Interventional Treatment Methods for Ureteral Complications After Kidney Transplant: A Single-Center Experience

OBJECYIVES

Ureteral complications are one of the most common complications after kidney transplant. Although these complications have been treated surgically in the past, almost all can be successfully treated with interventional methods today. In this study, we assessed the interventional treatment of ureteral complications after kidney transplants performed in our center and the long-term results of these treatments.

MATERIALS AND METHODS

We performed a retrospective analysis of 2223 kidney transplant recipients seen between January 1, 2000, and May 1, 2020. Among these, 70 kidney transplant recipients who experienced ureteral leakage or ureteral obstruction in the early or late posttransplant period were included in the study. Complications within the first 2 months posttransplant were classified as early complications, whereas those occurring after 2 months were considered late complications. We treated all patients with interventional methods.

RESULTS

In review of patients, 44 patients were diagnosed with ureteral obstruction (22 patients were early obstruction, 22 were late obstruction) and 26 patients with ureteral anastomosis leakage. All patients with early and late ureteral obstruction were successfully treated with percutaneous methods. In the group of patients with ureteral leakage, all patients except 2 patients were treated with interventional methods. For 2 patients with ureteral leakage, surgical treatment was necessary because of persistent leakage despite percutaneous treatment methods.

CONCLUSIONS

Ureteral complications after kidney transplant can be successfully treated with interventional methods in experienced centers without the need for surgery.

Contemporary risk factors for ureteral stricture following renal transplantation

INTRODUCTION

Allograft ureteral strictures after renal transplantation impact graft function and increase patient morbidity. They can be challenging to treat and may require complex surgical repair. Therefore, the objective of this study was to identify contemporary risk factors for the development of post-renal transplant ureteral strictures.

METHODS

A retrospective analysis was performed on all renal transplant patients at Vancouver General Hospital from 2008-2019. Demographics, clinical parameters, and outcomes were compared between patients who did and did not develop ureteral strictures. Putative risk factors for ureteral stricture were analyzed using logistic regression.

RESULTS

A total of 1167 patients were included with a mean followup of 61.9±40.8 months. Ureteral strictures occurred in 25 patients (2.1%). Stricture patients had no demographic differences compared to non-stricture patients but had significantly higher rates of postoperative complications, longer hospital stays, and decreased renal function one year post-transplant (all p<0.05). On multivariable analysis, cold ischemia time >435 minutes (odds ratio [OR] 43.9, confidence interval [CI] 1.6-1238.8, p=0.027), acute rejection (OR 3.0, CI 1.1-7.4, p=0.027), and postoperative complications (OR 112.4, CI 2.4-5332.6, p=0.016) were risk factors for stricture.

CONCLUSIONS

Renal transplant patients with ureteral stricture experience greater morbidity and reduced post-transplant renal function compared to non-stricture patients. Our findings support attempts to reduce cold ischemia time, acute rejection, and postoperative complications to mitigate this potential complication. Our study is limited by the low incidence of ureteral stricture resulting in a small sample of stricture patients. Future research in a larger, multicenter setting is warranted.

Classification of ureteral stenosis and associated strategy for treatment after kidney transplant

OBJECTIVES

Ureteral stenosis is a common complication after a kidney transplant. Treatment for ureteral stenosis ranges from interventional procedures to open surgery. The aim of this study is to present classification for ureteral stenosis and recommend the targeted strategy for effective treatment.

MATERIALS AND METHODS

Twelve cases of ureteral stenosis were diagnosed among 193 kidney transplants, of which 91 were from a live donor and 102 from a deceased donor. The mean age was 46.22 ± 13.23 years. The diagnosis of ureteral stenosis includes serum creatinine elevation, hydronephrosis, and presence of stricture on a pyelogram. The criterion for classification is based on the severity of stricture.

