| Abstract|| |
To determine the incidence and management of urological complications after livedonor renal transplantations at our center, we studied the medical records of 122 patients who underwent live kidney transplantation with a stented Lich-Gregoire anastomosis for ureteric reimplantation. The overall incidence of urological complications was 7.3 %. The early complications included four cases of ureteric stenosis, two cases of urinary leaks (one vesical fistula and one ureterovesical fistula) and one case of lymphocele causing ureteric obstruction. On the other hand, the late complications (> 6 months after surgery) included two cases of vesicoureteral reflux. No graft was lost and there was no urinary complication-related mortality. There was no association with recipient age, related or non-related donor, or cold ischemic time. The urinary complications were mostly caused by ureteral ischemia and extrinsic compression by lymphocele; the stent caused vesicular fistula in one patient and clot anuria caused ureteral obstruction in another. In conclusion, the Lich-Gregoire technique has low complication rate and technical ease to perform compared with Barry's extravesical technique.
Keywords: Transplantation, Renal, Urinary, Complications, Technique.
|How to cite this article:|
Al-Shaer M B, Al-Midani A. The Management of Urological Complications in Renal Transplant Patients. Saudi J Kidney Dis Transpl 2005;16:176-80
|How to cite this URL:|
Al-Shaer M B, Al-Midani A. The Management of Urological Complications in Renal Transplant Patients. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2015 Nov 30];16:176-80. Available from: http://www.sjkdt.org/text.asp?2005/16/2/176/32938
| Introduction|| |
Historically, transplant surgeons have used many techniques for vesicoureteral implantation. Even today, opinions differ on whether to use intravesical or extravesical implantation and whether or not to apply anti-refluxing techniques to these procedures. Previous training and individual experiences influence these choices. However, the urological complications after renal transplantation should be the most important factor in determining the appropriate technique. With the current improvements in graft survival and concomitant better immunosuppression, it is unacceptable to lose a patient or graft as a result of a technical issue. 
The traditional intravesical anti-reflux surgery is the Pollitano-Leadbetter technique originally used for the treatment of primary vesicoureteral reflux (VUR) in children.  It is performed through an anterior cystostomy to visualize the interior of the bladder. The transplant ureter is brought through a lateral hiatus into the bladder wall and tunneled for approximately two centimeters. The ureter is then trimmed, spatulated, and sutured to an incision on the bladder mucosa. The bladder is closed in two layers. Technically, this is a relatively difficult and time-consuming implantation and also has a higher risk of obstruction due to kinking of the ureter.
Extravesical ureteroneocystotomy by LichGregoire technique has gained popularity because of its low complication rate and technical ease.  The bladder is frequently distended with normal saline and neomycin irrigation via a urinary catheter. The detrusor muscle is incised at the anterio-lateral aspect of the bladder down to but not through the mucosa for a length of approximately 3 cm. A buttonhole of bladder mucosa is cut from the distal end of the incision. The ureter is spatulated and anastomosed with a fine absorbable suture to the bladder in a mucosato-mucosa approximation. The detrusor muscle is then reapproximated over the ureter with a running suture.
Both of these techniques employ the use of a tunnel in an attempt to prevent reflux.  However, most series in the past 15 years demonstrated a 5%-50% incidence of reflux despite the anti-reflux technique. Some of this discrepancy may be attributable to the type of study used to evaluate VUR, the timing of the study, and the quality of the bladder wall.
These series also evaluated reflux as a possible prognostic indicator. They compared the presence and grades of reflux to the incidence of urinary tract infection, hypertension, and deterioration of the glomerular filtration rate. A consistent correlation between VUR in the transplanted kidney and these factors has not been demonstrated. Therefore, it is the opinion of many that attempts to prevent reflux in the transplant population are less important than the performance of a good vesicoureteral anastamosis to avoid complications such as stenosis and obstruction. 
| Patient and Methods|| |
We reviewed the medical records of the patients who underwent transplantation from related and non-related living donors in our unit between 1998 and 2003. All the patients had the Lich-Gregoire technique for ureteral reimplantation.
The graft was revascularized in a standard way; the renal vein was anastomosed to the side of the external iliac vein in most cases and the common iliac vein or inferior vena cava in children. The renal artery anastomosis was performed end-to-end with the internal iliac artery in all the cases.
