Six patients returned to hemodialysis. In five, the underlying etiology was not related to recurrent obstruction or surgical complications. Sixteen patients underwent allograft biopsy after the operation, but features of tubulointerstitial nephritis were seen in only one. Tubular vesicopyelostomy operation is a safe and successful method for the surgical treatment of late and complicated ureteral obstructions with excellent long-term results. It may be a good, practical alternative to other more sophisticated surgical options.

Urological complications following unstented pediatric renal transplantation

Urological complications which develop post-renal transplantation can be associated with significant morbidity especially in children. We evaluated the occurrence and management of all urological complications in a series of unstented pediatric renal transplants in a tertiary pediatric hospital. We reviewed the medical records of children who underwent unstented renal transplant between January 1996 and December 2014. Postoperative urological complications and the outcomes of their management were analyzed. A total of 160 unstented renal transplants were performed, and 32 urological complications were noted in 29 transplants (18%). There were 20 boys and nine girls with an age range of 2.5 years to 18.4 years. Nine (31%) of these patients had LUTD. The most common complication was VUR occurring in 17 patients (10.6%). Urine leaks occurred in six patients (3.8%) and ureteric obstruction in six patients (3.8%), and three patients (1.9%) had unexplained hydronephrosis. Loss of graft occurred in three patients (1.9%), and one patient died from sepsis post-uretero-ureterostomy. Patients with LUTD had more urological complications (P = .037). Unstenting is feasible in most pediatric renal transplants. LUTD is associated with a higher incidence of urological complications, especially VUR.

Ureteral Stenosis of Transplanted Kidney

Introduction: Ureteral stenosis is one of the most commonly reported urological complications after kidney transplantation. Material and methods: This is a retrospective analysis of the risk factors for ureteral stenosis (type of donor, age of donor, presence of interior polar arteria, unilateral dual transplantation, diabetes mellitus of the recipient and the donor, BK positivity, child recipient, cold ischaemia time, and delayed graft function), as well as the causes and types of treating ureteral stenoses. Results: In the group of 278 patients, the occurrence was 7.2 %. The medial of occurrence of ureteral stenoses was 24.6 months. The independent risk factor for ureteral stenosis in our group was the age of the donor ≥ 70 years [HR 6.5833; 95 % CI 2.2448-19,3070 (P = 0.0006)], BK positivity [HR 13.6667; 95 % CI 6.9127-27.0196 (P<0.0001)], cold ischaemia time > 1080 min [HR 4.0368; 95 % CI 1.7250-9,4465 (P = 0.0013)], and diabetes mellitus in the donor’s history [HR 16.2667; 95 % CI 7.8629-33.6525 (P <0.0001)]. The most frequent type of treating the ureteral stenosis in our group was retroureteroneocystostomy. After surgical treatment, we recorded no recurrence of stenosis. Conclusion: In our analysis, the confirmed independent risk factor was diabetes mellitus of the donor. However, further monitoring and analyses of large groups of patients are necessary. Surgical treatment of ureteral stenosis is safe. However, the most important momentum in surgical treatment of ureteral stenosis still remains the surgeon´s experience in the given type of treatment.

Transplant Kidney Retrograde Ureteral Stent Placement and Exchange: Overcoming the Challenge

OBJECTIVE

To present a reliable technique for fluoroscopic controlled, large-bore, ureteral stent placement and exchange in transplant kidneys with persistent ureterovesical strictures.

MATERIALS AND METHODS

We reviewed the medical charts of all patients who underwent kidney transplant with persistent ureterovesical strictures who underwent ureteral stent placement or exchange at our institution between 2005 and 2015 using the new technique. Clinical characteristics and treatment outcomes of the study cohort were analyzed.

RESULTS

Ureteral stent insertion or stent exchange, using this technique, was performed in 32 renal transplant units. Median operating time was 24 minutes (interquartile range, 21-36.75 minutes). The overall success rate of the technique at first attempt was 96.9%. In 1 patient, drainage of the transplanted kidney with a nephrostomy tube was indicated after procedure failure. No other local or systemic complications were encountered, and no stent encrustation was noted in this cohort of patients. Renal function remained stable in all patients during a median follow-up of 59 months (interquartile range, 28-61 months).

