Risks and Benefits of Early Catheter Removal After Renal Transplantation

Early versus late removal of urinary catheter after kidney transplantation

BACKGROUND

The optimal treatment for end-stage kidney disease is kidney transplantation. During the operation, a catheter is introduced into the bladder and remains in place postoperatively to allow the bladder to drain. This decreases tension from the cysto-ureteric anastomosis and promotes healing. Unfortunately, urinary catheters can pose an infection risk to patients as they allow bacteria into the bladder, potentially resulting in a urinary tract infection (UTI). The longer the catheter remains in place, the greater the risk of developing a UTI. There is no consensus approach to the time a catheter should remain in place post-transplant. Furthermore, the different timings of catheter removal are thought to be associated with different incidences of UTI and postoperative complications, such as anastomotic breakdown.

OBJECTIVES

This review aimed to compare patients who had their catheter removed < 5 days post-transplant surgery to those patients who had their catheter removed ≥ 5 days following their kidney transplant. Primary outcome measures between the two groups included: the incidence of symptomatic UTIs, the incidence of asymptomatic bacteriuria and the incidence of major urological complications requiring intervention and treatment.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 13 April 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

All randomised controlled trials (RCTs) and quasi-RCTs comparing timing of catheter removal post-transplantation were eligible for inclusion. All donor types were included, and all recipients were included regardless of age, demographics or type of urinary catheter used.

DATA COLLECTION AND ANALYSIS

Results from the literature search were screened by two authors to identify if they met our inclusion criteria. We designated removal of a urinary catheter before five days (120 hours) as an 'early removal' and anything later than this as a 'late removal.' The studies were assessed for quality using the risk of bias tool. The primary outcome of interest was the incidence of asymptomatic bacteriuria. Statistical analyses were performed using the random effects model, and results were expressed as relative risk (RR) with 95% confidence intervals (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Two studies (197 patients) were included in our analysis. One study comprised a full-text article, and the other was a conference abstract with very limited information. The risk of bias in the included studies was generally either high or unclear. It is uncertain whether early versus late removal of the urinary catheter made any difference to the incidence of asymptomatic bacteriuria (RR 0.89, 95% Cl 0.17 to 4.57; participants = 197; I2 = 88%; very low certainty evidence). Data on other outcomes, such as the incidence of UTI and the incidence of major urological complications, were lacking. Furthermore, the follow-up of patients across the studies was short, with no patients being followed beyond one month.

AUTHORS' CONCLUSIONS

A high-quality, well-designed RCT is required to compare the effectiveness of early catheter removal versus late catheter removal in patients following a kidney transplant. At the present time, there is insufficient evidence to suggest any difference between early and late catheter removal post-transplant, and the studies investigating this were generally of poor quality.

Enhanced recovery after surgery recommendations for renal transplantation: guidelines

BACKGROUND

Enhanced Recovery After Surgery (ERAS) protocols are now widely practiced in major surgery, improving postsurgical outcomes. Uptake of these programmes have been slow in kidney transplantation due to challenges in evaluating their safety and efficacy in this high-risk cohort. To date, there are no unified guidance and protocols specific to ERAS in kidney transplantation surgery. This paper aims to summarise current evidence in the literature and develop ERAS protocol recommendations for kidney transplantation recipients.

METHODS

PubMed, Cochrane, Embase and Medline databases were screened for studies relevant to ERAS protocols in kidney transplantation, up to August 2021. A secondary search was repeated for each ERAS recommendation to explore the specific evidence base available for each section of the protocol. Randomised controlled trials, case-control and cohort studies were included. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework was used to evaluate the quality of evidence available and recommendations.

RESULTS

We identified six eligible studies with a total of 1225 participants. All studies found a reduction in length of hospital stay without affecting readmission rates. The evidence behind specific pre-operative, intra-operative and post-operative interventions included in current ERAS protocols are reviewed and discussed.

CONCLUSION

Compared to other surgical specialties, the evidence base for ERAS in kidney transplantation remains lacking, with further room for research and development. However, significant improvements to patient outcomes are already possible with application of the currently available evidence. This has shown that ERAS in kidney transplantation surgery is safe and feasible, with improved postoperative outcomes.

A STENTLESS MODIFIED LICH-GREGOIR TECHNIQUE FOR SAFE EARLY BLADDER CATHETER REMOVAL IN LIVING AND DECEASED KIDNEY TRANSPLANTS

OBJECTIVES

To describe a stentless modified Lich-Gregoir technique (mLG) for ureteroneocystostomy in renal transplantation (RT), with early bladder catheter (BC) removal (under 48 hours), and compare the postoperative results with those of the traditional technique (LG) with routine bladder catheter removal (4 to 5 days). The modification consists of maintaining a thin layer of detrusor fibers covering the bladder mucosa during dissection, which is incorporated into the anastomosis to reinforce the ureteroneocystostomy.

MATERIALS AND METHODS

This retrospective cohort study compared the postoperative outcomes of 100 consecutive patients who underwent mLG with early removal of BC between October 2018 to November 2019 with those of a historical cohort of 165 consecutive patients transplanted using stentless LG and routine removal of BC, who underwent surgery between July 2017 and September 2018. All transplants were performed by the same surgeon. Follow-up was 6 months.

