Kidney Transplant Ureteroneocystostomy Techniques and Complications: Review of the Literature

Robot-assisted ureteral reconstruction for managing kidney transplant patients with ureteric complications

PURPOSE

To evaluate the feasibility of robot-assisted ureteral reconstruction as a minimally invasive alternative to open surgery for managing ureteric complications in transplanted kidneys.

MATERIALS AND METHODS

From January 2020 to December 2023, robot-assisted ureteral reconstruction was performed on fifteen kidney transplant patients with vesicoureteral reflux (VUR) or ureteral stricture who had previously failed endoscopic treatments.

RESULTS

Twelve females and three males, with a mean age of 48.6±6.6 years, were included in the study. Nine patients (60.0%) underwent surgery due to VUR (grade III or higher) of the transplanted kidney, and six patients (40.0%) had transplanted ureteral strictures. Postoperative voiding cystourethrogram (VCUG) was performed at 3.2±1.6 months. Seven patients (77.8%) became VUR-free, while two patients (22.2%) had VUR regression from grade IV to I. All six patients who underwent reconstruction due to anastomosis site stricture became stenosis-free without the need for an indwelling ureteral catheter. In cases where the ureter was too short for reimplantation, a Boari flap or end-to-end anastomosis with the native ureter was performed. The mean hospital stay was 5.9±4.5 days. The urethral catheter was removed after 15.1±5.4 days, and the ureteral catheter was removed after 4.9±1.5 weeks. The mean follow-up period was 23.9±6.8 months, with no additional interventions required after surgery. No complications above Clavien-Dindo grade I were recorded.

CONCLUSIONS

Robotic ureteral reconstruction is technically feasible and offers an effective, minimally invasive treatment for ureteric complications in kidney transplant patients, serving as an alternative to open surgery.

In vitro effects of β3-adrenoceptor agonist mirabegron on the human ureter

INTRODUCTION

This study aimed to investigate the effect of mirabegron, a β3-adrenoceptor agonist with widespread clinical use for treating overactive bladder disease, on isolated healthy human ureter strips.

MATERIALS AND METHODS

This was a prospective study employing a series of in vitro organ bath experiments using ureteral tissues of kidney grafts from 10 healthy donors. The ureteral strips were subjected to cumulative mirabegron concentrations (10-9-10-4.5 M). Effects on frequency or amplitude of spontaneous, 10 mM KCl- or EFS-induced contractions were evaluated.

RESULTS

Mirabegron decreased the frequency of spontaneous ureteric contraction in a concentration-dependent manner. Statistically significant decrease in the frequency of spontaneous contraction was observed at 10-8-10-4.5 M. In 10 mM KCl medium, statistically significant change in frequency was observed at 10-9-10-4.5 M. Statistically significant decrease in the amplitudes of spontaneous contraction was observed at 10-7-10-4.5 M. In a 10 mM KCl medium, statistically significant change in amplitudes was observed at 10-8-10-4.5 M.

CONCLUSIONS

Mirabegron reduced the amplitude and frequency of human ureter activity in in vitro organ bath studies. This effect was achieved in a dose-dependent manner on isolated tissue strips. Although monotherapy with mirabegron remains uncertain, this study has the potential to elucidate the mechanism underlying the effectiveness of mirabegron, particularly in combination therapy for ureteral stones.

Current management of symptomatic vesicoureteral reflux in pediatric kidney transplantation-A European survey among surgical transplant professionals

BACKGROUND

Vesicoureteral reflux (VUR) is common in children and adolescents undergoing kidney transplantation (KTx) and may adversely affect allograft kidney function.

METHODS

To explore the current management of symptomatic native and allograft VUR in pediatric KTx recipients, an online survey was distributed to European surgical transplant professionals.

RESULTS

Surgeons from 40 pediatric KTx centers in 18 countries participated in this survey. Symptomatic native kidney VUR was treated before or during KTx by 68% of the centers (all/selected patients: 33%/67%; before/during KTx: 89%/11%), with a preference for endoscopic treatment (59%). At KTx, 90% favored an anti-reflux ureteral reimplantation procedure (extravesical/transvesical approach: 92%/8%; preferred extravesical technique: Lich-Gregoir [85%]). Management strategies for symptomatic allograft VUR included surgical repair (90%), continuous antibiotic prophylaxis (51%), bladder training (49%), or noninterventional surveillance (21%). Redo ureteral implantation and endoscopic intervention for allograft VUR were equally reported (51%/49%).

CONCLUSIONS

This survey shows uniformity in some surgical aspects of the pediatric KTx procedure. However, with regard to VUR, there is a significant variation in practice patterns that need to be addressed by future well-designed and prospective studies. In this way, more robust data could be translated into consensus guidelines for a more standardized and evidence-based management of this common condition in pediatric KTx.

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.

Improving Surgical Safety in Living Donor Renal Transplantation With Antiseptic Skin Preparation, Bladder Irrigation, Corner-Saving Vascular Anastomosis, DJ Stenting, and Extravesical Ureteroneocystostomy Modifications: A Comprehensive Approach

Introduction The antiseptic skin preparation, bladder irrigation, corner-saving vascular anastomosis, DJ stenting, and extravesical ureteroneocystostomy (ABCDE) approach encompasses a range of modifications applied during different stages of the surgical procedure in renal transplantation. These modifications include the following: A, antiseptic skin preparation sequentially with cetrimide 3.35%, chlorhexidine scrub 4%, spirit, and povidone-iodine 10%; B, bladder irrigation with amikacin and betadine solution; C, corner-saving end-to-side vascular anastomosis; D, DJ stenting with early postoperative removal within three weeks; and E, extravesical ureteroneocystostomy using our institute's modified Lich-Gregoir technique. Methods This prospective observational study was conducted at our institution between March 2021 and May 2023. Data were collected from the patients' medical records and analyzed using Statistical Package for the Social Sciences (SPSS) (IBM SPSS Statistics, Armonk, NY, USA). Statistical tests, including t-test, Mann-Whitney test, chi-square test, and Fisher's exact test, were used for analysis. The study assessed various recipient, donor, intraoperative, and post-transplant factors, as well as surgical complications and stent-related factors. Results Out of 72 renal transplantations, 12 (16.6%) had the following surgical complications: urinary (n = 4; 5.5%), wound-related (n = 3; 4.1%), and lymphocele (n = 5; 6.9%). The most common complications were lymphocele (n = 5; 6.9%) and urinary leak (n = 4; 5.5%). Surgical complications were more common in male recipients (91.6% versus 8.3%), as well as in recipients with longer dialysis duration (24 ± 17 versus 11.0 ± 7 months) and had extended hospitalization time (16.4 ± 8.6 versus 8.0 ± 2.9 days) (p < 0.05). Wound infection correlated with longer surgeries (>300 minutes) and other complications. Lymphocele patients had higher drain output (>500 mL) on day 1 and longer hospital stays (>15 days). Urinary tract infections (UTIs) were linked to dialysis duration (>24 months), diabetes, and longer indwelling times of DJ stents and urinary catheters. Early DJ stent removal (<3 weeks) reduced UTI incidence and symptoms (p < 0.05). All complications were categorized as minor (3a or less), according to the Clavien-Dindo classification. Conclusion The modified ABCDE surgical approach in renal transplantation decreased the complications, showing favorable outcomes compared to those in the literature.