RESULTS

One of ureteral stenoses was classified as grade 1, six were grade 2, and five were grade 3. Of 12 cases, 10 were live-donor kidney transplant, 4 had lymphocele, and 2 had a hematoma after transplant. The corresponding strategy for each grade of ureteral stenosis is as follows: grade 1, ureteral stent reinsertion; grade 2, cutting balloon dilatation or endoscopic incision of stenosis; grade 3, open surgery urinary tract reconstruction. All cases were successfully treated using these strategies.

CONCLUSIONS

This classification of ureteral stenosis provides guidance for effective management and avoids unnecessary procedures. In this series, ureteral stenosis was significantly associated with a live donor and surgical complications.

Urologic complications in kidney transplantation

Urologic complications in kidney transplantation have an incidence ranging from 3% to 20%, representing an important cause of organ loss. From January 2001 to September 2004, 123 renal transplantations were performed using an immunosuppressive protocol including basiliximab, mycophenolate mofetil, calcineurin inhibitors, and steroids. The surgical technique was vascular anastomoses to external iliac vessels, and ureteral anastomosis according to Lich Gregoire technique using a JJ ureteral stent. We report 5 renal complications (4.2%) and 4 extrarenal complications (3.5%), the majority of which required corrective surgery. The surgical strategy uses the clinical condition of the donor and the recipient; the anatomic anomalies of the graft, and a reduced cold ischemia time. Moreover, a reduction in acute rejection episodes and immediate renal function has been fundamental to reduce urologic complications. In fact, the main cause of urologic complications is ureteral ischemia, linked both to backtable surgery and to rejection episodes. Another important factor in the reduction of early urologic complications has been the routine use of a JJ stent, which allowed us a conservative approach in this setting.

Use of peripheral cutting balloon in the management of resistant benign ureteral and biliary strictures

PURPOSE

To report the initial and midterm results of percutaneous cutting balloon incision and dilation (PCBID) for the treatment of benign ureteral and biliary strictures in patients after failed high-pressure balloon dilation.

MATERIALS AND METHODS

The study sample consisted of 11 patients: three with ureteric strictures after renal transplantation, three with biliary anastomotic strictures after liver transplantation, three with pelvic metastatic disease compressing the ureter, one after a failed endoscopic papilla of Vater sphincterotomy, and one with tight stenosis at the choledochojejunal anastomosis. All strictures were resistant to high-pressure balloon dilation. Four patients underwent PCBID immediately after failed high-pressure balloon dilation in the same session, and seven underwent the procedure in a separate session within the subsequent week. The width of the peripheral cutting balloons did not exceed the diameter of the normal lumen (7-8 mm).

RESULTS

PCBID was successful in nine patients (82%). One failure occurred in a transplanted ureter and one occurred in a transplanted liver with a choledochocholedochal anastomosis. In both cases, PBCID was performed in the same session as failed high-pressure balloon dilation. There were no periprocedural complications. Patency was confirmed at the 3- and 6-month clinical and ultrasonographic follow-up.

CONCLUSION

PCBID is a simple minimally invasive method for the treatment of benign ureteric and biliary strictures. The success rate is high and no complications occurred.

Experiences in Kidney Transplantation With Duplicated Ureters

INTRODUCTION

The purpose of this study was to evaluate the complications of duplicated ureters in renal transplant recipients.

METHODS

Between 1983 and 2004, 12 patients (median age 34 years) received renal transplants from donors with duplicated ureters. In four patients the ureter to bladder anastomoses were performed separately according to the method described by MacKinnon, including two cases transplanted with ureteral catheters because of narrow widths. In the following cases of eight duplicated ureters an anastomosis was performed between the distal part of each ureter to form a common ureteral ostium, which was connected to the urinary bladder. A ureteral catheter was used to the splint ureterovesical anastomosis.

RESULTS

No graft loss to ureteral complications was observed. There was no ureteral necrosis in the postoperative period. No clinical symptoms of ureteral junction obstruction were revealed after removing the ureteral catheter. By ultrasound examination four patients showed a slight temporary pyelocaliectasis was observed and four patients developed temporary urinary fistulas.

CONCLUSION

Our ureterocystoneostomy procedures with duplicated ureters were safe and useful in kidney transplantation.