Posttransplant urinary complications; a thing of the past after insertion of inexpensive ureteral stent

Urological complications in renal transplantation from cadaveric donor grafts: a retrospective analysis of 20 years

INTRODUCTION

This study is a retrospective analysis of ureteral complications and their management from a monocenter series of 277 consecutive renal transplantations.

MATERIALS AND METHODS

From September 1979 to June 1999, 277 renal transplantations (cadaveric origin) were performed in 241 patients. The ureter from the kidney graft was inserted into the bladder according to the technique of extravesical implantation described by Lich-Gregoir and Campos-Freire. The study analyzed the time of occurrence and the type of complications observed. The different procedures to restore the transplanted urinary tract are presented.

RESULTS

Complications occurred in 43/277 renal transplantations (15.5%). Anastomotic urine leakage or ureteral stricture were the most frequent. The time to appearance of these complications was either short (<1 month) or late (>1 month) in a similar number of cases. Most cases were managed surgically: 33/43 cases (76.7%). The most frequent surgical repair was ureterovesical reimplantation (n=13), followed by: ureteroureteral end-to-end anastomosis (native ureter-ureter transplant, n=5); pyeloureteral anastomosis (native ureter-renal pelvis transplant, n=5); simple revision of ureterovesical implantation (n=4); resection and end-to-end anastomosis of the transplant ureter (n=2); calico-vesicostomy (graft-bladder, n=1); implantation according to Boari (n=1); pyelovesicostomy with bipartition of bladder (n=1), and pyeloileocystoplasty with detubularized ileal graft (n=1). No deaths related to any of the urological complications were reported. However, 2 consecutive vesico-renal refluxes led to the loss of the kidney graft in the long-term.

CONCLUSION

The rate of complications observed in this retrospective analysis is similar to the experience of other studies, ranging from 2 to 20%. If the classical extravesical ureteral bladder implantation is to remain an attractive technique due to its simplicity, the surgical team at the training center should be aware of all the means to prevent any ureteral complications, such as the choice of another implantation technique and/or insertion of a transient ureteral stent.

Stented Lich–Gregoir ureteroneocystostomy: Case series report and cost-effectiveness analysis

Extravesical ureteroneocystostomy to reestablish urinary tract continuity in renal transplantation has been examined through a meta-analysis of more than 14,000 kidney transplants leading to the finding that stented anastomosis was associated with a lower urologic complication rate compared with nonstented anastomoses. Fourteen stents must be used to prevent one urologic complication. We now report the urologic complication rate in our case series in which a stented Lich-Gregoir anastomosis was routinely utilized. We present a cost-effectiveness analysis regarding the usage of ureteral stents.

METHODS

The records of 395 consecutive renal transplants were reviewed. Minimum follow-up time was 6 months. The standard anastomosis was a Lich-Gregoir with a 6- or 8-F 12- or 14-cm J-J stent. Monitored urologic complications included postoperative vesicoureteral leak or ureteral necrosis, obstruction or stricture, or clinically significant hematuria. Charges in 2004 US dollars were reported by the hospital accounting office.

RESULTS

Four urologic complications were noted-three leaks and one stricture (complication rate of 1.0%). There were no stent-related complications requiring reoperation. There were no cases in which the urologic complication led to graft loss or patient death. Total charges associated with stent use were $1,087 per patient, or $15,218 per urologic complication prevented.

CONCLUSIONS

The urologic complication rate in this case series is similar to the five previously published randomized trials, as well as our previously published meta-analysis. These results support the routine use of a ureteral stent. Our analysis suggests that stent use is cost effective.

Stented versus nonstented extravesical ureteroneocystostomy in renal transplantation: a metaanalysis

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