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.

Laparoscopic ureteroneocystostomy and round ligament bladder hitching for ureteral stenosis in parametrial deep endometriosis: Our tips for a tension-free anastomosis

OBJECTIVE

To investigate the feasibility and the efficacy of laparoscopic ureteroneocystostomy with round ligament bladder hitching.

METHODS

This is a monocentric retrospective study. Enrolled patients affected by deep endometriosis underwent laparoscopic nerve-sparing parametrectomy and monolateral ureteroneocystostomy with bladder suspension to the round ligament. Perioperative and postoperative outcomes were collected, as well as urinary and pain symptoms before and after surgery.

RESULTS

Laparoscopic ureteroneocystostomy with round ligament bladder hitching was performed in nine women. The most frequent postoperative complication was post-voiding urinary retention (22.2%). No ureteral fistula or stenosis of the anastomosis was reported.

CONCLUSION

In selected cases of ureteral resection and reimplantation, performing a round ligament bladder hitching allowed us to overcome the ureteral gap. This is a safe and feasible procedure to ensure stability of the anastomosis and avoid the possible disadvantages of the "standard" psoas hitch procedure.

Recommendations for living donor kidney transplantation

This Guide for Living Donor Kidney Transplantation (LDKT) has been prepared with the sponsorship of the Spanish Society of Nephrology (SEN), the Spanish Transplant Society (SET), and the Spanish National Transplant Organization (ONT). It updates evidence to offer the best chronic renal failure treatment when a potential living donor is available. The core aim of this Guide is to supply clinicians who evaluate living donors and transplant recipients with the best decision-making tools, to optimise their outcomes. Moreover, the role of living donors in the current KT context should recover the level of importance it had until recently. To this end the new forms of incompatible HLA and/or ABO donation, as well as the paired donation which is possible in several hospitals with experience in LDKT, offer additional ways to treat renal patients with an incompatible donor. Good results in terms of patient and graft survival have expanded the range of circumstances under which living renal donors are accepted. Older donors are now accepted, as are others with factors that affect the decision, such as a borderline clinical history or alterations, which when evaluated may lead to an additional number of transplantations. This Guide does not forget that LDKT may lead to risk for the donor. Pre-donation evaluation has to centre on the problems which may arise over the short or long-term, and these have to be described to the potential donor so that they are able take them into account. Experience over recent years has led to progress in risk analysis, to protect donors' health. This aspect always has to be taken into account by LDKT programmes when evaluating potential donors. Finally, this Guide has been designed to aid decision-making, with recommendations and suggestions when uncertainties arise in pre-donation studies. Its overarching aim is to ensure that informed consent is based on high quality studies and information supplied to donors and recipients, offering the strongest possible guarantees.

Pearls and Pitfalls in Pediatric Kidney Transplantation After 5 Decades

Worldwide, over 1,300 pediatric kidney transplantations are performed every year. Since the first transplantation in 1959, healthcare has evolved dramatically. Pre-emptive transplantations with grafts from living donors have become more common. Despite a subsequent improvement in graft survival, there are still challenges to face. This study attempts to summarize how our understanding of pediatric kidney transplantation has developed and improved since its beginnings, whilst also highlighting those areas where future research should concentrate in order to help resolve as yet unanswered questions. Existing literature was compared to our own data of 411 single-center pediatric kidney transplantations between 1968 and 2020, in order to find discrepancies and allow identification of future challenges. Important issues for future care are innovations in immunosuppressive medication, improving medication adherence, careful donor selection with regard to characteristics of both donor and recipient, improvement of surgical techniques and increased attention for lower urinary tract dysfunction and voiding behavior in all patients.

Long-term outcome of non-antireflux robotic-assisted laparoscopic ureter reimplantation in ureteral obstruction

PURPOSE

Although robotic-assisted laparoscopic ureter reimplantation (RALUR) is a recognized alternative to open and laparoscopic ureter reimplantation in treating distal ureteral obstruction, there are limited data on long-term efficacy and safety outcomes of non-antireflux RALUR. We assessed patients undergoing RALUR, evaluating operative, functional and safety determinants.

MATERIALS AND METHODS

All consecutive patients undergoing non-antireflux RALUR between April 2015 and January 2020 were included in this retrospective cohort study. The primary outcome endpoint was recurrent distal ureteral obstruction.

RESULTS

Mean follow-up was 41.3 months (CI 95%, 33.3-49.2). Among the 26 included patients, none developed recurrent distal ureteral obstruction. Kidney function in terms of serum creatinine level (72.0 vs. 71.0 µmol/L, p=0.988) and glomerular filtration rate (92.0 vs. 91.0 mL/min, p=0.831) was stable between the preoperative period and the last follow-up. Renal pelvis dilatation decreased significantly postoperatively, from grade 2 to grade 0 (p<0.001). Most patients (73.1%) remained free from any clinical symptoms of reflux during the follow-up. The rate of postoperative complications (Clavien-Dindo grade ≥II) was 23.1%. All complications resolved without sequelae. No recurring urinary tract infections were reported.

CONCLUSIONS

Non-antireflux RALUR appears to be safe and effective in the management of distal ureteral obstruction. There was no recurrent ureteral obstruction after RALUR in our cohort during a mean follow-up of more than 3 years. Non-antireflux reimplantation did not seem to have any notable impact on renal function during the follow-up period.

Vesicoureteral Reflux in Nonfunctioning Renal Allograft Incidentally Detected in a Posttransplant 99mTc-DTPA Scan: Significance of Postvoid Imaging

ABSTRACT

In the present note, a case with rising serum creatinine shortly posttransplantation was referred for 99mTc-DTPA scan. The previous nonfunctioning renal allograft in the left hemipelvis showed no finding during dynamic phase of scan and filling phase of bladder but revealed a high-grade vesicoureteral reflux (VUR) in postvoid image, which can be responsible, partly, for the patient's present and prior symptoms.