RESULTS

Demographic characteristics were comparable, although patients in the mLG group had a higher mean preoperative urine volume (911±753.8mL vs. 629±638.6mL, p=0.016). Patients in the mLG group successfully underwent early BC removal (2.2±0.9 vs. 4.8±4.8 days, p<0.001), with no differences in the incidence of surgical or clinical complications, including urine leaks (1 vs. 3%, p=0.284). In addition, mLG patients presented a shorter mean length of hospital stay (6.5±5.0 vs. 7.1±6.2 days, p=0.023).

CONCLUSION

This stentless modified Lich-Gregoir technique enables safe early bladder catheter removal and is associated with reduced hospital length of stay.

Laparoscopic donor nephrectomy: technique and outcome, a single-center experience

Background

Laparoscopic donor nephrectomy (LDN) has been established as a surgical standard for living kidney donation. The aim of this work is to report our own experience with LDN regarding outcome and technique.

Methods

We prospectively identified 110 LDN cases between May 2017 and April 2020. Donor case files and operative notes were analyzed for age, sex, laterality, body mass index, warm ischemia time (WIT), intraoperative and postoperative complications, operative time, and length of hospital stay (LOS). Data were analyzed using SPSS version 10 (SPSS: An IBM Company, IBM Corporation, Armonk, NY, the USA).

Results

The mean age was 38 years, and 77% were males. Three cases (2.72%) required conversion to conventional open donor nephrectomy (ODN). Nevertheless, none of cases required intraoperative blood transfusion. The mean WIT was 2.6 min. Two cases (1.8%) developed major vascular injury (Clavien grade IIIb) and required conversion to ODN. Postoperatively, one patient (0.9%) needed transfusion of one unit of packed RBCs (Clavien grade II). The mean LOS was 2 days. Most common early postoperative complication was ileus (Clavien grade II) that developed in 4 (3.6%) cases. Incisional hernia (Clavien grade IIIb) was encountered in two (1.8%) cases. Two (1.8%) cases developed wound infection at the incision site and treated conservatively (Clavien grade I).

Conclusions

LDN is a safe technique with accepted intraoperative and postoperative morbidity. It offers short hospital stay, better cosmesis and early convalescence. In experienced hands, it can effectively deal with various vascular and ureteral anomalies without compromising early graft function.

Laparoscopic Live Donor Nephrectomy: Single-Center Experience of 200 Consecutive Cases

Background: Renal transplantation is the ideal treatment method for end-stage renal disease. Since deceased organ donation rates cannot meet the demand, live donor kidney transplantation (LDKT) is commonly performed worldwide. Laparoscopic donor nephrectomy (LDN) is currently the most commonly preferred minimally invasive donor nephrectomy technique. However, experienced surgeons should perform this procedure since the safety of the live donor is the priority in transplant practice. In this study, we aimed to investigate this procedure's safety at the hands of a surgeon during the transition period from open donor nephrectomy (ODN) to LDN. Methods: Data of the donors and recipients who underwent LDN and LDKT in Ankara Medicana Hospital between 2016 and 2019 were included in this study. Demographic, surgical, and immunological data of the donors and recipients were collected retrospectively. Donor data, including duration of surgery, warm ischemia time (WIT), complication rates, duration of hospital stay, and recipient data such as patient and graft survival rates, were compared with the published literature. Results: Two hundred donors and 200 recipients were included. The complication rate, surgical time, WIT at the donor site, and 1- and 3-year patient and graft survival rates were all comparable with the literature. Survival rates were irrespective of the relationship status of the donors with recipients. Conclusions: The LDN procedure can be safely performed by a surgeon with extensive laparoscopic surgery experience in general surgery cases and ODN.

Suprapubic cystostomy during renal transplantation in a patient with a urethral stricture after hypospadias surgery: A case report

Introduction

Renal transplantation often causes polyuria, and a Foley catheter is typically placed after transplantation. A urethral stricture often makes it difficult to insert a normal diameter urethral catheter.

Case presentation

We report on the case of a 16‐year‐old adolescent male with a history of hypospadias surgery who underwent a cystostomy during renal transplantation. A cystostomy was placed during transplantation because of stricture of the pendulous urethra. Urine leakage into the retroperitoneum occurred after cystostomy catheter removal. An 8‐Fr urethral catheter was placed, and urine was aspirated to prevent drainage failure. Voiding cystourethrography performed after 2 weeks showed that there was no leakage. After that, the patient had no trouble with urination.

Conclusion

A cystostomy may be one strategy for renal transplantation patients with a urethral stricture. Urine leak can occur because of the delay in wound healing caused by immunosuppressive therapy. Therefore, cystostomy management strategies should be considered carefully.

Use of single-dose perioperative antimicrobial therapy is acceptable in recipients of living-donor renal transplants in the rituximab era

OBJECTIVE

The aim of this study was to evaluate the efficacy of single-dose perioperative antimicrobial therapy as infection prophylaxis in recipients of living-donor renal transplants in the rituximab era.

