Is a selective splinted ureterocystostomy protocol feasible in renal transplantation? An analysis of 475 renal transplantations

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.

External ureteric stent versus internal double J stent in kidney transplantation: a retrospective analysis on the incidence of urological complications and urinary tract infections

Introduction

Urologic complications (UCs) and urinary tract infections (UTIs) are common after kidney transplantation. Intraoperative stent placement at the vesicoureteric anastomosis reduces UC risk, but increases UTI risk.

Methods

In 2014 our stenting protocol changed from external ureteric stent (ES) to internal double J stent (DJ). We retrospectively studied the occurrence of UCs and UTIs in relation to ES or DJ in 697 kidney recipients.

Methods

An ES was used in 403 patients (57.8%), in 294 (42.2%) a DJ. ES was removed 7-12 days and DJ 3-4 weeks post-operative. Induction immunosuppression was the same in both groups. Primary outcomes at 6 months follow-up were UC (urinary leakage/ureter stenosis) and UTI; they were related to stenting procedure and clinical and transplant characteristics. The incidence of UCs was similar for ES (8.4%) and DJ (6.8%), p=0.389. ES use was a significant risk factor for UTI (OR 1.69 (1.15-2.50), p=0.008). Post-transplant hospitalization was significantly shorter in the DJ group. Despite more acute rejection episodes with ES (ES/DJ: 16.4%/6.1%, p<0.001), no clinical relevant differences in graft outcomes existed.

Discussion

A DJ is, compared to ES, associated with a lower incidence of UTIs and comparable occurrence of UCs and is therefore the preferred technique for stenting the vesicoureteric anastomosis.

Surgical complications following 1670 consecutive adult renal transplantations: A single center study

BACKGROUND AND AIMS

The aim of the study was to clarify the frequency and the sequel of surgical complications occurring within 1 year after renal transplantation.

PATIENTS AND METHODS

Surgical complications after 1670 consecutive adult kidney transplantations performed between 2000 and 2009 were retrospectively analyzed. In 2%, a living-related allograft was used, and 10% were retransplantations. An intravesical technique without stenting was used for the ureteric implantation.

RESULTS

There were 282 surgical complications occurring in 259 (15.5%) transplantations. Ureteral obstruction occurred in 53 (3.1%), lymphoceles in 39 (1.5%), postoperative hemorrhage in 36 (2.1%), and renal vein thrombosis in 22 (1.3%) patients, respectively. Out of the 17 lung emboli, 4 were fatal. Male recipients had twice as much ureteral stenosis as female (2.4 vs 1.2%, p < 0.05), and the opposite was true of urinary leakage (1.8% vs 4.0%, p < 0.025). Five-year patient and graft survival was impaired in patients with complications compared with patients without complications. Five-year patient survival was 92% versus 88% and graft survival 87% versus 74%.

CONCLUSION

Surgical complications impair patient and graft survival after kidney transplantation.

Use of stenting in living donor kidney transplantation: does it reduce vesicoureteral complications?

The risk of urologic complications after kidney transplantation is 0% to 30%. We studied the impact of prophylactic stent placement during transplantation by assessing the necessity for a percutaneous nephrostomy (PCN) after living kidney transplantation. From January 2003 to December 2007, 342 living donor kidney transplantations were performed. Intra- and postoperative data were collected retrospectively from 285 patients with stent and 57 without. Baseline characteristics were not significantly different between groups, except for the number of previous transplantations: 31 (11%) patients with versus 16 (28%) without stent had a history of >1 transplantation (P < .001). From patients with PCN, 55 (87%) patients in the stented group received a PCN <3 months versus 11 (100%) in the nonstented group (P = .71). The reoperation rate for urologic complications was similar in both groups (3% (stented) versus 5% (nonstented; P = .43). In multivariate analysis, risk for PCN was similar in both groups (odds ratio 1.21, 95% confidence interval 0.5-2.5). Recipient survival was not significantly different. One- and 3-year death-censored graft survival was not significantly different between stented (89% and 84%) and nonstented group (90% and 85%, P = .71 and P = .96). Ureteral stent insertion is not associated with a reduced rate of PCN placement in living donor kidney transplantation.

There is no need to stent the ureterovesical anastomosis in live renal transplants

Double-J (DJ) stents are used in urology practice for various reasons. In renal transplantation, DJ stenting is used to treat the complications like urine leak and ureteric obstruction. However, the role of routine or prophylactic DJ stenting during renal transplantation is debatable. Most of the urinary complications occurring following renal transplantation are because of poor surgical technique and transplant ureteric ischemia. Routine DJ stenting cannot be a substitute for sound surgical technique, which avoids ureteric devascularization and create watertight ureterovesical anastomosis. DJ stenting increases the risk for complications like recurrent urinary tract infection, stent encrustation, stone formation, hematuria, and severe storage lower urinary tract symptoms. Routine DJ stenting during renal transplantation is not mandatory. It can harm an immunosuppressed renal transplant recipient by predisposing to various complications.

Effectiveness of a 5-day external stenting protocol on urological complications after renal transplantation

Background

Ureteral stents are successful in reducing urological complications after renal transplantation. However, the optimal duration and method of stenting have not yet been clarified. The objective of the present study was to investigate the frequency of urological complications when a 5-day external stented ureterocystostomy protocol was followed.

Methods

A single-center nonrandomized analysis of 392 kidney transplantations between June 2003 and June 2007 was conducted. From July 2005 all 196 renal transplant recipients received a 5-day external stented ureterocystostomy. A urological complication was defined as any cause leading to the placement of a percutaneous nephrostomy catheter and/or surgical revision of the ureterocystostomy.

Results

In the non-stented group, 21 of the 196 patients (10.7%) developed a urological complication compared to 13 patients (6.6%) in the stented group (p = 0.151). In the stented group, 2 of the 66 recipients of a living donor transplant (3.0%) developed a urological complication compared to 8 of the 59 recipients (13.6%) in the non-stented group (P = 0.030). Eleven of 130 recipients of a deceased donor transplant (8.5%) in the stented group developed a urological complication, compared to 13 of the 137 recipients (9.5%) in the non-stented group (P = 0.769). The surgical revision rate of the stented and the non-stented group was 5/13 39% and 6/21 29%, respectively.

Conclusions

A 5-day routine external stent protocol is efficacious in living donor renal transplantation in preventing early postoperative ureter obstruction, but this stenting period seems inadequate for deceased donor renal transplantation.