Surgical management of early and late ureteral complications after renal transplantation: techniques and outcomes

Effect of ureteral stricture in transplant kidney and choice of treatment on long-term graft survival

BACKGROUND

To explore the risk factors of ureteral stricture in transplant kidney and the clinical effects of different treatment methods.

METHODS

The 62 patients with transplant kidney ureteral stenosis as the experimental group, and another group of recipients from the same donor as the control group (n = 59 cases). The risk factors for ureteral stricture and the survival rate of transplant kidney were analyzed and compared. The 62 patients were divided into open operation, luminal operation, and magnetic compression anastomosis (MCA) operation group. The effect of the operation and the survival rate of transplant kidney among the three groups were compared.

RESULTS

In our study, we found that the above differences were statistically significant in clinical data such as gender, multiple donor renal arteries, history of infection, and delayed graft function (DGF) between the two groups (P < 0.05). Urinary tract infection and DGF history were the independent risk factors for the development of ureteral stricture. The open operation had the best treatment effect and the survival rate of the transplant kidney, followed by the MCA, the stricture recurrence rate in the luminal operation was the highest.

CONCLUSION

The ureteral stricture has a negative correlation with the long-term survival rate of the transplant kidney, the curative rate and long-term effect of open surgery are the best, stricture recurrence rate of luminal surgery is high, and it may require multiple operations in the future, the MCA is a new breakthrough and innovation in the treatment of ureteral stricture.

Risk Factors for Urologic Complications After Kidney Transplantation and Impact in Graft Survival

Background and Purpose

Kidney transplantation (KT) is the best therapy for chronic kidney disease (CKD). Major urologic complications (MUCs) are the second etiology associated to morbidity and graft loss following KT, after rejection episodes. The objective of this study was to estimate the incidence, risk factors and impact on graft survival associated to urological complications in KT patients.

Patients and Methods

A retrospective cohort based on electronic patient files of kidney transplant recipients from Colombiana de Trasplantes was created for the period August 2008 to September 2019. Initiation of follow-up was defined as the date of transplantation up to 3 years post-transplantation. Incidence of ureteral stenosis, ureteral obstruction, and ureteral leak was measured. A logistic regression multivariate model was adjusted to determine the associated factors to MUCs (yes/no). Patient and graft survival time were analyzed using a Kaplan-Meier method.

Results

A total of 1584 KT patients were included in the cohort. MUCs were present in 195 (12.6%) KT patients. We found that dialysis duration (OR: 1.004; p = 0.02) remained significant for the incidence of MUCs in KT patients of deceased donors. Probability of graft and patient survival at 3 years of follow-up was 90.5% and 85.5%, respectively. No significant difference was found on graft and patient survival in KT patients with or without MUCs.

Conclusion

MUCs are frequent complications for KT. We did not observe significant differences in graft or patient survival according to the presence of MUCs. The identification of MUCs and risk factors may guide transplant teams for future surgical and clinical decisions.

Simultaneous antegrade urography of the upper urinary tract and retrograde cystography combined with computed tomography imaging in the management of ureteral complications after renal transplantation

Background

To investigate the significance of simultaneous urography of the upper and lower urinary tract of transplanted kidneys combined with computed tomography urography (CTU), computed tomography arteriography (CTA), and computed tomography venography imaging in the planning of open surgery performed to treat any ureteral complications of a transplanted kidney.

Methods

In all, 24 patients with ureteral complications after renal transplantation were admitted, 12 of whom had renal graft ostomy during open surgery. Simultaneous antegrade urography of the upper urinary tract and retrograde cystography of the transplanted kidneys were performed on the patients. With the use of computed tomography imaging results, surgical planning was carried out.

Results

All surgeries were successfully completed according to preoperative planning. Three patients underwent end-to-end anastomosis of the ureter and bladder muscle flap, 8 patients underwent ureterocystostomy, and 1 patient underwent an end-to-end ureteral anastomosis. After the follow-up up to now, all the patients had stable renal function, and no complications such as ureteral stenosis or urine leakage have thus far reoccurred in the transplanted kidneys.

Conclusions

When open surgery is required to treat any ureteral complications following renal transplantation, preoperative multiangle imaging can be used to better understand the condition of the transplanted urinary tract and thus aid considerably in surgical planning.

