Urological complications in 1,000 consecutive renal transplant recipients

Diagnosis and Management of Ureteropelvic Obstruction in Kidney Transplant Recipients and Outcomes of Foley Y-V Pyeloplasty

OBJECTIVES

To evaluate the etiology and diagnostic tools for ureteropelvic obstruction in kidney transplant recipients, we investigated the short-term and long-term outcomes of Foley Y-V pyeloplasty.

MATERIALS AND METHODS

We retrospectively reviewed 10 patients who underwent kidney transplant followed by additional interventions to treat obstructive ureteral pathologies between 2016 and 2020. We enrolled 4 patients who had received intervention to treat ureteropelvic obstruction. For these 4 patients, serum creatinine and estimated glomerular filtration rate levels were recorded at baseline, during the symptomatic period, and long-term. In this single center study, we investigated diagnostic tools and management strategies for ureteropelvic obstruction and assessed performance of Foley Y-V nondismembered pyeloplasty in kidney transplant recipients.

RESULTS

Among 4 patients, graft function (assessed by serum creatinine and estimated glomerular filtration rate) worsened significantly (P = .03) in the symptomatic period of ureteropelvic obstruction in all patients; however, graft function levels improved rapidly to levels similar to baseline (P = .07) after Y-V pyeloplasty. In addition, no statistically significant difference was detected between baseline and longterm graft functions afterY-V pyeloplasty in follow-up (P = .28).

CONCLUSIONS

Diagnosis and management of ureteropelvic obstruction in kidney transplant recipients are challenging due to rarity and lack of an ideal management algorithm.There is no specific diagnostic tool to discriminate this pathology from other ureteral pathologies; therefore, a regimen of conventional imaging modalities and diuretic renogram combined with endoscopic evaluation is more reliable. Moreover, nondismembered Foley Y-V pyeloplasty is effective and safe for graft function in the short-term and long-term.

Routine Kidney Graft Ultrasound After Elective Ureteric Stent Removal: Does it Help?

Transplantation (KTx) is considered to be the best renal replacement therapy, and improving its outcomes remains a primary challenge. KTx ureteral stenting has been used to prevent urological complications, but there is no consensus on the timing of stent removal, and literature regarding routine ultrasonography after ureteric stent removal (RUSUS) to detect complications is lacking. Point-of-care ultrasound has been gaining drive in the medical community in recent years, including nephrologists. We aimed to define the incidence of urological complications diagnosed with RUSUS, if those findings changed patient's management and ultrasound utility. Contrary to previously published data, in our cohort RUSUS allowed a timely diagnosis and early treatment of urological complications, a key factor for successful transplantation. KTx point-of-care ultrasound is a cost-effective and reproducible test that provides relevant information to guide clinical decisions, seeming most efficient when performed approximately 2 weeks post ureteral stent removal. Interventional nephrologists can promptly perform these examinations, reducing waiting times and improving graft and patient's survival.

Kidney stones in renal transplant recipients: A systematic review

INTRODUCTION

Lithiasis in renal graft recipients might be a dangerous condition with a potential risk of organ function impairment.

EVIDENCE ACQUISITION

A systematic literature search was conducted through February 2023. The primary objective was to assess the incidence of lithiasis in kidney transplant (KT) recipients. The secondary objective was to assess the timing of stone formation, localization and composition of stones, possible treatment options, and the incidence of graft loss.

EVIDENCE SYNTHESIS

A total of 41 non-randomized studies comprising 699 patients met our inclusion criteria. The age at lithiasis diagnosis ranged between 29-53 years. Incidence of urolithiasis ranged from 0.1-6.3%, usually diagnosed after 12 months from KT. Most of the stones were diagnosed in the calyces or in the pelvis. Calcium oxalate composition was the most frequent. Different treatment strategies were considered, namely active surveillance, ureteroscopy, percutaneous/combined approach, or open surgery. 15.73% of patients were submitted to extracorporeal shock wave lithotripsy (ESWL), while 26.75% underwent endoscopic lithotripsy or stone extraction. 18.03% of patients underwent percutaneous nephrolithotomy whilst 3.14% to a combined approach. Surgical lithotomy was performed in 5.01% of the cases. Global stone-free rate was around 80%.

CONCLUSIONS

Lithiasis in kidney transplant is a rare condition usually diagnosed after one year after surgery and mostly located in the calyces and renal pelvis, more frequently of calcium oxalate composition. Each of the active treatments is associated with good results in terms of stone-free rate, thus the surgical technique should be chosen according to the patient's characteristics and surgeon preferences.

Ureterovesical Leak Following Renal Transplant and Effects of Acute Rejection and Antirejection Therapy: A Nested Case-Control Analysis and Outcome of 1102 Consecutive Renal Transplant Recipients

OBJECTIVES

Studies on nontechnical risk factors for ureterovesical leak after renal transplant are scarce. This study aimed to report the possible pre- and postoperative risk factors and the role of acute rejection and antirejection therapies for urine leak after transplant and its effect on graft and patient survival.

MATERIALS AND METHODS

We conducted a retrospective analysis of 13 patients (1.17%) with urine leak (case group) and 52 patients without leak (control group) (case-to-control ratio of 1:4) from 1102 living related (first degree) renal transplant recipients seen between January 2012 and December 2021. We analyzed demographic and clinical details and biochemical and outcome parameters using a nested case-control design.

RESULTS

Cases were olderthan controls (P = .018), were more ABO incompatible (P = .009), and had more 6/6 HLA mismatch transplants (P = .047). Donors of cases were older than donors of controls (P = .049). The rate of postoperative hypoalbuminemia was greaterin the case group (P = .050). Rates of acute rejection (P = .012) and plasmapheresis (P = .003) were greaterin the case group than in the control group. On multivariate logistic regression analysis, recipient age, 6/6 HLA mismatch, and plasmapheresis were found to independently associated with urine leak. None ofthe patient required surgical repair, as all responded to conservative therapy. Urine leak did not affect graft outcomes (P = .324), but overall survival was less in cases than in controls.

CONCLUSIONS

Nontechnical risk factors that cause posttransplant ureteric leak include older donor and recipient age and ABO incompatible and 6/6 HLA mismatch transplants. Acute rejection and plasmapheresis predispose leak, and an indwelling double J stent can allow adequate healing of the anastomosis. High index of suspicion and prompt management are imperative to preserve graft and patient outcome.

