Urine leaks after renal transplantation: value of percutaneous pyelography and drainage for diagnosis and treatment

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.

Renal cysts and urinomas

Renal cysts are a common imaging finding. Although most cysts never have symptoms, some cause pain, collecting system compression, hematuria, hypertension, and secondary infection. The mere presence of a cyst is not an indication for intervention, but treatment may be indicated in symptomatic patients or those with secondary obstruction. Urinomas generally are a contained collection of urine outside of the normal pathways where urine travels. As such, urinomas can arise anywhere from the upper abdomen down into the low pelvis and have a variety of etiologies. Ureteral obstruction with forniceal rupture and trauma (blunt, penetrating, or iatrogenic) are the most common causes of urinomas. When urinomas arise spontaneously, the likely cause varies with the patient's age. Blunt or penetrating trauma can cause perinephric urinomas by two mechanisms-direct disruption of the pelvis or collecting system or by degeneration of nonviable tissue. These urinomas are often perinephric, but can also occur in a subcapsular location. This review will discuss diagnosis, classification, and treatment of renal cysts and urinomas.

Extraperitoneal urine leak after renal transplantation: the role of radionuclide imaging and the value of accompanying SPECT/CT - a case report

BACKGROUND

The differentiation of the nature of a fluid collection as a complication of kidney transplantation is important for management and treatment planning. Early and delayed radionuclide renography can play an important role in the evaluation of a urine leak. However, it is sometimes limited in the evaluation of the exact location and extent of a urine leak.

CASE PRESENTATION

A 71-year-old male who had sudden anuria, scrotal swelling and elevated creatinine level after cadaveric renal transplantation performed Tc-99 m MAG3 renography to evaluate the renal function, followed by an ultrasound which was unremarkable. An extensive urine leak was evident on the planar images. However, an exact location of the urine leak was unknown. Accompanying SPECT/CT images confirmed a urine leak extending from the lower aspect of the transplant kidney to the floor of the pelvic cavity, presacral region and the scrotum via right inguinal canal as well as to the right abdominal wall.

CONCLUSIONS

Renal scintigraphy is very useful to detect a urine leak after renal transplantation. However, planar imaging is sometimes limited in evaluating the anatomical location and extent of a urine leak accurately. In that case accompanying SPECT/CT images are very helpful and valuable to evaluate the anatomical relationships exactly.

Update on the use of percutaneous nephrostomy/balloon dilation for the treatment of renal transplant leak/obstruction

PURPOSE

Retrospective evaluation of the efficacy of percutaneous nephrostomy and nephroureteral stent placement for treatment of post-transplant ureteral leak, and percutaneous nephrostomy and balloon dilation for treatment of post-transplant ureteral obstruction.

PATIENTS AND METHODS

Data were reviewed for all patients who underwent percutaneous therapy for complications after renal transplantation between January 1985 and June 1995. A total of 61 patients with complications (leak, n = 17; obstruction, n = 44) had been treated. Patients underwent percutaneous nephrostomy followed by antegrade placement of a nephroureteral stent. In addition, all patients with obstruction also underwent ureteral balloon dilation. Follow-up ranged from 9 weeks to 24 months. Positive outcome was defined as nonsurgical closure of leak, significant improvement in renal function, and removal of the nephroureteral stent with maintenance of stable renal function.

RESULTS

Regarding ureteral leak, 10 of 17 patients (59%) healed after treatment. Seven patients (41%) did not respond and went on to surgical repair. All patients with early (n = 13) ureteral obstruction (< 3 months after transplantation), had improved renal function (P < .025). Sixty-two percent of patients with early obstruction were cured (tube out with stable renal function) and 38% went to surgery for ureteral repair. In patients with late (n = 31) obstruction (> 3 months after transplantation), renal function improved in only 58% (P < .01). Only 16% of patients with late obstruction were cured (tube out with stable renal function). Ureteral obstruction was persistent in the remaining patients and did not respond to multiple balloon dilations. All complications were minor and included 23 of 61 (38%) patients with urinary tract infections and nine of 61 (14%) patients with limited hematuria.

CONCLUSION

Percutaneous nephrostomy is very effective in improving renal function in patients with early obstruction. It is moderately successful in treating ureteral leak. Ureteral balloon dilatation is moderately effective for treatment of obstruction in the early (< 3 months) postoperative period. However, balloon dilation is minimally successful in curing ureteric obstruction occurring more than 3 months after transplantation.

