Conservative surgical management of urological complications after cadaveric renal transplantation

Urological complications in pediatric renal transplantation: management and prevention

From 1973 through 1986, 166 consecutive renal transplants were performed in 143 patients. Urological complications included ureteral leakage/obstruction/necrosis, urinary tract infection, pyelonephritis, pelvic lymphocele, pelvic abscess, pelvic hematoma, infected hydrocele, bladder calculus, labial edema, renal artery/segmental stenosis, hydronephrosis, urinary incontinence, renal allograft malrotation and kidney rupture. Management options and preventive measures to avoid some of these dilemmas are highlighted.

Simultaneous transplant nephrectomy and ipsilateral second graft retransplantation

Six cases of simultaneous transplant nephrectomy and retransplantation in the ipsilateral iliac fossa are presented. All primary grafts were lost due to chronic rejection. Patients were followed from forty-one to one hundred months after the second graft transplant. The sources for all grafts were either living related donors or cadavers. Graft nephrectomy was performed through the previous lower quadrant incision; the arterial and venous stumps of the primary grafts were used when possible. In all cases continuity of the urinary tract was reestablished with a Politano-Leadbetter ureteroneocystostomy. There appears to be no increased morbidity in any of these 6 cases, and the survival rate of the second graft is comparable to that of transplantation into the contralateral virginal fossa. Advantages of the simultaneous procedure are discussed.

Nephrostomy drainage for renal transplant complications

The use of temporary diverting nephrostomy drainage in the management of immunosuppressed renal transplant patients with supravesical urinary extravasation, fistulas or ureteral obstruction is reviewed. In a literature survey covering an 11-year interval and 4,307 transplants there were 204 cases (4.7 per cent) of ureteral extravasation or fistula and 113 cases (2.6 per cent) of ureteral obstruction. Attempts at urologic repair in these 317 cases resulted in 30.9 per cent failure rate (98 cases), of which 86.7 per cent (85 cases) occurred in patients without nephrostomy compared to 13.3 per cent (13 cases) in patients with nephrostomy. In our 255 consecutive renal transplant patients there were 7 (2.7 per cent) with ureteral extravasation or fistula and 14 (5.5 per cent) with ureteral obstruction. Temporary nephrostomy was done in all 21 patients to protect the urologic repair and, when necessary, to control sepsis and allow for patient stabilization before delayed urinary tract reconstruction. In our series there was no mortality and only 1 renal unit (4.7 per cent) was lost as a consequence of urologic complications. The use of nephrostomy in transplant patients with ureteral extravasation, fistulas or ureteral obstruction is encouraged strongly to optimize patient and renal unit survival.

Urinary tract reconstruction in renal transplantation. Mayo Clinic experience and review of literature

Althrough rejection remains the most frequent cause of renal allograft failure, technical problems have contributed and continue to contribute to graft loss. Urologic complications may be caused by technical errors in the donor nephrectomy or in urinary tract reconstruction. During the past decade, however, with advances in medical and surgical management, the reported incidence of urologic complications in renal transplantation has declined steadily. This may be due to (1) more extensive donor and recipient preparation and evaluation for surgery, (2) improvement of surgical technique with increasing experience in donor and recipient, and (3) more refined diagnosis and treatment of urologic and infectious complications.