Corticosteroid Dose in Kidney Transplantation and Its Effect on Surgical Complication: A Systematic Review

OBJECTIVES

Although several studies have explored the connection between corticosteroids and renal transplant surgical complications, these studies have overlooked several factors. In addition, no review of the literature, to our knowledge, has been conducted to evaluate corticosteroid dose and incidence of posttransplant surgical complications in these patients. Thus, our objective was to carry out a systematic investigation ofthe correlationbetween corticosteroids and surgical complications in renaltransplant patients.

MATERIALS AND METHODS

A systematic search was conducted on the PubMed and Embase databases from their inception until April 2023. Retrospective and prospective cohort studies were included if they met the association between corticosteroids and surgical complications. The search strategy was performed using MeSH and non-MeSH key words. Terms used in the electronic search included kidney transplant* OR kidney transplant(mesh) AND steroid* OR steroids(mesh) AND complication* OR intraoperative complications(mesh).

RESULTS

From 3274 articles, 8 articles were included in the systematic review. Six studies were conducted as retrospective cohorts and 2 studies as prospective cohorts. The mean age of patients included in the studies was 42.1 years. The studies were conducted between 1981 and 2023. Findings suggested that decreasing the postoperative corticosteroid dosage was associated with a lower incidence of various postoperative surgical complications.

CONCLUSIONS

We investigated the potential benefits of reducing the dose of corticosteroids following kidney transplant. Findings suggested thatreducing the dose of corticosteroids following kidney transplant might be a viable strategy for minimizing the risk of surgical complications. However, it is essential to note that the optimal dosage and duration of corticosteroid therapy after kidney transplant may vary for each patient and should be carefully determined by the health care provider.

Living donor-gifted allograft lithiasis: surgical experience after bench surgery stone removal and follow-up

This study presents the surgical experience and long-term outcomes of living donor kidney transplantations involving asymptomatic kidney stones, using ex vivo flexible ureterorenoscopy (f-URS) during bench surgery for stone removal. Out of 1743 living kidney donors assessed between January 2012 and October 2022, 18 (1%) were diagnosed with urolithiasis. Among them, 12 donors were rejected, and 6 were accepted for kidney donation. Stone removal was successfully performed using f-URS during bench surgery, with no immediate complications or acute rejections observed. The study analyzed six living kidney transplants, of which 4 (67%) donors and three recipients were female, and 4 (67%) donors were blood-related to the recipient. The median age for donors and recipients was 57.5 and 51.5 years, respectively. The stones, primarily located in the lower calyx, had a median size of 6 mm. The median cold ischemia time during surgery was 41.6 min, and ex vivo f-URS ensured complete stone removal in all cases. After a median follow-up of 120 months, the remaining grafts were functioning well, and no urinary stone recurrence was observed in either the recipients or living donors. The findings suggest that bench f-URS is a safe approach for managing urinary stones in kidney grafts, providing good functional outcomes without stone recurrence in selected cases.

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.

Ureterovesical Anastomosis Complications in Kidney Transplantation: Definition, Risk Factor Analysis, and Prediction by Quantitative Fluorescence Angiography with Indocyanine Green

Ureteral stenosis and urinary leakage are relevant problems after kidney transplantation. A standardized definition of ureterovesical anastomosis complications after kidney transplantation has not yet been established. This study was designed to demonstrate the predictive power of quantitative indocyanine green (ICG) fluorescence angiography. This bicentric historic cohort study, conducted between November 2015 and December 2019, included 196 kidney transplantations. The associations between quantitative perfusion parameters of near-infrared fluorescence angiography with ICG and the occurrence of different grades of ureterovesical anastomosis complications in the context of donor, recipient, periprocedural, and postoperative characteristics were evaluated. Post-transplant ureterovesical anastomosis complications occurred in 18%. Complications were defined and graded into three categories. They were associated with the time on dialysis (p = 0.0025), the type of donation (p = 0.0404), and the number of postoperative dialysis sessions (p = 0.0173). Median ICG ingress at the proximal ureteral third was 14.00 (5.00–33.00) AU in patients with and 23.50 (4.00–117.00) AU in patients without complications (p = 0.0001, cutoff: 16 AU, sensitivity 70%, specificity 70%, AUC = 0.725, p = 0.0011). The proposed definition and grading of post-transplant ureterovesical anastomosis complications is intended to enable valid comparisons between studies. ICG Fluorescence angiography allows intraoperative quantitative assessment of ureteral microperfusion during kidney transplantation and is able to predict the incidence of ureterovesical anastomosis complications. Registration number: NCT-02775838.

[Lower urinary tract symptoms and urinary incontinence in renal transplant recipients and candidates: The French guidelines from CTAFU]

OBJECTIVE

To propose surgical recommendations for the management of lower urinary tract symptoms (LUTS) and urinary incontinence in kidney transplant recipients and candidates.

METHOD

Following a systematic approach, a review of the literature (Medline) was conducted by the CTAFU focusing on medical and surgical treatment of LUTS and urinary incontinence in kidney transplant recipients and candidates. References were assessed according to a predefined process to propose recommendations with levels of evidence.

RESULTS

Functional bladder capacity and bladder compliance are impaired during dialysis. LUTS, related to pre-kidney transplantion alterations, frequently improve spontaneously after kidney transplantation. LUTS secondary to benign prostatic hyperplasia (BPH) may be underestimated before kidney transplantation due to oliguria, low bladder compliance and low bladder capacity. In LUTS associated with BPH, anticholinergics require dosage adjustment with creatinine clearance. If surgery is indicated after kidney transplantation, procedure can be safely performed in the early post-transplant course after removal of ureteral stent. Surgical management of urinary incontinence does not seem to be associated with an icreased risk for infectious complications in kidney transplant recipients. Particular attention should be paid to the management of postvoid residual and bladder pressures in case of neurological bladder disease. Optimal care of neurological bladder should be provided prior to transplantation: with a cautious management, and despite an increased occurrence of febrile urinary tract infections, transplant survival is not compromised.

CONCLUSION

These recommendations must contribute to improve the management of lower urinary tract symptoms and urinary incontinence in kidney transplant patients and kidney transplant candidates.

Evaluation of Renal Allograft Vasculature Using Non-contrast 3D Inversion Recovery Balanced Steady-state Free Precession MRA and 2D Quiescent-interval Slice-selective MRA

BACKGROUND AND OBJECTIVES

Renal transplant patients often require periodic imaging to evaluate the transplant vessel anastomosis for potential vascular complications. The use of non-contrast enhanced magnetic resonance angiography (NCE-MRA) techniques is encouraged in these patients because they are at increased risk of nephrogenic systemic fibrosis (NSF) due to their renal insufficiency. This study aimed to evaluate the performance of two NCE-MRA techniques (three-dimensional [3D] balanced steady-state free precession [bSSFP] with inversion recovery and quiescent-interval slice-selective [QISS]) for the evaluation of renal allograft vasculature in patients with clinical suspicion, or Doppler ultrasound, or both of arterial anastomotic stenosis.

