Complications relating to the urinary tract associated with bladder-drained pancreatic transplantation

Pancreatic Transplantation: Surgical Anatomy and Complications

Pancreatic transplantation is a complex surgical procedure performed for patients with chronic severe diabetes, often performed in combination with renal transplantation. Vascular and exocrine drainage anatomy varies depending on the surgical technique. Radiology plays a critical role in the diagnosis of postoperative complications, requiring an understanding of grayscale/Doppler ultrasound as well as computed tomography and MR imaging. In this review, we detail usual surgical methods and normal postoperative imaging appearances. We then review the most common complications following pancreatic transplants, emphasizing diagnostic features of vascular (arterial/venous), surgical, and diffuse parenchymal pathologic conditions on multiple imaging modalities.

Urethral Injuries: Diagnostic and Management Strategies for Critical Care and Trauma Clinicians

Urologic trauma is a well-known cause of urethral injury with a range of management recommendations. Retrograde urethrogram remains the preferred initial diagnostic modality to evaluate a suspected urethral injury. The management thereafter varies based on mechanism of injury. Iatrogenic urethral injury is often caused by traumatic catheterization and is best managed by an attempted catheterization performed by an experienced clinician or suprapubic catheter to maximize urinary drainage. Penetrating trauma, most commonly associated with gunshot wounds, can cause either an anterior and/or posterior urethral injury and is best treated with early operative repair. Blunt trauma, most commonly associated with straddle injuries and pelvic fractures, can be treated with either early primary endoscopic realignment or delayed urethroplasty after suprapubic cystostomy. With any of the above injury patterns and treatment options, a well thought out and regimented follow-up with a urologist is of utmost importance for accurate assessment of outcomes and appropriate management of complications.

Surgical site infections: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of post-operative surgical site infections (SSIs) in solid organ transplantation. SSIs are a significant cause of morbidity and mortality in SOT recipients. Depending on the organ transplanted, SSIs occur in 3%-53% of patients, with the highest rates observed in small bowel/multivisceral, liver, and pancreas transplant recipients. These infections are classified by increasing invasiveness as superficial incisional, deep incisional, or organ/space SSIs. The spectrum of organisms implicated in SSIs in SOT recipients is more diverse than the general population due to other important factors such as the underlying end-stage organ failure, immunosuppression, prolonged hospitalizations, organ transportation/preservation, and previous exposures to antibiotics in donors and recipients that could predispose to infections with multidrug-resistant organisms. In this guideline, we describe the epidemiology, clinical presentation, differential diagnosis, potential pathogens, and management. We also provide recommendations for the selection, dosing, and duration of peri-operative antibiotic prophylaxis to minimize post-operative SSIs.

The impact of a muscle pump activator on incisional wound healing compared to standard stockings and compression devices in kidney and kidney-pancreas transplant recipients: A randomized controlled trial

INTRODUCTION

We aimed to evaluate the impact of thrombo-embolic-deterrent + intermittent pneumatic compression (TED + IPC) vs. muscle pump activator (MPA) on incisional wound healing in kidney and simultaneous pancreas- kidney (SPK) transplant recipients.

METHODS

We conducted a single-centre, randomized controlled trial in which 104 patients (kidney n=94; SPK n=10) were randomly assigned to wear TED + IPC (n= 52) or MPA (n=52) for the first six days following surgery. Patient demographics, postoperative outcomes, and incisional wound images were taken using a HIPAA-compliant application on postoperative days (POD) 3, 5, and 30, and assessed using the validated Southampton Wound Care Score.

RESULTS

There were no demographic differences between the groups. The MPA group had a significant improvement in wound healing on POD 3 (p=0.04) that persisted until POD 5 (p=0.0003). At POD 30, both groups were similar in wound healing outcomes (p=0.51). Bayesian inferential analysis revealed that the use of TED + IPC following transplantation had inferior outcomes compared to the use of MPA with sequential moderate evidence. The rate of complex wound infections was significantly greater in the TED + IPC group compared to the MPA group (29% vs. 12%, respectively; p=0.03). Patients were more satisfied with the use of a MPA device than TED + IPC. No major complications were encountered in either group.

CONCLUSIONS

The use of a MPA device in the immediate postoperative period leads to a significant improvement in immediate and early wound healing, and decreased number of complex wound infections following kidney and SPK transplantation compared to standard TED + IPC therapy. Patients were more satisfied with the use of a MPA device than TED + IPC.

Risk factors for surgical site infection after kidney and pancreas transplantation

OBJECTIVE

To evaluate the incidence of surgical site infection (SSI) in a cohort of pancreas transplant recipients and assess predisposing risk factors for SSI DESIGN: Retrospective cohort study SETTING: Single transplant center in CanadaPatientsPatients who underwent any simultaneous pancreas and kidney (SPK) or pancreas after kidney (PAK) transplant procedures between January 2000 and December 2015 METHODS: In this retrospective cohort evaluation of SPK or PAK recipients, we assessed the incidence of SSI and risk factors associated with superficial, deep, and organ/space SSI. Multivariate logistic regression was used to identify independent risk factors for SSI in SPK and PAK recipients.