Insertion of a double pigtail ureteral stent for the prevention of urological complications in renal transplantation: a prospective randomized study

PURPOSE

Urologists successfully use ureteral stents to protect the ureterovesical anastomosis in nontransplant patients.

MATERIALS AND METHODS

We determined the value of ureteral stents in transplant patients. The frequency of urological complications (leaks, obstructions and urinary tract infections) was compared in a prospective randomized series of 194 kidney transplantations (97 with and 97 without a double pigtail ureteral stent).

RESULTS

In the stent group 1 patient had a urinary leak and 35 had urinary tract infections (including 2 cases of Corynebacterium cystitis). In the no stent group 6 patients had urinary leaks, 4 had obstructions and 32 had urinary tract infections. The 1-year patient and graft survival rates were similar in both groups, and renal function at 1 year was also similar (229 versus 208 mumol./l. creatinine in the stent and no stent groups, respectively). A small number of stent related complications occurred (2 stent breakages and 1 stent migration). No stones formed in any case.

CONCLUSIONS

Ureteral stent insertion significantly decreases the rate of vesicoureteral leakage and obstruction in renal transplantation.

Delayed graft function in renal transplantation: etiology, management and long-term significance

PURPOSE

In cadaveric renal transplantation a period of delayed graft function postoperatively is not uncommon and often associated with a poor outcome. We reviewed the biology of reperfusion injury and delayed graft function in renal transplantation, as well as its prevention, management and long-term effects.

MATERIALS AND METHODS

The medical literature covering acute tubular necrosis, delayed graft function in renal transplantation and immunology of ischemia reperfusion injury was reviewed.

RESULTS

Delayed graft function is clearly associated with poor allograft survival, and is caused by an interaction of ischemic and immunological factors. Technical and pharmacological maneuvers can improve early function rates. The response to ischemic injury is complex, and may increase graft immunogenicity and promote the chronic proliferative changes seen in chronic allograft nephropathy.

CONCLUSIONS

Improvement in early renal function should be a primary goal in renal transplantation to enhance early and long-term results. Basic research into the injury response may yield insights into renal pathophysiology.

Urological complications in 1,000 consecutive renal transplant recipients

The urological complications in the first consecutive 1,000 renal transplants at our transplant center are reported with a minimum followup of 12 months. The kidney was implanted in the iliac fossa in all cases and in all but 3 the ureter was inserted into the bladder with a Politano-Leadbetter technique. Overall, there were 71 primary complications in 68 patients (7.1%), which included 36 ureteral obstructions, 25 ureteral or bladder leaks (including ureteral necrosis), 7 bladder outflow obstructions, 2 ureteral stones and 1 case of symptomatic vesicoureteral reflux. The use of high dose steroids in the early years was associated with a 10% urological complication rate, which decreased to 4% in patients receiving low dose steroids thereafter combined with azathioprine or cyclosporine. The urological complication was corrected after 1 procedure in 65 cases and after 2 procedures in 4. No grafts were lost due to urological complications. Two patients died, 1 of sepsis following transurethral resection of the prostate and subsequent ureteral necrosis, and 1 of hemorrhage following nephrostomy tube insertion. Most ureteral complications were treated by an open operation, although in recent years endoscopic techniques have become more common. Meticulous retrieval technique, low dose steroid protocols and rapid diagnosis are the crucial factors associated with a minimal incidence of urological complications after renal transplantation.

Treatment of renal transplant ureteral complications by percutaneous techniques

From January 1985 to October 1990, 487 adult renal transplantations were performed at our institution. Of 16 ureteral complications noted 15 were initially managed with percutaneous nephrostomy. Of the 8 complications that occurred during the last 2 years 5 resolved on percutaneous nephrostomy and stenting, or stenting with dilation alone. We conclude that percutaneous nephrostomy is indicated as an initial step in the diagnosis and treatment of urological transplant complications, and that it allows for nonoperative resolution of many of these complications.

Interventional radiology in the treatment of ureteric complications in transplant kidneys

Eleven patients who had radiological procedures because of urinary leakage or ureteric obstruction in transplant kidneys are reviewed in order to judge the clinical efficacy of interventional radiological techniques in the management of these complications. Initial technical success was attained in 9/9 dilatation attempts and 17/21 (81%) stent placement attempts. It is thought that 9/11 (82%) patients benefited from the radiological attempts at treatment and at long term follow up 7 kidneys were still functioning, 3 failed due to rejection and one after failed renal artery surgery. The complication rate due to the radiological procedure was low, with one iatrogenic urine leak being the single major procedural complication. Two patients had urinary tract infections while stented and there were two patients with perirenal abscesses.