Is routine ureteric stenting needed in kidney transplantation? A randomized trial

Routine Ureteral Stenting in Kidney Transplant Reduces Postoperative Hydronephrosis and Percutaneous Ureteral Interventions: A Single-Center Experience

OBJECTIVES

The effect of routine ureteral stenting on postoperative hydronephrosis and percutaneous ureteral intervention in kidney transplant remains unknown. This study aimed to evaluate the effects of routine ureteral stenting on hydronephrosis and percutaneous ureteral intervention and the cost benefit of ureteral stenting in kidney transplant.

MATERIALS AND METHODS

We retrospectively analyzed patients who underwent kidney transplant at a tertiary institution between 2005 and 2021. We adopted a ureteral stentingprotocol in2017, anda comparisonwas performed with previous patients without stents.

RESULTS

In total, 539 patients underwent kidney transplant(271 with stents [51.3%], 268 without stents [49.7%]). Hydronephrosis was detected in 16 cases (5.9%) and 30 cases (11.2%) of groups with and without stents,respectively (P = .041). Among patients with hydronephrosis, the number of patients who underwent percutaneous ureteral intervention was significantly lower in the stent group than in the nostent group (1 [6.25%] vs 10 [33.33%]; P= .014).Twenty patients (3.71%) experienced major urologic complications (19 [7.1%] in the no-stent group, and 1 [0.4%] in the stent group; P = .001). No significant differences between the groups were shown in the incidence of urinary tract infections within 3 months of transplant (24 [8.9%] vs 22 [8.2%]; P = .846). No differences were shown between the groups in ureterovesical anastomosis time (24.4 vs 24.03 min; P = .699) or 1-year graft survival (97% vs 97.8%; P = .803). The healthcare cost was significantly lower in the stent group than in the no-stent group by $1702.05 ($15000.89 vs $16702.95; P < .001).

CONCLUSIONS

Routine ureteral stenting in kidney transplant significantly decreased the incidence of postoperative hydronephrosis and percutaneous ureteral intervention. Stenting did notlead to increased urinary tract infections and was cost-effective.

Association Between the Placement of a Double-J Catheter and the Risk of Urinary Tract Infection in Renal Transplantation Recipients: A Retrospective Cohort Study of 1038 Patients

BACKGROUND

The incidence of urinary complications in transplantation is 2% to 20%, which can be decreased with the use of a double-J catheter. The objective of this study was to determine the association between the use of the catheter and the probability of urinary tract infection (UTI).

METHODS

We studied a retrospective cohort of 1038 patients divided into 2 groups: those treated with vs without a double-J catheter. Perioperative factors related to catheter use were analyzed. Second, whether the use of the catheter was associated with fewer other urinary complications was analyzed.

RESULTS

Of the whole sample, 72 patients were eliminated from the study, and 358 (37%) received a double-J catheter. UTIs occurred in 190 patients (19.6%), of whom a greater proportion received a catheter: 88 of 358 (24.6%) vs 102 of 608 (16.8%) (odds ratio, 1.61; 95% confidence interval, 1.17-2.22; P = .003).

CONCLUSIONS

The placement of a double-J catheter during transplant is associated with a higher proportion of UTIs, increasing their severity and the cost of care, without having a clear effect on other types of urinary complications.

Clinical Outcomes Following Single vs. Multiple Vessel Living-Donor Kidney Transplantation: A Retrospective Comparison of 210 Patients

Background: The use of living-donor kidney allografts with multiple vessels continues to rise in order to increase the donor pool. This requires surgeons to pursue vascular reconstructions more often, which has previously been associated with a higher risk of developing early post-transplant complications. We therefore wanted to investigate the prognostic role of using living-donor renal allografts with a single artery (SA) vs. multiple arteries (MA) at the time of transplant.

Methods: We retrospectively analyzed a cohort of 210 consecutive living-donor kidney transplants performed between January, 2008 and March, 2019, and compared the incidence of developing postoperative complications and other clinical outcomes between SA vs. MA recipients.

Results: No differences were observed between SA (N = 161) and MA (N = 49) kidneys in terms of the incidence of developing a postoperative (or surgical) complication, a urologic complication, hospital length of stay, delayed graft function, estimated glomerular filtration rate at 3 or 12 mo post-transplant, and graft survival.

Conclusions: The use of live-kidney allografts with MA requiring vascular reconstruction shows excellent clinical outcomes and does not increase the risk of developing postoperative complications or other adverse outcomes when compared with SA renal allografts.

Surgical Complications After Deceased Donor Renal Transplant

OBJECTIVES

Deceased donor renal transplant is an accepted treatment for patients with end-stage renal disease. We retrospectively analyzed urological and surgical complications and outcomes in our series.

MATERIAL AND METHODS

Since 2016, we have performed 263 renal transplants at the Gazi University Transplantation Center, Ankara, and 92 of these were from deceased donors. We retrospectively analyzed outcomes of these 92 deceased donor transplants from our database records. There were 45 female and 47 male recipients, and 20 were pediatric recipients. Mean recipient and donor ages were 36 ± 14 and 38 ± 18 years old, respectively. Immunosuppression therapy consisted of steroids, mycophenolate, and calcineurin inhibitors. Induction therapy was 20 mg basiliximab (Simulect) on day 0 and day 4. Antithymocyte globulin (2 mg∕kg) was used in steroid-resistant acute rejection cases.