Allograft Vesicoureteral Reflux after Kidney Transplantation

Allograft vesicoureteral reflux (VUR) is a leading urological complication of kidney transplantation. Despite the relatively high incidence, there is a lack of consensus regarding VUR risk factors, impact on renal function, and management. Dialysis vintage and atrophic bladder have been recognized as the most relevant recipient-related determinants of post-transplant VUR, whilst possible relationships with sex, age, and ureteral implantation technique remain debated. Clinical manifestations vary from an asymptomatic condition to persistent or recurrent urinary tract infections (UTIs). Voiding cystourethrography is widely accepted as the gold standard diagnostic modality, and the reflux is generally graded following the International Reflux Study Committee Scale. Long-term transplant outcomes of recipients with asymptomatic grade I-III VUR are yet to be clarified. On the contrary, available data suggest that symptomatic grade IV-V VUR may lead to progressive allograft dysfunction and premature transplant loss. Therapeutic options include watchful waiting, prolonged antibiotic suppression, sub-mucosal endoscopic injection of dextranomer/hyaluronic acid copolymer at the site of the ureteral anastomosis, and surgery. Indication for specific treatments depends on recipient's characteristics (age, frailty, compliance with antibiotics), renal function (serum creatinine concentration < 2.5 vs. ≥ 2.5 mg/dL), severity of UTIs, and VUR grading (grade I-III vs. IV-V). Current evidence supporting surgical referral over more conservative strategies is weak. Therefore, a tailored approach should be preferred. Properly designed studies, with adequate sample size and follow-up, are warranted to clarify those unresolved issues.

Taguchi versus Lich-Grégoir Extravesical Ureteroneocystostomy in Kidney Transplantation: A Systematic Review

INTRODUCTION

Ureteric implantation of the transplanted ureter into native urinary bladder tissue in kidney transplantation recipients is essential for post-operative kidney function. We aimed to determine the effects of Taguchi versus Lich-Grégoir extravesical ureteroneocystostomy in kidney transplantation.

METHODS

We searched multiple databases (MEDLINE, Cochrane Library, and Web of Science), trial registries, and conference proceedings until March 2021. We included prospective studies comparing Taguchi and Lich-Grégoir ureteroneocystostomy in kidney transplantation. Two review authors independently screened the identified records, extracted data, evaluated the risk of bias using ROBINS-I, and assessed the certainty of evidence according to GRADE.

RESULTS

We identified 3 prospective studies with serious or critical risk of bias, leading to low-certainty evidence. We downgraded the risk of bias due to study limitations. Assessment and/or reporting of baseline imbalances, co-interventions, and confounding factors was insufficient in all included studies. The effect of Taguchi ureteroneocystostomy remains unclear.

CONCLUSION

Currently available evidence is not useful to determine the effect of Taguchi versus Lich-Grégoir ureteroneocystostomy in kidney transplantation. There is a need for methodologically better designed and executed studies, such as randomized controlled trials with long-term follow-up reporting baseline imbalances, co-interventions, and confounding factors.

Robot-assisted Transplant Ureteral Repair to Treat Transplant Ureteral Strictures in Patients after Robot-assisted Kidney Transplant: A Case Series

OBJECTIVE

To describe the use of robotic-assisted transplant ureteral repair (RATUR) for treating transplant ureteral stricture (TUS) in 3 patients who had undergone robot assisted kidney transplant (RAKT).

METHOD

We reviewed the medical records of 3 patients who experienced TUS after RAKT and who underwent RATUR between 2017 and 2020. The patients' RAKT, post-transplant clinical course, endourological interventions, reoperation, and recovery were assessed.

RESULTS

All patients diagnosed with TUS presented with deterioration of kidney function after RAKT. Method of diagnosis included ultrasound, antegrade ureterogram, and CT scan. All 3 patients had a short (<1 cm) area of TUS and underwent RATUR. For 2 patients, distal strictures were bypassed with modified Lich-Gregoir ureteroneocystostomy reimplantation. One patient was treated with pyelo-ureterostomy to the contralateral native ureter. No intraoperative complications, conversions to open surgery, or significant operative blood loss requiring blood transfusion for any patient were observed. Also, no patients had urine leaks in the immediate or late postoperative period. After RATUR, 2 patients developed Clavien grade II complications with rectus hematoma or urinary tract infection.

CONCLUSION

RATUR is a technically feasible operation for kidney transplant patients with TUS after RAKT. This procedure may provide the same benefits of open operation without promoting certain comorbidities that may occur from open surgical procedures.

Results of a previously unreported extravesical ureteroneocystostomy technique without ureteral stenting in 500 consecutive kidney transplant recipients

Urologic complications can still occur following kidney transplantation, sometimes requiring multiple radiological and/or surgical procedures to fully correct the problem. Previously proposed extravesical ureteral reimplantation techniques still carry non-negligible risks of the patient developing urologic complications. About 10 years ago, a new set of modifications to the Lich-Gregoir technique was developed at our center, with the goal of further minimizing the occurrence of urologic complications, and without the need for initial ureteral stent placement. It was believed that an improvement in the surgical technique to minimize the risk of developing urologic complications was possible without the need for stent placement at the time of transplant. In this report, we describe the advantages of this technique (i.e., mobilized bladder, longer spatulation of the ureter, inclusion of bladder mucosa with detrusor muscle layer in the ureteral anastomosis, and use of a right angle clamp in the ureteral orifice to ensure that it does not become stenosed). We also retrospectively report our experience in using this technique among 500 consecutive (prospectively followed) kidney transplant recipients transplanted at our center since 2014. During the first 12mo post-transplant, only 1.4%(7/500) of patients developed a urologic complication; additionally, only 1.0%(5/500) required surgical repair of their original ureteroneocystostomy. Five patients(1.0%) developed a urinary leak, with 3/5 having distal ureteral necrosis, and 1/5 subsequently developing a ureteral stricture. Two other patients developed ureteral stenosis, one due to stricture and one due to ureteral stones. These overall results are excellent when compared with other reports in the literature, especially those in which routine stenting was performed. In summary, we believe that the advantages in using this modified extravesical ureteroneocystostomy technique clearly help in lowering the early post-transplant risk of developing urologic complications. Importantly, these results were achieved without the need for ureteral stent placement at the time of transplant.

Egyptian clinical practice guideline for kidney transplantation

Objective: To present the first Egyptian clinical practice guideline for kidney transplantation (KT).