METHODS

A total of 43 patients were included in this retrospective study. Two radiologists independently scored the images from 3D bSSFP and QISS MRA sequences for image quality and confidence in anastomosis interpretation, and the degree of stenosis at the arterial anastomosis. Correlations with digital subtraction angiography (DSA) were carried out when available. In addition, inter-rater agreement was calculated.

RESULTS

In total, 43 patients underwent QISS and 3D bSSFP MRA. For QISS, all cases were adequate for evaluation. For 3D SSFP, 86% of cases were adequate for evaluation. There was a good-to-excellent inter-rater agreement for all scores and an excellent correlation between NCE-MRA and DSA results when available (12 patients).

CONCLUSIONS

QISS and 3D SSFP showed good inter-rater agreement for image quality and stenosis grade, with more cases being of adequate image quality that used QISS. Further study is required; however, NCE-MRA shows potential as a risk-free alternative to CTA and contrast-enhanced MRA (CE-MRA) for the evaluation of arterial anastomoses in renal transplant patients.

Acute Urinary Retention After Kidney Transplant: Effect on Graft Function, Predictive Factors, and Treatment

BACKGROUND

Benign prostatic hyperplasia (BPH) is common in older adults. Although BPH may be asymptomatic in patients with chronic kidney disease (CKD) with low diuresis, the condition may become troublesome when diuresis resumes after transplantation. This study evaluated the effect that developing acute urinary retention (AUR) in first 4 months after kidney transplantation (KT) can have on graft function at 6 months. The study identified predictive factors and analyzed treatment of AUR in these patients.

METHODS

This study retrospectively included 303 men who received KT. Independent samples Student t test was used to compare glomerular filtration rates (GFRs) at 6 months. Logistic regression was applied to identify predictors of AUR.

RESULTS

The study found that 14 patients developed AUR within the first 4 months after KT. This group had lower GFR at 6 months post-KT. Nine patients required transurethral resection of the prostate, and 2 of these patients developed acute graft pyelonephritis following resection. Residual diuresis and recipient age were predictive factors. Recipient age >55 years was a risk factor. Medical therapy of BPH before transplantation was a protective factor.

CONCLUSIONS

Developing AUR in the first 4 months after KT was associated with lower graft GFR at 6 months, and transurethral resection of the prostate was required in 64% of these patients, with good results. Medical therapy for BPH before the transplant was associated with a lower risk of AUR. Older patients and patients with pretransplant low urine output had a higher risk of AUR. These patients should be closely monitored in the posttransplant period for the presence of obstructive uropathy.

Incarceration of transplanted kidney through incisional hernia

Transplanted allograft kidney herniation through an incisional hernia resulting in incarceration is a rare condition with only one other similar case reported in the literature. The primary imaging modalities used to diagnose kidney herniation are graft ultrasound, abdominal computed tomography and abdominal magnetic resonance imaging [Sugi et al. (Imaging of renal transplant complications throughout the life of the allograft: comprehensive multimodality review. Radiographics 2019;39:1327-1355)]. Treatment should be based on patient’s symptoms. This case report highlights the initial presentation of hematuria in a 57-year-old male that eventually led to the diagnosis of a right-sided incarcerated grafted kidney through an incisional hernia. Subsequently, the patient underwent transplant nephrectomy.

Hand-Assisted Laparoscopic Donor Nephrectomy in Living Donors with a History of Abdominal Surgery: A Retrospective Cohort Study

Background

Hand-assisted laparoscopic donor nephrectomy (HALDN) is frequently performed in living kidney transplantation donors. This study investigated the efficacy and safety of HALDN for living donors with abdominal surgical histories.

Material/Methods

A total of 573 living kidney donors underwent donor nephrectomies for living donor kidney transplantation between January 2008 and May 2015. Eighteen donors underwent open donor nephrectomy and were excluded from analyses. Left HALDN was performed in 533 donors, including 44 donors with abdominal surgical histories and 489 donors without abdominal surgical histories. Right HALDN was performed in 22 donors, including 11 donors with abdominal surgical histories and 11 donors without abdominal surgical histories. Graft quality including the lengths of arteries, veins and ureters, time to initial urination, recipient complications, and recipient estimated glomerular filtration rate (eGFR) and operation quality including warm ischemic time, blood loss, operation duration, donor complications and donor eGFR, were compared between donors with and without abdominal surgical histories in the left and right HALDN groups.

Results

The metrics of graft and operation quality were similar between living kidney donors with and without a history of abdominal surgery who underwent left or right HALDN.

Conclusions

The efficacy and safety of HALDN were not impaired by abdominal surgical histories.

Minimal-invasive management of urological complications after kidney transplantation

Kidney transplantation represents the gold standard treatment option for patients with end-stage renal disease. Improvements in surgical technique and pharmacologic treatment have continuously prolonged allograft survival in recent years. However, urological complications are frequently observed, leading to both postoperative morbidity and putative deterioration of allograft function. While open redo surgery in these patients is often accompanied by elevated surgical risk, endoscopic management of urological complications is an alternative, minimal-invasive option. In the present article, we reviewed the literature on relevant urological postoperative complications after kidney transplantation and describe preventive approaches during the pre-transplantation assessment and their management using minimal-invasive approaches.

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.

Urological Complications in Kidney Transplant Recipients: Analysis of the Risk Factors and Impact on Transplant Outcomes in the Era of “Extended Criteria Donors”

Urological complications (UC) following kidney transplantation (KT) are associated with increased morbidity. The aim of this study is to evaluate the risk factors for UC in the era of “extended criteria donors” (ECD) and their impact on patient and graft survivals. A retrospective monocentric study of all patients undergoing KT from 2010 to 2019 with a follow-up ≥30 days was performed. Out of 459 patients (males: 296 (64.5%); age: 57 (19–77) years) enrolled, 228 (49.7%) received ECD organs, moreover, 166 (67.2%) grafts had a cold ischemia time ≥10 h. UCs were reported in 32 (7%) patients. In 21 (65.6%) cases UC occurred within 3 months post-KT and 24 (5.2%) were associated with early urinary tract infection (UTI). The overall 5 year patient and graft survival rates were 96.5% and 90.6%, respectively. UC decreased graft survival (UC-group: 75.0% vs. noUC-group: 91.8%, p < 0.001), especially if associated with early UTI (UC-group: 71.4% vs. noUC-group: 77.8%, p < 0.001). At multivariate analysis, early UTI after KT (OR: 9.975, 95%-IC: 2.934–33.909, p < 0.001) and delayed graft function (DGF) (OR: 3.844, 95%-IC: 1.328–11.131, p: 0.013) were significant risk factors for UC, while ECD graft did not increase the risk of post-transplant UC. ECD grafts are not associated with UC. DGF and early UTI post-KT increase the risks of UC and reduce graft survival in the long-term. Therefore, aggressive management of early post-transplant UTI and strategies to reduce DGF incidence, such as machine preservation, are essential to prevent UC after KT.