RESULTS

In total, 445 adult transplant recipients were enrolled. The median age of these patients was 51 years (range, 19-71 years), and 64.9% were men. SSIs were documented in 108 patients (24.3%). Organ/space SSIs predominated (59 patients, 54.6%), followed by superficial SSIs (47 patients, 43.5%) and deep SSIs (3 patients, 2.8%). Factors predictive of SSIs in the multivariate analysis were cold pancreas ischemic time (odds ratio [OR], 1.002; P=.019) and SPK transplant (compared to PAK transplant recipients; OR, 2.38; P=.038). Patients with SSIs developed graft loss more frequently (OR, 16.99; P<.001).

CONCLUSIONS

Organ/space SSIs remain a serious and common complication after SPK and PAK. Prolonged cold ischemic time and SPK transplant were the risk factors predictive of SSIs. Appropriate perioperative prophylaxis in high-risk patients targeting the potential pathogens producing SSIs in kidney and/or pancreas transplant recipients and a reduction in cold ischemia may prove beneficial in reducing these SSIs.

Imaging spectrum after pancreas transplantation with enteric drainage

Since the introduction of pancreas transplantation more than 40 years ago, surgical techniques and immunosuppressive regiments have improved and both have contributed to increase the number and success rate of this procedure. However, graft survival corresponds to early diagnosis of organ-related complications. Thus, knowledge of the transplantation procedure and postoperative image anatomy are basic requirements for radiologists. In this article, we demonstrate the imaging spectrum of pancreas transplantation with enteric exocrine drainage.

Enteric conversion after pancreatic transplantation: resolution of symptoms and long-term results

PURPOSE

Bladder drainage (BD) of pancreatic transplants is associated with a unique set of complications. We intended to analyze the incidence, indications, complications and long-term results of enteric conversion procedures (EC).

METHODS

Using a prospective database, 32 EC patients out of 433 simultaneous pancreas-kidney-transplant (SPK) recipients were identified. Graft and patient survival rates were compared with those after primary enteric drainage (ED).

RESULTS

The mean SPK-EC interval was 5.0 yr, and the mean patient follow-up was 13.8 yr. Indications for EC were genitourinary symptoms (62.5%), duodenal complications (15.6%), graft pancreatitis (12.5%), pyelonephritis (6.3%), and metabolic acidosis (3.1%). All patients reported significant long-term resolution of symptoms. Surgical complications, reoperations, early graft loss, and 30-d mortality occurred in 31.3%, 25.0%, 6.3%, and 3.1% of cases, respectively. Pancreatic graft and patient survival rates at 1, 5, and 10 yr after SPK were comparable between EC patients and ED patients at the same institution.

CONCLUSION

For the treatment of symptoms associated with BD, EC results in excellent long-term graft function and significant resolution of symptoms even years after SPK. Postoperative morbidity after EC including early reoperation and graft loss, however, has to be considered.

Urological complications after simultaneous pancreas-kidney transplantation

OBJECTIVE

We evaluated the incidence of urological complications after simultaneous renal and pancreatic transplantation.

PATIENTS AND METHODS

We retrospectively reviewed urological complications following 107 simultaneous kidney-pancreas transplantations performed at our institution between March 1995 and June 2008. The 46 women and 61 men were of mean age 37.8 years (range, 25-66). The mean duration of diabetes mellitus was 23.0 years (range, 9-48) and the mean duration of dialysis was 19.9 months (range, 0-70). The exocrine pancreatic secretions were drained to bladder in 58 cases, or enterically in 49 patients. The mean length of follow-up was 51.7 months.

RESULTS

The most frequent urological complication was urinary tract infection, reported in 63.8% of patients: 42 bladder-drained and 25 enteric-drained (P = .011). Hematuria occurred in 13 patients (12.5%): 12 bladder-drained and 1 enteric-drained (P = .002). Five bladder-drained patients developed bladder calculi. Among 58 bladder-drained patients, reflux pancreatitis occurred in 28 patients and urine leaks related to the pancreatic graft occurred in 7 patients. Conversion of exocrine secretions from bladder to enteric diversion was required in 6 patients. One- and 3-year patient survival rates were 92.7% and 89.1%, respectively. Moreover, 1 and 3-year kidney graft survival rates were 90.6% and 84.4%, and pancreas graft survival rates were 78.1 and 70.3%, respectively.

