Some urological aspects of 93 consecutive renal homotransplants in modified recipients

Long-term outcomes of living-donor kidney transplant children weighing less than 15 kg: Comparison of the surgical approach

INTRODUCTION

Kidney transplantation (KTx) is the most effective treatment for end-stage renal disease in children.

OBJECTIVES

We aimed to compare the long-term outcomes and surgical complications of the intraperitoneal approach (IPA) and extraperitoneal approach (EPA) for KTx in children weighing <15 kg.

STUDY DESIGN

We performed a retrospective cohort study on pediatric kidney transplant recipients, weighing <15 kg, who received their first living-related kidney transplant between January 1987 and December 2015. Patients were divided into two groups based on the surgical approach (IPA or EPA) during transplant, and clinical data were extracted from the medical records.

RESULTS

The median follow-up duration was 14.1 years (interquartile range, 9.0-19.2). Comparing the two groups (IPA group, n = 62; EPA group, n = 38), the median age and body weight were significantly lower in the IPA group (4.2 vs. 4.8 years, P = 0.03; 11.7 vs. 13.0 kg, P < 0.01). There were 26 surgical complications (26%) in 19 patients during the follow-up period. The surgical complication rate was higher in the IPA group (39% vs. 6%).

DISCUSSION

We assessed the long-term outcomes of the surgical approaches used for pediatric patients weighing <15 kg who underwent KTx and received a size-mismatched adult donor kidney. There was no significant difference in renal transplantation prognosis using the surgical approach, but IPA-related complications were more frequent in the long term. Therefore, our data suggest that in cases of donor-recipient size mismatch in pediatric KTx, the EPA, associated with fewer surgical complications, is preferable to the IPA if the patient's body size has sufficient space for allograft placement.

CONCLUSION

The transplant approach did not influence the long-term outcomes in children weighing <15 kg, but EPA had fewer surgical complications and was technically safe.

The First Case of Ureteral Duplication in a Combined Liver-Kidney Transplantation

Aim

Kidney transplantation with ureteral duplication may represent a doubled risk factor in terms of ureteral stenosis or necrosis with urinary leakage usually from the site of ureteroneocystostomy. The incidence of complete duplication is very low at 0.19%. We report a kidney with ureteral duplication in the specific setting of multiorgan transplantation since it could be considered a adjunctive risk factor for urological complications.

Methods

The recipient was a 67-year old man, suffering from terminal renal insufficiency. He was also affected by HCV-related cirrhosis. The patient had been waiting for the combined transplantation for 27 months and in the last two months his hepatic function dramatically worsened. The donor was a 53-year old man who died of non-traumatic subarachnoid hemorrhage. Good HLA compatibility was observed between donor and recipient. During harvest both kidneys presented a complete ureteral duplication. So the ureters were freed together with a wide cuff of periureteral tissue and dissected distally. No vascular abnormalities were noted during the removal of either kidney. The grafts were flushed with University of Wisconsin solution and stored in the same solution.

Results

The liver was reperfused after 9 hours of cold ischemia. Subsequently the kidney was vascularized after 15 hours of cold ischemia. Urine production occurred immediately after revascularization. Two separated ureteroneocystostomies with a single antireflux technique were performed. Cyclosporine and steroids were given. Post-operative course was uneventful and liver and kidney function were normal. The 7-day cystography was normal. The 6, 12, 24 month ultrasonographies showed no signs of hydronephrosis or hydroureter. After 28 months renal cancer was diagnosed and the patient underwent a right nephrectomy. The liver-kidney recipient had excellent hepatic and renal function for 84.7 months. He died of malignancy from de novo tumor.

Conclusions

On the basis of this experience, a kidney with an ureteral duplication, while rare, can be satisfactorily used also in combined liver-kidney transplantation.

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.

Primary use of a double J silicone ureteric stent in renal transplantation

Vesicoureteric leakage and obstruction are the commonest urological complications after renal transplantation. A retrospective analysis of our initial experience using a double J silicone ureteric stent showed that primary splinting of the vesicoureteric anastomosis eliminated these complications, whereas their combined incidence was 13.6% in the non-stented patients. The presence of the stent was not associated with increased risks of urosepsis.

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.

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.