Risk Factors for Anastomosis Leakage After Kidney Transplantation

Purpose

Kidney transplantation is one of the best treatment options for end-stage renal disease with an incidence of urologic complications of 2.5 to 30%. One of the most serious and frequent urological complications is urinary leakage from ureteroneocystostomy anastomosis. The purpose of this study was to evaluate risk factors of urinary leakage from ureteroneocystostomy anastomosis after kidney transplantation.

Patients and Methods

A retrospective study was performed on patients who received kidney transplantation and were diagnosed with urinary leakage thereafter based on renal scan or drain creatinine per serum creatinine compared with patients in control group. Risk factor assessment was based on inpatient and outpatient information from hospital database.

Results

From 459 patients who received kidney transplantation in 2016-2018, there were 20 patients who were diagnosed with urinary leakage after they underwent ureteroneocystostomy anastomosis. The significant risk factors for anastomosis leakage were size of suture materials and duration of ureteral stent insertion. No statistically significant difference in other factors such as underlying disease, surgical technique or duration of urinary catheter was found. About overall urological complication, gender and body mass index significantly affected the outcome.

Conclusion

The rate of urinary leakage complications was found to be about 4.36%. The risk factors of overall complication comprised gender and body mass index. Although a lot of previous studies revealed many risk factors that could affect urinary leakage, size of suture materials and duration of ureteral stent insertion were the significant risk factors in our study. Proper consideration should be given to the size of suture materials and optimal duration of ureteral stent.

Paediatric kidney transplants from donors aged 1 year and under: an analysis of the Australian and New Zealand Dialysis and Transplant Registry from 1963 to 2018

Kidneys from very small donors have the potential to significantly expand the donor pool. We describe the collective experience of transplantation using kidneys from donors aged ≤1 year in Australian and New Zealand. The ANZDATA registry was analysed on all deceased donor kidney transplants from donors aged ≤1 year. We compared recipient characteristics and outcomes between 1963-1999 and 2000-2018. From 1963 to 1999, 16 transplants were performed [9 (56%) adults, 7 (44%) children]. Death-censored graft survival was 50% and 43% at 1 and 5 years, respectively. Patient survival was 90% and 87% at 1 and 5 years, respectively. From 2000 to 2018, 26 transplants were performed [25 (96%) adults, 1 (4%) children]. Mean creatinine was 73 µmol/l ±49.1 at 5 years. Death-censored graft survival was 85% at 1 and 5 years. Patient survival was 100% at 1 and 5 years. Thrombosis was the cause of graft loss in 12% of recipients in the first era from 1963 to 1999, and 8% of recipients in the second era from 2000 to 2018. We advocate the judicious use of these small paediatric grafts from donors ≤1 year old. Optimal selection of donor and recipients may lead to greater acceptance and success of transplantation from very young donors.

The outcome of kidney transplant from living donors with pelvi-ureteric junction dysfunction

Purpose

To assess the effect of receiving a kidney with PUJ dysfunction on the recipient renal graft function.

Methodology

198 patients, who underwent renal transplantation from 1st January 2004 to 31st December 2014 in a single Center in the North West of England, were retrospectively reviewed using a computerized database. Split kidney function and the PUJ dysfunction for the donors were assessed using Tc-99 m MAG3 renogram. Each recipient with PUJ dysfunction was matched with a control recipient by age, gender, and number of days after transplantation. Both groups were followed up for 3.5 years post-transplantation.

Results

Of the 198 recipients included in the study, 19 recipients received kidneys from donors with PUJ dysfunction. Prevalence of PUJ dysfunction was 9.5% and it was more common in males than females. There was no difference between the case group and the control group in terms of age, gender, and follow-up time post-transplantation. There was also no difference between the case group and the control group in mean creatinine (130 µmol/l and 138 µmol/l respectively, p = 0.305) or the mean eGFR (48.6 ml/min and 47.5 ml/min respectively, p = 0.054) at 3.5 year post-kidney transplantation.

Conclusion

This study showed that PUJ dysfunction of renal allograft has a negligible effect on graft function over 3.5 years period post-transplantation. A prospective randomized trial is needed to test these findings. In the presence of widened gap between demand and supply in renal transplantation, PUJ dysfunction in potential donors should not preclude them from donation.

No evidence for the need of a routine renal transplant ultrasound after elective transplant ureteric stent removal-A retrospective cohort study

Transplant ureteric stent insertion reduces the incidence of MUCs, but it is not known whether routine PSRGU is needed to detect unmasked MUCs. This study evaluated whether routine PSRGU in the pRTR is a useful tool to identify MUCs before they become clinically apparent. A retrospective analysis was undertaken of the clinical outcomes following elective stent removal from pediatric kidney-only transplant recipients at two London centers between 2012 and 2016. Our policy was to perform PSRGU either routinely or urgently if there were concerning symptoms or biochemical evidence of renal allograft dysfunction. Elective stent removal was performed in 86% (97 of 113 pRTR), and 75 (77%) of whom had routine PSRGU at a median (IQR) of 6 (2-8) days after stent removal. There were changes to management in 3 (4%) of pRTR with PSRGU identifying no MUC. Nineteen patients (25%) had urgent PSRGU, most commonly due to renal allograft dysfunction, at a median (IQR) of 5.5 (2.7-12.3) days after stent removal. Of these, two pRTR required ureteric intervention. For our current practice of removing transplant stents at 4-6 weeks post-transplantation, our study has found no evidence to support routine PSRGU after elective stent removal.

Physical activity in elderly kidney transplant patients with multiple renal arteries

INTRODUCTION

Kidney transplantation (KT) is the gold standard for treatment of patients with end- stage-renal disease. To expand the donor reserve, it is necessary to use marginal/suboptimal kidneys.

