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

Endoscopic balloon dilatation of primary obstructive megaureter: An effective first line management in children

AIM

This study evaluates outcomes of endoscopic balloon dilatation (EBD) in the management of primary obstructive megaureter (POM) in children.

METHODS

Retrospective data between 2013 and 2023 from two tertiary paediatric surgical centres in the UK were reviewed. Pre and post-operative clinical and imaging parameters of children managed with EBD were assessed. Failure of procedure was defined as requiring further intervention due to persistent/recurrent symptoms, upper tract dilatation and/or obstruction on MAG3 over the follow up period.

RESULTS

55 children with 61 renal units were evaluated. Median age at treatment was 18 months with a median follow up of 24 months. There was significant reduction in upper tract ultrasound measurements following balloon dilatation but there was no significant difference between the pre and post-operative renal function on MAG3. No significance difference was demonstrated when the outcomes of cutting and non-cutting balloons were compared. No significant difference was shown when outcomes after EBD were compared between infants vs older children as well as ureteric dilatation less than or over 25 mm (p = 0.841). 87% were successfully treated with a single dilatation and this increased to 95% after second dilatation. The remaining 5% had ureteric re-implantation.

DISCUSSION

Although a retrospective study, the patient population is relatively large. 87% success rate shown after EBD is comparable to similar studies. It has been suggested that children less than 12months and those with severe ureteric dilatation (>25 mm) may not be suitable for EBD. No significant difference was demonstrated when the outcomes of these categories of children were compared to other children with POM. All of the patients that had repeat balloon dilatation required no further intervention, a finding that has so far not been well evaluated in available literature.

CONCLUSIONS

This study demonstrates 87% success rate after single EBD in children with POM and this outcome increased to 95% following a second dilatation. EBD is shown to be an effective definitive surgical management option of POM. It can be safely offered as first line management in all patient groups and repeated if no initial response.

Robotic ureter reconstruction using the native ureter to treat long-segment ureteral stricture of the transplant kidney utilizing Indocyanine green: The first Korean experience

PURPOSE

Ureteral strictures are a common complication after kidney transplantation. Open reconstruction is preferred for long-segment ureteral strictures that cannot be resolved endoscopically; however, it is known to have the potential to fail. We report 2 successful cases of robotic reconstruction surgery of a transplant ureter using the native ureter with the aid of intraoperative Indocyanine green (ICG).

MATERIALS AND METHODS

Patients were placed in semi-lateral position. Using Da Vinci Xi, the transplant ureter was dissected, and the stricture site was identified. End-to-side anastomosis of the native ureter to the transplant ureter was performed. ICG was utilized to identify the course of the transplant ureter and confirm the vascularity of the native ureter.

RESULTS

Case 1: A 55-year-old female underwent renal transplantation at another hospital. She had recurrent febrile urinary tract infections (UTIs) and a ureteral stricture requiring percutaneous nephrostomy (PCN). The PCN and ureteral stent were removed successfully after surgery. The patient had only 1 febrile UTI episode after surgery. Case 2: A 56-year-old female underwent renal transplantation at another hospital. She had acute pyelonephritis 1-month post-transplantation, and a long-segment ureteral stricture was identified. She developed a UTI with anastomosis site leakage in the early postoperative period, which resolved with conservative treatment. The PCN and ureteral stent were removed 6 weeks after surgery.

CONCLUSIONS

Robotic surgery for managing long-segment ureteral stricture after kidney transplantation is safe and feasible. The use of ICG during surgery to identify the ureter course and its viability can improve the success.

Endourological approach in patients with anatomical urinary tract challenges

Objective:

This article reports our experience managing neoplasms, stenosis and urolithiasis in patients with anatomical variations of the urinary system, using an endourological approach, either with an antegrade access or with combined access.

Patients and methods:

A retrospective review was performed using medical records of all patients who underwent percutaneous endourological treatment at our institution between 2014 and 2019. Those with such urinary anatomical variations were selected.

Results:

Out of 185 patients, 10 were identified. The study group included patients with urinary diversion, renal transplantation and congenital anomalies. Patients were divided into two sets, A and B, based on the presence or absence of urolithiasis, respectively. In set A, the median operative time was 213 minutes (standard deviation ( SD)=65.91 minutes). Only one patient had lithiasis in the first postoperative evaluation. Two patients had postoperative complications graded ⩾II in the Clavien–Dindo classification. Regarding set B, the median operation time was 75 minutes ( SD=66.89 minutes). Two patients had postoperative complications graded ⩾II in the Clavien–Dindo classification.

Conclusions:

Patients with anatomical tract challenges currently have a longer life expectancy and are therefore prone to urological complications in their unusual structures. Treatment of urological complications is essential, and minimal invasive procedures should be considered to resolve them and to reduce morbidity.

