Percutaneous management of transplant ureteral fistulae is feasible in selected cases

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.

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.

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.

Diagnosis and management of ureteral complications following renal transplantation

When compared with maintenance dialysis, renal transplantation affords patients with end-stage renal disease better long-term survival and a better quality of life. Approximately 9% of patients will develop a major urologic complication following kidney transplantation. Ureteral complications are most common and include obstruction (intrinsic and extrinsic), urine leak and vesicoureteral reflux. Ureterovesical anastomotic strictures result from technical error or ureteral ischemia. Balloon dilation or endoureterotomy may be considered for short, low-grade strictures, but open reconstruction is associated with higher success rates. Urine leak usually occurs in the early postoperative period. Nearly 60% of patients can be successfully managed with a pelvic drain and urinary decompression (nephrostomy tube, ureteral stent, and indwelling bladder catheter). Proximal, large-volume, or leaks that persist despite urinary diversion, require open repair. Vesicoureteral reflux is common following transplantation. Patients with recurrent pyelonephritis despite antimicrobial prophylaxis require surgical treatment. Deflux injection may be considered in recipients with low-grade disease. Grade IV and V reflux are best managed with open reconstruction.

Urological Consequences following Renal Transplantation: A Review of the Literature

Renal transplant (RT) represents the treatment of choice for end-stage renal disease (ESRD) but harbours a wide range of possible complications and therapeutic challenges of urological competence. Dialysis years and clinical medical background of these patients are risk factors for sexual dysfunction and lower urinary tract symptoms (LUTS). On the contrary, RT itself may have a number of possible surgical complications such as ureteral stenosis and urinary leakage, while immunosuppressive treatment is a known risk factor for de-novo malignancies.

The present review describes the main urologic problems of RT patients and their up-to-date treatment options according to the most recently available literature evidences.

Endoscopic management of a chronic ureterocutaneous fistula using cyanoacrylic glue

Ureterocutaneous fistula is a rare complication of renal surgery. Cyanoacrylate glue is a tissue adhesive, used primarily for the endoscopic control of bleeding from gastric varices. A female aged 33 presented to our facility with a ureterocutaneous fistula after surgery. We used a retrograde endoscopic approach for the instillation of 2 ml of sealant into the ureteral lumen to seal the ureter and fistulous tract. The fistulous opening healed spontaneously a week after the procedure, and the patient remained dry and symptom free for 5 months following the procedure. Endoscopic delivery of cyanoacrylate sealant was a feasible and effective way in treating a ureterocutaneous fistula in our patient.

The current role of endourologic management of renal transplantation complications

Introduction. Complications following renal transplantation include ureteral obstruction, urinary leak and fistula, urinary retention, urolithiasis, and vesicoureteral reflux. These complications have traditionally been managed with open surgical correction, but minimally invasive techniques are being utilized frequently. Materials and Methods. A literature review was performed on the use of endourologic techniques for the management of urologic transplant complications. Results. Ureterovesical anastomotic stricture is the most common long-term urologic complication following renal transplantation. Direct vision endoureterotomy is successful in up to 79% of cases. Urinary leak is the most frequent renal transplant complication early in the postoperative period. Up to 62% of patients have been successfully treated with maximal decompression (nephrostomy tube, ureteral stent, and Foley catheter). Excellent outcomes have been reported following transurethral resection of the prostate shortly after transplantation for patients with urinary retention. Vesicoureteral reflux after renal transplant is common. Deflux injection has been shown to resolve reflux in up to 90% of patients with low-grade disease in the absence of high pressure voiding. Donor-gifted and de novo transplant calculi may be managed with shock wave, ureteroscopic, or percutaneous lithotripsy. Conclusions. Recent advances in equipment and technique have allowed many transplant patients with complications to be effectively managed endoscopically.

Successful endoscopic management of a chronic transplant ureterocutaneous fistula

OBJECTIVE

To illustrate a minimally invasive, well-tolerated, clinically, and cost-effective method for surgically managing a high-output, transplant ureterocutaneous fistula manifesting as chronic urinary tract infection and recurrent pyelonephritis. This method will subject the immunosuppressed patient to less morbidity and minimize risk to the functioning renal graft.

METHODS

A combined percutaneous-endoscopic fistula closure method was developed using Deflux® to cystoscopically occlude the transplant ureteral orifice and Bioglue® to seal the ureter and fistula tract.

RESULTS

The patient was infection free, completely dry, and had no voiding dysfunction after undergoing this occlusion method.

CONCLUSION

This report demonstrates that this minimally invasive technique is a safe, well-tolerated, and effective technique that may be offered as an outpatient, first-line therapy over open or laparoscopic excision.

Therapeutic option for infected urinary tract fistulas in renal transplantation

BACKGROUND

Approximately 20% of urinary tract fistulas after renal allografting are complicated by urinary tract infection, which presents a therapeutic challenge.

OBJECTIVE

To evaluate an option for treatment of urinary tract fistulas associated with urinary tract infection and unsuitable for minimally invasive or primary surgical urinary tract repair.

PATIENTS AND METHODS

The study included 650 recipients who underwent transplantation over 17 years. Urinary leakage was initially treated with indwelling bladder catheterization. Patients with fistulas refractory to treatment underwent surgical intervention to repair the urinary tract. In patients who were not candidates for primary repair of the urinary tract, temporary urinary diversion was performed, rather than classic percutaneous or open nephrostomy, using a ureteral stent (ie, a 6F or 8F Foley catheter with the balloon placed inside the renal pelvis).

RESULTS

Overall, urinary leakage occurred in 36 patients (5.5%). Conservative management was successful in 14 vesical fistulas (42.4%) and no ureteral fistulas (0%). Three patients died of sepsis during conservative treatment, before the new surgical approach. Five of 36 urinary leaks (13.9%) were managed using ureteral intubation with an 8F Foley catheter, with a success rate of 80%.

CONCLUSION

Ureteral catheterization with an 8F Foley catheter is a feasible therapeutic option to treat complicated urinary tract fistulas unsuitable for primary surgical repair of the urinary tract.

Diagnóstico y tratamiento de las complicaciones urológicas del trasplante renal

OBJECTIVE

To analyze the incidence of urological complications, like fistula and stenosis in our series of 282 renal transplants and their management.

MATERIALS AND METHODS

Between December 1995 and October 2005, 282 adult recipients underwent renal transplant. The most common urological complication was urinary fistula. This complication was observed in 24 cases (8.5%), ureteral stenosis in 18 cases (6.4%) and both of them in 5 (1.7%). The items recorded on these patients included the time to diagnosis, the image technique, the type of ureteral stents and the clinical evolution.

RESULTS

Endourologic treatment with percutaneos nefrostomy, double-J catheter and metalic endoprotesis was performed successfully in 76.4% of urinary fistula, in 66.7% of ureteral obstruction and in 60% of patients who developed both of them.

CONCLUSION

Endourologic procedures have replaced open reconstructive surgery in most patients with ureteral obstruction or urinary fistula after renal transplant, because they may offer a definitive treatment with low morbidity.