METHODS

We retrospectively evaluated the short/long-term outcome of 34 KT elderly patients who received allografts with vascular abnormalities (MRA group), in comparison with 34 KT patients who received a kidney with a single renal artery (SRA group) pair-matched by age, length of time on dialysis, comorbidity and donor age.

RESULTS

All participants completed the International Physical Activity Questionnaire at KT, and then 4, 8, and 12 weeks after transplantation. Our data indicate that kidney with vascular anatomical variants may be successfully transplanted, since the overall rate of surgical complications was 20.6% in the SRA group and 17.6% in the MRA group and that the 5-year survival rate after KT was 100% in both groups.

CONCLUSIONS

The data also underline that individualized physical activity programs induced similar excellent results in both groups, improving physical capacities, arterial pressure, lipid metabolism, insulin sensitivity, quality of life and physical and mental status.

Zoning inside the renal fascia: The anatomical relationship between the urinary system and perirenal fat

Objectives

To examine the anatomical relationship between the urinary system and perirenal fat, and to clarify the zoning inside the renal fascia.

Methods

Using computed tomography images from 50 men, we examined perinephric veins to reveal vessel communication in perirenal fat. Nine cadavers were dissected to investigate connective tissue continuity and vessel communication inside the renal fascia. Eight retroperitoneal specimens were macroscopically observed: four from the anterior and four from the posterior aspects. One specimen was used to obtain retroperitoneal transverse sections to study macroscopic anatomy and histology.

Results

Perinephric veins were classified into four types (superior, middle, inferior and lateral) using computed tomography. Most of the inferior perinephric veins were connected to the ipsilateral gonadal vein. In the cadaveric study, the superior and middle perinephric veins communicated with veins deriving from the ipsilateral adrenal gland. A fibrous connective tissue gap between perirenal fat and renal hilar fat was observed in posterior aspect dissection. From the gap, we could dissect the urinary system from perirenal fat en bloc along with a thin fibrous connective tissue layer. Communicating vessels between perirenal fat and the urinary system were rare.

Conclusions

Our results suggest that perirenal fat belongs to the connective tissue of the gonad and the adrenal gland. The urinary system is separate from perirenal fat, and is located on the dorsal side inside the renal fascia. This concept of zoning inside the renal fascia is valuable particularly in retroperitoneoscopic donor nephrectomy.

Post-renal transplant urolithiasis in children: an increasingly diagnosed complication: a retrospective cohort study

OBJECTIVE

Urolithiasis in renal transplant (RTx) recipients is a potential cause of allograft loss if obstruction is untreated. It is not clear if paediatric transplant recipients are following the global trend for increased prevalence of urolithiasis over time.

DESIGN/SETTING/PATIENTS

A retrospective chart review was undertaken to evaluate the frequency, risk factors and characteristics of post-RTx urolithiasis over two decades (1995-2016), in a tertiary Australian paediatric hospital.

RESULTS

Stones were diagnosed in 8 of 142 (5.6%) recipients, 6 of whom were transplanted in the latter decade. All patients were male, with a median age 4.9 years and median weight 11.8 kg. Presentation was with haematuria (n=4), pain (n=2), dysuria (n=2), stone passage (n=1) and asymptomatic (n=1). Time to presentation was bimodal; three stones were identified in the initial 3 months post RTx and the remainder after 31-53 months. Two stones were in association with retained suture material and two patients had recurrent urinary tract infections. The average stone size was 8.4 mm. Five stones were analysed; all contained calcium oxalate, three were mixed, including one with uric acid. Five (83.3%) children had hypercalciuria but none had hypercalcaemia. Cystolithotripsy was the the most common treatment (n=5), in combination with citrate supplementation. No graft was lost due to stones.

CONCLUSIONS

Calculi occur with increasing frequency after renal transplantation. Clinicians need a high index of suspicion as symptoms may be atypical in this population. The cause for the increased frequency of stones in transplant recipients is not clear but is in keeping with the increase seen in the general paediatric population.

Tubular Ectasia in Renal Allograft Biopsy: Associations With Occult Obstructive Urological Complications

BACKGROUND

Urological obstructive complications (UOC) affect up to 15% of kidney transplants (KTX). Most cases are excluded by ultrasonography (US); however, accuracy may be limited in the early transplant phase. Features of acute tubular injury (ATI) in KTX biopsy may be informative but histological features indicating UOC are ill defined. Tubular ectasia (TE) was shown to be associated with UOC in experimental data. We evaluated the association of histomorphological features, particularly TE, with occult (=without relevant hydronephrosis in US) UOC and renal outcomes.

METHODS

We included all recipients with an early indication biopsy (976 of 1537 consecutive KTX). The biopsy finding of TE classified as "suspicious of UOC" was compared with the following endpoints: delayed graft function, estimated glomerular filtration rate, and occult UOC. Additionally, histopathological features of ATI were reevaluated by a single pathologist to increase diagnostic accuracy.

RESULTS

Fifty-eight (5.9%) patients presented with TE, which was not related to delayed graft function or estimated glomerular filtration rate. Forty percent of patients had a UOC (most frequently ureteral stenosis) close to biopsy. Comparing these biopsies to matched controls, TE was significantly associated with UOC (odds ratio 2.69; P = 0.018). After histopathological reevaluation of these biopsies including additional features of ATI, we developed a final multivariate model with a highly significant relationship to UOC (Receiver operating characteristic-area under the curve: 0.77; P = 0.001). The model provides a specificity of 78% and negative predictive value of 73%.

CONCLUSIONS

TE together with additional signs of ATI indicates occult UOC. This histological phenotype should trigger more detailed evaluation for UOC when there is no evidence of relevant hydronephrosis in the ultrasonography.

Urologic complications in renal transplants

Urologic complications of renal transplant occur commonly and can have significant impact on graft function, survival, and patient morbidity. This review examines the prevalence of urologic complications, risk factors, diagnosis and options for management of the most common urologic complications.

Is delayed graft function associated with ureteral stenosis in the kidney transplant recipient? A case-control study

INTRODUCTION

Ureteral stricture (US) in the kidney transplant recipient is a rare complication that can lead to morbidity and graft loss. Risk factor recognition is crucial in the prevention and management of this entity. Delayed graft function (DGF), as defined by the need for dialysis in the first week after transplantation, has been proposed as a risk factor in previous studies. Our objective is to determine the impact of DGF in US development in kidney transplant patients.