The methods used for establishing urinary continuity were ureteroneocystostomy (LichGregoire method) in all the cases and ureteric stents were used routinely. A Foley catheter was left in the bladder for 4-5 days. Suction drains were used routinely and removed within seven days.
Several immunosuppressive regimens were used throughout the period of the study; initially they were azathioprine-based regimens and subsequently cyclosporin-based protocols.
Post surgical care included clinical and biochemical monitoring, Doppler ultrasound of the renal vascular and conventional ultrasonography before removing the stents, removal of the stent after four weeks, followed by ultra-sound of the renal graft. Investigations were performed to evaluate the presence of VUR if suspected after the stent removal.
Different modalities were used to diagnose a urological complication; like conventional ultrasonography, and aspiration of peri-graft collections, with determination of its creatinine content. Percutaneous nephrostomy with antegrade urography was carried out if indicated. Further diagnostic and therapeutic procedures depended on the findings and the clinical course.
| Results|| |
There were 122 patients (89 males and 33 females) in the study with a mean age of 39 years and a range of 10-68 years. The histocompatiblity antigen (HLA) matching was 4/6 in 19% of the patients, 5-6/6 in 14% and 3/6 in 66%. [Table - 1] shows the medical and surgical complications in our study patients.
[Table - 2] shows the urological complications in the study patients. The early complications included four cases of ureteric stenosis, two cases of urinary leaks (one vesical fistula and one ureterovesical fistula) and one case of lymphocele causing ureteric obstruction. On the other hand, the late complications (> 6 months after surgery) included two cases of vesicoureteral reflux. The overall incidence of urological complications was 7.3%. No graft was lost and there was no urinary complicationrelated mortality.
The cause of the vesical and ureterovesical fistulas was the inserted stents that eroded through the wall and the conservative management of both cases by prolonged catheter drainage was not successful. The lesions required open surgical repair and closure in two layers. We are no longer using this type of hard stent.
The four cases of intrinsic ureteric stenosis were limited to the vesico ureteral junction (VUJ). Urgent PCN percutaneous nephrostomy was required to save the function of the graft in two cases. Open surgical repair was required in all these cases.
There was a 10 year-old boy who developed hematuria one month post transplantation. He had a blood clot that obstructed the ureter. This case was treated successfully by percutaneous nephrostomy drainage till the urine was clear of blood.
Peri-graft collection of fluid was diagnosed by ultrasonography in nine patients of whom one patient had a significant collection that caused extramural obstruction of the ureter. Initially aspiration was not successful. Therefore, definitive surgical drainage was performed to solve the problem.
| Discussion|| |
Our study demonstrates a low incidence of urological complications (7.3%) in a large series of renal transplant patients who had living donors and who underwent transplantation in the same center using the same technique for ureteral reimplantation. The incidence of urological complications in large series is 2.6-15%. This wide range probably reflects the method of reporting; some authors do not include lymphoceles as a urological complication, and others include urinary tract infection (UTI). Furthermore, the complication rate was slightly higher in the patients who received kidneys from living donors than in those who received organs from cadavers. This is presumably the result of more extensive hilar dissection required during harvesting from the living donor, with the attendant risks of injury to the blood supply of the ureters.
We used the extravesical technique and had comparable incidence of urological complications to others who used the same technique. , In comparison with the intravesical ureteral implantation, we found that the extravesical (Lich-Gregoire technique) approach tended to produce fewer complications than the intravesical approach for ureteric implantation in renal transplantation. The extravesical technique is simple, requires less surgical time and, most importantly, avoids urologic complications. In our study, the average time of this type of anastomosis ranged from 15 to 22 minutes, without any fear of making a hole in the mucosa as is the case in intravesical (Barry) technique. Furthermore, the percentage of hematuria is very low in the early postoperative period and we no longer need to irrigate the urinary catheter many times after the operation, which is an unwelcome issue for nurses and junior doctors. Finally, the long term postoperative follow-up revealed a low percentage of urological complication.
