Salvage of difficult transplant urinary fistulae by ileal substitution of the ureter

Minimal-invasive management of urological complications after kidney transplantation

Kidney transplantation represents the gold standard treatment option for patients with end-stage renal disease. Improvements in surgical technique and pharmacologic treatment have continuously prolonged allograft survival in recent years. However, urological complications are frequently observed, leading to both postoperative morbidity and putative deterioration of allograft function. While open redo surgery in these patients is often accompanied by elevated surgical risk, endoscopic management of urological complications is an alternative, minimal-invasive option. In the present article, we reviewed the literature on relevant urological postoperative complications after kidney transplantation and describe preventive approaches during the pre-transplantation assessment and their management using minimal-invasive approaches.

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.

Artificial urinary conduit construction using tissue engineering methods

Introduction

Incontinent urinary diversion using an ileal conduit is the most popular method used by urologists after bladder cystectomy resulting from muscle invasive bladder cancer. The use of gastrointestinal tissue is related to a series of complications with the necessity of surgical procedure extension which increases the time of surgery. Regenerative medicine together with tissue engineering techniques gives hope for artificial urinary conduit construction de novo without affecting the ileum.

Material and methods

In this review we analyzed history of urinary diversion together with current attempts in urinary conduit construction using tissue engineering methods. Based on literature and our own experience we presented future perspectives related to the artificial urinary conduit construction.

Results

A small number of papers in the field of tissue engineered urinary conduit construction indicates that this topic requires more attention. Three main factors can be distinguished to resolve this topic: proper scaffold construction along with proper regeneration of both the urothelium and smooth muscle layers.

Conclusions

Artificial urinary conduit has a great chance to become the first commercially available product in urology constructed by regenerative medicine methods.

Tissue engineering and ureter regeneration: is it possible?

Large ureter damages are difficult to reconstruct. Current techniques are complicated, difficult to perform, and often associated with failures. The ureter has never been regenerated thus far. Therefore the use of tissue engineering techniques for ureter reconstruction and regeneration seems to be a promising way to resolve these problems. For proper ureter regeneration the following problems must be considered: the physiological aspects of the tissue, the type and shape of the scaffold, the type of cells, and the specific environment (urine). 
This review presents tissue engineering achievements in the field of ureter regeneration focusing on the scaffold, the cells, and ureter healing.

Use of appendix for complete transplant ureteral necrosis

A 3-yr-old boy with posterior urethral valves underwent cadaveric renal transplant. On the ninth day after transplantation the patient developed a urinary leak, with complete ureteral necrosis. There was insufficient length of undamaged ureter to permit ureteroneocystostomy, unavailability of a native ureter to permit ureteroureterostomy, and an inability to mobilize the transplant kidney or bladder sufficiently to permit direct pyelovesicostomy. As the kidney was otherwise functioning perfectly, we decided to create an appendiceal conduit in the hope of salvaging the patient's renal allograft. At present, 7 months post-transplant, the child is clinically well with a serum creatinine of 0.7 mg/dL. Complete ureteral necrosis is an infrequent but devastating complication following renal transplantation. We report a novel method that allowed an otherwise normally functioning cadaveric graft to be salvaged.