METHODS

We designed a matched case-control study. US cases in kidney transplant recipients were identified in the 2008-2017 period. We defined US as the rise in serum creatinine associated with findings suggesting obstruction in ultrasound, scintigraphy, or retrograde pyelogram; any other cause of graft dysfunction was excluded. Controls were defined as kidney transplant recipients from the same population and period without US, matched in a 1:2 fashion by age, sex, and donor type.

RESULTS

From 532 kidney transplant patients, 31 cases and 62 controls were included. Cumulative US incidence was 58 per 1000 cases. When calculating for odds ratio (OR), post-operative urinoma (OR 3.2; 95% confidence interval [CI] 2.36-4.37) and ureteral duplication (OR 3.29; 95% CI 2.40-4.51) were associated with an increased risk for US, while DGF was not found to be statistically significant as a risk factor (OR 3.3; 95% CI 0.96-11.52). No statistically significant differences were found between groups in other pre- and post-transplant-related factors CONCLUSIONS:: DGF was not associated with US in our cohort; however, ureteral duplication and postoperative urinoma were associated with an increased risk of graft ureteral stenosis development.

CT evaluation of the renal donor and recipient

Proper pre- and post-transplant diagnostic imaging work-up is fundamental in ensuring a successful outcome for renal transplantation. Despite exposure to ionizing radiation, CT has high spatial resolution and is a widely available and fast imaging technique. CT is performed routinely to delineate the anatomy of the kidney, relevant vasculature, and urinary collecting system in the living donor, to assess the iliac vessels in potential recipients prior to surgery, and to assess early and late-term post-transplant complications. The purpose of this article is to outline the optimal CT protocol and the main reportable findings for both the donor and the recipient diagnostic imaging work-up as well as to point out the main issues regarding ionizing radiation exposure and contrast medium injection in these subjects.

Early urological complications after kidney transplantation: An overview

Urological complications, especially urine leaks, remain the most common type of surgical complication in the early post-transplant period. Despite major advances in the field of transplantation, a small minority of kidney transplants are still being lost due to urological problems. Many of these complications can be traced back to the time of retrieval and implantation. Serial ultrasound examination of the transplanted graft in the early post-operative period is of key importance for early detection. The prognosis is generally excellent if recognized and managed in a timely fashion. The purpose of this narrative review is to discuss the different presentations, compare various ureterovesical anastomosis techniques and provide a basic overview for the management of post-transplant urological complications.

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.

Minimally invasive approach for the management of urological complications after renal transplantation: single center experience

BACKGROUND

The aim of the study was to characterise urological complications after renal transplantation and to evaluate the role of minimally invasive management for urological complications.

METHODS

A total of 920 kidney transplantations were performed between 2008 and 2015. All patients were followed up for at least 1 year after transplantation. Complications regarded as urological were urinary leakage, ureteral stricture, urinary malignancy, bladder outlet obstruction (BOO) and urinary calculi. We evaluated data from the time of occurrence of urological complications and the type of the management prescribed.

RESULTS

Among 920 transplantations performed in our clinic, 41 (4.4%) urological complications arose. Twenty (48.8%) of the complications occurred during the first 3 months and 21 (51.2%) occurred after 3 months, postoperatively. Ureteral strictures were found in 14 (34.1%) patients, urinary tract stones in seven (17%), BOO in 6 (14.6%) and urinary leakage was observed in 5 (12.1%) patients. Ureteral stricture was managed with endoscopic approach in eight (61.3%) patients. Urinary tract stones and urinary leakage were managed in 7 (100%) and 4 (75%) patients with endoscopic approach. Overall 29 (70.7%) of 41 urological complications were managed with endourological approaches.

CONCLUSIONS

It is likely that the importance of open surgery could decrease in the future. Endoscopic management of urological complications have come to have an important role in the treatment of urological complications after transplantation.

Robotic Autotransplantation and Management of Post-transplant Anastomotic Strictures: the Future Is Here

PURPOSE OF REVIEW

We set out to review the current published experience with robotic autotransplantation. Although the experience to date is limited, this surgery appears to be safe and technically feasible. We also examined the use of the robotic surgical platform for the management of post-transplant uretero-vesical anastomotic strictures.

RECENT FINDINGS

To date, only four reported cases of robotic autotransplantation have been described with two being performed completely intra-corporeally. An intra-corporeal approach is feasible for benign conditions, while malignant masses should be inspected and dissected extra-corporeally. Ureteric strictures after renal transplantation are common. To date, the experience with robotic surgical management is limited but has also been shown to be safe and feasible. While robotic autotransplantation is still in its infancy, it is feasible and appears to be safe. Renal allograft function and surgical outcomes are favorable and provide patients the option to have a historically more morbid surgery performed with a minimally invasive approach.

Risk factors for urological complications following living donor renal transplantation in children

The aim of this study was to detect possible risk factors for UC and UTI following pediatric renal Tx and effect of these complications on outcome. One hundred and eight children who underwent living donor Tx between 2009 and 2015 were retrospectively included. Extraperitoneal approach was used with stented tunneled extravesical procedure. Mean recipient age was 9.89 ± 3.46 years while mean weight was 25.22 ± 10.43 kg. Seventy-three (67.6%) recipients were boys while 92 (85.2%) were related to donors. Urological causes of ESRD were present in 33 (30.6%) recipients (14 [13%] posterior urethral valve, 16 [14.8%] VUR, and 3 [2.8%] neurogenic bladder). Augmentation ileocystoplasty was performed in 9 (8.3%) patients. Mean follow-up was 39.3 ± 17.33 months. UC were detected in 10 (9.3%) children (leakage 4 [3.7%], obstruction 3 [2.8%], and VUR 3 [2.8%]) while UTIs were reported in 40 (37%) children. After logistic regression analysis, UC were significantly higher in children with cystoplasty (44.4% vs 6.1%; P = .001). UTIs were significantly higher in girls (51.4% vs 30.1%; P = .001) and in children with urological causes of ESRD (51.5% vs 30.7%; P = .049). UC and UTI were not significantly associated with increased graft loss or mortality. UC were significantly higher in children with cystoplasty while UTIs were significantly higher in girls and children with urological causes of ESRD. Presence of UC did not affect the rate of graft loss or mortality due to its early detection and proper management.

Transplant Kidney Retrograde Ureteral Stent Placement and Exchange: Overcoming the Challenge

OBJECTIVE

To present a reliable technique for fluoroscopic controlled, large-bore, ureteral stent placement and exchange in transplant kidneys with persistent ureterovesical strictures.

