Ureteral stenosis after kidney transplantation: interventional radiology or surgery?

Effect of ureteral stricture in transplant kidney and choice of treatment on long-term graft survival

BACKGROUND

To explore the risk factors of ureteral stricture in transplant kidney and the clinical effects of different treatment methods.

METHODS

The 62 patients with transplant kidney ureteral stenosis as the experimental group, and another group of recipients from the same donor as the control group (n = 59 cases). The risk factors for ureteral stricture and the survival rate of transplant kidney were analyzed and compared. The 62 patients were divided into open operation, luminal operation, and magnetic compression anastomosis (MCA) operation group. The effect of the operation and the survival rate of transplant kidney among the three groups were compared.

RESULTS

In our study, we found that the above differences were statistically significant in clinical data such as gender, multiple donor renal arteries, history of infection, and delayed graft function (DGF) between the two groups (P < 0.05). Urinary tract infection and DGF history were the independent risk factors for the development of ureteral stricture. The open operation had the best treatment effect and the survival rate of the transplant kidney, followed by the MCA, the stricture recurrence rate in the luminal operation was the highest.

CONCLUSION

The ureteral stricture has a negative correlation with the long-term survival rate of the transplant kidney, the curative rate and long-term effect of open surgery are the best, stricture recurrence rate of luminal surgery is high, and it may require multiple operations in the future, the MCA is a new breakthrough and innovation in the treatment of ureteral stricture.

Ureteral stricture after pediatric kidney transplantation: Is there a role for percutaneous antegrade ureteroplasty?

INTRODUCTION

Ureteral obstruction following pediatric kidney transplantation occurs in 5-8% of cases. We describe our experience with percutaneous antegrade ureteroplasty for the treatment of ureteral stricture in pediatric kidney transplant patients.

METHODS

We retrospectively reviewed all pediatric kidney transplantation patients who presented with ureteral stricture and underwent percutaneous antegrade ureteroplasty at our institution from July 2009 to July 2021. Variables included patient demographics, timing of presentation, location and extent of stricture, ureteroplasty technique and clinical outcomes. Our primary outcome was persistent obstruction of the kidney transplant.

RESULTS

Twelve patients met inclusion criteria (4.2% of all transplants). Median age at time of ureteroplasty was 11.5 years (range: 3-17.5 years). Median time from kidney transplantation to ureteroplasty was 3 months. Patency was maintained in 50% of patients. Seven patients (58.3%) required additional surgery. Four patients developed vesicoureteral reflux. Patients with persistent obstruction had a longer time from transplant to ureteroplasty compared to those who achieved patency (19.3 vs 1.3 months, p = 0.0163). Of those treated within 6 months after transplantation, two patients (25%) required surgery for persistent obstruction (p = 0.06). All patients treated >1 year after transplantation had persistent obstruction following ureteroplasty (p = 0.06).

CONCLUSION

Percutaneous antegrade ureteroplasty can be considered a viable minimally invasive treatment option for pediatric patients who develop early ureteral obstruction (<6 months) following kidney transplantation. In patients who are successfully treated with ureteroplasty, 67% can develop vesicoureteral reflux into the transplant kidney. Patients who fail early percutaneous ureteroplasty or develop obstruction >1 year after transplantation are best managed with surgical intervention.

Perfect outcome of kidney recipients with ureteral stenosis after treatment with open surgery under magnetic resonance urography localization

Background

To evaluate the outcome of kidney recipients with ureteral stenosis after treatment with open surgery under magnetic resonance urography (MRU) localization.

Methods

We assessed 2,256 consecutive kidney transplant recipients between October 2010 and December 2018. Ureteral stenosis was detected by ultrasound, confirmed and positioned by Magnetic Resonance Urography. All patients underwent open ureteral reconstruction. The ureteral stenosis was located according to the location on the MRU during the operation. Surgical complications and recurrence rate were recorded in the stenosis group. Outcomes were compared with those of a matched control group of transplant recipients with no history of ureteric stenosis.