RESULTS

There were 13 surgical complications (14.1%) after 92 consecutive deceased donor renal transplants, and 4 of these were classified as miscellaneous surgical complications. Four of 9 cases were early, and the rest were classified as late complications. Postoperative early complications were bleeding (n = 2), urine leak (n = 1), and renal artery thrombosis (n = 1). Lymphoceles (n = 4) and urine leak (n = 1) occurred as late complications. Postoperative median follow-up was 78 months, during which 11 grafts (12%) were lost and 7 patients (7.6%) died from sepsis (n = 4), myocardial infarction, aortic dissection, and fungal pneumonia. No patients died from any surgical complications. The 1-year, 5-year, and 10-year survival rates of patients were 98%, 94%, and 94% and for grafts were 97%, 94%, and 88%, respectively.

CONCLUSION

Despite the limited number of deceased donor organs, improvements of surgical techniques at our center have facilitated success with deceased donor renal transplant at rates similar to other successful centers in the world.

Ureteric Trauma following Stent Removal in Kidney Transplant Recipient: A Unique Case of Prolonged Morbidity

A 52-year-old African-American male patient with end-stage renal disease due to hypertension underwent deceased donor kidney transplant procedure with no immediate complications. The postprocedure complications, interventions, and course were abstracted by chart review. The ureteric stent was removed with flexible cystoscopy on postoperative day (POD) 24. 24 hours later, the patient presented with abdominal pain and inability to urinate. An urgent ultrasound and noncontrast CT scan showed grade 4 hydronephrosis of the transplanted kidney. A percutaneous nephrostomy stent was placed for urinary diversion. A large ureteric hematoma filling the lumen of the mid to distal ureter was identified on the nephrostogram and was evacuated. A follow-up nephrostogram on POD 44 revealed a distal ureter stricture and persistent well-formed midureter filling defect. A repeat nephrostogram performed at POD 72 was done with stricture dilatation, internalization of stents, and removal of a percutaneous nephrostomy tube. The patient was maintained on antibiotics for UTI prophylaxis throughout the course.

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.

Surgical learning curve in kidney transplantation: A systematic review and meta-analysis

AIM

To assess the impact of the learning curve of kidney transplantation on operative and postoperative complications.

METHODS

A literature search was systematically conducted to evaluate the significance of the learning curve on complications in kidney transplantation. Meta-analyses of the effect of the learning curve on warm ischemic time, total operating time (TOT), vascular and urological complications, postoperative bleeding, lymphocele and infection.

RESULTS

Nine studies met the inclusion criteria and 2762 patients were included in the present meta-analyses. Surgeons at the beginning of the learning curve were found to have longer TOT (mean difference 41.77 (95% CI: 4.48-79.06; P = .03) and more urological complications (risk ratio 3.93; 95% CI: 1.87-8.25; P < .01). No differences were seen in warm ischemic time, postoperative bleeding, lymphocele, and vascular complications.

CONCLUSION

Surgeons at the beginning of their learning curve have a longer TOT and more urological complications, without an effect on postoperative bleeding, lymphocele, infection and vascular complications. For interpretation of the outcomes, the quality and sample size of the evidence should be taken into consideration.

The history of renal transplantation in Canada: A urologic perspective

While the urologist's involvement in kidney transplantation varies from center to center and country to country, urologists remain integral to many programs across Canada. From the early days of kidney transplant to contemporary times, the leadership, vision, and skillset of Canadian urologists have helped progress the field. In this review of Canadian urologists' role in kidney transplantation, the achievements of this professional group are highlighted and celebrated. Original contributors to the field, as well as notable achievements are highlighted, with a focus on the impact of Canadian urologists.

Stenting the ureteroneocystostomy reduces urological complications in kidney transplantation: a noninferiority randomized controlled trial, SPLINT trial

The role of ureteral stents in living-donor kidney transplantation remains uncertain. In this randomized controlled trial (SPLINT), we compared urological complications in living-donor kidney transplantations performed with or without stents. We included 200 consecutive patients that received living-donor kidney transplantations at the Erasmus MC, University Medical Center, Rotterdam. Patients (124 males, 76 females, mean age 54 ± 13) were randomized for suprapubic externalized single J stents (N = 100) or no stent (N = 100). The primary outcome was the probability of a percutaneous nephrostomy insertion (PCN) during a 12-month follow-up. To assess whether no stenting is noninferior to stenting, we allowed the probability of a PCN to increase by at most 5% (this is the noninferiority margin). Baseline characteristics were comparable between groups. In the no-stent group, there were more PCN insertions, 14% (95% CI 4.3-23.7%); urinary leakages, 12% (95% CI 5.4-21.3%); and surgical re-interventions because of urological complications, 8% (95% CI 1.5-14.5%). The stent group had more hematuria, 26% (95% CI 13.1-38.9%); and graft rejections, 15% (95% CI 2.7-27.3%). Patients in both groups had similar mean GFRs at several time points. Besides a better Euro-Qol-5D in the no-stent group at 2 and 6 weeks postoperative, similar quality of life was reported based on SF-36 and Euro-Qol-5D scores. In this trial, noninferiority has not been demonstrated for no-stent placement in relation to the number urological complications.

Timely surgical intervention for ureteric complications ensures adequate graft function in renal transplantation: a 10-year review

BACKGROUND

Ureteric complications can cause significant morbidity in renal and simultaneous pancreas-kidney (SPK) transplantation. This 10-year review identified transplant patients with ureteric complications necessitating surgical intervention in an Australian tertiary centre.

METHODS

The hospital records were scrutinized in detail to identify all patients who underwent renal or SPK transplantation from 1 June 2009 to 31 May 2019 with subsequent surgical management of ureteric complications. A case series of patients with ureteric complications was generated and findings were analysed.

RESULTS

A total of 893 renal and SPK transplants were performed over the 10-year period. Ten of these (1.12%; seven renal and three SPK) had ureteric complications. All were managed surgically. Five of the 10 had ureteric leaks (0.56%); three had ureteric strictures (0.34%), one had ureteric obstruction from extraluminal compression (0.11%) and one had both leak and stricture (0.11%). All 10 patients underwent ureteric reimplantation. Two patients required more than one operation for their ureteric complication. No graft loss or surgical mortality occurred. All 10 patients currently have functioning kidney transplants and none require maintenance dialysis.

