Complications of urinary drainage following renal transplantation

Genitourinary complications in renal transplantation

The surgical aspects of renal transplantation have now been studied thoroughly. Yet, technical complications are still common. This review may seem too complex, but proper attention to many small details means the difference between success and failure, or at least between large and small morbidity. Reduction of genitourinary complications is due to many innovations. The external ureteroneocystostomy is a primary method of urinary reconstruction which is simpler and produces fewer complications than the alternative procedures. Further, the complications that do occur are more easily and promptly treated. The end-to-side ureteroureterostomy, as currently performed, provides a ready secondary method of reconstruction if the primary method fails. The early exploration and operative correction of genitourinary complications substantially reduces long-term morbidity and mortality.

Pyeloureterostomy or ureteroneocystostomy in renal transplantation?

A retrospective comparison of pyeloureterostomy and external ureteroneocystostomy as methods of reconstructing the urinary tract in 128 renal transplants is presented. There was one urological complication in 52 pyeloureterostomies (1.9%) compared with 4 in the 76 ureteroneocystostomies (5.3%). 6/0 Polydioxanone (PDS) is preferred to Prolene for the anastomosis because of possible calculus formation on the latter. Wound sepsis is commoner in pyeloureterostomies undergoing concomitant nephrectomy, despite prophylactic antibiotics, though this is not statistically significant and the overall sepsis rate is higher for ureteroneocystostomy. Nephrectomy was avoided in 17 selected cases by simply ligating the recipient ureter where the pre-transplant urine output was low. Two of these patients developed hydronephrosis in the isolated kidney and required later nephrectomy.

Experience with pyeloureterostomy in renal transplantation

Pyeloureterostomy was used as the preferred method of urinary tract reconstruction in 260 of 371 consecutive renal allograft procedures performed between September 1967 and December 1980. Initially chromic catgut suture was used for the anastomosis in 96 patients with ten complications developing (10.4%). Because of the high incidence of anastomotic leakage (8.3%) with chromic catgut suture, the next 101 pyeloureterostomies were constructed using 7-0 Tevdek. Although urinary leakage occurred in only five of these patients (4.9%), late stone formation occurred along the suture material in three patients (2.9%), influencing the conversion to 7-0 Prolene for this anastomosis. With this suture material, only two complications have occurred in 63 subsequent pyeloureterostomies (3.1%), neither related to the anastomosis. In comparison, eight complications developed in 111 patients who underwent reconstruction with the Politano-Leadbetter method of ureteroneocystostomy (7.2%). The currently recommended method for pyeloureterostomy, as described, when combined with meticulous attention to technical details has made pyeloureterostomy a safe and effective method of urinary tract reconstruction in renal transplant recipients, with morbidity indistinguishable from that of ureteroneocystostomy.

Evaluation of anterior extravesical ureteroneocystostomy in kidney transplantation

We evaluated the anterior extravesical ureteroneocystostomy technique in 184 consecutive renal transplants done in 2 consecutive calendar years. Complications included 5 cases of ureteral and 1 of pelvic necrosis, and 2 of ureteral obstruction, with a ureteral complication rate of less than 4 per cent. All cases of pelvic or ureteral necrosis except 1 were seen in cadaver donor kidneys that were imported from other centers. No bladder complications were seen. Pelvioureteral obstruction, presumably of congenital origin in the cadaver donor, was discovered in the kidney after transplantation in 2 cases and was corrected successfully by pyeloureterostomy to the native ureter. The extraordinary simplicity of this technique, coupled with improvement in the complication rate, makes it our procedure of choice.

