Fibrosis of a renal transplant ureter

[Surgical treatment of ureteral stenosis after kidney transplantation]

Ureteral stenosis is the most frequent complication after kidney transplantation. The diagnosis is based on an elevated creatinine level and a dilatation of the urinary cavity. The first step of the management is a urinary diversion with endo-ureteral prosthesis or a nephrostomy placement. The surgical gold standard is the pyelo-ureterostomy. This is a safe and efficient technique in the treatment of this complication. We describe the different surgical alternatives and the endo-urologic management of the stenosis.

Urological complications after living-donor renal transplantation

OBJECTIVE

To determine the incidence and management of urological complications after 1200 consecutive live-donor renal transplantations, all of which were carried out in one centre; the possible risk factors and the effect on patient and graft survival were also assessed.

PATIENTS AND METHODS

Data were retrieved from an electronic database; the incidence of urological complications was determined, and correlated with relevant risk factors by univariate and multivariate analysis. The effect on patient and graft survival was assessed using Kaplan-Meier statistics.

RESULTS

There were 100 complications in 96 patients (8%); urinary leaks occurred in 37, ureteric strictures in 23 and lymphoceles causing ureteric obstruction in 17. Percutaneous needle biopsy was complicated by haematuria and clot anuria in six patients. Late complications included 11 cases of stones, four of bladder malignancy and two of haemorrhagic cystitis. There was evidence that the age of the recipients (< 10 years), method of establishing urinary continuity (uretero-ureteric anastomosis) and a high dose of steroids had an independent positive effect on the incidence of urological complications. However, their development did not influence graft or patient survival.

CONCLUSION

When there is meticulous attention to the technical details, renal transplantation should incur few urological complications. Early intervention with percutaneous drainage reduces morbidity and the likelihood loss of graft function. Proper and prompt management should not affect the graft and/or the patient's survival.

Late ureteral obstruction after kidney transplantation. Fibrotic answer to previous rejection?

Today, the incidence of urological complications following renal transplantation is 2%-10%. Most of these complications occur within the 1st year and affect the distal ureter. We report on two patients who developed very late ureteral obstruction, 14 and 18 years after transplantation. Both patients had rejection episodes 1 and 10 months prior to the ureteral stenosis. Histological examination of one resected ureter revealed findings strongly suggestive of a rejection process. Open surgery with antirefluxive reimplantation into the bladder was successful in both patients, with a postoperative observation time of 20 and 8 months, respectively. We conclude that a percutaneous nephrostomy may be required in patients with rising creatinine and incipient hydronephrosis even long after transplantation has been performed.

Endourologic management of complications in renal allografts

Because of the altered anatomy, the presence of immunosuppression, the possibility of graft rejection, and the serious implications of a problem involving a solitary kidney, the transplanted kidney presents unique challenges in the diagnosis and treatment of urologic complications. Historically, the mortality rate in these patients has been as high as 68%, and as many as 15% of the allografts have been lost. Today, endourologic procedures are used for prompt diagnosis, temporization, and even definitive management of many urologic complications, and many patients and allografts are being saved. The authors review present techniques and suggest others that may be available in the future.

Extracorporeal shock wave lithotripsy in a renal transplant patient

We report a case of nephrolithiasis in a transplanted kidney that was treated successfully with extracorporeal shock wave lithotripsy. The patient experienced transient partial obstruction after lithotripsy and, thus, intense monitoring of the transplant patient is necessary.

Current operative management of urinary calculi after renal transplantation

We examined the medical records of renal transplantation patients at our institution to determine the incidence and etiology of renal calculi after renal transplantation. Of 7 patients identified calculi formed on the basis of congenital hyperoxaluria in 2, secondary to chronic urinary infection in 1 and from iatrogenic causes in 4. We review the various surgical and radiological procedures used to treat these renal transplant patients. We also discuss the role of the new treatment modalities in managing urolithiasis in transplant recipients.

Combination extracorporeal shock wave lithotripsy and percutaneous extraction of calculi in a renal allograft

Renal calculi are a well documented although uncommon complication of kidney transplantation and may be associated with significant morbidity in this immunosuppressed population with a single functioning kidney. We describe a patient who presented with 2 episodes of staphylococcal bacteremia associated with a ureteral structure and struvite calculi involving the calices, renal pelvis and proximal ureter of a cadaveric renal allograft. The patient was treated successfully with a combination of extracorporeal shock wave lithotripsy, percutaneous extraction and balloon dilation of the ureteral stricture. Renal transplant function was not altered postoperatively. In selected cases shock wave lithotripsy can be used as effective adjunctive therapy in a renal allograft harboring stones.

