Lower urinary tract reconstruction in association with renal transplantation

Long-term kidney transplant survival in patients with continent urinary diversion

OBJECTIVES

To report the long-term survival of transplanted kidneys in patients with a continent urinary diversion.

METHODS

Between January 1987 and July 2015, 16 patients with a median age of 37 years (range 21-63 years) underwent kidney transplantation on a continent urinary diversion. A total of 14 patients presented irreversible dysfunction of the lower urinary tract, and two patients had required radical cystectomy because of bladder cancer. All continent urinary diversions were carried out before the transplantation. There were nine Kock pouches, five Mainz pouches, one Mainz neobladder and one Hautmann neobladder. A total of 11 patients had a previous non-continent urinary diversion. Of the transplants, 14 came from brain-dead donors and two from related living donors.

RESULTS

The median post-transplantation follow up was 171 months (range 30-298 months). Two patients died, while six patients lost their transplant and resumed hemodialysis. Nine patients (56.2%) were alive with a functional transplant at the end of follow up. The most common allograft complication was acute pyelonephritis, but no graft was lost as a result of urinary diversion complications. The kidney transplant survival rate was 73.3% after 10 years, and 66.6% after 15 years. Among patients who still had a functional transplant at the time of the study, creatinine clearance was >30 mL/min for seven patients and <30 mL/min for two patients.

CONCLUSIONS

The present study is the longest series to date of renal transplantation on continent urinary diversions. The long-term outcome shows that the presence of a continent urinary diversion does not reduce transplant survival.

Effects of ureteral stent on urologic complications in renal transplant recipients: a retrospective study

The aim of the present study was to analyze the effects of ureteral stents used in renal transplantation on urologic as well as other complications. Cases of renal transplants from living or deceased donors performed in our hospital were retrospectively evaluated. The effects of the routine use of ureteral stents on postoperative complications were investigated. All outcomes and complications encountered during the postoperative follow-up were recorded. The Lich-Gregoire technique, which is a method of extravesical ureteroneocystostomy, was performed on all patients. One hundred and twenty-two patients underwent renal transplantation between 2001 and 2007 in our hospital. Stents were placed routinely in all patients. Leakage was observed in one patient, and one patient developed an obstruction; however, none of the patients developed an infection. A lymphocele developed in one patient. All urologic complications were treated without major morbidity. Graft loss did not occur. Complications following urinary anastomosis have a high rate of morbidity in renal transplantation. Ureteral stenting in renal transplant recipients prevents early urologic complications. The data generated in the current study were compared to the literature.

[Renal transplantation and urinary diversion]

For patients with end-stage renal disease and dysfunctional or absent lower urinary tract, complex therapeutic strategies are necessary combining kidney transplantation and - if possible - continent urinary diversion. In this concept urinary diversion is the first step in a two-stage procedure followed by renal transplantation. Meticulous preoperative diagnostics, careful patient selection and life-long close surveillance are critical for the success of this concept. The published data concerning long-term graft and patient survival are promising.

Continent urinary diversion in preparation for renal transplantation: a staged approach

BACKGROUND

We prospectively assessed the safety of kidney transplantation into continent urinary intestinal reservoirs as a planned two-stage procedure in patients with absent or dysfunctional lower urinary tract.

METHODS

Between November 1990 and June 1999, 12 patients have undergone renal transplantation into continent urinary reservoirs, and a further patient with a diversion is awaiting transplantation. This was part of a larger series of 356 patients who had undergone continent diversions during that period. A further 174 patients (33%) had diversions into ileal conduits.

FINDINGS

Within a mean follow-up of 26.1 months (5-72) after transplantation renal function was stable with serum creatinine values ranging from 0.9 to 1.8 mg/dl. There were 5 reoperations in the 12 patients (40%). Two patients needed their continence mechanism replaced. One had renal vein thrombosis with loss of the transplant. The cause for this was unknown but it had been speculated that it could have been caused by graft/body size disproportion. A second kidney was successfully transplanted after 12 months. Two further revisions were required for ureteric kinking and lymphocele. The patient with orthotopic substitution voids to completion. The other patients are continent day and night with easy catheterization.

INTERPRETATION

This is one of the largest single series reported to date of renal transplantation into continent urinary diversions, and we commend the approach in carefully selected patients, but the difficulties must not be underestimated and the specific problems of intestinal urinary reservoirs have to be reckoned with. These procedures should be confined to centers with considerable experience with this type of surgery and its complications. Lifelong close surveillance is critical for the success of this concept.