Renal autotransplantation for recurrent renal colic

Indications for and results of renal autotransplantation

PURPOSE OF REVIEW

To understand the indications and outcomes of renal autotransplantation, and when to consider this unique procedure for patients.

RECENT FINDINGS

Renal autotransplantation confers acceptably low rates of graft failure and prevents need for long-term dialysis. Renal autotransplantation remains an important management strategy in very select patients for complex renovascular disease, ureteral stricture disease, ureteral trauma, upper urinary tract urothelial carcinoma, renal cell carcinoma, and Loin-Pain Hematuria Syndrome. With advancements in minimally invasive procedures, the application of renal autotransplantation for refractory stone disease is rare but exists. Robot-assisted laparoscopic renal autotransplantation demonstrates reproducible graft success and complication rates with improved perioperative outcomes (ex. hospital length of stay) - though comparative studies are lacking. Patients would benefit from a multidisciplinary approach from renal transplant surgeons, vascular surgeons, urologists, nephrologists, dieticians, pain management providers, social workers, and psychiatrists.

SUMMARY

In experienced hands, renal autotransplantation is a reasonable treatment approach for complex and refractory renal vascular disease, Loin-Pain Hematuria Syndrome, ureteral strictures and trauma, upper urinary tract malignancy, and stone disease in highly select patients.

Kidney Autotransplantation: Between the Past and the Future

PURPOSE OF REVIEW

The practice of kidney autotransplantation (KAT) has become an increasingly favorable approach in the treatment of certain renovascular, ureteral, and malignant pathologies. Current KAT literature describes conventional open procedures, which are associated with substantial risks. We sought to compare previously reported outcomes, evaluate common surgical indications, and assess associated risks and benefits of current KAT methods. A thorough evaluation and review of the literature was performed with the keywords "autologous transplantation" and "kidney."

RECENT FINDINGS

Early outcomes of robotic KAT are encouraging and have been associated with fewer complications and shorter hospital stay, but require robotic technique proficiency. KAT is an important method to manage selected complex urological pathologies. Robotic KAT is promising. Nevertheless, future studies should utilize larger patient cohorts to better assess the risks and benefits of KAT and to further validate this approach.

The role of renal autotransplantation in complex urological reconstruction

From 1972 to 1988, 108 patients underwent renal autotransplantation for renal artery disease (67), ureteral replacement (27), or renal cell carcinoma present bilaterally or in a solitary kidney (14). The most common indication for renal autotransplantation was to allow extracorporeal repair of complex branch renal artery lesions. Of the 54 patients in this group technically satisfactory branch renal arterial reconstruction and a successful clinical outcome were achieved in 52 (96%). Renal autotransplantation is the treatment of choice in these patients and also in selected children with main renal artery disease. Renal autotransplantation provided excellent results in 25 of 27 patients (92%) who required replacement of all or a major portion of the ureter. Over-all renal function was well preserved in these patients and only 1 has experienced chronic bacteriuria. Renal autotransplantation is a useful alternative to ileal interposition in this setting. Extracorporeal partial nephrectomy and renal autotransplantation were successful in 12 of 14 patients (85%) undergoing a nephron-sparing operation for renal cell carcinoma. In situ techniques are associated with less morbidity and currently are preferred in this group.

Ureteral reconstruction and bypass: experience with ileal interposition, the Boari flap-psoas hitch and renal autotransplantation

A total of 18 patients underwent an operation for extensive ureteral loss from 1980 to 1986. The indications included recurrent calculi, retroperitoneal fibrosis, surgical trauma and tumor. Of the patients 10 had construction of an ileal ureter (4 had bilateral reconstruction), 6 had creation of a psoas hitch with a Boari bladder tube and 2 were treated by autotransplantation. Mean duration of followup was 4.8 years. The procedure was successful in 17 patients. There were no apparent differences among the groups. Selection criteria and potential complications are discussed with regard to each technique. These procedures provide an excellent means for reconstruction of the urinary tract in patients who have failed other treatments.

