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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 1999  |  Volume : 10  |  Issue : 1  |  Page : 36-40
Urological complications of Cadaveric Renal Transplantation

Department of Urology, Armed Forces Hospital, Riyadh, Saudi Arabia

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Urological complications in 211 consecutive primary and secondary cadaveric renal transplants, performed t our institution between March 1993 and December 1996, were encountered in 13 patients (6.2%). The complications included urine leakage in four cases (1.9%)., obstruction of the upper urinary tract in seven (3.3%), urethral strictures in two (1%) and stone formation in one. Successfully treated complications amounted to 86%. Associated infection and urinary leak resulted in the loss of two grafts.

Keywords: Renal transplantation, cadaveric donor (CAD), complications, Percutaneous techniques.

How to cite this article:
Said MT, Abomelha MS, Al Otaibi KE, Orkubi SA, Kourah MA, Shaaban AA. Urological complications of Cadaveric Renal Transplantation. Saudi J Kidney Dis Transpl 1999;10:36-40

How to cite this URL:
Said MT, Abomelha MS, Al Otaibi KE, Orkubi SA, Kourah MA, Shaaban AA. Urological complications of Cadaveric Renal Transplantation. Saudi J Kidney Dis Transpl [serial online] 1999 [cited 2019 Nov 14];10:36-40. Available from: http://www.sjkdt.org/text.asp?1999/10/1/36/37300

   Introduction Top

The Riyadh Armed Forces Hospital (RAFH) has been a pioneer in the Kingdom of Saudi Arabia in performing the first renal transplant from a live donor (LRD) in 1979. Furthermore, it was a pioneer in transplanting the first cadaveric kidney, which was donated from Europe (E-CAD) in 1983. This was followed by the first pediatric renal transplantation in 1983, and transplantation from locally harvested cadaveric kidney (L-CAD) in 1984. [1],[2]

Urological complications of renal transplant­ation, especially urine leakage and ureteral obstruction can lead to serious morbidity and morality. [3] Hence, their early diagnosis and treatment are of paramout importance. [4]

We report here the urological complications that were encountered in our cadaveric renal transplants and their outcome.

   Materials and Methods Top

Between March 1979 and December 1006, a total of 211 renal transplants from cadaveric donors (CAD) were preformed at the RAFH. These consisted of 147 (70%) L-CAD and 64 (30%) E-CA. The E-CAD were donated from Eurotransplant Foundation in the period between 1983 and 1990. The combined cadaveric graft from both sources included 160 (76%) adult kidneys, 47 (22%) pediatric kidneys and four (2%) neonatal kidneys. The cold ischemia time (CIT) of L-CAD ranged from 5 to 24 hours with a mean of 18 hors, and that of E-CAD was 24 to 70 hours with a mean of 47 hours.

These kidneys were transplanted in 190 patients whose age range was 5 to 61 years (mean 29 years). Male to female ratio was 1:1. Thirty children (16%) were below 16 years. Secondary transplantation was per­formed in 30 patients; 26 of hem received two grafts, three received three grafts and one received four grafts.

All the patients received cyclosporine­based immunotherapy. [1],[2],[3],[4],[5] Standard procedures were followed in transplanting the kidney into the iliac fossa. Leadbetter-Politano ureteroneo-cystostomy without urethral stenting was used in all patients. Bladders were closed in two layers and drained by urethral catheter for three to four days.

All the study group was followed up from the time of the complication till the most recent evaluation. Serial serum renal function, ultrasound, DTPA renography were performed at regular intervals. Follow p ranged from 1 to 12 years with an average of 6 years.

   Results Top

Urological complications occurred in 13 patients (6.2%). All the complications occurred in the period between 1984 and 1991 and none afterwards till the time of this review.

The incidence of these complications was significantly higher in pediatric recipients (16.6%) than in adult recipients (5%). On the other hand, the incidence of compli­cations in pediatric kidneys (8%) and E­CAD kidneys (8%) was only marginally higher than their counterparts of adult Kidneys (5.6%) and L-CAD kidneys (5.4%), respectively; the difference being stati­stically not significant.

