Primary reconstruction is a good option in the treatment of urinary fistula after kidney transplantation

Ureterovesical Leak Following Renal Transplant and Effects of Acute Rejection and Antirejection Therapy: A Nested Case-Control Analysis and Outcome of 1102 Consecutive Renal Transplant Recipients

OBJECTIVES

Studies on nontechnical risk factors for ureterovesical leak after renal transplant are scarce. This study aimed to report the possible pre- and postoperative risk factors and the role of acute rejection and antirejection therapies for urine leak after transplant and its effect on graft and patient survival.

MATERIALS AND METHODS

We conducted a retrospective analysis of 13 patients (1.17%) with urine leak (case group) and 52 patients without leak (control group) (case-to-control ratio of 1:4) from 1102 living related (first degree) renal transplant recipients seen between January 2012 and December 2021. We analyzed demographic and clinical details and biochemical and outcome parameters using a nested case-control design.

RESULTS

Cases were olderthan controls (P = .018), were more ABO incompatible (P = .009), and had more 6/6 HLA mismatch transplants (P = .047). Donors of cases were older than donors of controls (P = .049). The rate of postoperative hypoalbuminemia was greaterin the case group (P = .050). Rates of acute rejection (P = .012) and plasmapheresis (P = .003) were greaterin the case group than in the control group. On multivariate logistic regression analysis, recipient age, 6/6 HLA mismatch, and plasmapheresis were found to independently associated with urine leak. None ofthe patient required surgical repair, as all responded to conservative therapy. Urine leak did not affect graft outcomes (P = .324), but overall survival was less in cases than in controls.

CONCLUSIONS

Nontechnical risk factors that cause posttransplant ureteric leak include older donor and recipient age and ABO incompatible and 6/6 HLA mismatch transplants. Acute rejection and plasmapheresis predispose leak, and an indwelling double J stent can allow adequate healing of the anastomosis. High index of suspicion and prompt management are imperative to preserve graft and patient outcome.

Identifying Early Extraperitoneal High-Volume Urine Leak Post Kidney Transplantation

Transplant clinicians need to be watchful of several potential surgical complications in the early post-transplant period, including haemorrhage, extraperitoneal urine leak, and lymphocele. While haemorrhage and extraperitoneal urine leak usually present in the early post kidney transplant period, lymphoceles usually present 2–6 weeks after transplantation. While the colour and volume of the drained fluid can give some indication of the problem, is not enough evidence for a confident urine leak diagnosis. Further investigations, such as serum biochemical parameter analysis of the drained fluid and ultrasonography, help to identify the true cause. This paper discusses how to identify high-volume extraperitoneal urine leaks in the early post kidney transplant period and considers the differential diagnoses. Different ureteroneocystostomy procedures, including the Lich–Grégoir, Politano–Leadbetter, and U-stitch techniques, are discussed and compared regarding complication rates (especially urine leak and haematuria). The authors also address the management of low- and high-volume extraperitoneal urine leak, the follow-up needed, and the impact of urine leak on graft and patient survival, length of hospital stay, and rate of hospital readmission.

Early urological complications after kidney transplantation: An overview

Urological complications, especially urine leaks, remain the most common type of surgical complication in the early post-transplant period. Despite major advances in the field of transplantation, a small minority of kidney transplants are still being lost due to urological problems. Many of these complications can be traced back to the time of retrieval and implantation. Serial ultrasound examination of the transplanted graft in the early post-operative period is of key importance for early detection. The prognosis is generally excellent if recognized and managed in a timely fashion. The purpose of this narrative review is to discuss the different presentations, compare various ureterovesical anastomosis techniques and provide a basic overview for the management of post-transplant urological complications.

Preoperative Risk Factors Associated With Urinary Complications After Kidney Transplantation

BACKGROUND

Only surgically irrelevant risk factors including sex, African-American ancestry, or exceptional U-stitch anastomosis have been identified to associate with urinary complications after kidney transplantation. The objective was to identify modifiable and nonmodifiable risk factors associated with urinary complications after kidney transplantation.

METHODS

A single-center study of 3,129 kidney transplants performed over 40 years was conducted to identify independent risk factors using χ² tests and logistic regression analysis.

RESULTS

We identified the quality of the transplant's ureter, cystographic abnormalities in the recipient, and repeat transplantations as independent risk factors for overall urinary complications occurring after kidney transplantation in multivariable analysis. Obesity was associated with an increased risk of urinary fistula, while the presence of a JJ stent was associated with a reduced risk of urinary fistula. The risk of urinary surgical complications for kidney transplantations was reduced when the kidney was recovered from a living related compared to a deceased donor.

CONCLUSIONS

The risk factors identified in the present study will allow candidates for kidney transplantation to be more informed and will also allow for surgical modifications to limit the occurrence of urinary complications.