CONCLUSION

Herein, we present in detail a step-by-step technique for the insertion and exchange of large-bore ureteral stents in transplanted kidneys. The technique was shown to be safe, effective, and highly successful.

Surgical Complications After Kidney Transplantation

Since the first successful organ transplant conducted between twins in 1954, kidney transplant has evolved considerably over the past 50 years. Kidney transplant plays an important role in the treatment of end-stage kidney disease to improve the quality of life and prolong the life of patients. Despite significant advances, postoperative medical and surgical complications still represent important causes of morbidity and mortality. Many problems can be avoided through prophylactic correction of abnormalities detected during the preoperative evaluation; however, it is critical that technical mishaps at all stages of the transplant process (donor nephrectomy, benchwork preparation, and implant) be prevented and that careful postoperative monitoring be carried out, including thorough examination by attending physicians. However, despite these advances, surgical complications still present serious problems in kidney transplant recipients.

High Position of the Third Renal Transplant and Alternative Urinary Tract Reconstruction in a Complicated Case

The decision-making process for treatment of patients with end-stage renal failure, multiple failed renal transplants, and severe comorbidities can be exceedingly difficult due to the inapplicability of many common surgery methods. In this article, we report the treatment of such a patient who underwent a third renal transplant and subsequently developed a ureteral stenosis. The third kidney had been transplanted with a high abdominal position and a partially intra- and retroperitoneally placed ureter due to a bilaterally obtained iliac fossa and severe abdominal adhesions. For the severe ureteric stenosis, an alternative urinary tract reconstruction was developed by making use of the native ureter contralateral to the graft by tunneling under the sigmoid. We recommend this surgical method as a valid alternative for patients with severe ureteric graft stenosis, when treatment with stenting and common surgical ureter reconstruction methods are not feasible.

Wound Healing Complications in Kidney Transplant Recipients Receiving Everolimus

BACKGROUND

De novo use of mammalian target of rapamycin inhibitors after kidney transplantation is associated with a concentration-dependent incidence of wound healing adverse events (WHAE). The objective of this analysis was to compare the incidence of WHAE in patients receiving everolimus (EVR) or mycophenolate sodium (MPS).

METHODS

This was a predefined subanalysis of a single-center prospective randomized study in which 288 kidney transplant recipients receiving tacrolimus and prednisone were randomized for 3 different regimens: rabbit antithymocyte globulin (r-ATG)/EVR (N = 85); basiliximab (BAS)/EVR (N = 102); BAS/MPS (N = 101). Clinical WHAE were prospectively collected using a prespecified case report form in all study visits. Abdominal ultrasound was performed at 30 days posttransplant to capture subclinical abnormalities. Surgeons were blinded to randomized treatment and no specific surgical procedures were implemented.

RESULTS

A higher proportion of patients in BAS/EVR showed at least 1 clinical WHAE (22.3% vs 35.3% vs 22.0%, P = 0.03) and total clinical and subclinical WHAE (35% vs 42% vs 26%, P = 0.014) compared with BAS/MPS, respectively. A higher proportion of patients in r-ATG/EVR showed subclinical WHAE (13% vs 7% vs 4%, P = 0.025) compared with BAS/MPS, respectively. Patients receiving EVR showed a higher risk of developing clinical or subclinical WHAE (r-ATG/EVR vs BAS/MPS hazard ratio 1.30; BAS/EVR vs BAS/MPS hazard ratio 1.73, P = 0.028).

CONCLUSIONS

In this cohort of de novo kidney transplant recipients receiving tacrolimus and prednisone, the use of EVR was associated with higher incidence of combined clinical and subclinical WHAE compared with MPS.

Clinical Impact of Surgical Complications in Kidney Transplant Recipients in a Reference Hospital in Salvador, Bahia, Brazil

BACKGROUND

Renal transplantation is the treatment of choice for patients with stage V chronic kidney disease, which does not have contraindications to the procedure and is more cost-effective than dialysis treatments and provides better survival and quality of life.

OBJECTIVE

The objective of this study was to evaluate the incidence of postoperative complications in kidney transplant recipients in a reference hospital.

METHODOLOGY

This was a descriptive and retrospective study involving the analysis of patient records during hospitalization and outpatient treatment. We analyzed the demographics, clinical indicators, surgical techniques, and postoperative complications.