Urinary tract infection in pediatric renal transplantation

Urinary tract infection is a frequent complication following renal transplantation and represents a potential focus for systemic infection in the immunosuppressed transplant recipient. The incidence, etiologic factors, temporal pattern, bacteriology, and prognostic significance of urinary tract infection were determined by analysis of 85 renal allografts in 69 patients. Significant bacteriuria occurred after 49 of 85 transplants (58 per cent). The incidence of infection was not related to success or source of the allograft, but was related to patient gender. Urinary tract infections developed in 68 per cent of females, while only 43 per cent of males became infected (p less than 0.05). Escherichia coli caused most first infections (30 per cent), while Pseudomonas aeruginosa and E. coli were equally responsible for recurrent infections (25 per cent each). Children with previous reconstructive urologic surgery had similar allograft success (63 per cent) and infection rates (53 per cent) as our other children (61 per cent and 58 per cent, respectively). No apparent correlation was noted between episodes of infection and graft rejection. Thorough preoperative assessment and preparation and prompt, specific treatment minimize the adverse influences of urinary tract infection.

Post-transplantation pyelonephritis: factors producing low patient and transplant morbidity

A retrospective study of 1,100 consecutive renal transplantations done on 959 patients revealed postoperative pyelonephritis in 15 patients, 14 of whom were women. Sixteen of the 20 episodes of pyelonephritis were caused by Escherichia coli and only 4 episodes occurred within the first year after transplantation, thus revealing the crucial differentiation from a rejection episode. When the etiology of the original renal failure was pyelonephritis the incidence of pyelonephritis in the transplanted kidneys was high. This high incidence also was true for cases associated with post-transplantation urological complications. When the etiology of renal failure was diabetes or polycystic renal disease, or when urologic abnormalities pre-existed the incidence of pyelonephritis was low. No transplant or patient loss was caused by post-transplantation pyelonephritis, probably because of prompt, correct diagnosis and a low urological complication rate.

[Transplant pyelonephritis (author's transl)]

Examinations of the urine in 216 kidney allograft recipients resulted in significant bacteriuria in 274 samples of 1,802 urines tested. Bacteruria was found in 30 patients with recurrent or chronic persistent infections of the urinary tract; this patient group was studied by examination of 399 urine samples (mean 13.3 samples per patient). Four patients suffered from urologic complications after kidney grafting and were excluded from the study; 15 patients were diagnosed clinically and/or histologically with transplant pyelonephritis, 11 patients with cystitis. Of main importance for the diagnosis of transplant pyelonephritis were findings of persistent leucocyturia and the presence of antibody-coated bacteria. Both of these findings were repeatedly seen in all patients with transplant pyelonephritis. Clinical symptoms included fever and dysuria. In contrast to patients suffering from cystitis, transplant function detoriated in 13 of 15 patients with transplant pyelonephritis; two patients had to be treated by hemodialysis. Septicemia occurred in eight of the 15 patients studied. The data illustrate the frequency of transplant pyelonephritis as observed in 15 of 26 patients accompaining chronic urinary tract infection after kidney allograft transplantation. As a predisposing factor, obstruction of the urinary tract was diagnosed in eight of the 15 transplant recipients with pyelonephritis. The prednisone dose was higher than 10 mg in eight of 15 patients at the time transplant infection was diagnosed. Successful antibiotic treatment resulted in stable transplant function in three patients; four patients exhibited even lower serum creatinine levels after therapy.

Urological complications in 119 consecutive renal transplants

One hundred and nine patients undergoing 119 transplants have been followed up from 8 months to 9 years. Urological complications occurred in 16 transplants, an incidence of 13.4%. Ureteroneocystostomy was performed primarily in all cases; in 98 by the conventional Politano-Leadbetter technique with 9 (9.2%) urological complications and in 32 by an extravesical technique with 7 (21.8%) urological complications. One patient died as a result of ureteric obstruction, without operation. In 3 patients with lower ureteric obstruction, transurethral ureteric meatotomy was successful in 2 cases and resulted in no change in renal function in the third. Two patients with urinary fistulae were managed successfully by continuous drainage with indwelling urethral catheters. The remaining 10 patients required 12 open surgical procedures for relief of ureteric obstruction, with improvement in function in 7 patients.

Controversy in renal transplantation: antireflux versus non-antireflux ureteroneocystostomy

A comparison of 118 consecutive nephroureteral allografts suggests that ureteroneocystostomy provides excellent results with (60 cases) or without (52 cases) an antireflex procedure. Reflux was noted in less than 10% of each group after transplantation and no morbidity could be attributed to reflux when it was found. There was no obstruction or anastomotic leakage in either group. The advantages of each procedure are discussed.