Level of evidence:

Not applicable.

Update on the Management of Urological Problems Following Kidney Transplantation

Urological problems in kidney transplant recipients are not limited only to posttransplantation urological complications. These problems are a cause of significant patient mortality and morbidity that have wide-ranging effects on graft survival throughout the entire life of the graft. Ultimately, the transplant comprises a major portion of the urinary system; therefore, the transplant team should be prepared for foreseeable and unforeseeable urological problems in the short and long terms. These mainly include postoperative urological complications (urine leakage, ureteral stenosis, and vesicoureteral reflux), bladder outlet obstruction, and graft urolithiasis. In recent years, significant advances have been made in the management of urological complications, especially due to advances in endourologic interventions. The aim of this review is to summarize the management of urological problems after kidney transplantation in the context of the current literature.

Retrograde ureteric stent insertion from percutaneous suprapubic access to the bladder in renal transplant recipients with ureteric stenosis: a novel minimally invasive technique

Background

Ureteric stricture is a common and salvaging complications after renal transplantation. Two treatment methods are usually used, retrograde ureteral stent placement and percutaneous nephrostomy. The former has a higher failure rate, the latter has a great risk. Therefore, a safe and reliable treatment is needed.

Case presentation

A technique of retrograde insertion of ureteral stent was established, which was applicable in three transplant recipients with post-transplant ureteral stenosis, and the data was retrospectively recorded. The patients are 2 men and 1 woman, ages 44, 27 and 32 years. These patients underwent a total of five times of retrograde insertion of ureteral stent between 2018 and 2019. None of these patients had any postoperative complication, but all patients had complete recovery from oliguric status within two weeks.

Conclusions

The retrograde ureteric stent insertion by percutaneous suprapubic access to the bladder (RUS-PSAB) was demonstrated feasibility and safety in a case series with short-term follow-up. However, larger prospective studies are needed.

Minimally Invasive Approach to Ureteral Stricture in Transplant Kidney by Periodic Retrograde Ureteral Stent Placement and Exchange

PURPOSE

The aim of the study was to evaluate the effectiveness of minimally invasive treatment of ureteral strictures and describe the technique that we used for retrograde placement of ureteral stent in transplant kidneys.

MATERIAL AND METHODS

We reviewed the medical cards of all transplant kidney patients with persistent ureteral strictures who were managed with periodical ureteral stent placement and balloon dilatation between 2008 and 2016. Different maneuvers that were used to overcome the difficulties for retrograde ureteral stent placement and exchange were discussed. Clinical characteristics and treatment outcomes of the study cohort were analyzed.

RESULTS

Between 2008 and 2016, a total of 1026 transplantations were performed in our clinic, and ureteral stricture was found in 13 patients (1.26%). Of the 13 patients, 8 were treated with periodic ureteral stent insertion and balloon dilatation. Ureteral stent insertion or stent exchange was performed in 52 transplant renal units. The overall success rate of retrograde ureteral stent insertion at the first attempt was 75% and stent exchange success rate was 100%. Renal function remained stable in all patients during a median follow-up of 41 months (range, 13-60 months). No other local or systemic complication was encountered and no stent encrustation was noted.

CONCLUSIONS

Endoscopic management of ureteral stricture by periodical retrograde ureteral stent replacement and balloon dilatation is safe, effective, and highly successful in transplant patients who are not eligible for open reconstructive surgery.

Routine double-J stenting for live related donor kidney transplant recipients: It doesn't serve the purpose, but does it serve a better purpose?

Purpose

Despite meticulous techniques, surgical complications continue to be problematic in kidney transplant recipients. Role of routine stenting to reduce complications is controversial. In this study, we compare incidence of early urological complications, lymphoceles, urinary tract infections (UTI) and graft function; with or without double-J stenting.

Materials and Methods

All patients who underwent live related donor renal transplantation from February 2014 to February 2016 were included. Transplants prior to February 2015 were without routine stenting; subsequent transplants were with routine stenting. Patients with neurogenic bladder, previously operated bladder and delayed or low urinary output were excluded. Follow-up was for at least three months. Descriptive statistics was performed for all parameters. Chi square test and Fisher's Exact test were used for qualitative variables. For quantitative variables, Mann-Whitney test was used to test median difference and independent samples t-test for mean difference. The p-value ≤0.05 was considered significant.

Results

We analysed 74 patients (34 stented and 40 non-stented). There was no difference in the incidence of urinary leak, anastomotic obstruction, lymphoceles or UTI (p>0.4 for all comparisons). However, mean estimated glomerular filtration rate at sixth day, 14th day, one month and two months were 76.1 vs. 61.5 (p=0.025), 72.1 vs. 56.6 (p=0.005), 79.4 vs. 63.1 (p=0.002) and 82.0 vs. 63.3 (p=0.001) in the stented versus non-stented groups.

