The allograft ureter

Ureteroneocystostomy in renal transplantation: a simple transvesical technique

A simple transvesical technique for transplant ureteroneocystostomy is described. The method has been used in 245 transplants during a 6-year period. Only 4 significant complications (1.6 per cent) were recognized and no kidney was lost owing to a complication of ureteroneocystostomy.

Genitourinary complications in renal transplantation

The surgical aspects of renal transplantation have now been studied thoroughly. Yet, technical complications are still common. This review may seem too complex, but proper attention to many small details means the difference between success and failure, or at least between large and small morbidity. Reduction of genitourinary complications is due to many innovations. The external ureteroneocystostomy is a primary method of urinary reconstruction which is simpler and produces fewer complications than the alternative procedures. Further, the complications that do occur are more easily and promptly treated. The end-to-side ureteroureterostomy, as currently performed, provides a ready secondary method of reconstruction if the primary method fails. The early exploration and operative correction of genitourinary complications substantially reduces long-term morbidity and mortality.

External ureteroneocystostomy in renal transplantation

The urologic complications of 184 consecutive renal transplants (68 living-related and 116 cadaveric) performed at Walter Reed Army Medical Center are reviewed. An anterior extravesical technique modified from Witzel, Sampson, and Lich was used to reimplant the ureter. Urologic complications occurred in 11 patients (6%): urine leak (4), obstruction (3), stricture (3), and total ureteral necrosis (1). These complications occurred in the first 115 patients; no complications have been documented in the last 69 patients. The several advantages of extravesical ureteroneocystostomy include: less operative time, avoidance of a separate cystotomy, virtually no hematuria, ability to use short ureters, no need for splints or stents, shortened Foley catheter drainage, and no interference with native ureteral function. Complications are few and become uncommon with practice.

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.

[Early ureteral complications after renal transplantation (author's transl)]

Ureteral complications occurred in 23 cases after 225 renal transplantations. The complications consisted of 17 urinary fistulas and 6 stenoses of the ureter. Fourteen of the urinary fistulas were successfully treated by conservative management. Two transplants were lost secondary to operation because of ureteral obstruction. Factors contributing to ureteral leakage were the technique of ureteral anastomosis, the handling of the donor ureter during donor nephrectomy and possibly ureteral necrosis by rejection crises. Ureteral stenosis and rejection crisis may have the same symptoms. Urinary fistulas can easily be observed by the urine extravasation. The treatment of urinary fistulas can be managed only by replacing the suprapubical drainage. The stenosis of ureter with subsequent deterioration of graft function needs an operation with the danger of loss of the transplanted kidney.

Ureteral reconstruction in renal transplantation

The complications associated with ureteral reconstruction in renal transplantation produce significant morbiditiy and mortality rates. We have evolved a combined intravesical-extravesical nonstented ureteroneocystostomy and have used it in 100 consecutive transplants, 50 of which were in high-risk diabetic recipients. No instances of urinary extravasation, fistula formation, disruption of the ureterovesical anastomosis, ureteral solughing, or ureterovesical obstruction have occurred in this series. The lack of urologic complications utilizing this technique offers reduced morbidity and mortality to transplant recipients.

Renal transplantation in patients with urologic abnormalities

Of patients undergoing renal transplantation during a recent 18-month period 42 per cent had significant urologic abnormalities. A thorough pre-transplant evaluation is especially critical in these patients. Massive reflux is an indication for pre-transplantation nephroureterectomy. Reconstructive operations provided a functional bladder in some patients who had previously undergone urinary diversion. Other patients required formation of intestinal conduits. Suggestions for the management of transurethral prostatectomy in patients with renal failure are outlined. Patients with a variety of abnormalities of the urinary tract had a transplantation success rate comparable to that of azotemic patients with normal urinary systems.

Simplified experimental ureteroneocystostomy

Improvement in renal transplantation has been the result of increased clinical experience and laboratory investigation. One of the causes of transplant failure is urinary leakage and slough at the ureteroneocystostomy site. A simplified extravesical ureteral implantation technique is described. This method has been used in more than 200 canine renal transplants producing consistently good results.

Ureteroneocystostomy versus ureteropyelostomy: a comparison in the same renal allograft series

Of the 132 transplants in our series 44 patients underwent reconstruction by ureteropyelostomy (group 1) and 88 underwent reconstruction by ureteroneocystostomy (group 2). The rates of major urologic complications were 11 percent in group 1 and 4 per cent in group 2. These results support the widely held opinion that ureteroneocystostomy is the superior method for urinary reconstruction in renal allograft cases. However, the alternative of ureteropyelostomy should be part of every transplant surgeons' armamentarium, especially for cadaver transplants when ureteral blood supply may be compromised.