Complex Ureteral Reconstruction in Kidney Transplantation

OBJECTIVES

Despite advances in surgical techniques and organ preservation, transplant ureteric strictures remain a common complication in kidney transplantation. A variety of endourological and surgical techniques have been utilized; however, there is a lack of consensus on the optimal modality in dealing with these complex cases.

MATERIALS AND METHODS

We present challenging ureteral reconstruction cases after failed attempts at ureteral dilatation, failed conventional open repairs, and/or with bladder dysfunction.

RESULTS

All renal allografts were salvaged by successful use of bladder Boari flap and intestinal segment interpositions/diversions.

CONCLUSIONS

Operative repair remains the most durable and successful approach, and minimally invasive options should be reserved for nonsurgical candidates, with consideration of a single attempt in patients with early, distal, short (<2 cm), nonischemic strictures.

Perfect outcome of kidney recipients with ureteral stenosis after treatment with open surgery under magnetic resonance urography localization

Background

To evaluate the outcome of kidney recipients with ureteral stenosis after treatment with open surgery under magnetic resonance urography (MRU) localization.

Methods

We assessed 2,256 consecutive kidney transplant recipients between October 2010 and December 2018. Ureteral stenosis was detected by ultrasound, confirmed and positioned by Magnetic Resonance Urography. All patients underwent open ureteral reconstruction. The ureteral stenosis was located according to the location on the MRU during the operation. Surgical complications and recurrence rate were recorded in the stenosis group. Outcomes were compared with those of a matched control group of transplant recipients with no history of ureteric stenosis.

Results

The incidence of ureteral stenosis in our center was 3.1% (70/2,256). Sixty-four cases (91.4%) were confirmed to have distal stenosis and were reconstructed with ureterovesical re-implantation; six cases (8.6%) were confirmed to have mid-distal stenosis and were subjected to ureteroureterostomy with the use of native ureter. The overall success rate was 100% and the graft function was salvaged in all cases. There was no recurrence of stenosis after a mean follow-up of 38.9±26.3 months. The complication rate was 5.7%. The 110-month graft survival and patient survival were not significantly different between the stenosis and control groups.Conclusions: MRU is an effective method for non-invasive and accurate diagnosis of ureteral stenosis in kidney transplant recipients. Open ureteral reconstruction surgery under MRU localization for treatment of ureter stenosis after kidney transplantation had a high success rate, low recurrence rate and high safety.

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.

Results of Pediatric Kidney Transplants in an 8-Year Period: A Retrospective Study

BACKGROUND

Patient survival and quality of life is better after a kidney transplant compared with dialysis. In this retrospective study, we analyzed the results of pediatric kidney transplants in an 8-year period in our center.

METHODS

We reviewed the files of 166 children and adolescents who had undergone kidney transplants between 2008 and 2015 in our center. All the patients were younger than 18 years old and had been followed up for at least 2 years.

RESULTS

The transplanted kidneys were taken from live donors in 146 (88%) of the cases and from cadavers in 20 (12%) of the cases. They were procured from unrelated and related donors in 129 (90%) and 17 (10%) of the cases, respectively. Laparoscopic nephrectomy was done on 141 donors. The kidney vessels were anastomosed to the aorta, the common iliac, and the internal iliac in 3.6%, 56%, and 40.4% of cases, respectively. Preemptive kidney transplants were performed on 62 patients. The mean of patient survival was 124 ± 1.37 months. One- and five-year patient survival rates were 99% and 97%, respectively. The mean of graft survival was 118.29 ± 2.47 months. One- and five-year graft survival rates were 94% and 93%, respectively. Preemptive kidney transplants had a higher graft survival rate (P < .02).

CONCLUSION

Kidney transplant is a safe and feasible procedure in children and adolescents based on patient and graft survival outcomes. In our center, surgery complications led to kidney loss in very few cases.

[Results of surgical revisions for ureteral complications after renal transplantation]

OBJECTIVE

To analyze the results of surgical revision for ureteral complication (ureteric stenosis or urinary leakage) after renal transplantation over a period of 10 years.

MATERIALS AND METHODS

We performed a retrospective study on 1313 consecutive kidney transplantations carried out in a University Hospital Center between 2005 and 2014. The data of the patients who developed a ureteral stenosis or a urinary leakage secondary to a renal transplantation were analyzed. Combined organ transplantations (kidney-liver and kidney-pancreas), as well as pediatric transplantations were excluded.