Comparison of Urologic Complications Between Ureteroneocystostomy and Ureteroureterostomy in Renal Transplant: A Meta-Analysis

OBJECTIVES

Transplant surgeons use a myriad of ureteral anastomotic techniques in renal transplant. Although the Lich-Gregoir extravesical anastomosis is the most common, ureteroureterostomy also is used. In this meta-analysis, our objective was to compare the complication rates of these 2 techniques as reported in the literature.

MATERIALS AND METHODS

A systematic review of the literature revealed 44 articles, 6 of which met our inclusion criteria. Studies were compiled using Review Manager (RevMan version 5.3, Nordic Cochrane Centre, Cochrane Collaboration, Copenhagen, Denmark). Forest plots were generated to assess relative risk. A fixed-effects model was used for low heterogeneity, and a random-effects model was used for high heterogeneity.

RESULTS

Overall complications were similar for both procedures (relative risk, 1.22; 95% confidence interval, 0.9-1.65), as were rates of urine leak and fistula (relative risk, 0.79; 95% confidence interval, 0.17-3.64) and hematuria (relative risk, 0.24; 95% confidence interval, 0.001-4.84). Stricture, obstruction, and stone formation were more common after ureteroureterostomy (relative risk, 0.63; 95% confidence interval, 0.45-0.88), whereas vesicoureteral reflux (relative risk, 6.82; 95% confidence interval, 1.68-27.61) and urinary tract infection (relative risk, 2.29; 95% confidence interval, 1.3-4.03) were more common after ureteroneocystostomy.

CONCLUSIONS

With similar overall complication rates, both procedures can be viewed as being acceptable primary anastomotic techniques. In light of differing individual complication rates and the scarcity of data comparing the 2 methods, no specific recommendation regarding that technique should be used can currently be elucidated. We believe that further prospective studies comparing ureteroneocystostomy and primary ureteroureterostomy may reveal which is superior regarding complication rates.

Urological Consequences following Renal Transplantation: A Review of the Literature

Renal transplant (RT) represents the treatment of choice for end-stage renal disease (ESRD) but harbours a wide range of possible complications and therapeutic challenges of urological competence. Dialysis years and clinical medical background of these patients are risk factors for sexual dysfunction and lower urinary tract symptoms (LUTS). On the contrary, RT itself may have a number of possible surgical complications such as ureteral stenosis and urinary leakage, while immunosuppressive treatment is a known risk factor for de-novo malignancies.

The present review describes the main urologic problems of RT patients and their up-to-date treatment options according to the most recently available literature evidences.

Pedicled greater omentum graft: a new technique to repair recurrent urinary fistulae after kidney transplantation

Urinary fistula is the most frequent urologic complication within the first month after kidney transplantation, which often leads to graft loss and mortality. Open surgery is the most popular approach for the treatment of these fistulae; however, it is associated with high failure rates. Here, we present a new technique of pedicled greater omentum graft to repair recurrent urinary fistulae after kidney transplantation. We used this technique in the repair of recurrent urinary fistulae in 13 post-kidney transplant patients. All operations were successful at the first attempt, and there was no fistula recurrence. Further, no complications associated with the technique have been observed during the follow-up (1-7 years). In conclusion, the use of pedicled greater omentum graft for the repair of recurrent urinary fistulae after kidney transplantation is both effective and safe.

Therapeutic option for infected urinary tract fistulas in renal transplantation

BACKGROUND

Approximately 20% of urinary tract fistulas after renal allografting are complicated by urinary tract infection, which presents a therapeutic challenge.

OBJECTIVE

To evaluate an option for treatment of urinary tract fistulas associated with urinary tract infection and unsuitable for minimally invasive or primary surgical urinary tract repair.

PATIENTS AND METHODS

The study included 650 recipients who underwent transplantation over 17 years. Urinary leakage was initially treated with indwelling bladder catheterization. Patients with fistulas refractory to treatment underwent surgical intervention to repair the urinary tract. In patients who were not candidates for primary repair of the urinary tract, temporary urinary diversion was performed, rather than classic percutaneous or open nephrostomy, using a ureteral stent (ie, a 6F or 8F Foley catheter with the balloon placed inside the renal pelvis).

RESULTS

Overall, urinary leakage occurred in 36 patients (5.5%). Conservative management was successful in 14 vesical fistulas (42.4%) and no ureteral fistulas (0%). Three patients died of sepsis during conservative treatment, before the new surgical approach. Five of 36 urinary leaks (13.9%) were managed using ureteral intubation with an 8F Foley catheter, with a success rate of 80%.

CONCLUSION

Ureteral catheterization with an 8F Foley catheter is a feasible therapeutic option to treat complicated urinary tract fistulas unsuitable for primary surgical repair of the urinary tract.