Urological complications in 119 consecutive renal transplants

Intravesical versus extravesical ureteroneocystostomy in kidney transplantation: a systematic review and meta-analysis

Urological complications are still a major problem postoperatively with a reported incidence of up to 30%, associated with significant morbidity, mortality, prolonged hospital stay and high medical costs. To date, there is no evidence favouring either an extravesical or an intravesical approach. The purpose of this systematic review and meta-analysis is to determine if an intravesical or extravesical anastomosis in kidney transplantation is to be preferred. Comprehensive searches were conducted in PubMed, Embase and the Cochrane Library. Reference lists were searched manually. The methodology was in accordance with the PRISMA statement. Two randomized controlled trials and seventeen cohort studies were identified. Based on the meta-analysis, outcome was in favour of the extravesical anastomosis. A relative risk (RR) for stenosis of 0.67 (confidence interval (CI), 0.48-0.93; p = 0.02), for leakage 0.55 (CI 0.39-0.80; p = 0.001) for the total number of urological complications 0.56 (CI 0.41-0.76; p < 0.001) and for haematuria of 0.41 (CI 0.22-0.76; p = 0.005) was demonstrated. Based on our results, we conclude that there is evidence in favour of the extravesical ureteroneocystostomy for having a smaller amount of urological complications in kidney transplantation.

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

Routine splinting of the ureterocystostomy during renal transplantation lowers the urological complication rate but increases patient's morbidity. The number needed to treat to prevent one urological complication is high. The aim of this study was to identify risk factors, which can be used in the implementation of a selective splinting ureterocystostomy protocol. Retrospective analysis of 475 consecutive renal transplantations performed between January 1999 and December 2004. Donor, surgical-technical and recipient factors were assessed. Urological complications occurred in 62 (13%) patients. In 29 of these 62 patients (6.1%), only a temporary percutaneous nephrostomy catheter was necessary and in 33 (6.9%) surgical revision was required. Episodes of acute rejection and delayed graft function were identified as the only independent risk factors for a urological complication: odds ratio 2.62 [95% confidence interval: (CI) 1.38-4.97] and 2.22 (95% CI: 1.14-4.33), respectively. None of the risk factors for urological complications after renal transplantation that are known at the time of performing the ureterocystostomy are useful for the implementation of a selective splinting protocol.

Papillary necrosis causing hydronephrosis in renal allograft treated by percutaneous retrieval of sloughed papilla

Obstructive uropathy is the second most common urological complication in a transplanted kidney. The usual causes of obstruction are ureteral stenosis and calculi. Papillary necrosis as a cause of obstruction in a transplant kidney is extremely rare with only one prior report published. Moreover, percutaneous removal of sloughed papilla in a transplant kidney has not previously been reported. We report an unusual case of a sloughed papilla causing hydronephrosis of a transplant kidney and its successful percutaneous removal. The recognition of renal papillary necrosis is important, not only because it can be a sign of acute rejection but also it because it can lead to obstruction, infection and potentially the loss of the transplant as exemplified by our case. Rapid diagnosis and meticulous retrieval technique are the crucial factors in minimizing the complications due to obstruction of a transplanted kidney by sloughed papilla.

Stented versus nonstented extravesical ureteroneocystostomy in renal transplantation: a metaanalysis

Stenting of the extravesical ureteroneocystostomy in renal transplantation is controversial. This study is a metaanalysis of 49 published studies over 30 years time in which the extravesical technique was used. Stented and nonstented anastomoses were compared. One-hundred six articles published between 1973 and 2002 were reviewed and 49 met criteria for inclusion. Articles were required to list original, numeric, previously unpublished data and to report or to describe the use of an extravesical ureteroneocystostomy, with or without stent. Data were analyzed within separate groups, (1) randomized, controlled trials and (2) case series. Data were included from five randomized, controlled trials and 44 case series. In the controlled trials group, there were urologic complications in 6 of 407 stented (1.5%), and 35 of 389 nonstented subjects (9.0%) (p < 0.0001, OR 0.24, 95% CI 0.10-0.57). In the case-series group, there were urologic complications in 137 of 4245 stented (3.2%) and 433 of 9077 nonstented subjects (4.8%) (p = 0.007, OR 0.58, 95% CI 0.39-0.86). Renal transplants with stented extravesical ureteroneocystostomy have a significantly lower urologic complication rate than those with nonstented anastomoses. All five randomized, controlled trials individually found stented anastomoses to have a lower complication rate and this was confirmed by metaanalysis of these trials and of case-series data.

Urological complications in 1,000 consecutive renal transplant recipients

The urological complications in the first consecutive 1,000 renal transplants at our transplant center are reported with a minimum followup of 12 months. The kidney was implanted in the iliac fossa in all cases and in all but 3 the ureter was inserted into the bladder with a Politano-Leadbetter technique. Overall, there were 71 primary complications in 68 patients (7.1%), which included 36 ureteral obstructions, 25 ureteral or bladder leaks (including ureteral necrosis), 7 bladder outflow obstructions, 2 ureteral stones and 1 case of symptomatic vesicoureteral reflux. The use of high dose steroids in the early years was associated with a 10% urological complication rate, which decreased to 4% in patients receiving low dose steroids thereafter combined with azathioprine or cyclosporine. The urological complication was corrected after 1 procedure in 65 cases and after 2 procedures in 4. No grafts were lost due to urological complications. Two patients died, 1 of sepsis following transurethral resection of the prostate and subsequent ureteral necrosis, and 1 of hemorrhage following nephrostomy tube insertion. Most ureteral complications were treated by an open operation, although in recent years endoscopic techniques have become more common. Meticulous retrieval technique, low dose steroid protocols and rapid diagnosis are the crucial factors associated with a minimal incidence of urological complications after renal transplantation.