Methods: A panel of multidisciplinary subspecialties related to KT prepared this document. The sources of information included updates of six international guidelines, and review of several relevant international and Egyptian publications. All statements were graded according to the strength of clinical practice recommendation and the level of evidence. All recommendations were discussed by the panel members who represented most of the licensed Egyptian centres practicing KT.

Results: Recommendations were given on preparation, surgical techniques and surgical complications of both donors and recipients. A special emphasis was made on the recipient’s journey with immunosuppression. It starts with setting the scene by covering the donor and recipient evaluations, medicolegal requirements, recipient’s protective vaccines, and risk assessment. It spans desensitisation and induction strategies to surgical approach and potential complications, options of maintenance immunosuppression, updated treatment of acute rejection and chemoprophylactic protocols. It ends with monitoring for potential complications of the recipient’s suppressed immunity and the short- and long-term complications of immunosuppressive drugs. It highlights the importance of individualisation of immunosuppression strategies consistent with pre-KT risk assessment. It emphasises the all-important role of anti-human leucocyte antigen antibodies, particularly the donor-specific antibodies (DSAs), in acute and chronic rejection, and eventual graft and patient survival. It addresses the place of DSAs across the recipient’s journey with his/her gift of life.

Conclusion: This guideline introduces the first proposed standard of good clinical practice in the field of KT in Egypt.

Abbreviations: Ab: antibody; ABMR: Ab-mediated rejection; ABO: ABO blood groups; BKV: BK polyomavirus; BMI: body mass index; BTS: British Transplantation Society; CAN: chronic allograft nephropathy; CDC: complement-dependent cytotoxicity; CKD: chronic kidney disease; CMV: cytomegalovirus; CNI: calcineurin inhibitor; CPRA: Calculated Panel Reactive Antibodies; (dn)DSA: (de novo) donor-specific antibodies; ECG: electrocardiogram; ESWL: extracorporeal shockwave lithotripsy; FCM: flow cytometry; GBM: glomerular basement membrane; GN: glomerulonephritis; HIV: human immunodeficiency virus; HLA: human leucocyte antigen; HPV: human papilloma virus; IL2-RA: interleukin-2 receptor antagonist; IVIg: intravenous immunoglobulin; KT(C)(R): kidney transplantation/transplant (candidate) (recipient); (L)(O)LDN: (laparoscopic) (open) live-donor nephrectomy; MBD: metabolic bone disease; MCS: Mean channel shift (in FCM-XM); MFI: mean fluorescence intensity; MMF: mycophenolate mofetil; mTOR(i): mammalian target of rapamycin (inhibitor); NG: ‘not graded’; PAP: Papanicolaou smear; PCN: percutaneous nephrostomy; PCNL: percutaneous nephrolithotomy; PKTU: post-KT urolithiasis; PLEX: plasma exchange; PRA: panel reactive antibodies; PSI: proliferation signal inhibitor; PTA: percutaneous transluminal angioplasty; RAS: renal artery stenosis; RAT: renal artery thrombosis;:rATG: rabbit anti-thymocyte globulin; RCT: randomised controlled trial; RIS: Relative MFI Score; RVT: renal vein thrombosis; TB: tuberculosis; TCMR: T-cell-mediated rejection; URS: ureterorenoscopy; (CD)US: (colour Doppler) ultrasonography; VCUG: voiding cystourethrogram; XM: cross match; ZN: Ziehl–Neelsen stain

Results of Haberal's Corner-Saving Ureteral Anastomosis Technique for Renal Transplantation: A Retrospective Study

BACKGROUND

Urological complications after renal transplantation (RT), including urine leaks, remain the most common type of surgical complications in the early post-transplant period. In this study we evaluated 324 consecutive RTs recipients in whom Haberal's corner-saving anastomosis technique was used for ureteroneocystostomy.

MATERIAL AND METHODS

Since January 2018, 461 RTs were performed at our center. Haberal's corner-saving anastomosis technique was used in 324 of these 461 RTs and the effectiveness of the technique was analyzed retrospectively. There were 115 female patients and 209 male patients, with a mean age of 42.1 ± 13.9 years. The most common etiology resulting in RT was hypertension among the recipients.

RESULTS

We observed 8 (2.4%) ureteral complications in 7 recipients as follows: ureteral stenosis in 2 recipients (0.6%), anastomotic leaks in 1 (0.3%), concomitant leak-stenosis in 1 (0.3%), and vesicoureteral reflux in 3 (0.9%). Six complications were treated with interventional radiological techniques and 2 were treated surgically. There was no graft and patient loss in the event of urological complications.

CONCLUSION

Because of the low complication rate, we believe that Haberal's corner-saving ureteral anastomosis technique is a safe method for performing a ureteroneocystostomy.

Risk Factors for Anastomosis Leakage After Kidney Transplantation

Purpose

Kidney transplantation is one of the best treatment options for end-stage renal disease with an incidence of urologic complications of 2.5 to 30%. One of the most serious and frequent urological complications is urinary leakage from ureteroneocystostomy anastomosis. The purpose of this study was to evaluate risk factors of urinary leakage from ureteroneocystostomy anastomosis after kidney transplantation.

Patients and Methods

A retrospective study was performed on patients who received kidney transplantation and were diagnosed with urinary leakage thereafter based on renal scan or drain creatinine per serum creatinine compared with patients in control group. Risk factor assessment was based on inpatient and outpatient information from hospital database.

Results

From 459 patients who received kidney transplantation in 2016-2018, there were 20 patients who were diagnosed with urinary leakage after they underwent ureteroneocystostomy anastomosis. The significant risk factors for anastomosis leakage were size of suture materials and duration of ureteral stent insertion. No statistically significant difference in other factors such as underlying disease, surgical technique or duration of urinary catheter was found. About overall urological complication, gender and body mass index significantly affected the outcome.

Conclusion

The rate of urinary leakage complications was found to be about 4.36%. The risk factors of overall complication comprised gender and body mass index. Although a lot of previous studies revealed many risk factors that could affect urinary leakage, size of suture materials and duration of ureteral stent insertion were the significant risk factors in our study. Proper consideration should be given to the size of suture materials and optimal duration of ureteral stent.

The Ureter in the Kidney Transplant Setting: Ureteroneocystostomy Surgical Options, Double-J Stent Considerations and Management of Related Complications

Purpose of Review

In the setting of kidney transplantation, the ureter is a common source for complications. As a result, prevention of ureteral complications and their management is of crucial importance. In this context, the purpose of this review is to summarize recent literature on the ureter in the kidney transplant setting with a special focus on new findings. We conducted a PubMed and Medline search over the last 10 years to identify all new publications related to ureteroneoimplantations, stents and management of complications in the kidney transplant setting.