MATERIALS AND METHODS

We reviewed the medical charts of all patients who underwent kidney transplant with persistent ureterovesical strictures who underwent ureteral stent placement or exchange at our institution between 2005 and 2015 using the new technique. Clinical characteristics and treatment outcomes of the study cohort were analyzed.

RESULTS

Ureteral stent insertion or stent exchange, using this technique, was performed in 32 renal transplant units. Median operating time was 24 minutes (interquartile range, 21-36.75 minutes). The overall success rate of the technique at first attempt was 96.9%. In 1 patient, drainage of the transplanted kidney with a nephrostomy tube was indicated after procedure failure. No other local or systemic complications were encountered, and no stent encrustation was noted in this cohort of patients. Renal function remained stable in all patients during a median follow-up of 59 months (interquartile range, 28-61 months).

CONCLUSION

Herein, we present in detail a step-by-step technique for the insertion and exchange of large-bore ureteral stents in transplanted kidneys. The technique was shown to be safe, effective, and highly successful.

[Bellini duct carcinoma: a new case study and literature review]

Bellini duct carcinoma is a very rare type of renal cell carcinoma (RCC), accounting for less than 1%. It arises from the distal nephron, more specifically from the collecting duct. Its morphological features are extremely variable, making its diagnosis difficult. We report the case of a 62-year old patient admitted with a painless progressive left flank swelling. CT scan showed a huge mass occupying the upper portion of the left kidney. The patient underwent radical nephrectomy. Anatomopathological examination showed collecting duct carcinoma of the kidney. Patient's evolution was exceptionally favorable: no recurrence, no locoregional metastasis and no distant metastasis.

Timing and Predictors of Early Urologic and Infectious Complications After Renal Transplant: An Analysis of a New York Statewide Database

OBJECTIVES

The most common complications after renal transplant are urologic and are a cause of significant morbidity in a vulnerable population. We sought to characterize the timing and predictors of urologic complications after renal transplant using a statewide database.

MATERIALS AND METHODS

We queried the New York Statewide Planning and Research Cooperative System database to identify patients who underwent renal transplant from 2005 to 2013. Postoperative complications included hydronephrosis, ureteral stricture, vesicoureteral reflux, nephrolithiasis, and urinary tract infections. Cox proportional hazards model was used to assess independent predictors of urologic complications.

RESULTS

In total, 9038 patients were included in the analyses. Urologic complications occurred in 11.3% of patients and included hydronephrosis (12.0%), nephrolithiasis (2.8%), ureteral stricture (2.4%), and vesicoureteral reflux (1.5%). We found that 23% experienced at least one urinary tract infection. On multivariate analysis, predictors of urologic complications included medicare insurance, hypertension, and prior urinary tract infection. Graft recipients from living donors were less likely to experience urologic complications than deceased-donor kidney recipients (P < .001).

CONCLUSIONS

Urologic complications occur in a significant proportion of renal transplants. Further study is needed to identify risk factors for complications after renal transplantation to decrease morbidity in this vulnerable population.

Urologic Complications After Renal Transplant: A Single-Center Experience

OBJECTIVES

Urologic complications after kidney transplant are associated with significant morbidity, mortality, and prolonged hospital stay. An intervention or second surgical procedure is frequently required. Here, we report urologic complications in adult kidney recipients.

MATERIALS AND METHODS

Since 2006, 171 adult kidney transplant procedures have been performed at the Gazi University Transplantation Center (Ankara, Turkey). Among these patients, there were 65 adult female (38%) and 106 adult male (62%) recipients. Donor source included 61 deceased donations (36%) and 110 living related donations (64%). The Haberal corner-saving technique was used for ureteroneocystostomy anastomosis. All recipients received a calcineurin-based triple immunosuppression regimen. All recipients also received trimethoprim/sulfamethoxazole prophylaxis for 3 months after transplant.

RESULTS

In the 171 adult kidney recipients analyzed for urologic complications, mean age was 32.5 ± 14.1 years (median: 32.5 y; range, 18-67 y); mean donor age was 41 ± 14.2 years (median: 42 y). We focused on 3 specific urologic complications: urine leak, ureteric stenosis, and symptomatic vesicoureteral reflux. In our study group, urologic complications were encountered in 7 patients (4%), with 5 complications detected in the early period and 2 complications detected in the late period. No symptomatic vesicoureteral reflux complications were shown in this study group. Urologic complications did not result in any patient deaths or graft loss.

CONCLUSIONS

In this study, the Haberal corner-saving suture technique with double J stent seemed to have a protective effect for development of urologic complications.

Outcome of the Double-J Stent Placement in Pediatric Kidney Transplant: A Single Center Experience

OBJECTIVES

Double J stent placement at kidney transplant may reduce stenosis or leakage complication rates. However, placement may also increase risk for early urinary tract infection (ie, < 3 mo after transplant). In children, the usefulness of double J stent placement is not well defined.

MATERIALS AND METHODS

We analyzed retrospective data from children who received transplants at the Gazi University Transplantation Center and Pediatric Nephrology (Ankara, Turkey) for outcomes related to double J stents. At our center, double J stent placement decision is made by the transplant surgery team during operation. Placements were routinely performed in all transplant recipients. Stent removal occurs within 6 week after transplant.

RESULTS

Among 42 transplants since 2006, early urinary tract infection was seen in 7% and stenosis in 3.6% of patients, with no leakage reported. Mean stent removal time was 6 ± 0.5 weeks. Early urinary tract infection was seen in 3 recipients with posterior urethral valve and neurogenic bladder (2 recipients) and meningoma cells and neurogenic bladder (1 recipient). All 3 recipients with early urinary tract infection received clean intermittent catheterization after transplant for adequate emptying of the bladder. In our study group, stent complications such as migration (2 patients) and hematuria (1 patient) were seen, but crusting, breakage, and stone formation were not seen. The 3 patients with urinary tract infection had neurogenic bladder types, complicating the urine outflow system. Stent placement was not a significant risk factor for early urinary tract infection and but had a protective effect.

CONCLUSIONS

In our study group, we observed no risk factors for routine double J stent placement in pediatric renal transplant procedures. Stent placement was not a risk factor for early urinary tract infection. However, regardless of stent placement, when a recipient had complicated urologic outflow problems, infection became a long-term hurdle.

Application of modified small bladder patch-to-bladder double-layer sutures to improve renal transplantation in mice

Background

This study aimed to introduce an improved surgical procedure to reduce the incidence of urinary tract complications after renal transplantation in mice using a modified bladder patch-to-bladder anastomosis technique.

