Routine Stenting of Extravesical Ureteroneocystostomy in Kidney Transplantation: A Systematic Review and Meta-analysis

Routine Ureteral Stenting in Kidney Transplant Reduces Postoperative Hydronephrosis and Percutaneous Ureteral Interventions: A Single-Center Experience

OBJECTIVES

The effect of routine ureteral stenting on postoperative hydronephrosis and percutaneous ureteral intervention in kidney transplant remains unknown. This study aimed to evaluate the effects of routine ureteral stenting on hydronephrosis and percutaneous ureteral intervention and the cost benefit of ureteral stenting in kidney transplant.

MATERIALS AND METHODS

We retrospectively analyzed patients who underwent kidney transplant at a tertiary institution between 2005 and 2021. We adopted a ureteral stentingprotocol in2017, anda comparisonwas performed with previous patients without stents.

RESULTS

In total, 539 patients underwent kidney transplant(271 with stents [51.3%], 268 without stents [49.7%]). Hydronephrosis was detected in 16 cases (5.9%) and 30 cases (11.2%) of groups with and without stents,respectively (P = .041). Among patients with hydronephrosis, the number of patients who underwent percutaneous ureteral intervention was significantly lower in the stent group than in the nostent group (1 [6.25%] vs 10 [33.33%]; P= .014).Twenty patients (3.71%) experienced major urologic complications (19 [7.1%] in the no-stent group, and 1 [0.4%] in the stent group; P = .001). No significant differences between the groups were shown in the incidence of urinary tract infections within 3 months of transplant (24 [8.9%] vs 22 [8.2%]; P = .846). No differences were shown between the groups in ureterovesical anastomosis time (24.4 vs 24.03 min; P = .699) or 1-year graft survival (97% vs 97.8%; P = .803). The healthcare cost was significantly lower in the stent group than in the no-stent group by $1702.05 ($15000.89 vs $16702.95; P < .001).

CONCLUSIONS

Routine ureteral stenting in kidney transplant significantly decreased the incidence of postoperative hydronephrosis and percutaneous ureteral intervention. Stenting did notlead to increased urinary tract infections and was cost-effective.

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.

A STENTLESS MODIFIED LICH-GREGOIR TECHNIQUE FOR SAFE EARLY BLADDER CATHETER REMOVAL IN LIVING AND DECEASED KIDNEY TRANSPLANTS

OBJECTIVES

To describe a stentless modified Lich-Gregoir technique (mLG) for ureteroneocystostomy in renal transplantation (RT), with early bladder catheter (BC) removal (under 48 hours), and compare the postoperative results with those of the traditional technique (LG) with routine bladder catheter removal (4 to 5 days). The modification consists of maintaining a thin layer of detrusor fibers covering the bladder mucosa during dissection, which is incorporated into the anastomosis to reinforce the ureteroneocystostomy.

MATERIALS AND METHODS

This retrospective cohort study compared the postoperative outcomes of 100 consecutive patients who underwent mLG with early removal of BC between October 2018 to November 2019 with those of a historical cohort of 165 consecutive patients transplanted using stentless LG and routine removal of BC, who underwent surgery between July 2017 and September 2018. All transplants were performed by the same surgeon. Follow-up was 6 months.

RESULTS

Demographic characteristics were comparable, although patients in the mLG group had a higher mean preoperative urine volume (911±753.8mL vs. 629±638.6mL, p=0.016). Patients in the mLG group successfully underwent early BC removal (2.2±0.9 vs. 4.8±4.8 days, p<0.001), with no differences in the incidence of surgical or clinical complications, including urine leaks (1 vs. 3%, p=0.284). In addition, mLG patients presented a shorter mean length of hospital stay (6.5±5.0 vs. 7.1±6.2 days, p=0.023).

CONCLUSION

This stentless modified Lich-Gregoir technique enables safe early bladder catheter removal and is associated with reduced hospital length of stay.

The impact of prophylactic ureteral stenting during kidney transplantation on postoperative surgical outcomes

Background

The aim of this study was to evaluate the safety and feasibility of prophylactic ureteric stenting during kidney transplantation (KT).

Methods

The authors retrospectively reviewed patients who underwent KT between June 2016 and June 2019. The prophylactic ureteral stenting group (double-J [DJ]) and no-stent group (no-DJ) were compared with respect to the clinical data and surgical outcomes.