Recent Findings

Performance of the “Lich-Gregoir” technique for ureteroneocystostomy seems to be favourable in regard to postoperative complications when compared with other methods described in the literature. Moreover, major urologic complications can be further reduced by ureteral stenting.

Summary

A new approach for management of ureteral strictures in renal transplants is presented. We discussed the usage of a ureteral stent covered with a biostable polymer aiming to prevent tissue ingrowth into the lumen as a new option for management of ureteral stricture in the kidney transplant setting.

Native ureteroureterostomy in renal allograft recipient surgery: A single-center 5-year experience

Introduction

In renal transplant, surgeons use a myriad of ureteral anastomotic techniques. Although ureteroneocystostomy (UNC) using Lich-Gregoir extravesical anastomosis is used most commonly, ureteroureterostomy with native ureter has its own importance in certain situations.

Materials and Methods

We retrospectively reviewed records of patients who underwent renal transplantation at our center from March 2011 to February 2016. Records of patients who underwent ureteroureterostomy with the native ureter were reviewed for the indications and complications of the procedure.

Results

Of 1050 renal transplants during the study period, 32 patients underwent native ureteroureterostomy. Among these 32 patients, 20 patients were planned preoperatively for native ureteroureterostomy (elective), and intraoperative decision was made in 12 patients (emergency). On follow-up, only one patient had ureteral obstruction due to kink just distal to ureteroureterostomy and was managed by double-J stenting. Other patients had an expected postoperative course.

Conclusion

In our experience, ureteroureterostomy with native ureter is technically and functionally good option for ureteric reimplantation in kidney transplant patients. It can be used selectively for elective and emergency situations where UNC is not possible. Hence, the kidney transplant surgeon should be well versed with both techniques.

Urologic Evaluation and Management of Pediatric Kidney Transplant Patients

Urologic causes of end-stage renal disease are estimated between 25% and 40% of causes. The goal of renal transplantation in chronic kidney disease patients is to provide renal replacement therapy with less morbidity, better quality of life, and improved overall survival compared with dialysis. A patient's urologic history can be a significant source of problems related to infections, recurrence of disease, and surgical complications. Many of the urologic risks are modifiable. Proper evaluation and management can mitigate the potential problems after transplantation, and these patients with complex urologic problems are seen to have similar graft function outcomes.

A survey of Canadian renal transplant surgeons: Use of ureteric stents and technique of the ureteroneocystotomy

INTRODUCTION

The role of ureteric stenting in renal transplant has been well-demonstrated. The goal of this survey was to determine the utilization of ureteric stents by Canadian transplant surgeons, and how the ureteroneocystotomy and followup is performed.

METHODS

An online survey was sent to the 40 surgeon members of the Canadian Society of Transplantation. The primary outcome was the rate of ureteric stent use at the time of renal transplantation. The secondary outcomes were the ureteric stent dwell time, use and type of prophylactic antibiotics, and the use of routine post-transplant ultrasonography.

RESULTS

All respondents (25) used ureteric stent routinely and 92% remove the stent between four and six weeks postoperatively. Prophylactic antibiotics were used 64% of the time for ureteric stent removal. The majority of surgeons do not routinely perform a post-stent removal ultrasound. Fifty-six percent of respondents perform a refluxing anastomosis.

CONCLUSIONS

Ureteric stents are routinely used in renal transplant in Canada. Areas for improvement and topics of debate identified from this survey are the need for peri-stent removal antibiotics, the role of post-stent removal ultrasound, the duration of stent dwell time, and the need for a non-refluxing ureteroneocystotomy.

Renal function outcomes in pediatric patients with symptomatic reflux into the transplanted kidney treated with redo ureteroneocystostomy

INTRODUCTION

Asymptomatic post-renal transplant reflux is common but only 5-10% patients are diagnosed with vesico-ureteral reflux in the setting of post-transplant febrile urinary tract infections, requiring redo ureteroneocystostomy (redo-UNC). Here we report the renal function outcomes of 37 such patients, stratified by lower urinary tract (LUT) status.

OBJECTIVE

We hypothesized that those with pre-transplant LUT dysfunction would have lower glomerular filtration rate (GFR) on follow-up.

STUDY DESIGN

Using procedure codes, 37 patients who underwent renal transplant followed by redo-UNC for transplant reflux at our institution between 1991 and 2014 were identified. Patient characteristics and GFR levels from four different time points were recorded. Comparisons were made between those with and without LUT dysfunction, using Fisher's exact, Wilcoxon rank sum, or signed-rank tests. Generalized estimating equations were constructed to account for the clustered nature of GFR within each LUT group and to assess their change over time.

RESULTS

Twelve patients (32%) had pre-transplant LUT dysfunction. The proportion of males in this group was significantly higher (75% vs. 32%, p = 0.032), and there was no statistical difference towards presenting earlier with post-transplant reflux (1.4 vs. 2.3 years, p = 0.087). After an average of 4.9 years, the median GFRs were similar between the two groups (53 mg/dL vs. 58 mg/dL, p = 0.936). There was no significant difference in GFR at this last follow-up time point in patients with and without LUT dysfunction.

DISCUSSION

Vesicoureteral reflux in the setting of renal transplantation is common and doesn't often require repair. In our series, we found that those with LUT dysfunction did not present statistically sooner with symptomatic transplant reflux. Longer-term follow-up did show a decline in GFR but did not reveal a difference in GFR in patients' with and without LUT dysfunction.

CONCLUSIONS

Pediatric post-transplant GFR after open redo ureteral reimplant decreases over time in similar fashion in patients with symptomatic reflux regardless of whether they have LUT dysfunction or normal anatomy. Vigilance should apply to the recognition, treatment, and follow-up of all symptomatic transplant reflux regardless of LUT status.

Preperitoneal Surgical Approach to Treat Vesicoureteral Anastomotic Leakage, Distal Stenosis or Reflux After Kidney Transplantation

BACKGROUND

If endourological approaches are not applicable to treat vesicoureteral anastomotic complications after kidney transplantation, the surgical gold standard in many transplant centers is pyeloureterostomy or ureteroureterostomy using the native ureter. We report an original preperitoneal technique that can be used for vesicoureteral reanastomosis in kidney transplant recipients not eligible for endourological treatment.