CONCLUSION

Simultaneous kidney-pancreas transplantation with bladder drainage is associated with a high frequency of urological complications. Appropriate treatment can resolve most complications. In our opinion, both enteric and bladder drainage seemed to be safe and effective alternatives to manage pancreatic exocrine secretions.

Refractory hematuria in an oliguric patient after pancreas transplantation with exocrine pancreas bladder drainage

A 52-yr-old man presented with hematuria and clot retention. He had undergone simultaneous pancreas-kidney transplantation with exocrine pancreas bladder drainage 16 yr ago. The patient suffered from progressive transplant kidney failure with gradually decreasing urine output and needed hemodialysis every other day. Gross hematuria persisted after removal of all blood clots. Cystoscopy showed multiple small, flat ulcers of the bladder mucosa. Some bled discretely and were coagulated cautiously. However, hematuria was refractory to multiple urological interventions, which eventually necessitated an enteric diversion of the exocrine pancreas. Hematuria ceased following an uneventful postoperative course.

Pancreas transplants

Cadaveric, whole pancreas transplantation has proved an effective therapy in the treatment of long-standing type 1 diabetes mellitus and is capable of achieving an insulin-independent eugyclaemic state. As a result, this procedure is being increasingly performed. However, the surgical procedure is complex and unfamiliar to many radiologists. Imaging with computed tomography (CT) and magnetic resonance imaging (MRI) gives excellent results and can be used confidently to diagnose vascular, enteric, and immune-mediated complications. We present a review of the normal post-transplantation appearance and the features of early and late complications.

Bowel complications seen on CT after pancreas transplantation with enteric drainage

OBJECTIVE

Bowel-related complications from pancreas transplantation account for much of the postsurgical morbidity. In a review of 98 pancreas transplant recipients, we found 19 (19.4%) with such complications.

CONCLUSION

The most common problems were small-bowel obstruction and anastomotic leaks. Adhesions and internal hernias accounted for most postoperative bowel obstructions.

Diagnosis and Classification of Urethral Injuries

Urethral injuries are uncommon and rarely life-threatening in isolation. They are, how-ever, among the most devastating urinary system injuries because of significant long-term sequelae, including strictures, incontinence, erectile dysfunction, and infertility. Urethral trauma may be categorized by mechanism of injury (ie, blunt versus penetrating injury) and by location (ie, posterior versus anterior urethra). Injuries to the posterior urethra are classically associated with pelvic fractures, while anterior urethral trauma usually arises secondary to injudicious instrumentation or perineal straddle injury. This article reviews the major etiologies and mechanisms of urethral trauma, describes how these injuries are diagnosed, and explains classifications of urethral trauma. Timely and accurate diagnosis and classification of urethral injuries leads to appropriate acute management and reduced long-term morbidity.

Outcomes with the selective use of enteric exocrine drainage in pancreas transplantation

BACKGROUND

Bladder drainage of the exocrine secretions of pancreas transplants has been the standard of practice as it affords the ability to monitor for rejection and is thought to be associated with decreased morbidity. Recently, there has been renewed interest in avoiding the urinary tract complications and metabolic derangements that accompany bladder drainage by draining pancreatic exocrine secretions into the jejunum (enteric drainage). We sought to determine whether enteric drainage of pancreas transplants is safe and offers advantages without compromise in graft function or longevity.

METHODS

We retrospectively reviewed all pancreas transplants performed at the University of Washington between 2000 and 2003. Selection of the exocrine drainage method was based on the length of cold ischemia time and whether the pancreas was transplanted alone or in combination with a kidney. Pearson's chi-square and Fisher's Exact tests were used for statistical comparisons in complications or rejections between the groups.

RESULTS

Thirty-four pancreas transplants were performed with exocrine drainage into the bladder used in 17 and enteric drainage in 17. The complication rate was 53% in the bladder-drained group and 41% (P=.49) in the enteric-drained group. The incidence of pancreas rejection was 24% in the bladder-drained versus 29% in the enteric-drained patients (P=.50). One graft failed, which was in the bladder cohort.

CONCLUSIONS

We found comparable rejection and complication rates between groups. We conclude that enteric drainage is safe when used selectively, and entails no increased risks compared with bladder drainage.

Late urinary tract infection after renal transplantation in the United States

BACKGROUND

Although urinary tract infection (UTI) occurring late after renal transplantation has been considered "benign," this has not been confirmed in a national population of renal transplant recipients.

METHODS

We conducted a retrospective cohort study of 28,942 Medicare primary renal transplant recipients in the United States Renal Data System (USRDS) database from January 1, 1996, through July 31, 2000, assessing Medicare claims for UTI occurring later than 6 months after transplantation based on International Classification of Diseases, 9th Revision (ICD-9), codes and using Cox regression to calculate adjusted hazard ratios (AHRs) for time to death and graft loss (censored for death), respectively.