Anaerobic bacteriuria in renal transplantation

Renal allograft recipients were studied prospectively utilizing improved culture techniques to investigate anaerobic bacteriuria. The study population was compared with a population of patients with chronic renal insufficiency and end stage renal disease. The over-all incidence of anaerobic urinary tract infection was 7.5 per cent while the over-all incidence of aerobic urinary tract infection was 23.5 per cent. Patients with cadaver renal transplants during the early postoperative period had the highest incidnece of both anaerobic (42.9 per cent) and aerobic (71.4 per cent) urinary tract infection of all groups. The potential association between significant anaerobic bacteriuria during the first postoperative month and poor prognosis for cadaver renal allografts merits further investigation.

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.

Spermatic cord: cause of ureteral obstruction in renal allotransplant recipients

Two cases of renal allotransplants are presented with urologic complications caused by the spermatic cord. Management of these patients is discussed, and a question is raised about the insistence of placing the ureter under the spermatic cord in all cases.

Bacteriuria and renal infection in kidney-transplant recipients

In 64 patients who had undergone renal transplantation, later on followed by bilateral nephrectomy, bacterial growth culture was performed from the original kidneys. The presence of bacteria in the nephrectomy specimens was compared with the occurrence of significant bacteriuria before transplantation and in the period between transplantation and nephrectomy. Bacteria could be cultured from the nephrectomy specimens of 18 (28.1 per cent) of the patients, almost exclusively confined to cases of obstructive chronic pyelonephritis, analgesic nephropathy and congenital renal disease. Before transplantation, bacteriuria had been recorded in 34.4 per cent of the patients, most frequently in the three groups of diseases just mentioned. Between the transplantation and nephrectomy, bacteriuria occurred in 75.0 per cent of the patients. Patients with E. coliuria before transplantation were particularly liable to have E. coliuria also after the transplantation and to E. coli in the nephrectomy specimens, whereas patients in whon E. coliuria did not occur until in the post-transplantation period were less susceptible to E. coli infection involving the kidneys. Probably the presence of bacteria in the nephrectomy specimens is related to the primary disease rather than to immunosuppressive and antiobiotic agents administered in the post-transplantation period.

Urinary infection in kidney transplantation

Urinary tract infection is the most frequent complication following renal transplantation and is important in the etiology of post-transplantation sepsis. The 87 renal homografts done in 1974 at The New York Hospital-Cornell Medical Center were reviewed retrospectively, with at least one year follow-up, in all cases, with particular attention to factors relating urinary tract infection to ultimate success or failure of the renal graft. The over-all incidence of urinary tract infection was 61%. Early infection was associated with a particularly poor prognosis for graft survival. Most patients with urinary infections after successful transplantation experience a combination of both early and late infections. Anatomic factors constitute a remediable cause of urinary infections after transplantation and should be searched for in cases of multiple, recurrent infections, de novo hypertension, or deterioration of previously stable graft function. There were significant differences in the bacteriologic spectrum of urinary tract infections associated with successful transplants as opposed to unsuccessful transplants.

The surgical approach to urological complications in renal allotransplant recipients

Urinary extravasation or ureteral obstruction occurred in 22 patients who received 30 transplants in a series of 290 renal transplants. This incidence represent 10.3 per cent of the entire transplant experience at The Johns Hopkins Hospital and Baltimore City Hospitals from 1968 to the present time. Ureteroneocystostomy was used as the primary form of urinary tract reconstruction in all but 1 patient who had urinary complications. These 22 patients received 30 renal transplants: 6 from living related donors and 24 from cadaver sources. There were 15 instances of urinary extravasation and 14 instances of obstruction. All but 2 fistulas were diagnosed within 30 days of the original transplant. Obstruction occurred later, with 4 cases of ureterovesical obstruction being diagnosed 3 to 5 years after the transplant procedure. The ureterovesical junction or bladder was the site of complication in 17 of the 29 instances. Surgical management in these cases was highly individualized, with successful outcomes more commonly attained in those cases characterized by obstruction. Ureteral stents were used in all but 1 secondary procedure involving the ureter and these stents were not associated with an increased incidence of urinary tract infection. Death directly related to the urological complications occurred in 2 cases, 5 patients underwent transplant nephrectomy and 2 patients died of rejection and infection more than 6 months after the urinary fistulas were successfully managed. From the original series, there are 15 of the 22 patients who have stable renal function after secondary or tertiary urological procedures on the transplanted kidney. Four patients underwent surgical correction of hydronephrosis associated with infection or diminishing renal function more than 3 years after the transplantation and 3 of these had good results.

