Kidney transplants: 92 cases. Results, lessons learned, future prospects

Prevention of lymphocele formation following renal allotransplantation

Lymphocele formation is a recognized complication of renal allotransplantation that can jeopardize the graft and cause major morbidity for the allograft recipient. Previously, emphasis has been placed on treatment as opposed to prevention. We attempted to prevent lymphocele formation by adopting 2 techniques in performing the renal transplantation: 1) we limited the area of dissection in the recipient to that necessary to obtain vessel control of the segment of iliac vessel that was to be used for the vascular anastomosis (to decrease the number of lymphatics that were divided or destroyed) and 2) we practiced lymphostasis as meticulously as we did hemostasis. We did not attempt to ligate any lymphatics in the hilus of the kidney. Using these techniques we have performed 198 consecutive renal allografts without the development of an identifiable lymphocele. The limitation of the area of vessel dissection has not increased either the rate of major vascular complications (2 per cent) or the development of major pulmonary embolism (0.5 per cent) after transplantation. We conclude that extensive dissection of the iliac vessels is not necessary to prevent major vascular complications or pulmonary emboli after renal transplantation, that careful lymphostasis in the allograft recipient will prevent the development of a lymphocele and, therefore, that the lymph fluid in a lymphocele is derived primarily from the allograft recipient and not from the allograft itself.

Nontraumatic rupture of renal allografts

Eight cases of nontraumatic renal allograft rupture were identified in 237 renal transplants performed at UCLA Medical Center. Careful clinicopathologic studies in these patients suggest three principal underlying causes: major graft vessel occlusion, hyperacute or accelerated rejection, and acute rejection. The clinical and pathologic features of these various categories are compared and contrasted.

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.

Late ureteropelvic necrosis after transplantation

Total ureteropelvic necrosis of the transplanted kidney occurred more than one month after transplantation in 5 of 575 consecutive renal transplants performed at the University of Minnesota Hospital since 1963. Necrosis became evident long after normal renal function had been established. Histologic signs of rejection were minimal, but perinephric or periureteral hematomas were found in 3 of 5 patients: post-transplant acute tubular necorsis requiring hemodialysis occurred in all. The pathogenesis of this complication probably involves (1) a primary deficit of blood supply from the renal vessels to the pelvis and ureter, (2) a failure to develop a new ureteral blood supply because of surrounding hematoma, (3) early swelling of the ischemic ureter resulting in oliguria interpreted as acute tubular necrosis, (4) resolution of edema resulting in diuresis, and (5) late patchy ureteral necrosis and fistula formation due to ureteral ischemia.