Renal function after autotransplantation with direct pyelocystostomy. Long-term follow-up

The function of 20 human autologous kidney grafts was studied for 4 to 8 years (mean 5 1/2) after autotransplantation with a direct pyelocystostomy. The indications for the operation were low-grade, low-stage tumour of the renal pelvis and/or ureter, frequently recurrent renal stones and remaining outflow obstruction after pyeloplasty for hydronephrosis. The wide pyelocystostomy implies reflux of urine from the urinary bladder to the renal pelvis but no significant changes were found in glomerular or tubular function, studied with 51Cr-EDTA clearance, 131I-Hippuran renography, analysis of beta 2-microglobulin and total protein excretion in urine, and determination of concentration ability after administration of desmopressin. No increase in the severity or frequency of urinary tract infections was observed.

Future aspects of renal transplantation

New and exciting advances in renal transplantation are continuously being made, and the horizons for organ transplantation are bright and open. This article reviews only a few of the newer advances that will allow renal transplantation to become even more widespread and successful. The important and exciting implications for extrarenal organ transplantation are immediately evident.

Management of the short ureter in urinary tract reconstruction

Among our 56 patients who have undergone urinary tract reconstruction with intact bladders 45 have required some compensation for lost ureteral length. Of these patients 33 had only distal ureteral loss and underwent reconstruction with a combination of a psoas hitch, transureteroureterostomy and primary reimplantation. Four patients with more extensive ureteral loss underwent a Boari flap procedure, and of the 8 patients with major ureteral loss 6 had small bowel interposition and 2 have had renal autotransplantation to compensate for lost ureteral length. All patients are well with stable renal function at 1 to 7-year followup.

Long-term results with renal autotransplantation for ureteral replacement

From 1970 to 1984 renal autotransplantation was performed on 23 patients to replace all or a major portion of the ureter. The conditions necessitating ureteral replacement were postoperative ureteral injury in 16 cases, recurrent renal colic in 4, urinary undiversion in 2 and an atonic ureter in 1. Six patients presented with a solitary kidney and 1 underwent staged bilateral autotransplantation. After autotransplantation urinary continuity was restored by ureteroneocystostomy in 11 patients, pyelovesicostomy in 7, ureteroureterostomy in 2, pyeloureterostomy in 2 and ureterosigmoidostomy in 1. Postoperatively, there was no mortality and all but 1 of the autotransplanted kidneys functioned immediately. Two kidneys required removal postoperatively owing to bleeding. Currently, 20 patients are alive with functioning renal autotransplants at intervals of 1.5 to 14 years. The current serum creatinine level in these patients ranges from 1.1 to 2.2 mg. per dl., which in each case is improved or stable compared to the preoperative determination. Only 1 patient has experienced chronic bacteriuria. We conclude that renal autotransplantation provides excellent long-term treatment for patients who require ureteral replacement.

Combined Boari bladder flap-psoas bladder hitch procedure in ureteral replacement

Uncomplicated injuries to the ureter are commonly treated with end-to-end ureteroureterostomy or reimplantation into the bladder. The Boari bladder flap and the psoas bladder hitch have been used separately when distal ureteral replacement is required. In cases of more extensive ureteral damage extending above the pelvic rim, more complex procedures have been performed. These procedures (transureteroureterostomy, intestinal replacement or renal autotransplantation) often represent a considerable surgical challenge and may be associated with numerous complications. Combining the principles of the psoas bladder hitch and Boari flap affords the clinician a means of traversing extensive ureteral defects with standard surgical techniques. We report herein patients with ureteral damage who have undergone replacement of various lengths of ureter with combined psoas hitch/Boari flap procedures. The technique is suitable for traversing ureteral defects at least to the lower pole of the kidney. An obvious advantage is that the replacement utilizes only normal urinary tract, it does not endanger ipsilateral kidney nor contralateral ureter or kidney and can be employed in patients with decreased renal function. In our experience ureteral replacement with the combination of the psoas bladder hitch and Boari bladder flap is an excellent method which is surgically simpler and safer than the other methods described for more extensive ureteral injuries.