Results

The incidence of ureteral stenosis in our center was 3.1% (70/2,256). Sixty-four cases (91.4%) were confirmed to have distal stenosis and were reconstructed with ureterovesical re-implantation; six cases (8.6%) were confirmed to have mid-distal stenosis and were subjected to ureteroureterostomy with the use of native ureter. The overall success rate was 100% and the graft function was salvaged in all cases. There was no recurrence of stenosis after a mean follow-up of 38.9±26.3 months. The complication rate was 5.7%. The 110-month graft survival and patient survival were not significantly different between the stenosis and control groups.Conclusions: MRU is an effective method for non-invasive and accurate diagnosis of ureteral stenosis in kidney transplant recipients. Open ureteral reconstruction surgery under MRU localization for treatment of ureter stenosis after kidney transplantation had a high success rate, low recurrence rate and high safety.

Timely surgical intervention for ureteric complications ensures adequate graft function in renal transplantation: a 10-year review

BACKGROUND

Ureteric complications can cause significant morbidity in renal and simultaneous pancreas-kidney (SPK) transplantation. This 10-year review identified transplant patients with ureteric complications necessitating surgical intervention in an Australian tertiary centre.

METHODS

The hospital records were scrutinized in detail to identify all patients who underwent renal or SPK transplantation from 1 June 2009 to 31 May 2019 with subsequent surgical management of ureteric complications. A case series of patients with ureteric complications was generated and findings were analysed.

RESULTS

A total of 893 renal and SPK transplants were performed over the 10-year period. Ten of these (1.12%; seven renal and three SPK) had ureteric complications. All were managed surgically. Five of the 10 had ureteric leaks (0.56%); three had ureteric strictures (0.34%), one had ureteric obstruction from extraluminal compression (0.11%) and one had both leak and stricture (0.11%). All 10 patients underwent ureteric reimplantation. Two patients required more than one operation for their ureteric complication. No graft loss or surgical mortality occurred. All 10 patients currently have functioning kidney transplants and none require maintenance dialysis.

CONCLUSION

We report a low rate (1.12%) of ureteric complications in our renal and SPK transplants. Our standard practice of definitive correction by ureteric reimplantation is proving successful. The authors confirm that appropriate surgery is a viable and durable option in renal transplant patients with excellent graft outcomes.

Impact of ureteral stricture and treatment choice on long-term graft survival in kidney transplantation

We aimed to evaluate the influence of urological complications occurring within the first year after kidney transplantation on long-term patient and graft outcomes, and sought to examine the impact of the management approach of ureteral strictures on long-term graft function. We collected data on urological complications occurring within the first year posttransplant. Graft survivals, patient survival, and rejection rates were compared between recipients with and without urological complications. Male gender of the recipient, delayed graft function, and donor age were found to be significant risk factors for urological complications after kidney transplantation (P < .05). Death censored graft survival analysis showed that only ureteral strictures had a negative impact on long-term graft survival (P = .0009) compared to other complications. Death censored graft survival was significantly shorter in kidney recipients managed initially with minimally invasive approach when compared to the recipients with no stricture (P = .001). However, graft survival was not statistically different in patients managed initially with open surgery (P = .47). Ureteral strictures following kidney transplantation appear to be strongly negatively correlated with long-term graft survival. Our analysis suggests that kidney recipients with ureteral stricture should be managed initially with open surgery, with better long-term graft survival.

Optimal management of distal ureteric strictures following renal transplantation: a systematic review