Urine Leakage

Urine leakage was encountered in four recipients (1.9%). All the complications occurred in the first five weeks of trans­plantation.

The first two transplants were adults who had primary transplantation from L-CAD and E-CAD adult kidneys. Urinary leak in both of them was due to lower ureteral fistulae, which were cured by percutaneous nephrostomy (PCN) and antegrade double J (D) stenting.

The third patient was an adult who received his second transplant from L-CAD adult kidney. His urinary leak was caused by an infracted lower pole of the kidney, which was reconstructed, and DJ tented, however, due to the development of hema­toma and sepsis transplant nephrectomy was performed.

The fourth patient was a child who received his second transplant from L-CAD pediatric kidney. He had necrosis of renal pelvis that was initially treated by drainage of urinoma, PCN and DJ stenting, but unfortunately, he developed perinephric abscess and serious infection that necessitated transplant nephrectomy.

It is noteworthy that cystostomies per­formed at the time of Leadbetter-Politano uretero-neocystostomy healed well in all patients and none caused urinary leak.

Obstruction of the Upper Urinary Tract

Obstruction of the upper urinary tract was encountered in seven recipients (3.3%). All had primary transplants using four L-CAD and three E-CARD, three of hem were pediatric kidneys. In all cases, obstruction occurred between three and 12 months of transplantation. The causes of obstruction and their treatment are shown in [Table - 1]. All patients were managed initially by PCN and DJ stenting, in addition to the subsequent definitive treatment. DJ stents were removed not later than 6 weeks. The obstruction was successfully corrected in all patients and all grafts were saved.

Other Urological Complications

Two patients developed urethral strictures. One of them had associated urine leakage. Both were children who received E-CAD pediatric kidneys with long cold ischemia time (36 and 42 hours). They were treated by internal optical urethrotomy.

Another child formed a stone, which passed down till it impacted behind the external urethral meatus and it was extracted. The outcome of the patients after long follow­up was favorable. Successfully treated uro­logical complications amounted to 86%. Asso­ciated infection with urinary leak resulted in thee loss of two grafts. There was no mortality attributed to the urological complications.

   Discussion Top

In the early ear of kidney transplantation, the incidence of urological complications was reported to be between 10 and 25% with mortality rate of 25 to 50%, usually due to associated sepsis. [6],[7] Currently, the incidence of urological complications ranges from 2 to 10% with graft loss or mortality being rare. [3],[4],[6],[8] The major change is attributed to several factors including better immune suppression, lower steroid doses, early diagnosis with easily obtainable ultrasound fan refinement in surgical and permutations techniques. [6],[9]

The latter either helps allowing bet time for reconstructive procedure or is used as a definitive successful therapy in some selected patients. In spite of that, operative intervention continues to be the mainstay for the majority of patients. [6],[9]

The diagnosis of a urological complication is not always straightforward, as it may be clinically silent. Deterioration of renal function may indicate existence of a urological problem, but it is non-specific. Urological complications must be distinguished from rejection. [10] We found that ultrasound and DTPA renal scan are very helpful in reaching a definitive diagnosis.

The rate of urological complication (6.2%) reported in this study, is acceptable and comparable to the current reports. [6],[8],[9] The source and chronological age of the kidneys had no effect on the rate of complications, while they were higher in our pediatric recipients (16.6%). Upper urinary tract obstruction and fistulation were the main complications, which occurred in 11 out of 13 (84.5%) of our patients. Although obstruction was more common (7 cases) than urine leakage (4 cases), the latter resulted in loss of two grafts due to associated life threatening infection. Therefore, early diagnosis and treatment of urine leakage is important.

We found percutaneous techniques very helpful in managing our patients with urine leakage and obstruction. This is in agreement with the findings of Campbell et al. [9] PCN, which provides initial drainage and enhances early diagnostic studies, was applied in all the obstructed cases and the majority of urine leakage cases. DJ stents inserted mainly antegradely was effective in curing two lower ureteral fistulae and as an adjunctive tool to the definitive surgical treatment of the urinary obstructed cases. Dilatation by percutaneous antegrade balloon was applied in two cases, one with a short lower ureteral stricture and one with an upper ureteral narrowing thought to be a stricture. The balloon dilation was successful in the first vase but failed in the second. Subsequent exploration of the latter case revealed the presence of periureteral fibrosis, which was successfully treated by ureterolysis and DJ stenting.