PATIENTS AND METHODS

Between 2009 and 2017, 84 recipients underwent living-donor renal transplantation (LDRT) at Okayama University Hospital; 3 with vascular/urinary complications requiring additional surgery were excluded from this analysis. Data including recipient characteristics, antimicrobial prophylaxis and administration of rituximab were retrospectively examined for an association with perioperative infections. Prophylactic antimicrobial agents, selected according to the Results of preoperative urine cultures, were administered just before incision. Perioperative infections, which consisted of surgical site infections, remote infections, and urinary tract infections, were defined as a positive culture indicating required administration of additional antimicrobial agents.

RESULTS

Among the 81 recipients, prophylactic cefazolin, ampicillin/sulbactam, and others were administered to 66 (82%), 13 (16%), and 2 (3%) recipients, respectively. Twenty-one (26%) received single-dose antimicrobial prophylaxis, while 60 (74%) received multiple doses up to 7 days. Rituximab was used in 59 (72.8%) recipients. The incidence of urinary tract infection, surgical site infection and remote infection was 13 (16%), 1 (1%), and 0, respectively. Univariate analysis could not demonstrate any significant risk factors for postoperative urinary tract infections, including a single dose vs multiple doses of antimicrobial therapy (P = 0.069) and administration of rituximab (P = 0.717).

CONCLUSIONS

Our data suggest that the use of single-dose perioperative antimicrobial therapy is acceptable for prophylaxis of infections in patients undergoing LDRT, even in the rituximab era.

Early Rehospitalization Post-Kidney Transplant Due to Infectious Complications: Can We Predict the Patients at Risk?

INTRODUCTION

Rehospitalization early post-kidney transplant is common and has a negative impact in morbidity, graft survival, and health costs. Infection is one the most common causes, and identifying the risk factors for early readmission due to infectious complications may guide a preventive program and improve outcome. The aim of this study was to evaluate the incidence, characterize the population, and identify the risk factors associated with early readmission for infectious complications post-kidney transplantation.

METHODS

We performed a retrospective cohort study of all the kidney transplants performed during 2015. The primary outcome was readmission in the first 3 months post-transplant due to infectious causes defined by clinical and laboratory parameters.

RESULTS

We evaluated 141 kidney transplants; 71% of subjects were men, with an overall mean age of 50.8 ± 15.4 years. Prior to transplant, 98% of the patients were dialysis dependent and 2% underwent pre-emptive living donor kidney transplant. The global readmission rate was 49%, of which 65% were for infectious complications. The most frequent infection was urinary tract infection (n = 28, 62%) and the most common agent detected by blood and urine cultures was Klebsiella pneumonia (n = 18, 40%). The risk factors significantly associated with readmission were higher body mass index (P = .03), diabetes mellitus (P = .02), older donor (P = .007), and longer cold ischemia time (P = .04). There were 3 graft losses, but none due to infectious complications.

CONCLUSION

There was a high incidence of early rehospitalization due to infectious complications, especially urinary tract infections to nosocomial agents. The risk factors identified were similar to other series.

Clinical Utility of Routine Follow-up Cystography in the Management of Traumatic Bladder Ruptures

OBJECTIVE

To evaluate if follow-up cystography alters clinical management in patients after treatment of traumatic bladder ruptures.

METHODS

Patients with uncomplicated blunt trauma bladder ruptures between 2000 and 2014 were identified in our institutional trauma registry. Primary management strategies consisted of either cystorrhaphy or catheter drainage. Primary outcome analyzed was occurrence of positive follow-up cystogram. Secondary outcomes were use of follow-up cystography and time to negative cystogram.

RESULTS

One hundred forty patients were identified with a median follow-up of 6.2 months (interquartile range [IQR] 3.0-32.4). Eighty-two patients (58.6%) had extraperitoneal (EP) ruptures, 49 had intraperitoneal (IP) ruptures (35.0%), and 9 had combined EP/IP rupture (6.4%). Fifty-six EP patients were managed with catheter drainage, whereas all other patients underwent cystorrhaphy. Thirty-five cystorrhaphy patients (42%) had no imaging before catheter removal. Forty-nine patients (58%) had cystograms at a median of 15.0 days (IQR 10.0-22.0) after cystorrhaphy, with only 1 patient having a persistent leak. Forty-six catheter drainage EP patients (82%) had negative cystograms at a median of 19.0 days (IQR 15.0-33.0). Of the 10 patients with persistent extravasation, 7 required operations for related complications, whereas 3 had negative imaging at a median of 38.0 days (IQR 25.8-66.8), with a mean of 2.8 cystograms before a negative study.

CONCLUSION

Follow-up cystography after cystorrhaphy for uncomplicated blunt trauma-associated bladder ruptures rarely, if ever, provides unanticipated clinical information. For catheter drainage EP patients, cystography remains clinically valuable, as at least 18% of patients will have signs of continued extravasation. The optimal timing of cystography and catheter removal remains unknown.