RESULTS

The cumulative incidence of UTI during the first 6 months after renal transplantation was 17% (equivalent for both men and women), and at 3 years was 60% for women and 47% for men (P < 0.001 in Cox regression analysis). Late UTI was significantly associated with an increased risk of subsequent death in Cox regression analysis (P < 0.001; AHR, 2.93; 95% confidence interval [CI], 2.22, 3.85); and AHR for graft loss was 1.85 (95% CI, 1.29, 2.64). The association of UTI with death persisted after adjusting for cardiac and other infectious complications, and regardless of whether UTI was assessed as a composite of outpatient/inpatient claims, primary hospitalized UTI, or solely outpatient UTI.

CONCLUSION

Whether due to a direct effect or as a marker for serious underlying illness, UTI occurring late after renal transplantation, as coded by clinicians in the United States, does not portend a benign outcome.

Perioperative treatment with octreotide minimizes technical complications after enteric conversion of bladder-drained pancreas transplants

We review our experience with enteric conversion of previously bladder-drained pancreas transplants (PTx) using a short perioperative course of octreotide (OCT). Between July 1994 and December 2001, 45 consecutive primary bladder-drained PTx were performed. Immunosuppression consisted of a combination of tacrolimus, mycophenolate mofetil and steroids after induction with monoclonal or polyclonal antibodies. A total of 16 patients underwent enteric conversion at an average of 3 months after the initial transplant. Each patient received OCT perioperatively. We report no technical complications with the exception of one superficial wound infection and good early and late PTx survival rates. Perioperative treatment with octreotide is well tolerated and may reduce technical complications while performing enteric conversion of previously bladder-drained PTx.

Vascularized islet-cell transplantation in miniature swine. I. Preparation of vascularized islet kidneys

BACKGROUND

Whereas clinical pancreatic transplantation has been highly successful in correcting the hyperglycemia of insulin-dependent diabetes mellitus (type 1), the results of islet transplantation have been disappointing. This discrepancy may be because of, at least in part, nonspecific loss of islets during the time required for revascularization. To test this hypothesis, we have designed composite kidney grafts containing vascularized autologous islets that can be used to compare the engraftment potential of vascularized versus nonvascularized islet tissue.

METHODS

(1) Islet-cell isolation: miniature swine underwent either partial pancreatectomy to isolate autologous islets or total pancreatectomy to isolate minor antigen-mismatched islets. Islets were purified from excised pancreatic tissue by enzymatic digestion and discontinuous density gradient purification. Isolated islets were cultured for 3 days before transplant. (2) Creation of vascularized islet kidneys (IK): autologous islets alone (n=6), minor-mismatched islets alone (n=3), and minor-mismatched islets plus simultaneous autologous thymic tissue (n=3) were transplanted beneath the renal capsule of juvenile miniature swine. Minor antigen-mismatched islets were also transplanted into both the vascularized thymic graft of a thymokidney (to produce a thymo-islet kidney [TIK]) and the contralateral native kidney (n=3) and both the host thymus and beneath the renal capsule (n=2). All recipients receiving minor-mismatched islets were treated with a 12-day intravenous (IV) course of either cyclosporine A (CsA) at 10 mg/kg per day or FK506 at 0.15 mg/kg per day. (3) Assessment of Function: to evaluate the function of the transplanted islets, three animals bearing TIK and IK underwent total pancreatectomy 3 months following islet transplantation.

RESULTS

(1) Islet-cell yields: an average of 254,960+/-51,879 (4,452+/-932 islet equivalents [IEQ]/gram of pancreas) and 374,410+/-9,548 (4,183+/-721 IEQ/gram of pancreas) viable islets were obtained by partial pancreatectomy and complete pancreatectomy, respectively. (2) Creation of IK: autologous islets engrafted indefinitely, whereas recipients of minor-mismatched islets alone rejected the islets within 2 months. However, when minor-mismatched islets were implanted into both the thymokidney and the contralateral kidney of animals bearing a thymokidney, the islets engrafted indefinitely in both sites (>3 months). Simultaneous implantation of islets into the host thymus and under the renal capsule also led to permanent engraftment of minor-mismatched islets. (3) Function of vascularized islets: three animals with both a TIK and an IK in place for 3 months underwent total pancreatectomy. All three animals maintained normoglycemia thereafter. In two of these animals, the IKs were removed 2 months after the pancreatectomy, and in both cases normoglycemia was maintained thereafter by the TIK.

CONCLUSIONS

The implantation of islets beneath the autologous renal capsule permitted the establishment of a vascular supply and thereby supported normal islet-cell growth and function. The presence of thymic tissue beneath the autologous renal capsule facilitated the engraftment of minor-mismatched islets, and such grafts achieved results similar to autologous islet transplants. Therefore, the ability to create vascularized islet grafts may provide a strategy for successful islet transplantation across allogeneic and potentially across xenogeneic barriers.