Urological complications of renal transplantation

Urological complications in renal transplantation from cadaveric donor grafts: a retrospective analysis of 20 years

INTRODUCTION

This study is a retrospective analysis of ureteral complications and their management from a monocenter series of 277 consecutive renal transplantations.

MATERIALS AND METHODS

From September 1979 to June 1999, 277 renal transplantations (cadaveric origin) were performed in 241 patients. The ureter from the kidney graft was inserted into the bladder according to the technique of extravesical implantation described by Lich-Gregoir and Campos-Freire. The study analyzed the time of occurrence and the type of complications observed. The different procedures to restore the transplanted urinary tract are presented.

RESULTS

Complications occurred in 43/277 renal transplantations (15.5%). Anastomotic urine leakage or ureteral stricture were the most frequent. The time to appearance of these complications was either short (<1 month) or late (>1 month) in a similar number of cases. Most cases were managed surgically: 33/43 cases (76.7%). The most frequent surgical repair was ureterovesical reimplantation (n=13), followed by: ureteroureteral end-to-end anastomosis (native ureter-ureter transplant, n=5); pyeloureteral anastomosis (native ureter-renal pelvis transplant, n=5); simple revision of ureterovesical implantation (n=4); resection and end-to-end anastomosis of the transplant ureter (n=2); calico-vesicostomy (graft-bladder, n=1); implantation according to Boari (n=1); pyelovesicostomy with bipartition of bladder (n=1), and pyeloileocystoplasty with detubularized ileal graft (n=1). No deaths related to any of the urological complications were reported. However, 2 consecutive vesico-renal refluxes led to the loss of the kidney graft in the long-term.

CONCLUSION

The rate of complications observed in this retrospective analysis is similar to the experience of other studies, ranging from 2 to 20%. If the classical extravesical ureteral bladder implantation is to remain an attractive technique due to its simplicity, the surgical team at the training center should be aware of all the means to prevent any ureteral complications, such as the choice of another implantation technique and/or insertion of a transient ureteral stent.

LONG-TERM GRAFT SURVIVAL AFTER UROLOGICAL COMPLICATIONS OF 695 KIDNEY TRANSPLANTATIONS

PURPOSE

We ascertain the incidence, management and long-term outcome of early urological complications requiring surgical exploration in kidney transplantation.

MATERIALS AND METHODS

Data of 695 consecutive kidney transplantations performed between January 1985 and January 1997 were assessed in regard to urological complications that occurred within 1 year after transplant. A computerized database was used to analyze graft recipient characteristics, the implantation procedure, complications and outcome in select patients and all those who underwent transplant during the same period. In the noncomplication group sufficient data for evaluation was available for 556 patients. We performed the Cox proportional hazards analysis with overall graft failure, graft failure or death as end points of observation.

RESULTS

Overall, 42 (6.0%) patients required revision of vesicoureteral anastomosis. Complications were identified after a median of 6 days (range 0 to 135). The primary reconstruction technique was extravesical in 64% and transvesical in 33% of patients, including 1 that involved ureteral Bricker anastomosis. Obstruction and/or leakage at vesicoureteral anastomosis accounted for 69% of urological complications. Revision was performed with a number of different reconstruction techniques. A second revision was required in 16.7%. Mean followup after primary transplant was 9.1 years (range 3.2 to 15). Multivariate analysis showed that surgical treatment of urological complication during year 1 after kidney transplantation did not increase the risk of overall graft failure, graft failure or death.

CONCLUSIONS

Our results indicate that long-term graft survival is not affected by a surgically treated urological complication.

Developments and dilemmas in renal transplantation

The number of patients waiting for a kidney transplant is about three times greater than the number of transplants performed each year. This article highlights current immunosuppression protocols and the newer immunosuppressive drugs under investigation in a number of multicenter trials. These hold out the promise of reducing the frequency of acute rejection and of prolonging graft survival. They are divided into three groups. The first, like cyclosporine, interferes with the action of interleukin 2. The second, like azathioprine, are antimetabolites; and the third, new monoclonal antibodies. The use of antibody-induction therapy is compared with standard regimens. There are risks related to prednisone withdrawal protocols and inadequate cyclosporine dosing that may lead to accelerated graft loss. Cardiovascular disease is a significant problem in older diabetic patients for whom coronary angiography is recommended. A defined set of risk factors is outlined that predicts which younger diabetic patients should have a cardiovascular evaluation. Chronic liver disease is a growing problem and rational strategies are emerging from studies of patients with biopsy-proven active hepatitis. The presence of hepatic inflammation is associated with progressive liver disease and patients must be made aware of this risk when seeking transplantation. A large number of studies of various prophylactic regimens are starting to provide data on the cost-effective reduction of cytomegalovirus disease in transplant recipients. It is recommended that patients receiving antibody therapy also receive preemptive gangciclovir. The issue of chronic allograft rejection is discussed briefly. The most important predictors of chronic allograft rejection are the frequency of acute rejection, inadequate immunosuppression, and infections.(ABSTRACT TRUNCATED AT 250 WORDS)