Methods

Renal isotransplantation was performed in 28 male C57BL/6 mice. The urinary tract was reconstructed with a ureteral anastomosis between the donor’s small bladder patch and the recipient’s bladder. The bladder patch was secured through a cystotomy in the recipient’s bladder mucosa and seromuscular layers, which were sutured in a double-layer manner. The food intake and survival of mice were recorded for 100 days in addition to monitoring appearance, weight, and symptoms of pain. On post-transplantation day 7, the native kidney in the recipients was removed and the transplanted kidney assessed visually. Urine leakage from the transplanted graft was monitored by assessing the degree of ascites.

Results

The success rate of renal transplantation was 82 % (23 of 28 cases). Arterial thrombosis at the site of anastomosis occurred in 3 cases (11 %) and hemorrhagic shock in 2 cases (7 %). The mean ± SD time of the operation in recipients was 81 ± 5 min. No complications were noted in the successfully transplanted animals.

Conclusions

The modified procedure of a small bladder patch-to-bladder with double-layer suturing minimizes complications after renal transplantation in mice while requiring the same operating time as other approaches such as ureter to bladder anastomosis, which are associated with more complications.

Inguinal Herniation Containing Bladder, Causing Contralateral Allograft Hydroureteronephrosis-A Case Report and Literature Review

We report the first documented case of an inguinal hernia containing bladder, resulting in contralateral allograft hydroureteronephrosis. A 39-year-old male patient presented with allograft dysfunction, a contralateral inguinoscrotal hernia, and marked hydroureteronephrosis on ultrasound (US). Percutaneous nephrostogram and a retrograde cystogram suggested bladder herniation with incorporation of the contralateral ureteroneocystostomy into the hernia. Paraperitoneal bladder herniation was confirmed at surgery and hernioplasty was performed. Six-week follow-up revealed normal renal function with no sign of hernia recurrence. Despite occurring rarely, transplant ureter or bladder herniation should be considered in the differential diagnosis of hydroureteronephrosis. This case illustrates that the contralateral position of hernia to allograft does not necessarily preclude the hernia as the source of ureteric obstruction.

Incidence of kidney stones in kidney transplant recipients: A systematic review and meta-analysis

AIM

To evaluate the incidence and characteristics of kidney stones in kidney transplant recipients.

METHODS

A literature search was performed using MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews from the inception of the databases through March 2016. Studies assessing the incidence of kidney stones in kidney transplant recipients were included. We applied a random-effects model to estimate the incidence of kidney stones.

RESULTS

Twenty one studies with 64416 kidney transplant patients were included in the analyses to assess the incidence of kidney stones after kidney transplantation. The estimated incidence of kidney stones was 1.0% (95%CI: 0.6%-1.4%). The mean duration to diagnosis of kidney stones after kidney transplantation was 28 ± 22 mo. The mean age of patients with kidney stones was 42 ± 7 years. Within reported studies, approximately 50% of kidney transplant recipients with kidney stones were males. 67% of kidney stones were calcium-based stones (30% mixed CaOx/CaP, 27%CaOx and 10%CaP), followed by struvite stones (20%) and uric acid stones (13%).

CONCLUSION

The estimated incidence of kidney stones in patients after kidney transplantation is 1.0%. Although calcium based stones are the most common kidney stones after transplantation, struvite stones (also known as “infection stones”) are not uncommon in kidney transplant recipients. These findings may impact the prevention and clinical management of kidney stones after kidney transplantation.

Outcomes of Kidney Transplant Recipients With Percutaneous Ureteral Interventions: A Single-Center Study

Background

Long-term outcomes of kidney transplantation recipients with percutaneous ureteral management of transplant ureteral complications are not well characterized.

Methods

Electronic records of 1753 recipients of kidney-alone transplant between January 2000 and December 2008 were reviewed. One hundred thirty-one patients were identified to have undergone percutaneous ureteral management, with placement of percutaneous nephrostomy tube or additional intervention (nephroureteral stenting and/or balloon dilation). Indications for intervention included transplant ureteral stricture or ureteral leak. Kaplan-Meier survival curves and multivariable regression modeling were performed to determine survival outcomes.

Results

Kaplan- Meier graft survival (P = 0.04) was lower in patients with percutaneous ureteral intervention for transplant ureteral complication. Graft survival at 1, 5, and 10 years was 94.3% 78.3%, and 59.1% for no intervention and 97.2%, 72.1%, and 36.2% for intervention cohort. Patient survival (P = 0.69) was similar between cohorts. Multivariate analysis demonstrated no association with graft failure (hazard ratio, 1.21; 95% confidence interval, 0.67-2.19; P = 0.53) or patient death (hazard ratio, 0.56; 95% confidence interval, 0.22-1.41; P = 0.22) in intervention group. The major cause of graft failure was infection for percutaneous ureteral intervention group (20.4%) and chronic rejection for those without intervention (17.3%).

Conclusions

Kidney transplant recipients with percutaneous ureteral interventions for ureteral complications do not have a significant difference in graft and patient survival outcomes. Therefore, aggressive nonoperative management can be confidently pursued in the appropriate clinical setting.

The development and current status of minimally invasive surgery to manage urological complications after renal transplantation

Introduction:

In the past, urological complications after renal transplantation were associated with significant morbidity. With the development and application of endourological procedures, it is now possible to manage these cases with minimally invasive techniques.

Materials and Methods:

A MEDLINE search for articles published in English using key words for the management of urological complications after renal transplantation was undertaken. Forty articles were selected and reviewed.

Results:

The incidence of urological complications postrenal transplantation was reported to be 2–13%. Ureteric leaks occurred in up to 8.6%, and 55% were managed endourologically. The incidence of lymphocele was as high as 20%, and less that 12% of the cases required treatment. Ureteric stricture was the most common complication, and endourological management was successful in 50–70%. The occurrence of complicated vesicoureteral reflux was 4.5%, and 90% of low-grade reflux cases were successfully treated with deflux injections. Stones and obstructive voiding dysfunction occurred in about 1% of kidney transplant recipients.

Conclusion:

Minimally invasive techniques have a critical role in the management of urological complications after renal transplantation. Urinary leakage should be managed with complete decompression. Percutaneous drainage should be the first line of treatment for lymphocele that is symptomatic or causing ureteric obstruction. Laparoscopic lymphocele deroofing is successful in aspiration-resistant cases. Deflux is highly successful for the management of complicated low-grade kidney transplant reflux. The principles of stone management in a native solitary kidney are applied to the transplanted kidney. Early identification and treatment of bladder outlet obstruction after renal transplantation can prevent urinary leakage and obstructive uropathy.