CONCLUSION

We report a low rate (1.12%) of ureteric complications in our renal and SPK transplants. Our standard practice of definitive correction by ureteric reimplantation is proving successful. The authors confirm that appropriate surgery is a viable and durable option in renal transplant patients with excellent graft outcomes.

Is peritoneal dialysis prior to kidney transplantation a risk factor for ureteral stenosis after adult to adult live kidney transplantation

Objectives

Major urinary complications such as urinary leaks, stenosis or urinary tract infections after kidney transplantation can lead to graft or patient loss. The effect of peritoneal dialysis on post-kidney transplantation complications have been discussed but its effect on ureteral stenosis is unknown. In this study, it was aimed to analyze factors effecting major ureteral complications after living donor kidney transplantation and impact of peritoneal dialysis and double J-stents (JJ stents).

Material and Methods

This study included 116 adult to adult living donor kidney transplant patients. Factors effecting major urologic complications after living donor kidney transplantation were analyzed. The donors were primary relatives of the recipients.

Results

Major urologic complications after living donor kidney transplantation was 8/116 (6.9%). Urinary leak was present in 2 (1.7%) patients. Ureteral stenosis was encountered in 6 (5.2%) patients. Double J stents were used in 84 (72.4%) of the cases. The effect of JJ ureteral stent was not statistically significant for urinary leak, ureteral stenosis (p= 0.074, p= 0.470, respectively). A total of 29 (25%) patients had peritoneal dialysis before kidney transplantation. Preoperative peritoneal dialyses and bacteriuria after kidney transplantation were independent risk factors for ureteral stenosis in multivariate analysis (p= 0.013, and p= 0.010 respectively).

Conclusion

In the guidance of the results of the present study, peritoneal dialysis prior to kidney transplantation and bacteriuria are independent risk factors for ureteral stenosis after living donor kidney transplantation. JJ stents have no effect on urologic complications after living donor kidney transplantation.

[Indocyanine green fluorescence to visualize the ureteric vascularization of kidney transplants: An exploratory study]

INTRODUCTION

Urinary complications after kidney transplantation are common and can compromise renal function. While they are mainly attributed to ischemic lesions of the ureter, there is no existing method to evaluate its vascularization during surgery. The aim of the study was to evaluate if indocyanine green, revealed by infra-red light andused to visualize tissue perfusion, could provide an appreciation of the ureter's vascularization during kidney transplantation.

METHODS

This feasibility study was conducted over one month, on eleven consecutive kidney transplants. During transplantation, an injection of indocyanine green enabled the surgeon to visualize in real time with an infra-red camera the ureter fluorescence. Its intensity was reported on a qualitative and semi-quantitative scale. Occurrence of urinary complications such as stenosis or ureteral fistula were collected during 6 months.

RESULTS

In all of the 11 cases (100%), the last centimeters of the ureters were not fluorescent. Three (27%) ureters were poorly or partiallly fluorescent. Out of these three cases, only one case of urinary fistula occurred, followed by ureteric stenosis. In the series, two fistulas (18%) and two ureteric stenoses (18%) occurred. No side effects were observed. The low number of events did not allow statistical analysis.

CONCLUSION

Infra-red fluorescence of indocyanine green could be a simple and innovative way to appreciate the transplant's ureteric vascularization during kidney transplantation. It could help surgeons to identify the level of ureter section and to decide the anastomosis technique, in order to limit urinary complications.

LEVEL OF EVIDENCE

3.

Timing of Ureteric Stent Removal and Occurrence of Urological Complications after Kidney Transplantation: A Systematic Review and Meta-Analysis

Implanting a ureteric stent during ureteroneocystostomy reduces the risk of leakage and ureteral stenosis after kidney transplantation (KTx), but it may also predispose to urinary tract infections (UTIs). The aim of this study is to determine the optimal timing for ureteric stent removal after KTx. Searches were performed in EMBASE, MEDLINE Ovid, Cochrane CENTRAL, Web of Science, and Google Scholar (until November 2017). For this systematic review, all aspects of the Cochrane Handbook for Interventional Systematic Reviews were followed and it was written based on the PRISMA-statement. Articles discussing JJ-stents (double-J stents) and their time of removal in relation to outcomes, UTIs, urinary leakage, ureteral stenosis or reintervention were included. One-thousand-and-forty-three articles were identified, of which fourteen articles (three randomised controlled trials, nine retrospective cohort studies, and two prospective cohort studies) were included (describing in total n = 3612 patients). Meta-analysis using random effect models showed a significant reduction of UTIs when stents were removed earlier than three weeks (OR 0.49, CI 95%, 0.33 to 0.75, p = 0.0009). Regarding incidence of urinary leakage, there was no significant difference between early (<3 weeks) and late stent removal (>3 weeks) (OR 0.60, CI 95%, 0.29 to 1.23, p = 0.16). Based on our results, earlier stent removal (<3 weeks) was associated with a decreased incidence of UTIs and did not show a higher incidence of urinary leakage compared to later removal (>3 weeks). We recommend that the routine removal of ureteric stents implanted during KTx should be performed around three weeks post-operatively.

Does early removal of double J stents reduce urinary infection in living donor renal transplantation?

INTRODUCTION

Prophylactic use of double J (DJ) stents in recipients is highly accepted in renal transplantation. In this study, the association between the frequency of urologic complications (UC) and urinary tract infections (UTI), and the early or late removal of DJ stents was investigated.