External ureteroneocystostomy and ureteroureterostomy in renal transplantation

Reported are 204 primary external ureteroneocystostomies and 16 primary ureteroureterostomies in a series of 220 consecutive renal transplants. A total of 12 (5%) complications occurred; however, only seven (3%) required major operative repair, whereas five (2%) were minor and were repaired by cystoscopic or transvesical procedures. There was no mortality and no allograft loss from these complications, which tend to occur late and be amenable to prompt repair. Since the complications of external ureteroneocystostomy differ from those of the internal ureteroneocystostomy, a discussion of their treatment is provided. A review of literature shows that the external repair is growing in popularity because of its good results. The good results are attributable to the use of a short length of ureter, to the use of a continuous monofilament suture that produces an anastomosis less likely to leak, and to the need of a very small cystostomy.

Genitourinary complications in renal transplantation

The surgical aspects of renal transplantation have now been studied thoroughly. Yet, technical complications are still common. This review may seem too complex, but proper attention to many small details means the difference between success and failure, or at least between large and small morbidity. Reduction of genitourinary complications is due to many innovations. The external ureteroneocystostomy is a primary method of urinary reconstruction which is simpler and produces fewer complications than the alternative procedures. Further, the complications that do occur are more easily and promptly treated. The end-to-side ureteroureterostomy, as currently performed, provides a ready secondary method of reconstruction if the primary method fails. The early exploration and operative correction of genitourinary complications substantially reduces long-term morbidity and mortality.

Transplant ureteral obstruction masquerading as recurrent rejection episodes: management by percutaneous antegrade balloon dilatation

We report a 52-year-old male renal transplant recipient who had three "rejection episodes." The first of these responded to conventional antirejection therapy; however, the next two episodes showed incomplete responses to treatment for rejection. At subsequent presentation with deteriorating renal function, ureteral obstruction was evident and was relieved with percutaneous antegrade balloon dilatation with a return of his plasma creatinine to normal. Obstruction of the ureter was a major component in our patient's course given the lack of response to conventional antirejection therapy and the normalization of renal function with relief of the documented ureteral stenosis. This case illustrates that ureteral obstruction can mimic rejection in the renal transplant recipient. Management of ureteral stenosis in transplant patients with percutaneous antegrade balloon dilatation appears to be an effective procedure and can supplant the need for open surgical procedures.

Interventional radiologic procedures in the management of the renal transplant patient

Interventional radiologic procedures have become an important adjunct to the management of the renal transplant patient. Numerous problems can be dealt with, and in our experience these have included the diagnosis and treatment of ureteric obstruction, dilatation of renal artery stenoses, drainage of abscesses, hematomas and lymphoceles, management of complications of pancreatitis and treatment of bleeding due to fistulas and pseudoaneurysms.

Calycovesicostomy for total ureteral obstruction after renal transplantation

Surgical reconstruction for ureteral obstruction is necessary in 1 to 10 per cent of renal transplants. On an acute basis edema, ischemia, lymphocele and hematoma formation cause ureteral obstruction. Chronic etiologies include ureterovesical obstruction and retroperitoneal or ureteral fibrosis. Options for repair are myriad and include repeat ureteral reimplantation, pyeloureterostomy, ureteroureterostomy, pyelocystostomy and calycovesicostomy. We report on the desirability of calycovesicostomy as a last resort option for total ureteral obstruction after renal transplantation.

Nephrostomy drainage for renal transplant complications

The use of temporary diverting nephrostomy drainage in the management of immunosuppressed renal transplant patients with supravesical urinary extravasation, fistulas or ureteral obstruction is reviewed. In a literature survey covering an 11-year interval and 4,307 transplants there were 204 cases (4.7 per cent) of ureteral extravasation or fistula and 113 cases (2.6 per cent) of ureteral obstruction. Attempts at urologic repair in these 317 cases resulted in 30.9 per cent failure rate (98 cases), of which 86.7 per cent (85 cases) occurred in patients without nephrostomy compared to 13.3 per cent (13 cases) in patients with nephrostomy. In our 255 consecutive renal transplant patients there were 7 (2.7 per cent) with ureteral extravasation or fistula and 14 (5.5 per cent) with ureteral obstruction. Temporary nephrostomy was done in all 21 patients to protect the urologic repair and, when necessary, to control sepsis and allow for patient stabilization before delayed urinary tract reconstruction. In our series there was no mortality and only 1 renal unit (4.7 per cent) was lost as a consequence of urologic complications. The use of nephrostomy in transplant patients with ureteral extravasation, fistulas or ureteral obstruction is encouraged strongly to optimize patient and renal unit survival.