Our objective was to define optimal management of distal ureteric strictures following renal transplantation. A systematic review on PubMed identified 34 articles (385 patients). Primary endpoints were success rates and complications of specific primary and secondary treatments (following failure of primary treatment). Among primary treatments (n = 303), the open approach had 85.4% success (95% CI 72.5-93.1) and the endourological approach had 64.3% success (95% CI 58.3-69.9). Among secondary treatments (n = 82), the open approach had 93.1% success (95% CI 77.0-99.2) and the endourological approach had 75.5% success (95% CI 62.3-85.2). The most common primary open treatment was ureteric reimplantation (n = 33, 81.8% success, 95% CI 65.2-91.8). The most common primary endourological treatment was dilation (n = 133, 58.6% success, 95% CI 50.1-66.7). Fourteen complications, including death (4 weeks post-op) and graft loss (12 days post-op), followed endourological treatment. One complication followed open treatment. This is the first systematic review to examine the success rates and complications of specific treatments for distal ureteric strictures following renal transplantation. Our review indicates that open management has higher success rates and fewer complications than endourological management as a primary and secondary treatment for post-transplant distal ureteric strictures. We also outline a post-transplant ureteric stricture evaluation and treatment algorithm.

Efficacy of Interventional Radiology Procedures for the Treatment of Early Ureteral Complications After Kidney Transplantation

Ureteral stricture and ureteral leakage are the most common early urological complications after kidney transplantation causing decreased urine output and increased serum creatinine and blood urea nitrogen. We report our experience with internal-external ureteral stent placement and ureteroplasty.

MATERIALS AND METHODS

From August 1999 to January 2005, we treated nine patients presenting with stricture or leak. After an anterograde pyelogram, an internal-external nephrostomy catheter was inserted in all patients; in four patients we also performed ureteroplasty.

RESULTS

The stricture and leak appeared from 12 to 93 days after kidney transplantation (mean = 39 +/- 29 days). After a mean of 80 +/- 43 days (range 25-141 days), the stent was successfully removed in seven patients (77%); no patient had a recurrence. The success was confirmed by a decline in serum creatinine (from 3.7 +/- 1.4 to 1.6 +/- 0.7 mg/dL) and blood urea nitrogen (from 54 +/- 24 to 28 +/- 7 mg/dL) with resolution of hydronephrosis on sonography. No procedure-related complications were observed. Surgical correction was necessary in two patients due to the persistence of a stricture. At long-term follow-up (50 +/- 17 months), seven kidneys were still functioning and two had failed due to chronic rejection.

CONCLUSION

Nephrostomy catheter placement and ureteroplasty are safe, effective alternatives to surgery to treat early ureteral complications after kidney transplantation. Interventional radiology procedures reducing the morbidity and the likelihood of loss of graft function may improve graft and patient survival.

Endourological management is better in early-onset ureteral stenosis in kidney transplantation

INTRODUCTION

The incidence of ureteral stenosis in kidney transplant recipients is 3%-8%. The treatment of ureteral stenosis has been traditionally operative reconstruction, although such intervention is associated with high rates of serious complications, including graft loss and even perioperative mortality. More recently, endourological treatment has been proposed due to its low morbidity.

OBJECTIVE

The objective of this study was to assess the usefulness of balloon percutaneous dilatation as a treatment technique for ureteral stenosis in kidney transplant recipients.

PATIENTS AND METHODS

Among 1000 kidney transplantations performed between 1980 and 2004, the coexistence of high creatinine values and urinary tract dilatation in the postoperative period, after discarding concomitant causes, was managed with a percutaneous nephrostomy. Once renal function recovered, antegrade pyelography was performed to confirm the presence and determine the location of ureteral stenosis. Ureteral dilatation was performed using a 5-French balloon-fitted angioplasty catheter.

RESULTS

Fifty-six patients were diagnosed with ureteral stenosis during follow-up, an incidence of 5.6%. Transluminal balloon dilatation was the first therapeutic option in 45 cases, whereas surgery was performed directly on 11 patients. Disappearance of the stenosis as well as maintenance of an improved creatinine level was verified in 45% of cases (20 patients). Two patients experienced graft loss. Both a short time to diagnosis after transplantation (P = .06) and the presence of a previous acute rejection episode (P < .05) were good prognosis factors for the endourologic solution of a ureteral stricture.

CONCLUSIONS

Balloon dilatation may be considered the definitive procedure for treatment of ureteral stenosis in selected cases. Percutaneous nephrostomy should be used for initial diagnosis and improvement in the renal function before attempting an open procedure.