Transplant ureteral obstruction masquerading as recurrent rejection episodes: management by percutaneous antegrade balloon dilatation

We report a 52-year-old male renal transplant recipient who had three "rejection episodes." The first of these responded to conventional antirejection therapy; however, the next two episodes showed incomplete responses to treatment for rejection. At subsequent presentation with deteriorating renal function, ureteral obstruction was evident and was relieved with percutaneous antegrade balloon dilatation with a return of his plasma creatinine to normal. Obstruction of the ureter was a major component in our patient's course given the lack of response to conventional antirejection therapy and the normalization of renal function with relief of the documented ureteral stenosis. This case illustrates that ureteral obstruction can mimic rejection in the renal transplant recipient. Management of ureteral stenosis in transplant patients with percutaneous antegrade balloon dilatation appears to be an effective procedure and can supplant the need for open surgical procedures.

The manifestation and management of late urological complications in renal transplant recipients: use of the urological armamentarium

The incidence of urological complications in renal transplant patients is well documented. The majority of these complications occur in the early postoperative period; late occurrences (more than 3 months) are much less common. We have had experience with 7 patients who presented with late complications 3 months to 7 years after transplantation: ureteral obstruction occurred in 4 patients, ureteral disruption or laceration in 2 and neurogenic bladder with hydronephrosis in 1. Management of these patients has been varied and has included cystoscopic stent placement, Boari flap, ureteropyelostomy, ureteroneocystostomy, bladder augmentation and urinary undiversion. Grafts have been salvaged in 6 of 7 patients. Transplant patients who present with late urological complications can be challenging. However, the potential for intervention and graft salvage is excellent.

The percutaneous removal of calculi from transplanted kidneys

Renal calculi complicating transplanted kidneys are uncommon but they can be an important cause of deterioration in graft function. We report 2 complicated cases managed by percutaneous nephrostolithotomy.

Anuria in transplant patient following inguinal herniorrhaphy

We report ureteral ligation following inguinal herniorrhaphy in a transplant patient. Successful treatment was accomplished by percutaneous nephrostomy and ureteral reimplantation.

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.

Experience with pyeloureterostomy in renal transplantation

Pyeloureterostomy was used as the preferred method of urinary tract reconstruction in 260 of 371 consecutive renal allograft procedures performed between September 1967 and December 1980. Initially chromic catgut suture was used for the anastomosis in 96 patients with ten complications developing (10.4%). Because of the high incidence of anastomotic leakage (8.3%) with chromic catgut suture, the next 101 pyeloureterostomies were constructed using 7-0 Tevdek. Although urinary leakage occurred in only five of these patients (4.9%), late stone formation occurred along the suture material in three patients (2.9%), influencing the conversion to 7-0 Prolene for this anastomosis. With this suture material, only two complications have occurred in 63 subsequent pyeloureterostomies (3.1%), neither related to the anastomosis. In comparison, eight complications developed in 111 patients who underwent reconstruction with the Politano-Leadbetter method of ureteroneocystostomy (7.2%). The currently recommended method for pyeloureterostomy, as described, when combined with meticulous attention to technical details has made pyeloureterostomy a safe and effective method of urinary tract reconstruction in renal transplant recipients, with morbidity indistinguishable from that of ureteroneocystostomy.

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.

Urologic complications in renal transplantation

The current overall reported incidence of major urologic complications following renal transplantation is 5 per cent. The presence of such a complication increases the likelihood of patient mortality by a factor of three. Standard utilization of postoperative radionuclide scanning is very useful in early diagnosis. Vesical fistulas generally result from improper bladder closure. The incidence of bladder complications increases with secondary and tertiary grafts. Ureteral complications result when the blood supply of the ureter is impaired. These include fistula formation, necrosis, and obstruction. Immediate surgical correction is indicated in almost all serious urologic complications following transplantation; otherwise there is marked increase in morbidity and mortality. Complications appearing early in the postoperative period carry a poor prognosis for both graft and recipient survival. The presence of urinary tract infection early in the postoperative period also correlates negatively with graft survival. The presence of multiple renal arteries in the donor has been associated with an increased rate of urologic complications. Ureteral fistulas can be avoided by meticulous dissection of the donor at the time or organ harvesting. Great care must be taken to preserve the arterial and venous blood supply to the ureter by avoiding any dissection into the renal hilum. Aberrant renal arteries must be preserved or repaired if damaged. Ureteroneocystostomy is the preferred method for re-establishing urinary tract continuity following transplantation. The immediate surgical correction of urologic complications is mandatory, and the techniques involved are highly specialized and must be individualized with each patient.

Incidence of later ureteral obstruction after antireflux surgery in infants and children

Forty infants and children who underwent antireflux surgery for primary reflux had long-term follow-up with intravenous pyelograms (IVP). The IVPs were evaluated for the incidence of late ureteral obstruction. Although 4 cases (5.5 per cent) of early ureteral obstruction were noted, no instances of late ureteral obstruction were found. After antireflux surgery, patients should have a follow-up IVP within the first six months to rule out the possibility of early ureteral obstruction. The need for performing periodic IVPs for many years postoperatively, when obstruction is absent in the immediate postoperative period, is questioned.