MATERIAL AND METHODS

A total of 116 live-donor renal transplant patients were included in the study during a 4-year period, with a mean follow-up of 29.2 ±15.3 months. In all, DJ stents were used. All patients were clinically monitored for graft function by assessment of the complete blood count, renal biochemistry, urine analysis and blood drug level according to our follow-up protocol.

RESULTS

The patients were divided into 2 groups according to the time of their stent removal: group I (n = 44), removal within the first 14 days; and group II (n = 72), removal after 14 days. No urinary leaks were detected in either of the groups. Three patients suffered from anastomotic stricture (group I, n = 1; group II, n = 2). The rates of UTI were similar in groups I and II (13.6% vs. 16.6%, respectively, p = 0.79). The rate of UTI in women was found to be 3.8 times higher than in men.

CONCLUSIONS

The results of our study demonstrated that DJ stent removal within 14 days did not reduce the risk of UTI when compared to stent removal after 14 days. Similar effects on complication rates for ureteral stenting for these 2 removal periods were observed.

Routine double-J stenting for live related donor kidney transplant recipients: It doesn't serve the purpose, but does it serve a better purpose?

Purpose

Despite meticulous techniques, surgical complications continue to be problematic in kidney transplant recipients. Role of routine stenting to reduce complications is controversial. In this study, we compare incidence of early urological complications, lymphoceles, urinary tract infections (UTI) and graft function; with or without double-J stenting.

Materials and Methods

All patients who underwent live related donor renal transplantation from February 2014 to February 2016 were included. Transplants prior to February 2015 were without routine stenting; subsequent transplants were with routine stenting. Patients with neurogenic bladder, previously operated bladder and delayed or low urinary output were excluded. Follow-up was for at least three months. Descriptive statistics was performed for all parameters. Chi square test and Fisher's Exact test were used for qualitative variables. For quantitative variables, Mann-Whitney test was used to test median difference and independent samples t-test for mean difference. The p-value ≤0.05 was considered significant.

Results

We analysed 74 patients (34 stented and 40 non-stented). There was no difference in the incidence of urinary leak, anastomotic obstruction, lymphoceles or UTI (p>0.4 for all comparisons). However, mean estimated glomerular filtration rate at sixth day, 14th day, one month and two months were 76.1 vs. 61.5 (p=0.025), 72.1 vs. 56.6 (p=0.005), 79.4 vs. 63.1 (p=0.002) and 82.0 vs. 63.3 (p=0.001) in the stented versus non-stented groups.

Conclusions

Placement of ureteral stent in renal transplant does not significantly affect the incidence of early urinary complications or UTI. However, graft function is significantly better in stented recipients, at least in the short term.

Early Versus Delayed Double J Stent Removal in Deceased Donor Renal Transplant Recipients: A Prospective Comparative Study

Introduction: Prophylactic ureteric stents have been commonly employed to reduce the incidence of ureteric obstruction and anastomotic leaks following renal transplantation. There are very few studies on the duration of ureteric stenting in deceased donor renal transplantation (DDRT). We performed a prospective study to compare early and late double J stent removal in DDRT.

Aims and methods: The aim of this study was to compare the early and delayed removal of ureteric stents after DDRT. We performed 80 DDRTs at our center from August 2012 to December 2016, which were included in the study. However, we enrolled 48 patients as the remaining had to be excluded based on the high-risk factors. The recipients were allocated on the 14th postoperative day to two groups. Group 1 underwent early stent removal on the fourteenth postoperative day and in group 2, the stent was removed in the sixth postoperative week. The two groups were followed up for six months and the incidence of urological complications and urinary tract infections (UTI) was compared.

Results: The incidence of UTI during the follow-up period of six months was significantly lower in the early stent removal group (two out of 24) than in delayed stent removal group (eight out of 24) (p=0.016). Asymptomatic bacteriuria occurred in six out of 24 (25%) in group 1 and 10 out of 24 (41.6%) in group 2 (p=0.120). There was no significant difference in the incidence of urinary leak, hematuria, or ureteric obstruction between the two groups (p=0.900). However, stent-related symptoms were significantly more in the delayed stent removal group (three in group 1 versus 18 in group 2) (p=0.001).

Conclusion: Prolonged stenting is associated with an increased risk of UTI and stent-related symptoms in immunosuppressed renal transplant recipients. The early removal of double J stents can be done in carefully selected patients to reduce stent-related complications in DDRT.

Routine Stenting of Extravesical Ureteroneocystostomy in Kidney Transplantation: A Systematic Review and Meta-analysis

BACKGROUND

Although rare, major urologic complications (MUC) in kidney transplantation can cause significant morbidity, increased cost, and may even lead to graft loss. Ureteric stents are routinely used to prevent MUC, although complications related to their use have been reported. Here, we systematically reviewed the role of routine stenting in preventing MUC in kidney transplantation with extravesical ureteric implantation and performed a meta-analysis of 6 randomized controlled trials.

METHODS

A PubMed search was performed for studies on MUC and stents in kidney transplant recipients. Randomized controlled trials were shortlisted for the review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RevMan 5 was used for statistical analysis, and outcome analysis was done with Cochran-Mantel-Haenszel test using random effect model.

RESULTS

Six trials meeting the criteria were identified. Although stent use did not decrease the incidence of urinary leak (odds ratio [OR], 0.39; 95% CI, 0.14-1.11; P = .08) or obstruction (OR, 0.41; 95% CI, 0.13-1.24; P = .11), it was associated with a higher incidence of urinary tract infection (OR, 3.59; 95% CI, 1.33-9.75; P = .01).

CONCLUSION

In the present era of extravesical ureterovesical anastomosis, routine stenting has a limited role in decreasing major urologic complications and may be associated with higher incidence of urinary tract infections.

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.