Results

A total of 42 patients underwent KT; 17 patients were classified into the DJ group and 25 patients into the no-DJ group. Antithymocyte globulin induction and donor-specific antibody positivity were significantly higher in the DJ group. There were no significant differences between the groups in terms of symptomatic urinary tract infection (UTI). The time to postoperative UTI was significantly shorter in the DJ group than in the no-DJ group (33.5±7.8 vs. 105.3±71.6 days, P=0.013). The development of postoperative BK viremia was significantly higher in the no-DJ group (0.0% vs. 16.0%, P=0.035). Urologic complications were significantly higher in the no-DJ group (0.0% vs. 16.0%, P=0.035). In the no-DJ group, urologic complications occurred in four patients ureteroneocystostomy stenosis in three patients and ureteroneocystostomy leakage in one patient. Percutaneous ureteral interventions were performed for all patients using percutaneous nephrostomy and reno-uretero-vesical stenting. However, there were no postoperative urologic complications in the DJ group.

Conclusions

Prophylactic ureteric stenting during KT may be safe and feasible without significantly increasing the incidence of UTI and BK viremia. Additionally, prophylactic ureteric stenting may reduce urologic complications after KT.

Egyptian clinical practice guideline for kidney transplantation

Objective: To present the first Egyptian clinical practice guideline for kidney transplantation (KT).

Methods: A panel of multidisciplinary subspecialties related to KT prepared this document. The sources of information included updates of six international guidelines, and review of several relevant international and Egyptian publications. All statements were graded according to the strength of clinical practice recommendation and the level of evidence. All recommendations were discussed by the panel members who represented most of the licensed Egyptian centres practicing KT.

Results: Recommendations were given on preparation, surgical techniques and surgical complications of both donors and recipients. A special emphasis was made on the recipient’s journey with immunosuppression. It starts with setting the scene by covering the donor and recipient evaluations, medicolegal requirements, recipient’s protective vaccines, and risk assessment. It spans desensitisation and induction strategies to surgical approach and potential complications, options of maintenance immunosuppression, updated treatment of acute rejection and chemoprophylactic protocols. It ends with monitoring for potential complications of the recipient’s suppressed immunity and the short- and long-term complications of immunosuppressive drugs. It highlights the importance of individualisation of immunosuppression strategies consistent with pre-KT risk assessment. It emphasises the all-important role of anti-human leucocyte antigen antibodies, particularly the donor-specific antibodies (DSAs), in acute and chronic rejection, and eventual graft and patient survival. It addresses the place of DSAs across the recipient’s journey with his/her gift of life.

Conclusion: This guideline introduces the first proposed standard of good clinical practice in the field of KT in Egypt.

Abbreviations: Ab: antibody; ABMR: Ab-mediated rejection; ABO: ABO blood groups; BKV: BK polyomavirus; BMI: body mass index; BTS: British Transplantation Society; CAN: chronic allograft nephropathy; CDC: complement-dependent cytotoxicity; CKD: chronic kidney disease; CMV: cytomegalovirus; CNI: calcineurin inhibitor; CPRA: Calculated Panel Reactive Antibodies; (dn)DSA: (de novo) donor-specific antibodies; ECG: electrocardiogram; ESWL: extracorporeal shockwave lithotripsy; FCM: flow cytometry; GBM: glomerular basement membrane; GN: glomerulonephritis; HIV: human immunodeficiency virus; HLA: human leucocyte antigen; HPV: human papilloma virus; IL2-RA: interleukin-2 receptor antagonist; IVIg: intravenous immunoglobulin; KT(C)(R): kidney transplantation/transplant (candidate) (recipient); (L)(O)LDN: (laparoscopic) (open) live-donor nephrectomy; MBD: metabolic bone disease; MCS: Mean channel shift (in FCM-XM); MFI: mean fluorescence intensity; MMF: mycophenolate mofetil; mTOR(i): mammalian target of rapamycin (inhibitor); NG: ‘not graded’; PAP: Papanicolaou smear; PCN: percutaneous nephrostomy; PCNL: percutaneous nephrolithotomy; PKTU: post-KT urolithiasis; PLEX: plasma exchange; PRA: panel reactive antibodies; PSI: proliferation signal inhibitor; PTA: percutaneous transluminal angioplasty; RAS: renal artery stenosis; RAT: renal artery thrombosis;:rATG: rabbit anti-thymocyte globulin; RCT: randomised controlled trial; RIS: Relative MFI Score; RVT: renal vein thrombosis; TB: tuberculosis; TCMR: T-cell-mediated rejection; URS: ureterorenoscopy; (CD)US: (colour Doppler) ultrasonography; VCUG: voiding cystourethrogram; XM: cross match; ZN: Ziehl–Neelsen stain