Conclusions

Placement of ureteral stent in renal transplant does not significantly affect the incidence of early urinary complications or UTI. However, graft function is significantly better in stented recipients, at least in the short term.

Minimally invasive approach for the management of urological complications after renal transplantation: single center experience

BACKGROUND

The aim of the study was to characterise urological complications after renal transplantation and to evaluate the role of minimally invasive management for urological complications.

METHODS

A total of 920 kidney transplantations were performed between 2008 and 2015. All patients were followed up for at least 1 year after transplantation. Complications regarded as urological were urinary leakage, ureteral stricture, urinary malignancy, bladder outlet obstruction (BOO) and urinary calculi. We evaluated data from the time of occurrence of urological complications and the type of the management prescribed.

RESULTS

Among 920 transplantations performed in our clinic, 41 (4.4%) urological complications arose. Twenty (48.8%) of the complications occurred during the first 3 months and 21 (51.2%) occurred after 3 months, postoperatively. Ureteral strictures were found in 14 (34.1%) patients, urinary tract stones in seven (17%), BOO in 6 (14.6%) and urinary leakage was observed in 5 (12.1%) patients. Ureteral stricture was managed with endoscopic approach in eight (61.3%) patients. Urinary tract stones and urinary leakage were managed in 7 (100%) and 4 (75%) patients with endoscopic approach. Overall 29 (70.7%) of 41 urological complications were managed with endourological approaches.

CONCLUSIONS

It is likely that the importance of open surgery could decrease in the future. Endoscopic management of urological complications have come to have an important role in the treatment of urological complications after transplantation.

Endoscopic Management of Ureteral Strictures: an Update

PURPOSE OF REVIEW

This review focuses on the role of endoscopic treatment of ureteral stricture disease (USD) in the era of minimally invasive surgery.

RECENT FINDINGS

There is a relative paucity of recent literature regarding the endoscopic treatment of USD. Laser endopyelotomy and balloon dilation are associated with good outcomes in treatment-naïve patients with short (< 2 cm), non-ischemic, benign ureteral strictures with a functional renal unit. If stricture recurs, repetitive dilation and laser endopyleotomy is not recommended, as success rates are low in this scenario. Patients with low-complexity ureteroenteric strictures and transplant strictures may benefit from endoscopic treatment options, although formal reconstruction offers higher rates of success. Formal ureteral reconstruction remains the gold-standard treatment for ureteral stricture disease as it is associated with higher rates of complete resolution. However, in carefully selected patients, endoscopic treatment modalities provide a low-cost, low-morbidity alternative.

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.

The development and current status of minimally invasive surgery to manage urological complications after renal transplantation

Introduction:

In the past, urological complications after renal transplantation were associated with significant morbidity. With the development and application of endourological procedures, it is now possible to manage these cases with minimally invasive techniques.

Materials and Methods:

A MEDLINE search for articles published in English using key words for the management of urological complications after renal transplantation was undertaken. Forty articles were selected and reviewed.

Results:

The incidence of urological complications postrenal transplantation was reported to be 2–13%. Ureteric leaks occurred in up to 8.6%, and 55% were managed endourologically. The incidence of lymphocele was as high as 20%, and less that 12% of the cases required treatment. Ureteric stricture was the most common complication, and endourological management was successful in 50–70%. The occurrence of complicated vesicoureteral reflux was 4.5%, and 90% of low-grade reflux cases were successfully treated with deflux injections. Stones and obstructive voiding dysfunction occurred in about 1% of kidney transplant recipients.

Conclusion:

Minimally invasive techniques have a critical role in the management of urological complications after renal transplantation. Urinary leakage should be managed with complete decompression. Percutaneous drainage should be the first line of treatment for lymphocele that is symptomatic or causing ureteric obstruction. Laparoscopic lymphocele deroofing is successful in aspiration-resistant cases. Deflux is highly successful for the management of complicated low-grade kidney transplant reflux. The principles of stone management in a native solitary kidney are applied to the transplanted kidney. Early identification and treatment of bladder outlet obstruction after renal transplantation can prevent urinary leakage and obstructive uropathy.

Optimal management of distal ureteric strictures following renal transplantation: a systematic review

Our objective was to define optimal management of distal ureteric strictures following renal transplantation. A systematic review on PubMed identified 34 articles (385 patients). Primary endpoints were success rates and complications of specific primary and secondary treatments (following failure of primary treatment). Among primary treatments (n = 303), the open approach had 85.4% success (95% CI 72.5-93.1) and the endourological approach had 64.3% success (95% CI 58.3-69.9). Among secondary treatments (n = 82), the open approach had 93.1% success (95% CI 77.0-99.2) and the endourological approach had 75.5% success (95% CI 62.3-85.2). The most common primary open treatment was ureteric reimplantation (n = 33, 81.8% success, 95% CI 65.2-91.8). The most common primary endourological treatment was dilation (n = 133, 58.6% success, 95% CI 50.1-66.7). Fourteen complications, including death (4 weeks post-op) and graft loss (12 days post-op), followed endourological treatment. One complication followed open treatment. This is the first systematic review to examine the success rates and complications of specific treatments for distal ureteric strictures following renal transplantation. Our review indicates that open management has higher success rates and fewer complications than endourological management as a primary and secondary treatment for post-transplant distal ureteric strictures. We also outline a post-transplant ureteric stricture evaluation and treatment algorithm.