Urologic Complications After Renal Transplant: A Single-Center Experience

OBJECTIVES

Urologic complications after kidney transplant are associated with significant morbidity, mortality, and prolonged hospital stay. An intervention or second surgical procedure is frequently required. Here, we report urologic complications in adult kidney recipients.

MATERIALS AND METHODS

Since 2006, 171 adult kidney transplant procedures have been performed at the Gazi University Transplantation Center (Ankara, Turkey). Among these patients, there were 65 adult female (38%) and 106 adult male (62%) recipients. Donor source included 61 deceased donations (36%) and 110 living related donations (64%). The Haberal corner-saving technique was used for ureteroneocystostomy anastomosis. All recipients received a calcineurin-based triple immunosuppression regimen. All recipients also received trimethoprim/sulfamethoxazole prophylaxis for 3 months after transplant.

RESULTS

In the 171 adult kidney recipients analyzed for urologic complications, mean age was 32.5 ± 14.1 years (median: 32.5 y; range, 18-67 y); mean donor age was 41 ± 14.2 years (median: 42 y). We focused on 3 specific urologic complications: urine leak, ureteric stenosis, and symptomatic vesicoureteral reflux. In our study group, urologic complications were encountered in 7 patients (4%), with 5 complications detected in the early period and 2 complications detected in the late period. No symptomatic vesicoureteral reflux complications were shown in this study group. Urologic complications did not result in any patient deaths or graft loss.

CONCLUSIONS

In this study, the Haberal corner-saving suture technique with double J stent seemed to have a protective effect for development of urologic complications.

Ureteral Complications in Kidney Transplantation: Analysis and Management of 853 Consecutive Laparoscopic Living-Donor Nephrectomies in a Single Center

BACKGROUND

We report the incidence and nature of ureteral and surgical complications in our series of 853 consecutive living-donor renal transplants after laparoscopic living-donor nephrectomy. The aim of this study was to analyze the therapeutic approaches to ureteral complications in kidney transplantations and their relationship with recipient outcome.

METHODS

The medical records of patients who underwent kidney transplantation from 2000 to 2014 were reviewed retrospectively. After the donor nephrectomies were performed with the use of laparoscopic, hand-assisted laparoscopic, and vesico-ureteral anastomosis, the recipient's ureteral complications were classified according to the mechanism and site of urinary tract involvement: anastomosis stricture, anastomosis leakage, vesico-ureteral reflux, and urolithiasis.

RESULTS

Among the 853 cases of kidney transplantation, ureteral complications occurred in 66 patients (7.73%). The most common complication was urinary tract infection caused by vesico-ureteral reflux (n = 24, 2.81%), which was managed with by means of sub-ureteral polydimethylsiloxane injection. The second most common complication was the anastomosis site stricture (n = 23, 2.69%), which was treated by means of ureteral re-implantation or percutaneous nephrostomy. Anastomosis site leakage occurred in 11 patients (1.28%) and was managed by percutaneous nephrostomy with double-J stenting and drainage or ureteral re-implantation. Urolithiasis occurred in 8 patients (0.93%).

CONCLUSIONS

There was an 8% rate of recipient ureteral complications at our institution. Of the 66 patients, 46 (5.4%) required surgical repair. The remaining 20 patients with ureteral complications were treated with conservative care or minimally invasive procedures. The keys to successful management of these problems are early diagnosis and prompt reconstruction whenever possible. Most ureteral complications are easily managed with a successful outcome with early intervention.

Atrophic bladder in long-term dialysis patients increases the risk for urological complications after kidney transplantation

OBJECTIVES

To evaluate the risk for urological complications after kidney transplantation at a single medical center in Japan.

METHODS

In the present study, 408 kidney recipients (255 men, 153 women) were enrolled. There were 349 living and 59 deceased donors. The average age of the recipients was 42.5 ± 13.5 years, and the average pretransplant dialysis period was 71.8 ± 88.2 months. Ureteroneocystostomy was carried out on 347 patients, and ureteroureterostomy on 61 patients. We investigated the relationship between pretransplant duration of dialysis and bladder capacity, and examined the risk factors for urological complication. We also evaluated the incidence of vesicoureteral reflux in 191 recipients who underwent ureteroneocystostomy during transplantation.

RESULTS

The preoperative duration of dialysis therapy showed a significant negative correlation with bladder capacity (R²  = 0.33, P < 0.001). The overall urological complication rate was 3.4% (14 patients), including urinary leakage (12 patients) and ureteral stricture (two patients). Univariate analysis showed that atrophic bladder, long-term dialysis therapy, deceased donor and ureteroureterostomy were associated with a higher incidence of urological complications (odds ratio 8.05, 4.43, 3.42 and 3.35; P < 0.01, P = 0.01, P = 0.04 and P = 0.04, respectively). Furthermore, multivariate analysis showed that atrophic bladder was the only significant factor associated with urological complications (odds ratio 10.37; P = 0.01). Among 191 recipients, vesicoureteral reflux was observed in 32 (16.8%). The incidence of vesicoureteral reflux was significantly higher in patients with atrophic bladder.

CONCLUSIONS

Bladder atrophy in renal transplant recipients after long-term dialysis therapy is associated with a higher risk of urological complications.

The prevalence and predictive factors of urinary tract infection in patients undergoing renal transplantation: A meta-analysis

BACKGROUND

Urinary tract infections (UTIs) are the main cause of infectious complications in renal transplant (RTx) recipients and are considered as a potential risk factor for poorer graft outcomes. However, the risk factors of UTIs are controversial. We estimated the incidence and predisposing factors of UTIs in patients undergoing RTx.

METHODS

Seventeen studies (6,671 patients) evaluated the prevalence and the risk factors of UTIs in patients with RTx published January 2000-October 2014 were included. The data were pooled using the fixed effect model or DerSimonian-Laird random effect model according to I².