Generally, most donor ureteral obstructions are distal, and often involve the ureterovesical junction. Distal ischemia is the most common cause of distal stricture formation.  This compromised blood supply can be due to problems in operative technique, or high dose immunosuppression. Upon removal of the donor kidney and ureter, the donor ureter is dependent on the renal artery as its sole source of blood. Two surgical errors may compromise this supply. The first involves stripping the ureter of its adventitia and connective tissue, leading to ischemia and necrosis of the distal ureter. The second error involves compromise of the ureteral branch of the renal artery by dissecting too high into the renal hilum. Trauma to the renal artery during donor nephrectomy, as caused by excessive traction on the renal vessels during nephrectomy or damage from the perfusion cannula, which can cause distal ureteral ischemia. ,,, There were four cases of ureteral stenosis in our study restricted to the distal part of ureter. One of them was due to wide mucosal dissection that allowed the vesical wall to work as a valve that obstructed the ureter. In the three other cases the most likely reason was distal ischemia in the distal ureter. Advocated endourological management in the form of percutaneous drainage, antegrade dilatation and stenting was not used due to lack of endoscopic facilities in our center. ,
We used stents routinely for all patients. Several authors advocate the routine use of ureteric stents as this would result in a lower incidence of urological complications, particularly urinary leaks and early postoperative obstruction.  Benoit et al confirmed this in a randomized study.  However, the use of stents is not without potential hazards, as was the case of a patient who had vesical fistula due to the stent itself. In addition, there is reported degradation of the polyurethane stents, encrustation, migration and increased incidence of UTI. ,
We conclude that Lich-Gregoire technique has low complication rate and technical ease to perform compared with extravesical technique. Prevention of urological complication, especially in terms of appropriate surgical technique without compromising the ureteral blood supply, is very important. As mentioned before, the extravesical ureteroneocystostomy had been shown to have a lower incidence of complication than the intravesical technique.
This is especially true when ureteral stenting is employed with the extravesical technique. Ureteral stent placement at time of transplantation results in few urological complications.
| References|| |
|1.||Cranston D. Urological complications after Renal transplantation. In: Morris PJ ed. Kidney Transplantation: principles and practice. WB Saunders 2001. 5th Edition 350-338. |
|2.||Campbell SC, Streem SB, Zelch M, Hodge E, Novick AC. Percutaneous management of transplant ureteral fistulas: patient selection and long-term Urol 1993; 150:1115-7. |
|3.||Kinnaert P, Hall M, Janssen F, Vereerstraeten P, Toussaint C, Van Geertruyden J. Ureteral stenosis after kidney transplantation: true incidence and long term follow up after surgical correction. J Urol 1985;133:17-20. [PUBMED] |
|4.||Masahiko H, Kazunari T, Tokumoto T, Ishikawa N, Yagisawa T, Toma H. Comparative study of urosurgical complications in renal transplantation: intravesical versus extravesical ureterocystoneostomy. Transplant Proc 2000;32(7):1844-6. |
|5.||Gruessner RW, Fasola C, Benedetti E, et al. Laparoscopic drainage of lymphoceles after kidney transplantation: indications and limitations. Surgery 1995;117(3):288-95. |
|6.||Shimmura H, Ishikawa N, Tanabe K, et al. Angiographic embolization in patients with renal allograft arteriovenous fistula. Transplant Proc 1998;30(7):2990-2. |
|7.||Rivera M, Marcen R, Burgos J, et al. Treatment of post-transplant lymphocele with povidone - Iodine Sclerosis: long-term follow-up. Nephron 1996;74(2):324-7. |
|8.||Benoit G, Alexandre L, Moukarzel M, Yataghene Y, Charpentier B, Jardin A. Percutaneous antegrade dilation of ureteral strictures in kidney transplants. J Urol 1993;150:37-9 [PUBMED] |
|9.||Butterworth PC, Horsburgh T, Veitch PS, Bell PR, Nicholson ML. Urological complications in renal transplantation: impact of a change of technique. Br J Urol 1997;79: 499-502. [PUBMED] |
|10.||El-Mekresh M, Osman Y, Ali-El-Dein B, El-Diasty T, Ghoneim MA. Urological complications after living-donor renal transplantation. BJU Int 2001;87(4):295-306. |
|11.||Pleass HC, Clark KR, Rigg KM, et al. Urologic complications after renal transplantation: a prospective randomized trial comparing different techniques of ureteric anastomosis and the use of prophylactic ureteric stents. Transplant Proc 1995;27:1091-2. [PUBMED] |
M B Al-Shaer
Consultant Transplant Surgeon, Kidney Transplantation Unit, Mouassat University Hospital, Damascus
[Table - 1], [Table - 2]