METHODS

Between January 2011 and December 2015, 18 kidney transplant recipients underwent this new surgical procedure. Of this number, 15 subjects with at least 1 year of follow-up were included in the analysis. The indications were vesicoureteral reflux, anastomotic stenosis, and leakage in 8, 5, and 2 patients, respectively. Briefly, a double J stent was preoperatively inserted into the grafted ureter. Surgery was performed through a Pfannenstiel incision. The preperitoneal space surrounding the bladder was dissected and the distal part of the grafted ureter was identified and mobilized. The anastomotic area was resected and another vesicoureteral anastomosis was performed (Lich-Gregoir technique), keeping the JJ stent in place for three weeks.

RESULTS

This procedure was performed 213 days (range 17-2608) after kidney transplantation. Median surgical duration was 179 minutes (range 112-314) and median hospital stay 8 days (range 4-14). The success rate was 86.7% (13/15), with a median follow-up of 1148 days (range 517-1808). In two patients, symptomatic recurrence of vesicoureteral reflux required a pyeloureterostomy using the native ureter.

CONCLUSIONS

The authors describe a simple technique that avoids transperitoneal dissection, potentially yielding more esthetic results thanks to easy access, as well as excellent outcomes.

Comparison of Surgical Correction Techniques for Post-Renal Transplantation Vesicoureteral Reflux

BACKGROUND

Symptomatic urinary tract infection (UTI) after renal transplantation (RT) is an important morbidity in transplant recipients and may cause pyelonephritis and sepsis. Surgical correction of high-grade vesicoureteral reflux (VUR) after RT is suggested, performing ureteral reimplantation or pyelo-ureteral/uretero-ureteral anastomosis. Recently, extravesical seromuscular tunnel lengthening techniques have been reported with favorable results and low complication rates.

METHODS

We retrospectively reviewed the charts of 38 patients with post-transplantation VUR who underwent reflux correction surgery. Patient characteristics were analyzed to compare our extravesical seromuscular tunnel lengthening technique with uretero-ureteral and pyelo-ureteral anastomosis techniques.

RESULTS

Twenty patients were treated with the extravesical approach (group I) and 18 patients by pyelo-ureteral or uretero-ureteral anastomosis with the use of native ureter (group II). Mean operative time was significantly shorter in group I than in group II (64.8 vs 110.1 min; P < .05), and mean duration of hospital stay after the operation also was shorter in group I (1.5 vs 5.1 d; P < .05). We determined persistent VUR in postoperative voiding cystouretrography in 2 patients (10%) in group I, but there was regression in VUR grades of all of the patients. There was no significant difference in postoperative number of UTI episodes and serum creatinine levels between the 2 groups.

CONCLUSIONS

Extravesical seromuscular tunnel lengthening is an effective and safe technique for post-transplantation VUR management.

Vesicoureteral Reflux in Kidney Transplantation

BACKGROUND

Vesicoureteral reflux (VUR) is frequently found after transplantation, but its impact on graft function, urine tract infection, and graft loss remains uncertain. Therefore our objective was to evaluate the effects of VUR on the outcome of renal transplantation.

MATERIAL AND METHODS

We included 1008 adult renal transplant recipients of whom a 1-week posttransplant voiding cystourethrogram was available. Study end points included occurrence of bacteriuria, renal function, and graft survival.

RESULTS

In total, 106 (10.5%) of 1008 graft recipients had a diagnosis of VUR on voiding cystography. The incidence of bacteriuria was comparable in the reflux and nonreflux group (17% vs 17.4%, P = .91). There was no significant difference in renal function at 3 months and 1 year in patients with and without VUR. One- and 5-year graft survival in patients with VUR was 85.8% and 82.1% compared to 87.3% and 83.0% in patients without VUR ( P = .68 and P = .80).

CONCLUSION

Posttransplant VUR has no correlations with early bacteriuria, renal function, and graft survival.

Comparison of Urologic Complications Between Ureteroneocystostomy and Ureteroureterostomy in Renal Transplant: A Meta-Analysis

OBJECTIVES

Transplant surgeons use a myriad of ureteral anastomotic techniques in renal transplant. Although the Lich-Gregoir extravesical anastomosis is the most common, ureteroureterostomy also is used. In this meta-analysis, our objective was to compare the complication rates of these 2 techniques as reported in the literature.

MATERIALS AND METHODS

A systematic review of the literature revealed 44 articles, 6 of which met our inclusion criteria. Studies were compiled using Review Manager (RevMan version 5.3, Nordic Cochrane Centre, Cochrane Collaboration, Copenhagen, Denmark). Forest plots were generated to assess relative risk. A fixed-effects model was used for low heterogeneity, and a random-effects model was used for high heterogeneity.

RESULTS

Overall complications were similar for both procedures (relative risk, 1.22; 95% confidence interval, 0.9-1.65), as were rates of urine leak and fistula (relative risk, 0.79; 95% confidence interval, 0.17-3.64) and hematuria (relative risk, 0.24; 95% confidence interval, 0.001-4.84). Stricture, obstruction, and stone formation were more common after ureteroureterostomy (relative risk, 0.63; 95% confidence interval, 0.45-0.88), whereas vesicoureteral reflux (relative risk, 6.82; 95% confidence interval, 1.68-27.61) and urinary tract infection (relative risk, 2.29; 95% confidence interval, 1.3-4.03) were more common after ureteroneocystostomy.

CONCLUSIONS

With similar overall complication rates, both procedures can be viewed as being acceptable primary anastomotic techniques. In light of differing individual complication rates and the scarcity of data comparing the 2 methods, no specific recommendation regarding that technique should be used can currently be elucidated. We believe that further prospective studies comparing ureteroneocystostomy and primary ureteroureterostomy may reveal which is superior regarding complication rates.

[Management of urological complications after renal transplantation]

Urological complications after kidney transplantation can cause a major reduction in renal function. Surgical complications like urinary leakage and ureteral obstruction need to be solved by a specialist in the field of endourological procedures and open surgical interventions. The article summarizes this and other common urological problems after kidney transplantation.

Complete Absence of Iliac Arteries in the Left Hemipelvis in a Case of Deceased Donor Renal Transplantation

Renal transplantation is an established method of treating end-stage renal failure. Whilst the majority of procedures follow a standard technique, vascular anomalies may pose intraoperative challenges and, therefore, careful preoperative assessment is warranted. We present a unique, complex case compounded by complete absence of iliac arteries in the left hemipelvis in association with double inferior vena cava in a young recipient.