RESULTS

Thirteen eligible articles with a total of 3,364 patients were evaluated and the pooled prevalence of UTIs was 38.0% (95% confidence interval [CI], 29%-47%; P < .01). The estimated risk factors for UTI include female sex (odds ratio [OR], 3.11; 95% CI, 2.10-4.13), older age (OR, 1.032; 95% CI, 1.01-1.04), duration of catheter (OR, 1.52; 95% CI, 1.03-2.03), acute rejection episodes (OR, 1.64; 95% CI, 1.11-2.41), and receiving a kidney from a deceased donor (OR, 1.28; 95% CI, 1.09-1.52).

CONCLUSIONS

More than one-third of RTx patients had at least 1 UTI after surgery. Female sex, older age of the recipient, long duration of catheter, acute rejection episodes, and cadaveric donor were associated with higher risk of UTI.

The development and current status of minimally invasive surgery to manage urological complications after renal transplantation

Introduction:

In the past, urological complications after renal transplantation were associated with significant morbidity. With the development and application of endourological procedures, it is now possible to manage these cases with minimally invasive techniques.

Materials and Methods:

A MEDLINE search for articles published in English using key words for the management of urological complications after renal transplantation was undertaken. Forty articles were selected and reviewed.

Results:

The incidence of urological complications postrenal transplantation was reported to be 2–13%. Ureteric leaks occurred in up to 8.6%, and 55% were managed endourologically. The incidence of lymphocele was as high as 20%, and less that 12% of the cases required treatment. Ureteric stricture was the most common complication, and endourological management was successful in 50–70%. The occurrence of complicated vesicoureteral reflux was 4.5%, and 90% of low-grade reflux cases were successfully treated with deflux injections. Stones and obstructive voiding dysfunction occurred in about 1% of kidney transplant recipients.

Conclusion:

Minimally invasive techniques have a critical role in the management of urological complications after renal transplantation. Urinary leakage should be managed with complete decompression. Percutaneous drainage should be the first line of treatment for lymphocele that is symptomatic or causing ureteric obstruction. Laparoscopic lymphocele deroofing is successful in aspiration-resistant cases. Deflux is highly successful for the management of complicated low-grade kidney transplant reflux. The principles of stone management in a native solitary kidney are applied to the transplanted kidney. Early identification and treatment of bladder outlet obstruction after renal transplantation can prevent urinary leakage and obstructive uropathy.

The embedded nipple: An optimal technique for re-implantation of primary obstructed megaureter in children

Objectives

To present a novel ureteric re-implantation technique for primary obstructed megaureter (POM) that ensures success in the short- and long-term, as conventional techniques are not ideal for megaureters especially in children, with ureteric stenosis and reflux being common complications after re-implantation.

Patients and methods

Between 2009 and 2012, 22 paediatric patients with POM were enrolled. We performed a new technique for re-implantation of these ureters to ensure minimal incidence of ureteric strictures and easy subsequent endoscopic access. We performed follow-up voiding cystourethrography (VCUG) at 6 months postoperatively.

Results

The cohort comprised 14 boys and eight girls, with a median age of 22 months. Six patients underwent bilateral re-implantation. The mean (range) duration of indwelling ureteric catheterisation was 7.8 (4–14) days. There were no complications in the perioperative and postoperative periods. There was no reflux on follow-up VCUG in any of the patients. One patient developed Grade I reflux after 1 year and presented with a urinary tract infection. Diagnostic cystoscopy was performed in 13 patients showing that the nipple was directed similarly to the native ureteric orifice.

Conclusion

The embedded-nipple technique for re-implantation of POM guarantees successful results and permits easy subsequent ureteroscopic access when needed.

Imaging Complications of Renal Transplantation

Renal transplant complications are categorized as those related to the transplant vasculature, collecting system, perinephric space, renal parenchyma, and miscellaneous complications including posttransplant lymphoproliferative disorder. Many of these renal transplant complications are diagnosed with imaging. Medical complications including rejection, acute tubular necrosis, and drug toxicity also can impair renal function. These medical complications are typically indistinguishable at imaging, and biopsy may be performed to establish a diagnosis. Normal transplant anatomy, imaging techniques, and the appearances of renal transplant complications at ultrasound, computed tomography, and MR imaging are reviewed.

[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.

Impact of ureteral stenting on urological complications after kidney transplantation surgery: a single-center experience

BACKGROUND

Urological complications such as ureteral strictures and ureteral leakage can affect the outcome of kidney transplantation by increasing morbidity and mortality, including graft loss. Controversy still exists regarding the role of stents in renal transplantation. The aim of this study was to evaluate the role of ureteral stenting in kidney transplantation.

METHODS

We performed a retrospective study on a series of 798 consecutive renal transplants performed in our center between January 1, 2004, and December 31, 2011. Ureteral stents were used in 152 cases (19.1%) of the total (stent group) and were removed 2 weeks postoperatively. Donor and recipient age, sex, type of ureteroneocystostomy, stent and non-stent patients, cold and warm ischemia time, and urological complications were analyzed.

RESULTS

The overall incidence of urological complications was 7.8% (62 cases). Ureteral stenosis (3.1%) and ureteral leakage (2.4%) were the most common complications; 39.7% (25 cases) of complications were recorded in the first month after transplantation. Major urological complication rate was 3.3% in the stent group compared with 8.8% in the non-stent group (P = .04). However, stent use was associated with the increase of urinary tract infections rate in the stent group (51.3%) compared with the non-stent group (17.9%) (P = .03).

CONCLUSIONS

In our study, the use of ureteral stents significantly decreased urological complications in kidney transplant recipients but increased the risk for development of urinary tract infections.

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.

Double-J Versus External Ureteral Stents in Kidney Transplantation: A Retrospective Analysis

Background:

Kidney transplantation has long been recognized as the best available therapy for end stage kidney disease.