Impact of ureteral stenting on urological complications after kidney transplantation surgery: a single-center experience

BACKGROUND

Urological complications such as ureteral strictures and ureteral leakage can affect the outcome of kidney transplantation by increasing morbidity and mortality, including graft loss. Controversy still exists regarding the role of stents in renal transplantation. The aim of this study was to evaluate the role of ureteral stenting in kidney transplantation.

METHODS

We performed a retrospective study on a series of 798 consecutive renal transplants performed in our center between January 1, 2004, and December 31, 2011. Ureteral stents were used in 152 cases (19.1%) of the total (stent group) and were removed 2 weeks postoperatively. Donor and recipient age, sex, type of ureteroneocystostomy, stent and non-stent patients, cold and warm ischemia time, and urological complications were analyzed.

RESULTS

The overall incidence of urological complications was 7.8% (62 cases). Ureteral stenosis (3.1%) and ureteral leakage (2.4%) were the most common complications; 39.7% (25 cases) of complications were recorded in the first month after transplantation. Major urological complication rate was 3.3% in the stent group compared with 8.8% in the non-stent group (P = .04). However, stent use was associated with the increase of urinary tract infections rate in the stent group (51.3%) compared with the non-stent group (17.9%) (P = .03).

CONCLUSIONS

In our study, the use of ureteral stents significantly decreased urological complications in kidney transplant recipients but increased the risk for development of urinary tract infections.

Diagnosis and management of ureteral complications following renal transplantation

When compared with maintenance dialysis, renal transplantation affords patients with end-stage renal disease better long-term survival and a better quality of life. Approximately 9% of patients will develop a major urologic complication following kidney transplantation. Ureteral complications are most common and include obstruction (intrinsic and extrinsic), urine leak and vesicoureteral reflux. Ureterovesical anastomotic strictures result from technical error or ureteral ischemia. Balloon dilation or endoureterotomy may be considered for short, low-grade strictures, but open reconstruction is associated with higher success rates. Urine leak usually occurs in the early postoperative period. Nearly 60% of patients can be successfully managed with a pelvic drain and urinary decompression (nephrostomy tube, ureteral stent, and indwelling bladder catheter). Proximal, large-volume, or leaks that persist despite urinary diversion, require open repair. Vesicoureteral reflux is common following transplantation. Patients with recurrent pyelonephritis despite antimicrobial prophylaxis require surgical treatment. Deflux injection may be considered in recipients with low-grade disease. Grade IV and V reflux are best managed with open reconstruction.

Current status of minimally invasive endoscopic management of ureteric strictures

Endourological techniques are used more often nowadays in the treatment of ureteric strictures of various etiologies. Advances in technology have provided new tools to the armamentarium of the endoscopic urological surgeon. Numerous studies exist that investigate the efficiency and safety of each of the therapeutic modalities available. In this review, we attempt to demonstrate the available and contemporary evidence supporting each minimally invasive modality in the management of ureteric strictures.

The current role of endourologic management of renal transplantation complications

Introduction. Complications following renal transplantation include ureteral obstruction, urinary leak and fistula, urinary retention, urolithiasis, and vesicoureteral reflux. These complications have traditionally been managed with open surgical correction, but minimally invasive techniques are being utilized frequently. Materials and Methods. A literature review was performed on the use of endourologic techniques for the management of urologic transplant complications. Results. Ureterovesical anastomotic stricture is the most common long-term urologic complication following renal transplantation. Direct vision endoureterotomy is successful in up to 79% of cases. Urinary leak is the most frequent renal transplant complication early in the postoperative period. Up to 62% of patients have been successfully treated with maximal decompression (nephrostomy tube, ureteral stent, and Foley catheter). Excellent outcomes have been reported following transurethral resection of the prostate shortly after transplantation for patients with urinary retention. Vesicoureteral reflux after renal transplant is common. Deflux injection has been shown to resolve reflux in up to 90% of patients with low-grade disease in the absence of high pressure voiding. Donor-gifted and de novo transplant calculi may be managed with shock wave, ureteroscopic, or percutaneous lithotripsy. Conclusions. Recent advances in equipment and technique have allowed many transplant patients with complications to be effectively managed endoscopically.