Acute pyelonephritis in a transplant patient with an ileal loop mimicking rejection

The clinical picture of an enlargement in kidney size, a decrease in renal function and an increase in temperature in a patient with a transplanted kidney into an ileal loop presents a problem in differential diagnosis among rejection, acute tubular necrosis and acute pyelonephritis.

Aggressive management of genitourinary complications of renal transplantation

In the course of 184 renal transplantations performed in St. Louis since 1963, twenty-six minor and twenty-three major complications have occurred. As a result of these complications four kidneys have been lost and 1 patient has died. Aggressive therapy has been utilized in the management of all but two of the major complications and is associated with one death and the loss of two kidneys. On the basis of these results intensive therapy for genitourinary complications is encouraged, and the principles of therapy are discussed.

Urologic complications in renal primary and retransplantation. Experience with 202 consecutive transplants

In a period of two years, 202 kidneys were transplanted in 162 patients at the Downstate Medical Center. On hundred twenty-nine patients had primary transplantations, twenty-nine second transplantations, and five third transplantations. Urologic complications occurred in twenty-four of the patients (12%). There were eight complications involving the urinary bladder and fifteen ureteric complications. In twenty-one patients the complications appeared within six weeks after surgery. Surgical correction immediately upon diagnosis of the urinary complications resulted in a high degree of early restoration of the urinary tract continuity and preservation of renal function. Leakage from the bladder was frequently associated with previous surgery. In five of eight patients, bladder leakage occurred after the second or third transplantations. Complications of the urinary bladder in general had a significantly favorable prognosis as compared with ureteric complications. Although all the patients with bladder complications fully recovered and maintained good renal function, four patients with ureteric complications either died or lost the graft.

Effect of ureteral stent on urinary tract infections in renal transplantation

A retrospective study was carried out to determine the effect of ureteral intubation during renal transplantation. We noted urinary tract infections in 76 per cent of those patients whose ureters were intubated during transplantation, as opposed to 45 per cent in those transplant recipients without ureteral stents. The incidence of recurrent urinary tract infections also increased from 18 to 34 per cent with the use of ureteral catheters. Ten separate episodes of bacteremia, indirectly related to indwelling catheters, are noted.

Squamous cell carcinoma of the ureterovesical junction after renal transplantation

A case of squamous cell carcinoma of the bladder occurring at the ureterovesical junction in a renal transplant recipient is presented. References are made to ureteral obstruction in transplanted kidneys, the broader field of squamous cell carcinoma of the bladder in non-transplanted patients and the relationship of malignancy to transplantation. We anticipate that an ever increasing number of these unusual cases will be forthcoming in the urological literature as renal transplantation develops.

Urinary tract infection and wound infection in kidney transplant patients

The frequency of urinary tract and wound infections was studied in 53 patients most of whom had received kidneys from donors without heart action. Urinary infection was demonstrated soon after the transplantation in 46 out of 47 with functioning kidneys. Recurrent infections took place during the first 3 months and still half of the patients were infected or under treatment 6 months after the operation. The urinary infection seems mainly to arise via indwelling catheters. Wound infections were demonstrated in 18 out of the 53 patients and in addition abscess formation took place in 9 of these. In the majority of the infected wounds previous infected drains were demonstrated. In all, 36 of the patients had infected drains, the use of which therefore is to be avoided.

A modified nephrostomy in the management of urinary fistula after renal transplantation

A technique for complete urinary diversion was used in the management of urinary fistula following renal transplantation. Nephrostomy was modified by closing the renal pelvis at the ureteropelvic junction. No impairment of renal function occurred. In the presence of infection, it is reasonable first to treat the infection and postpone the reconstructive procedure until the infection has subsided.

Vesico-ureteric reflux following renal transplantation

Twenty-eight patients who had received a renal transplant have been studied in order to determine the incidence and significance of vesico-ureteric reflux in association with urinary infection.

The ureters had been anastomosed either by uretero-ureteric or ureterovesical techniques without an anti-reflux procedure.

Ten of the 28 patients had reflux into the transplant and 4 had reflux into a non-functioning ureteric stump. Reflux was significantly more frequent in the ureterovesical group.

Marked reflux in patients with recurrent urinary infections was associated with renal damage. Marked reflux in uninfected patients or mild reflux in patients with recurrent urinary infections was not associated with renal damage.