Objectives:

This study aimed to compare outcomes of double-J versus percutaneous ureteral stent placement in renal transplantation.

Patients and Methods:

A retrospective analysis was performed on data of renal transplantations performed at our institution in a 12-month period. In this period, external and double-J stents were used in parallel. Length of hospital stay and stent-associated complications were evaluated.

Results:

In 76 kidney transplants, 43 external (group 1) and 33 double-J (group 2) urinary stents were used. No significant difference was observed in the number of urinary tract infections, ureteric stenosis or necrosis. The mean overall length of hospital stay was comparable in both groups (20.7 days in group 1 vs 19.3 days in group 2, P = 0.533). For patients without immunological complications, the hospital stay was significantly reduced using double-J stents (12.9 days in group 1, 10.8 days in group 2, P = 0.018). Leakage of the ureteroneocystostomy occurred in 6 out of 43 patients in group 1 (13.9%). No case of anastomotic insufficiency was observed in group 2 (P = 0.035). Macrohematuria was detected in 13 out of the 43 patients in group 1 (30.2%), compared to 3 out of 33 patients in group 2 (9.1%; P = 0.045).

Conclusions:

This nonrandomized comparison of stent types in kidney transplantation supports the use of prophylactic double-J stents in terms of decreased ureteric complications and reduced length of hospital stay.

Urinary tract reconstruction using uretero-ureteral end-to-side anastomosis in kidney transplant recipients

BACKGROUND

In kidney transplant recipients, the most widely used method for the reconstruction of the urinary pathway is ureteroneocystostomy, which may be difficult in cases with disused atrophic bladder. In this study, we evaluated kidney transplant recipients who underwent uretero-ureteral end-to-side anastomosis (UUA) in urinary reconstruction due to disused atrophic bladder.

METHODS

To clarify the effectiveness of this method, we retrospectively reviewed the clinical records of kidney transplant recipients in our hospital.

RESULTS

A total of 9 recipients with urinary reconstruction using UUA were evaluated. All of these patients had a history of long-term hemodialysis before transplantation, accompanied by complete anuria and small capacity of the bladder. In 4 patients, cranial native ureter was ligated, whereas it was not ligated in the remaining 5 patients. In 2 of 4 patients with cranial ligation, hydronephrosis developed in the native kidney with no further treatment being required. No patients experienced urinary tract complications including hydronephrosis in the graft, urine extravasation, or urinary tract infection in the follow-up period (757.6 ± 491.3 days). Allograft function was maintained well in all patients (serum creatinine level, 1.08 ± 0.23 mg/dL).

CONCLUSIONS

Although UUA is not a routine method of urinary reconstruction in kidney transplantation, it can be safely performed and should be a surgical option, especially for recipients with disused atrophic bladder. The ligation of cranial native ureter may lead to hydronephrosis of the native kidney, and it is tentatively concluded that UUA without native ureteral ligation is clinically feasible.

Management of urologic complications in renal transplantation: a single-center experience

INTRODUCTION

Ureterovesical complications subsequent to renal transplantation are associated with a high morbidity leading to graft loss or even death. In the present study, the management of these complications by using interventional and surgical procedures (native pyeloureterostomy [NPUS]/ureteroureterostomy [NUU] vs ureteroneocystostomy [UNC]) was evaluated retrospectively.

PATIENTS AND METHODS

Between 1994 and 2012, a total of 780 kidney transplantations (690 deceased and 90 living donors) were performed at our institution. Demographic, clinical, and laboratory data from patients with urologic complications were analyzed and compared.

RESULTS

Fifty patients (6.4%) exhibited ureterovesical complications, and 18 patients (36%) were operated on immediately. In 32 (64%) of 50 patients, an interventional procedure was initially performed, with 21 patients (66%) undergoing operation due to therapy failure. NPUS/NUU and UNC were performed in 26 (66.6%) and 13 (33.3%) patients, respectively. Indications for an operation were ureteral stenosis in 12 patients (30.8%), ureteral necrosis and urine leakage in 19 patients (48.7%), and symptomatic vesicoureteral reflux in 8 patients (20.5%). Long-term results were comparable between all groups.

CONCLUSIONS

Surgical revision of ureteral complications should be the standard therapy. NPUS/NUU, UNC, and the successful interventional procedures did not differ significantly in terms of long-term results.

A nipple-valve technique for ureteroneocystostomy in pediatric kidney transplantation

The ureteroneocystostomy in kidney transplantation can be performed with a variety of techniques. Over a 20-yr period, we utilized a technique of nipple-valve ureteroneocystostomy for the pediatric kidney transplants performed at our institution. The distal ureter is everted upon itself and anchored in place with four interrupted sutures to create a nipple valve, which is then inserted into the bladder and sewn mucosa-to-mucosa with the same sutures. The muscularis layer is closed around the ureter without tunneling and without routine ureteral stenting. After 109 transplants, patient survival was 97.2, 97.2, and 86.9% at one, five, and 10 yr, respectively. Graft survival was 91.7, 71.7, and 53.9% at one, five, and 10 yr, respectively. The most common cause of graft loss was acute or chronic rejection, seen in 75% of those experiencing graft loss. Two patients (1.8%) developed pyelonephritis in the transplanted kidney. Nipple-valve ureteroneocystostomy in pediatric kidney transplantation is a safe and simple method for performing the ureterovesical anastomosis with a low rate of pyelonephritis after transplantation.

Surgical complications following 1670 consecutive adult renal transplantations: A single center study

BACKGROUND AND AIMS

The aim of the study was to clarify the frequency and the sequel of surgical complications occurring within 1 year after renal transplantation.