RESULTS

In the analysis of 147 transplantations, there was a higher incidence of transplantation in female recipients, average age of 37 years with a predominance of cadaveric transplantation. Of all pretransplantation comorbidities, hypertension was the most frequent. The overall incidence of surgical complications was 29.9%, with an incidence of vascular complications of 12.7%, 13.4% of surgical site complications, 8.2% of urologic complications, and 3% of hemorrhagic complications.

DISCUSSION

Vascular complications are serious complications and are associated with increased risk of graft loss (relative risk, 8.4), particularly arterial thrombosis. Patients with ureteral anastomosis using Lich-Gregoir technique showed lower urologic complications compared with patients with anastomosis by Leadbetter-Politano technique.

CONCLUSION

Surgical complications have different clinical effects, depending on their category. The vascular complications are associated with graft lost.

Retrograde endoureterotomy for persistent ureterovesical anastomotic strictures in renal transplant kidneys after failed antegrade balloon dilation

OBJECTIVE

To evaluate the long-term outcomes and complications of retrograde endoureterotomy for persistent ureterovesical anastomotic strictures in renal transplant patients after percutaneous balloon dilation failure.

METHODS

From January 2000 to May 2010, 26 (2.6%) of 1004 renal transplant patients developed ureterovesical anastomotic stricture after surgery. Seven of these patients and five additional referred patients with similar characteristics were treated with retrograde endoureterotomy after ≥1 previous unsuccessful attempt at percutaneous balloon dilation. All strictures treated were <1 cm in length. The clinical characteristics and outcomes were analyzed. Success was defined as the absence of symptoms and the resolution of obstruction on imaging after the procedure.

RESULTS

The median interval from initial treatment to endoureterotomy was 2.9 months (range 1.3-62.1). Before endoscopic treatment, 8 patients (67%) were treated with a single trial of balloon dilation and 4 (33%) with multiple trials. Endoureterotomy was performed using cold knife, holmium:yttrium-aluminum-garnet laser, and Bugbee electrode in 9, 2, and 1 patients, respectively. The median follow-up period was 44.4 months (range 2.4-68.6). Recurrent stricture developed in 2 patients during a mean follow-up of 4.7 months. Thus, the overall success rate was 83%. Postoperative complications appeared in 3 patients (25%) with culture-positive urinary tract infection. One graft failure occurred but was not related to a recurrent stricture.

CONCLUSION

After failure of antegrade percutaneous balloon dilation, retrograde endoureterotomy is an effective salvage procedure for well-selected cases of renal transplant patients with a short ureterovesical anastomotic stricture.

Bladder rupture in immediate postrenal transplant period of uncertain cause

Bladder rupture in patients undergoing renal transplant is rare. A 26-year-old man underwent a deceased-donor renal transplant. Postoperatively, he showed a good clinical course, but after removal of the urethral catheter, he complained of pain in the lower aspect of the abdomen and in the left flank. Findings of abdominal computed tomography and retrograde cystography revealed an extraperitoneal bladder rupture. We did not identify specific causes for this condition and believe that the bladder rupture was spontaneous. However, we could not rule out the possibility of traumatic rupture by the double-J ureteral stent. We decided to manage this case conservatively, with an indwelling urethral catheter and antibiotics, instead of by surgical repair. Results of repeated serial cystography during the treatment showed decreased contrast extravasation, and cystographic findings at 6 weeks showed no leakage of contrast medium. We confirmed complete healing of the ruptured bladder and removed the urethral catheter. Since then, the patient has maintained good renal function without any complications.

Urological complications and their impact on survival after kidney transplantation from deceased cardiac death donors

Urological complications after kidney transplantation may result in significant morbidity and mortality. However, the incidence of such complications after deceased cardiac death (DCD) donor kidney transplantation and their effect on survival is unknown. Purpose of this study was to estimate the incidence of urological complications after DCD kidney transplantation, and to estimate their impact on survival. Patient records of all 76 DCD kidney transplantations in the period 1997-2004 were reviewed for (urological) complications during the initial hospitalization until 30 days after discharge, and graft survival until the last hospital visit. Urological complications occurred in 32 patients (42.1%), with leakage and/or obstruction occurring in seven patients (9.2%). The latter seems to be comparable with the incidence reported in the literature for deceased heart-beating (DHB) transplantations (range 2.5-10%). Overall graft survival was 92% at 1 year and 88% at 3 years, comparable to the rates reported in the literature for kidneys from DHB donors, and was not affected by urological complications (chi(2) = 0.27, P = 0.61). Only a first warm-ischaemia time of 30 min or more reduced graft survival (chi(2) = 4.38, P < 0.05). We conclude that urological complications occur frequently after DCD kidney transplantation, but do not influence graft survival. The only risk factor for reduced graft survival in DCD transplant recipients was the first warm-ischaemia time.