Nephrostomy drainage for renal transplant complications

The use of temporary diverting nephrostomy drainage in the management of immunosuppressed renal transplant patients with supravesical urinary extravasation, fistulas or ureteral obstruction is reviewed. In a literature survey covering an 11-year interval and 4,307 transplants there were 204 cases (4.7 per cent) of ureteral extravasation or fistula and 113 cases (2.6 per cent) of ureteral obstruction. Attempts at urologic repair in these 317 cases resulted in 30.9 per cent failure rate (98 cases), of which 86.7 per cent (85 cases) occurred in patients without nephrostomy compared to 13.3 per cent (13 cases) in patients with nephrostomy. In our 255 consecutive renal transplant patients there were 7 (2.7 per cent) with ureteral extravasation or fistula and 14 (5.5 per cent) with ureteral obstruction. Temporary nephrostomy was done in all 21 patients to protect the urologic repair and, when necessary, to control sepsis and allow for patient stabilization before delayed urinary tract reconstruction. In our series there was no mortality and only 1 renal unit (4.7 per cent) was lost as a consequence of urologic complications. The use of nephrostomy in transplant patients with ureteral extravasation, fistulas or ureteral obstruction is encouraged strongly to optimize patient and renal unit survival.

Urological complications in 119 consecutive renal transplants

One hundred and nine patients undergoing 119 transplants have been followed up from 8 months to 9 years. Urological complications occurred in 16 transplants, an incidence of 13.4%. Ureteroneocystostomy was performed primarily in all cases; in 98 by the conventional Politano-Leadbetter technique with 9 (9.2%) urological complications and in 32 by an extravesical technique with 7 (21.8%) urological complications. One patient died as a result of ureteric obstruction, without operation. In 3 patients with lower ureteric obstruction, transurethral ureteric meatotomy was successful in 2 cases and resulted in no change in renal function in the third. Two patients with urinary fistulae were managed successfully by continuous drainage with indwelling urethral catheters. The remaining 10 patients required 12 open surgical procedures for relief of ureteric obstruction, with improvement in function in 7 patients.

Conservative surgical management of urological complications after cadaveric renal transplantation

Review of a consecutive series of 85 cadaveric renal transplants revealed urinary fistulas in 7 cases. Bladder fistulas originated from the anterior cystostomy suture line in 3 patients and required secondary closure in every case. Ureteral fistulas from the donor ureter often required a multistaged operation. In every case the end result has been satisfactory, with closure of the fistula and preservation of renal function.

Management of urinary fistulas after renal transplantation

Urinary fistulas developed in 13 of 134 patients after renal transplantation. Bladder fistulas originating from the anterior suture line in 6 patients were satisfactorily managed by urethral or paravesical drainage. Fistulas arising from the donor ureter were best treated by surgical repair using the recipient's own ureter. Caliceal fistulas in 3 patients were successfully treated with nephrostomy drainage. A favorable outcome was achieved in 11 of the 13 patients, with closure of the fistula and preservation of renal function.

Urologic complications in renal primary and retransplantation. Experience with 202 consecutive transplants

In a period of two years, 202 kidneys were transplanted in 162 patients at the Downstate Medical Center. On hundred twenty-nine patients had primary transplantations, twenty-nine second transplantations, and five third transplantations. Urologic complications occurred in twenty-four of the patients (12%). There were eight complications involving the urinary bladder and fifteen ureteric complications. In twenty-one patients the complications appeared within six weeks after surgery. Surgical correction immediately upon diagnosis of the urinary complications resulted in a high degree of early restoration of the urinary tract continuity and preservation of renal function. Leakage from the bladder was frequently associated with previous surgery. In five of eight patients, bladder leakage occurred after the second or third transplantations. Complications of the urinary bladder in general had a significantly favorable prognosis as compared with ureteric complications. Although all the patients with bladder complications fully recovered and maintained good renal function, four patients with ureteric complications either died or lost the graft.

The management of urinary fistulae following cadaveric renal transplantation

Vesicoureteric, ureteric and calyceal fistulae in cadaver transplants may be successfully treated by early exploration and nephrostomy splintage with silastic tubing for a period of not less than 6 weeks.

Extravesical ureteroneocystostomy in 170 renal transplant patients

Urinary tract reconstitution was done in 170 consecutive renal transplant patients, using an extravesical ureteronecystostomy. The urologic complication rate was 8.5 per cent but complications associated directly with the anastomosis occurred in only 5 per cent of the cases. There have been no anastomotic complications in the last 104 transplants. Vesicoureteral reflux occurred in 20 per cent of 50 patients surveyed. Death in 2 cases and loss of the kidney in 1 were associated with urologic complications.