RESULTS

Seventy-six patients (5.8%) had ureteric stenosis or urinary leakage after renal transplantation. Forty-six patients (3.5%) underwent surgical revision: 27 for ureteral stenosis, 19 for urinary leakage. Early success was achieved in 26 patients (56.5%), including 14 ureteric stenosis (51.9%) and 12 urinary leakage (63.2%) (P=0.45). After a complementary endoscopic or surgical treatment, the final success rate was increased to 73.1% (34 patients): 20 ureteric stenosis (74.1%) and 14 urinary leakage (73.7%) (P=0.98). There were 2 graft losses (4.3%) and one death (2.2%). The mean glomerular filtration rate estimated by the MDRD was 44.58mL/min/1.73m² (±14.7) before surgery and 45.37mL/min/1.73m² (±16.5) 6 months after surgery (P=0.92).

CONCLUSION

Although frequently challenging, surgical revisions for ureteral complications after renal transplantation give good results, with a low rate of graft loss and mortality.

LEVEL OF EVIDENCE

4.

Urologic complications in renal transplants

Urologic complications of renal transplant occur commonly and can have significant impact on graft function, survival, and patient morbidity. This review examines the prevalence of urologic complications, risk factors, diagnosis and options for management of the most common urologic complications.

Is delayed graft function associated with ureteral stenosis in the kidney transplant recipient? A case-control study

INTRODUCTION

Ureteral stricture (US) in the kidney transplant recipient is a rare complication that can lead to morbidity and graft loss. Risk factor recognition is crucial in the prevention and management of this entity. Delayed graft function (DGF), as defined by the need for dialysis in the first week after transplantation, has been proposed as a risk factor in previous studies. Our objective is to determine the impact of DGF in US development in kidney transplant patients.

METHODS

We designed a matched case-control study. US cases in kidney transplant recipients were identified in the 2008-2017 period. We defined US as the rise in serum creatinine associated with findings suggesting obstruction in ultrasound, scintigraphy, or retrograde pyelogram; any other cause of graft dysfunction was excluded. Controls were defined as kidney transplant recipients from the same population and period without US, matched in a 1:2 fashion by age, sex, and donor type.

RESULTS

From 532 kidney transplant patients, 31 cases and 62 controls were included. Cumulative US incidence was 58 per 1000 cases. When calculating for odds ratio (OR), post-operative urinoma (OR 3.2; 95% confidence interval [CI] 2.36-4.37) and ureteral duplication (OR 3.29; 95% CI 2.40-4.51) were associated with an increased risk for US, while DGF was not found to be statistically significant as a risk factor (OR 3.3; 95% CI 0.96-11.52). No statistically significant differences were found between groups in other pre- and post-transplant-related factors CONCLUSIONS:: DGF was not associated with US in our cohort; however, ureteral duplication and postoperative urinoma were associated with an increased risk of graft ureteral stenosis development.

Impact of ureteral stricture and treatment choice on long-term graft survival in kidney transplantation

We aimed to evaluate the influence of urological complications occurring within the first year after kidney transplantation on long-term patient and graft outcomes, and sought to examine the impact of the management approach of ureteral strictures on long-term graft function. We collected data on urological complications occurring within the first year posttransplant. Graft survivals, patient survival, and rejection rates were compared between recipients with and without urological complications. Male gender of the recipient, delayed graft function, and donor age were found to be significant risk factors for urological complications after kidney transplantation (P < .05). Death censored graft survival analysis showed that only ureteral strictures had a negative impact on long-term graft survival (P = .0009) compared to other complications. Death censored graft survival was significantly shorter in kidney recipients managed initially with minimally invasive approach when compared to the recipients with no stricture (P = .001). However, graft survival was not statistically different in patients managed initially with open surgery (P = .47). Ureteral strictures following kidney transplantation appear to be strongly negatively correlated with long-term graft survival. Our analysis suggests that kidney recipients with ureteral stricture should be managed initially with open surgery, with better long-term graft survival.

Outcomes of Kidney Transplant Recipients With Percutaneous Ureteral Interventions: A Single-Center Study

Background

Long-term outcomes of kidney transplantation recipients with percutaneous ureteral management of transplant ureteral complications are not well characterized.

Methods

Electronic records of 1753 recipients of kidney-alone transplant between January 2000 and December 2008 were reviewed. One hundred thirty-one patients were identified to have undergone percutaneous ureteral management, with placement of percutaneous nephrostomy tube or additional intervention (nephroureteral stenting and/or balloon dilation). Indications for intervention included transplant ureteral stricture or ureteral leak. Kaplan-Meier survival curves and multivariable regression modeling were performed to determine survival outcomes.