PATIENTS AND METHODS

Surgical complications after 1670 consecutive adult kidney transplantations performed between 2000 and 2009 were retrospectively analyzed. In 2%, a living-related allograft was used, and 10% were retransplantations. An intravesical technique without stenting was used for the ureteric implantation.

RESULTS

There were 282 surgical complications occurring in 259 (15.5%) transplantations. Ureteral obstruction occurred in 53 (3.1%), lymphoceles in 39 (1.5%), postoperative hemorrhage in 36 (2.1%), and renal vein thrombosis in 22 (1.3%) patients, respectively. Out of the 17 lung emboli, 4 were fatal. Male recipients had twice as much ureteral stenosis as female (2.4 vs 1.2%, p < 0.05), and the opposite was true of urinary leakage (1.8% vs 4.0%, p < 0.025). Five-year patient and graft survival was impaired in patients with complications compared with patients without complications. Five-year patient survival was 92% versus 88% and graft survival 87% versus 74%.

CONCLUSION

Surgical complications impair patient and graft survival after kidney transplantation.

The Role of Prophylactic versus Selective Ureteric Stenting in Kidney Transplant Patients: A Retrospective Review

Objective

To evaluate the role of prophylactic versus selective ureteric stenting in the development of postoperative ureterovesical complications in kidney transplant recipients.

Methods

Records of 614 transplant patients seen from January 2006 to May 2011 were retrospectively reviewed. The primary outcome was the rate of ureterovesical complications, defined as the development of ureteric obstruction or a ureterovesical anastomotic leak. The secondary outcomes were the rate of urinary tract infections and forgotten stents. Using a χ2 test, we compared the primary and secondary outcomes across the selective and prophylactic cohorts. Logistic regression was used to compare the 2 cohorts while adjusting for potential confounders.

Results

The selective and prophylactic cohorts consisted of 258 and 330 patients, respectively. Unadjusted analysis showed that the prophylactic group had a significantly lower rate of ureterovesical complications than did the selective group (2.12% vs 6.20%; odds ratio, 0.33; P = .01). After adjustment for differences in sex and donor type, the prophylactic group still had a lower risk for ureterovesical complications (odds ratio, 0.30; P = .009). Rates of urinary tract infections and forgotten stents did not differ significantly between the 2 groups.

Conclusions

Prophylactic stenting is associated with a significantly lower rate of ureterovesical complications than is selective stenting.

Ureteral Stent Placement Increases the Risk for Developing BK Viremia after Kidney Transplantation

The placement of ureteral stent (UrSt) at kidney transplantation reduces major urological complications but increases the risk for developing nephropathy from the BK virus. It is unclear whether UrSt placement increases nephropathy risk by increasing risk of precursor viral replication or by other mechanisms. We retrospectively investigated whether UrSt placement increased the risk for developing BK Viremia (BKVM) in adult and pediatric kidney transplants performed at the University of Florida between July 1, 2007, and December 31, 2010. In this period all recipients underwent prospective BKV PCR monitoring and were maintained on similar immunosuppression. Stent placement or not was based on surgeon preference. In 621 transplants, UrSt were placed in 295 (47.5%). BKVM was seen in 22% versus 16% without UrSt (P = 0.05). In multivariate analyses, adjusting for multiple transplant covariates, only UrSt placement remained significantly associated with BKVM (P = 0.04). UrSt placement significantly increased the risk for BKVM. Routine UrSt placement needs to be revaluated, since benefits may be negated by the need for more BK PCR testing and potential for graft survival-affecting nephritis.

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.

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.

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.

Routine intraoperative ureteric stenting for kidney transplant recipients

BACKGROUND

Major urological complications (MUCs) after kidney transplantation contribute to patient morbidity and compromise graft function. The majority arise from the vesicoureteric anastomosis and present early after transplantation. Ureteric stents have been successfully used to treat such complications. A number of centres have adopted a policy of universal prophylactic stenting, at the time of graft implantation, to reduce the incidence of urine leaks and ureteric stenosis. Stents are associated with specific complications and some centres advocate a policy of only stenting selected anastomoses.

OBJECTIVES

To examine the benefits and harms of routine ureteric stenting to prevent urological complications in kidney transplant recipients.

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register (up to 8 January 2013) through contact with the Trials' Search Co-ordinator using search terms relevant to this review.

SELECTION CRITERIA

All RCTs and quasi-RCTs were included in our meta-analysis.

DATA COLLECTION AND ANALYSIS

Four reviewers assessed the studies for quality against four criteria (allocation concealment, blinding, intention-to-treat and completeness of follow-up). The primary outcome was the incidence of MUCs. Further outcomes of interest were graft and patient survival and the incidence of adverse events (urinary tract infection (UTI), haematuria, irritative symptoms, pain and stent migration). Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) with 95% confidence intervals (CI).

MAIN RESULTS

Seven RCTs (1154 patients) of low or moderate quality were identified. The incidence of MUCs was significantly reduced (RR 0.24, 95% CI 0.07 to 0.77, P = 0.02, NNT 13) by universal prophylactic stenting. This was dependent on whether the same surgeon performed, or was in attendance, during the operations. Two patients lost their grafts to infective urinary tract complications in the stented group. UTIs, in general, were more common in stented patients (RR 1.49, 95% CI 1.04 to 2.15) unless the patients were prescribed cotrimoxazole 480 mg/d: in which case the incidence was equivalent (RR 0.97, 95% CI 0.71 to 1.33). Stents appeared generally well tolerated, although studies using longer stents (≥ 20 cm) for longer periods (> 6 weeks) had more problems with encrustation and migration.

AUTHORS' CONCLUSIONS

Routine prophylactic stenting reduces the incidence of MUCs. Studies comparing selective stenting and universal prophylactic stenting, whilst difficult to design and analyse, would address the unresolved quality of life and economic issues.