Independent risk factors for early urologic complications after kidney transplantation

Urologic complications are the most frequent technical adverse events following kidney transplantation (KTX). We evaluated traditional and novel potential risk factors for urologic complications following KTX. Consecutive KTX recipients between December 1, 2006 and December 31, 2010 with at least six-month follow-up (n = 635) were evaluated for overall urologic complications accounting for donor, recipient, and transplant characteristics using univariate and multivariate logistic regression. Urologic complications occurred in 29 cases (4.6%) at a median of 40 d (range 1-999) post-transplantation and included 17 ureteral strictures (2.6%), five (0.8%) ureteral obstructions due to donor-derived stones or intraluminal thrombus, and seven urine leaks (1.1%). All except two complications occurred within the first year of transplantation. Risk factors for urologic complications on univariate analysis were dual KTX (p = 0.04) and renal artery multiplicity (p = 0.02). On multivariate analysis, only renal artery multiplicity remained significant (aHR 2.4, 95% confidence interval 1.1, 5.1, p = 0.02). Donation after cardiac death, non-mandatory national share kidneys, donor peak serum creatinine > 1.5 mg/dL or creatinine phosphokinase > 1000 IU/L, and donor down time were not associated with urologic complications. Our data suggest that donor artery multiplicity is an independent risk factor for urologic complications following KTX.

Ureteric reconstruction for the management of transplant ureteric stricture: a decade of experience from a single centre

This study was conducted to review the outcomes of patients who had undergone surgical repair of a ureteric stricture following renal transplantation. All patients who developed a ureteric stricture and underwent ureteric reconstruction following renal transplantation, between December 2003 and November 2013, were reviewed. One thousand five hundred and sixty renal transplants were performed during the study period. Forty patients required surgical repair of a ureteric stricture (2.5%, 25 male, median age 48 [14-78]). The median time to stricture was 3 [1-149] months. 19 patients were reconstructed by reimplantation to the bladder, 18 utilized a Boari flap, two were a pre-existing ileal conduit and one was an anastomosis to a native ureter. In one patient, reconstruction was impossible and consequently an extra-anatomic stent was used. Two patients required re-operation for restricture and kinking. Median serum creatinine at 12 months following surgery was 148 [84-508] μmol/l. There was no 90-day mortality. Eleven grafts were lost at the time of this study, a median time of 11 [1-103] months after reconstruction. The incidence of ureteric stricture following renal transplant is low. Surgical reconstruction of the transplant ureter is the optimal treatment and is successful in the majority of patients.

Comparative urologic complications of ureteroneocystostomy in kidney transplantation: transvesical Leadbetter-Politano versus extravesical Lich-Gregoir technique

BACKGROUND

The incidence of urologic complications after kidney transplantation remains high despite improvements in diagnosis and operative techniques. Urinary tract reconstruction is usually done by ureteroneocystostomy (UCNS), and several techniques are available. In this study, we evaluated the outcomes of 2 different UCNS techniques performed in our department, the transvesical Leadbetter-Politano (L-P) and the extravesical Lich-Gregoire (L-G) technique.

MATERIAL AND METHODS

We evaluated the outcomes of 2 different UCNS techniques, L-P versus L-G, performed in our department between July 1, 2006, and December 31, 2011. During this period, we performed 524 consecutive renal transplantations-264 cases using the L-P technique (50.3%) and 260 cases with L-G technique (49.7%). Renal grafts were obtained from cadaveric donors in 146 cases (27.86%) and from living-related donors in 378 cases (72.14%). Recipient mean age was 35.64 years and the male to female ratio was 1.63:1.

RESULTS

Urologic complications after kidney transplantation occurred in 22 cases in the L-P UCNS group (8.33%). The most common complications were ureteral stenosis (3.41%) and leakage (2.65%). Other complications recorded were lymphoceles (1.89%) and hematoma with secondary ureteral obstruction (0.38%). Compared with the L-P UCNS technique, the L-G technique was associated with fewer overall complications (6.15% vs 8.33%; P = .06), a lesser rate of ureteral stenosis (2.31% vs 3.41%; P = .08), and a similar rate of leakage. However, statistical analysis revealed no differences between the 2 techniques (P = .06). In addition, we did not note any differences in graft and patient survival between the 2 groups.

CONCLUSIONS

In our study, the extravesical L-G technique has a lower complication rate compared with transvesical L-P procedure, but without statistical differences. Furthermore, the L-G technique is easier and faster to perform, it avoids a separate cystotomy, and requires a shorter ureteral length. In conclusion, we recommend L-G technique as technique of choice in kidney transplantation.

Does bladder augmentation negatively affect renal transplant outcome in posterior urethral valve patients?

OBJECTIVE

Although renal transplant (RT) is a safe and effective treatment for end-stage renal disease, the outcome of RT has been mixed for posterior urethral valve (PUV) patients. In addition, some PUV patients need an augmentation cystoplasty (AC), which may negatively affect their RT outcome. The aim of this study is to compare RT outcome between PUV children with and without AC.

MATERIALS AND METHODS

Between 1985 and 2012 a total of 309 children received 369 RTs at our institution. Among these patients, 36 were had classified as having PUV. Of these, 12 underwent an AC before RT (AC group) and 24 did not (controls). Data, including age at transplant, allograft source, urological complications, urinary tract infection (UTI) incidence, the presence of vesicoureteral reflux (VUR), and patient and graft survival, were compared between groups.

RESULTS

Mean age at RT and mean follow-up were 7.6 versus 7.9 years and 8.9 versus 7.9 years in the AC group and in the control group, respectively (not significant [NS]). Allografts were from living donors in 50% of the AC group and in 41.6% of the controls (NS). The rate of UTI was 0.02 UTI/patient/year and 0.004 UTI/patient/year in the AC and control group, respectively (p = 0.001). Of the nine patients with UTI in the augmented group, five (55.5%) had VUR, while 5/8 (62.5%) patients in the control group with UTI had VUR. All patients with VUR in either group had UTIs previously. Of the five AC patients with more than three UTIs, two (40%) were non-compliant with clean intermittent catheterization (CIC), and UTI incidence was not associated with either a Mitrofanoff conduit or the urethra being used for CIC. Graft function at the end of study was 87.8 ± 40.5 ml/min/m(2) in the AC group and 88.17 ± 28.20 ml/min/m(2) in the control group (NS). The 10-year graft survival rate was 100% in AC group and 84.8% in controls. Two patients in the AC group lost their grafts (mean follow-up 13.3 ± 0.8 years) and five in the control group (mean follow-up 7.1 ± 4.7 years).