Pyelovesicostomy: an alternative to ureteropelvic junction-plasty in pelvic ectopic kidneys

Pyelovesicostomy was performed in 2 cases of hydronephrosis in pelvic kidneys secondary to ureteropelvic junction obstruction. In the first patient, who presented with a solitary kidney, the procedure was done after failure of a dismembered pyeloplasty, while in the second patient the procedure was performed electively. Both patients had sterile urines and stable renal function, although some dilatation persisted in the first case. The indications and the functional aspects of this surgical solution are discussed.

Calycovesicostomy for total ureteral obstruction after renal transplantation

Surgical reconstruction for ureteral obstruction is necessary in 1 to 10 per cent of renal transplants. On an acute basis edema, ischemia, lymphocele and hematoma formation cause ureteral obstruction. Chronic etiologies include ureterovesical obstruction and retroperitoneal or ureteral fibrosis. Options for repair are myriad and include repeat ureteral reimplantation, pyeloureterostomy, ureteroureterostomy, pyelocystostomy and calycovesicostomy. We report on the desirability of calycovesicostomy as a last resort option for total ureteral obstruction after renal transplantation.

Autologous renal transplantation with direct pyelocystostomy in the treatment of recurrent renal calculi

Six male patients with severe recurrent urinary calculus disease underwent renal autotransplantation with direct pyelocystostomy to allow spontaneous passage of stones. The only serious complication was an early renal vascular thrombosis with graft loss in one patient who had been operated on three times before with ipsilateral partial resections for nephrolithiasis. The other five patients did well (observation time 4-34 months). Their renal function has remained unchanged. Autotransplantation with direct pyelocystostomy should be considered in patients with multiple recurrent stones of the upper urinary tract, especially when some degree of obstruction has developed or when other predisposing anomalies prevail.

Endoscopic removal of staghorn calculi in patient with high urinary diversion

The treatment of recurrent renal calculi in patients after ureteroileal urinary diversion is difficult, especially when urinary stones are formed in the presence of urinary tract infection. In many cases, these patients already have undergone multiple renal operations and more surgery could pose difficult technical problems. We report on a patient with a high urinary diversion in whom bilateral staghorn renal calculi developed, and then were endoscopically removed. The conversion of ureteroileocutaneous diversion to a high pyeloileocutaneous diversion is recommended in selected cases as alternate treatment for patients with recurrent stone formation.

Vesicopyelostomy using a tubed bladder flap-multiple psoas hitch technique to an orthotopic kidney

A case is reported in which a long upper ureteral stricture, resulting from a failed pyeloureteroplasty, was repaired using a pedicle bladder tube. A vesico-psoas hitch was performed as the initial procedure. A 17 cm. long bladder flap was based posteriorly and extended across the dome and the anterior wall onto the contralateral posterolateral aspect of the bladder. Stepwise stretching and hitching of the bladder flap to the psoas major muscle at 5 places ensured successful bridging of the gap without compromising its vascularity. At followup cystography the bladder tube was noted to accommodate the reflux of contrast material, preventing its entry into the pelviocaliceal system. The patient regained a bladder capacity of about 300 ml. This procedure should be considered before ileal ureteral replacement or autotransplantation in cases of extensive ureteral loss.

Renal bench surgery

Eighteen patients undergoing bench surgery and autotransplantation are reported. The major indications for this procedure are renovascular hypertension and neoplasms affecting either both kidneys or a solitary kidney. The least satisfactory results were obtained when calculus disease was present.

Extracorporeal renal surgery and autotransplantation: indications, techniques and results

Renal autotransplantation and/or an extracorporeal renal operation has been done 67 times in 65 patients. The indications for operation were severe ureteral injury in 8 patients, urinary undiversion in 2, renovascular hypertension in 10, carcinoma in a solitary kidney in 3, recurrent renal colic in 1 and donor arterial reconstruction before renal transplantation in 43. Methods of renal preservation and operative repair are described. Sixty-five operations were successful and 2 operations failed because of severe perirenal fibrosis in patients undergoing urinary undiversion. Renal autotransplantation and extracorporeal reconstruction can provide the best solution for selected urologic problems not correctable by conventional methods.