Results

Kaplan- Meier graft survival (P = 0.04) was lower in patients with percutaneous ureteral intervention for transplant ureteral complication. Graft survival at 1, 5, and 10 years was 94.3% 78.3%, and 59.1% for no intervention and 97.2%, 72.1%, and 36.2% for intervention cohort. Patient survival (P = 0.69) was similar between cohorts. Multivariate analysis demonstrated no association with graft failure (hazard ratio, 1.21; 95% confidence interval, 0.67-2.19; P = 0.53) or patient death (hazard ratio, 0.56; 95% confidence interval, 0.22-1.41; P = 0.22) in intervention group. The major cause of graft failure was infection for percutaneous ureteral intervention group (20.4%) and chronic rejection for those without intervention (17.3%).

Conclusions

Kidney transplant recipients with percutaneous ureteral interventions for ureteral complications do not have a significant difference in graft and patient survival outcomes. Therefore, aggressive nonoperative management can be confidently pursued in the appropriate clinical setting.

The Utility of Routine Ultrasound Imaging after Elective Transplant Ureteric Stent Removal

Background. Ureteric stent insertion during kidney transplantation reduces the incidence of major urological complications (MUCs). We evaluated whether routine poststent removal graft ultrasonography (PSRGU) was useful in detecting MUCs before they became clinically or biochemically apparent. Methods. A retrospective analysis was undertaken of clinical outcomes following elective stent removals from adult single renal transplant recipients (sRTRs) at our centre between 1 January 2011 and 31 December 2013. Results. Elective stent removal was performed for 338 sRTRs. Of these patients, 222 had routine PSRGU (median (IQR) days after stent removal = 18 (11–31)), 79 had urgent PSRGU due to clinical or biochemical indications, 12 had CT imaging, and 25 had no further renal imaging. Of the 222 sRTRs who underwent routine PSRGU, 210 (94.6%) had no change of management, three (1.4%) required repeat imaging only, and eight patients (3.6%) had incidental (nonureteric) findings. One patient (0.5%) had nephrostomy insertion as a result of routine PSRGU findings, but no ureteric stenosis was identified. Of 79 patients having urgent PSRGU after elective stent removal, three patients required transplant ureteric reimplantation. Conclusions. This analysis found no evidence that routine PSRGU at two to three weeks after elective stent removal provides any added value beyond standard clinical and biochemical monitoring.

Acute and Chronic Allograft Dysfunction in Kidney Transplant Recipients

Allograft dysfunction after a kidney transplant is often clinically asymptomatic and is usually detected as an increase in serum creatinine level with corresponding decrease in glomerular filtration rate. The diagnostic evaluation may include blood tests, urinalysis, transplant ultrasonography, radionuclide imaging, and allograft biopsy. Whether it occurs early or later after transplant, allograft dysfunction requires prompt evaluation to determine its cause and subsequent management. Acute rejection, medication toxicity from calcineurin inhibitors, and BK virus nephropathy can occur early or later. Other later causes include transplant glomerulopathy, recurrent glomerulonephritis, and renal artery stenosis.

Urologic considerations and complications in kidney transplant recipients

Urologic considerations during the kidney transplantation process, starting with initial recipient evaluation and continuing through the post-transplant, long-term follow-up, are critical for minimizing urologic complications and improving graft survival. Appropriate, targeted, preoperative urologic evaluation of the recipient allows for an optimized urinary tract to accept the graft, whereas post-transplant urologic follow-up and monitoring decrease the risk of graft lost secondary to a urologic cause, particularly in patients with a urologic reason for their kidney failure and in those patients with concomitant urologic diagnoses. Urologic complications comprise the second most common adverse post-transplant event, occurring in 2.5% to 14% of patients and are associated with high morbidity, graft loss, and mortality. Early and late urologic complications, including hematuria, hematoma, lymphocele, urine leak, ureteral stricture, nephrolithiasis, and vesicoureteral reflux, and their causes and treatment options are explored. A multidisciplinary team approach to kidney transplantation, including transplant surgery, urology, and nephrology, optimizes outcomes and graft survival. Although the current role of the urologist in kidney transplantation varies greatly by institution, appropriate consultation, participation, and monitoring in select patients is essential.