How Early Postoperative Urinary Tract Infections Affect Renal Graft Function at 1-Year Follow-up

BACKGROUND

Urinary tract infection (UTI) occurs in 21% of kidney recipients within the first 3 months after transplantation (KTx). It is associated with impaired graft function. Ureteral stent placement increases the occurrence of UTIs. The aim of this study was to assess the correlation between double-J placement, UTI incidence, and graft function.

MATERIAL AND METHODS

We conducted an observational study in 753 patients transplanted between 2010 and 2017 in compliance with the Helsinki Congress and the Istanbul Declaration. Recipients with preserved graft function at the 1-year follow-up were included. Medical records were searched for intraoperative double-J placement, UTI incidence, and estimated glomerular filtration rate (eGFR) on the 30th and 360th days post-transplant. Pretransplant hypothetical estimated GFR (heGFR) of each donor was calculated from donors' age and physiological age-dependent loss of functional nephrons. Spearman's correlation and linear regression analyses were applied. P < .05 was considered significant.

RESULTS

UTIs occurred in 239 (31.8%) patients. On the 30th day after KTx, eGFR was significantly lower in the UTI group (median, 39.5 vs 43.2; P < .01). A similar pattern was seen 1 year after KTx (47.5 vs 54.2; P < .01). Urinary stents were placed in 213 (28.3%) patients. UTIs occurred in 92 (43.2%) of them and in 147 (27.2%) of nonstented patients (odds ratio: 2; 95% confidence interval [CI], 1.5-2.8; P < .01). Median donor heGFR was 105.8 mL/min/1.73 m², whereas median donor Modification of Diet in Renal Disease (MDRD) GFR was 64.2 mL/min/1.73 m². A moderate correlation between age-adjusted heGFR and 1-year transplant function (r = .47) was noted.

CONCLUSIONS

UTIs in the early post-transplant period decreased 1-year eGFR by 4 to 5 mL/min/1.73 m². UTIs occurred twice as often when a urinary stent was placed.

Is peritoneal dialysis prior to kidney transplantation a risk factor for ureteral stenosis after adult to adult live kidney transplantation

Objectives

Major urinary complications such as urinary leaks, stenosis or urinary tract infections after kidney transplantation can lead to graft or patient loss. The effect of peritoneal dialysis on post-kidney transplantation complications have been discussed but its effect on ureteral stenosis is unknown. In this study, it was aimed to analyze factors effecting major ureteral complications after living donor kidney transplantation and impact of peritoneal dialysis and double J-stents (JJ stents).

Material and Methods

This study included 116 adult to adult living donor kidney transplant patients. Factors effecting major urologic complications after living donor kidney transplantation were analyzed. The donors were primary relatives of the recipients.

Results

Major urologic complications after living donor kidney transplantation was 8/116 (6.9%). Urinary leak was present in 2 (1.7%) patients. Ureteral stenosis was encountered in 6 (5.2%) patients. Double J stents were used in 84 (72.4%) of the cases. The effect of JJ ureteral stent was not statistically significant for urinary leak, ureteral stenosis (p= 0.074, p= 0.470, respectively). A total of 29 (25%) patients had peritoneal dialysis before kidney transplantation. Preoperative peritoneal dialyses and bacteriuria after kidney transplantation were independent risk factors for ureteral stenosis in multivariate analysis (p= 0.013, and p= 0.010 respectively).

Conclusion

In the guidance of the results of the present study, peritoneal dialysis prior to kidney transplantation and bacteriuria are independent risk factors for ureteral stenosis after living donor kidney transplantation. JJ stents have no effect on urologic complications after living donor kidney transplantation.