CONCLUSIONS

Bladder augmentation does not negatively affect renal outcome in PUV patients undergoing transplantation. However, recurrent UTIs are more frequent in transplanted PUV patients with an AC than in those without AC, and they are generally related to non-compliance with CIC or the presence of VUR but, mostly, they will not result in impaired graft function.

Ureterovesical anastomotic techniques for kidney transplantation: a systematic review and meta-analysis

No consensus exists about which ureterovesical anastomosis technique to use for kidney transplantation. The aim of this systematic review was to compare the existing techniques in relation to the risk of urological complications. All studies that compared ureterovesical anastomotic techniques in kidney transplantation were included. Study endpoints were urinary leakage, ureteral stricture, vesicoureteral reflux and hematuria. Subanalyses of stented and nonstented techniques were performed. Two randomized clinical trials and 24 observational studies were included. Meta-analyses were performed on the Lich-Gregoir (LG) versus Politano-Leadbetter (PL) techniques and LG versus U-stitch (U) techniques. Compared with the PL technique, the LG technique had a significantly lower prevalence of urinary leakage (risk ratio (RR): 0.47, 95% confidence interval (CI): 0.30 to 0.75) and a significantly lower prevalence of hematuria when compared with both PL and U techniques (RR: 0.28, 95% CI: 0.16 to 0.49 and RR: 0.23, 95% CI: 0.11 to 0.50, respectively), regardless of ureteral stenting. There was no difference in the prevalence of ureteral strictures or vesicoureteral reflux between the various techniques. Of the three most frequently used ureterovesical anastomotic techniques, the LG technique results in fewer urological complications than the PL and U techniques.

Independent risk factors for urological complications after deceased donor kidney transplantation

Urological complications after kidney transplantation are mostly related to the ureteroneocystostomy, often requiring interventions with additional costs, morbidity and mortality. Our aim was to assess risk factors for urological complications in deceased donor kidney transplantation. Between January 2000 and December 2011, 566 kidney transplantations were performed with deceased donor kidneys. Recipients were divided in a group with, and a group without urological complications, defined as the need for a percutaneous nephrostomy catheter or surgical revision of the ureteroneocystostomy. Univariate and multivariate analyses were performed. Univariate analysis showed increased number of male donors (p = 0.041), male recipients (p = 0.002), pre-emptively transplanted recipients (p = 0.007), and arterial reconstructions (p = 0.004) in the group with urological complications. Less urological complications occurred in recipients on hemodialysis (p = 0.005). More overall surgical interventions (p<0.001), surgical site infections (p = 0.042), urinary tract infections (p<0.001) and lymphoceles (p<0.001) occurred in the group with urological complications. Multivariate analysis showed that male recipients (p = 0.010) and arterial reconstructions (p = 0.019) were independent risk factors. No difference was found between both groups in patient or graft survival. In conclusion, recipient male gender and arterial reconstruction are independent risk factors for urological complications after deceased donor kidney transplantation. Nevertheless, graft and recipient survival is not different between both groups.

Comparative study of one-stitch versus Lich-Gregoir ureterovesical implantation for kidney transplants

OBJECTIVE

To compare the outcomes of standard Lich-Gregoir technique and a modified one-stitch technique of ureteroneocystostomy in renal transplantation.

PATIENTS AND METHODS

Data from 645 transplant recipients by two different ureteroneocystostomy techniques were retrospectively reviewed at the first Affiliated Hospital, Medical College of Xi'an Jiaotong University, between January 2002 and December 2007.

RESULTS

There were 418 recipients in the Lich-Gregoir group and 227 in new one-stitch group. The overall ureteral complication rate for new one-stitch technique was 19.8 % (n = 45) as opposed to 15.79 % (n = 66) for the Lich-Gregoir technique. No significantly different rate of ureteral complications occurred in two groups (P > 0.05). In comparison, there was a higher proportion of hematuria at the limit of statistical significance in new one-stitch group (P < 0.05). Average operative time for the modified one-stitch and Lich-Gregoir techniques was 8.8 ± 1.4 and 21.9 ± 6.1 min, respectively (P < 0.05). Urinary tract infections, delayed graft function and rejection rates were not significantly different between the two groups (P > 0.05).

CONCLUSION

Although the modified one-stitch technique may predispose patients to higher rates of hematuria, it has no significant difference in ureteral complications compared with the Lich-Gregoir group. Based on this large series and data analyses, we believe that this new technique will become one of our multiple choices in our setting.

Primate models in organ transplantation

Large animal models have long served as the proving grounds for advances in transplantation, bridging the gap between inbred mouse experimentation and human clinical trials. Although a variety of species have been and continue to be used, the emergence of highly targeted biologic- and antibody-based therapies has required models to have a high degree of homology with humans. Thus, the nonhuman primate has become the model of choice in many settings. This article will provide an overview of nonhuman primate models of transplantation. Issues of primate genetics and care will be introduced, and a brief overview of technical aspects for various transplant models will be discussed. Finally, several prominent immunosuppressive and tolerance strategies used in primates will be reviewed.

Feasibility and outcomes of ureteroureterostomy and extravesical ureteroneocystostomy as part of radical surgery for infiltrating gynecologic disease

OBJECTIVE

Abdominopelvic infiltrative disease may require aggressive surgical procedures. This study reports on our experience with distal ureterectomy, ureteroureterostomy, and extravesical ureteroneocystostomy as part of radical surgery for infiltrating gynecologic disease.

PATIENTS AND METHODS

Twenty-one women required surgery to the distal ureter at the Queensland Centre for Gynecological Cancer, Australia, from January 2006 to September 2012. Details of the patient's history, operation record, inpatient notes, and follow-up data were obtained through chart review.

RESULTS

Patients' median age was 57.8 ± 14.7 years (range, 30-80 years). Seventeen patients had gynecologic cancer. Mean operating time was 3.9 ± 0.9 hours (range, 2.5-5.5 hours). Restoration of continuity was achieved through extravesical ureteroneocystostomy and ureteroureterostomy in 18 and 3 patients, respectively. Boari flap was used in 3 patients, and psoas hitch was the technique chosen in 11 patients. Urinary tract infection was the most common clinical adverse event. Albeit clinically irrelevant, 38% of the patients showed structural renal tract changes postoperatively.

CONCLUSIONS

To achieve maximal surgical radicalness, resection of the distal ureter with subsequent ureteroureterostomy or extravesical ureteroneocystostomy is feasible and safe. Radical surgery to the urinary tract should be considered as a legitimate part of a gynecologic oncologist's surgical armamentarium to increase a patient's probability of survival and its positive effect on kidney function.