In two patients, we successfully used native ureter segments to graft ureteroureterostomy. One of these patients had a mid ureteral stricture and had undergone a failed attempt of local excision and end-to-end anastomosis. The other patients had a long lower ureteral stricture. This approach is in accordance with what was advised by others. [6],[7] WE believe that it is wise to consider utilization of native ureters to graft while performing uretero­neocystostomy or ureteropyelostomy in cases with graft ureteral loss or long strictures before embarking on using loops of bowel to bridge long ureteral gaps.

The urethral strictures, which occurred in two children, might have been secondary to repeated and prolonged catheterization. One patient developed it after his second transplant and the other had urinary leak requiring prolonged catheterization.

Stone formation in renal transplant patients has been rarely reported. [11] Our only case was a child who passed the stone down, but it had to be extracted out from fossa navicularis. In general, stones in our renal transplant patients are usually treated as if they were in native kidneys, preferably with the least invasive modality of extracorporal shock wave lithotripsy or endourology.

We conclude that urological complications may threaten graft survival. Prompt recognition and treatment utilizing percutaneous techniques would allow a high rate of graft survival.

   References Top

1.Al Otaibi K, AL-Khader AA, Abomelha M. First local cadaveric renal transplantation in Saudi Arabia. Saudi Med J 1985;663:217­-23.  Back to cited text no. 1    
2.Al-Khader AA, Al Suleiman MH, Mousa DH, Al Hawas F. some of the lessons learnt from renal transplant recipients cared fo rat Riyadh Armed Forces Hosptial. Saudi J Kidney Dis Transplant 1996;7(2):139-44.  Back to cited text no. 2    
3.Koga S, Tanabe K, Yagisawa TT, toma H. Urological complications in renal transplantation. Transplant Proc 1996;28(3):1472-3.  Back to cited text no. 3    
4.Salvatierra O Jr, Olcott C4th, Amend WJ Jr, cochrun KC, Freduska NJ. Urological complications of renal transplantation can be prevented or controlled. J Urol 1997;117:421-4.  Back to cited text no. 4    
5.Chang RW, Saltissi D, Al-Khader AA, Abomelha M, Jawdat M. successful use of cyclosporine in renal grafts with prolonged ischemic times. Transplant Proc 1987;19:2080.  Back to cited text no. 5    
6.Rosenthal JT. Urological complications of renal transplantation. J Urol 1993;150:1121-2.  Back to cited text no. 6  [PUBMED]  
7.Starzl TE, Groth CG, Putnam CW, et al. Urological complications in 216 human recipients of renal transplants. Ann Surg 1970;172(1):1-22.  Back to cited text no. 7    
8.Hashimoto Y, Nagano S, Ohsima S, et al. Surgical complications in kidney transplantation: experience from 1200 transplants performed over 20 years at six hospital in central Japan. Transplant Proc 1996;28(3):1465-7.  Back to cited text no. 8    
9.Campbell SC, Streem SB, Zelch M, Hogde E, Novick AC. Percutaneous management of transplant ureteral fistulas: patient selection and long-term results. J Urol 1993;150:1115-7.  Back to cited text no. 9    
10.Mundey AR, Podesta ML, Bewick M, Rudge CJ, Ellis FG. The urological complications of 1000 renal transplants. Br J Urol 1981;53:397-402.  Back to cited text no. 10    
11.Heron SP, O'Brien DP 3 rd, Whelchel JD, Neylam JF. Ureteral obstruction due to calculi in the early postoperative period in renal cadaveric transplantation: a case report and discussion of ureteral obstruction in the renal transplant patients. J Urol 1995;153:1211-3.  Back to cited text no. 11    

Correspondence Address:
Mohammad T Said
Department of Urology, Riyadh Armed Forces Hospital, P.O. Box 7897-C158, Riyadh 11159
Saudi Arabia
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PMID: 18212412

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