Surgical treatment of urologic complications after renal transplantation

AIM

The incidence of urologic complications after renal transplantation has been reported to be between 2.5% and 27%. The aim of this study was to evaluate urologic complications of and their surgical treatment in our series of renal transplantations.

MATERIALS AND METHODS

We retrospectively evaluated urologic complications among 395 renal transplant recipients in our institute.

RESULTS

The urologic complications were ureteral leakage (n = 8), stricture of ureteral anastomosis (n = 3), hydronephrosis secondary to stone (n = 2) and bladder outlet obstruction (n = 2), recurrent urinary infection because of vesicoureteral reflux to native kidney (n = 2), renal tumor in native kidney (n = 1), hydroceles (n = 3), technical complications (n = 2), and clot retention (n = 1).

CONCLUSION

Major urologic complications following renal transplantation are ureteral leakage and stricture resulting from disrupture of the distal ureteral blood supply during the donor operation. Extravesical ureteroneocystostomy over a JJ stent seems feasible to minimize urologic complication. Early diagnosis and endourologic techniques are the mainstays of treatment.

Early and late urological complications corrected surgically following renal transplantation

The purpose of this study was to assess outcomes of urological complications after kidney transplantation operation. Nine-hundred and sixty-five patients received a kidney transplant between 2000 and 2006. In total, 58 (6.01%) developed urological complications, including urinary leakage (n = 15, 1.55%), stenosis (n = 29, 3%), vesicoureteral reflux (VUR) (n = 12, 1.2%), calculi (n = 1, 0.1%) and parenchymal fistulae (n = 1, 0.1%). Urinary leakage cases were treated by ureteroneocystostomy (UNS) via a double-J stent and stenosis cases by UNS. Fenestration was performed in patients developing lymphoceles and unresponsive to percutaneous drainage. VUR treatment was performed by ureteroneocystostomy revision or UNS. Stent usage during ureteric reimplantation was observed to reduce urinary leakage. Surgical complication rates in renal transplantation recipients according to donor type (living versus cadaveric) and the status of stent use (with stent versus without stent) were 5.53% vs. 7.27% (P = 0.064) and 5.24% vs. 20% (P < 0.01) respectively. No recurrence, graft loss or death was seen after these interventions. Comparison of recipients with and without urological complication showed that there was no difference between groups (P > 0.05) with respect to last creatinine level. No graft or patient loss was associated with urological complications. Urological complications that can be surgically corrected should be aggressively treated by experienced surgeons and graft loss avoided.

Comparing two ureter reimplantation techniques in kidney transplant recipients

We compared the incidence of urological and anastomotic complications for the ureteroureterostomy and Lich-Gregoir techniques in kidney transplant recipients. Between May 2003 and February 2004, 75 kidney transplant recipients from living donors were divided into two similar groups to receive ureteroureterostomy (n = 41, 28 male, 13 female) and Lich-Gregoir techniques (n = 34, 24 male, 10 female) for ureteral reimplantation. Patients with vesicoureteral reflux (VUR) to the native kidneys were excluded from the study. The urological complications included complicated hematuria, ureteral stenosis, symptomatic VUR, recurrent urinary tract infection (UTI). There was no statistical significance between two groups in terms of gender, age, end-stage renal disease etiology, human leucocyte antigen (HLA) mismatch numbers, type and duration of dialysis, and cold ischemia time. The incidence of urologic and anastomotic complications was 12%. Complications in the Lich-Gregoir group included symptomatic VUR in 8.8% and stent migration in 2.9% of cases. Complications observed in the ureteroureterostomy group were ureteral stricture 7.3% and complicated hematuria in 4.9% of cases. However, symptomatic reflux was not observed in the ureteroureterostomy group. UTI frequency was similar in both groups. Ureteroureterostomy can be safely performed as a primary choice in kidney transplant recipients.