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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2007  |  Volume : 18  |  Issue : 3  |  Page : 365-369
New technique for allograft ureteroneocystomy for better transvesical endoscopic handling of allograft urological complications

Department of Urology, Transplant Service, Imam Hospital, Tabriz Medical University, Tabriz, Iran

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We studied a new ureteroneocystostomy technique for the anastomosis of the transplanted ureter and the native bladder that involves the change of the position of the neoureteral orifice during renal graft transplantation to the posterio-lateral aspect of the bladder's dome. We applied the technique on 30 consecutive renal transplant recipients (25 males and five females with ages between 15-50 years). Mucosa to mucosa anastomosis was performed, and all of the patients had double J (DJ) stents inserted in the ureters. The patients were followed for one year. At the time of removing the DJ stents, we evaluated the ureters by inserting ureteral catheters and by performing ureteroscopy transvesically and the results were compared with another group of 30 patients who underwent the conventional anterio-lateral ureteroneocystostomy. The retrograde stenting of the ureters was much more easily performed in the study group than the controls. During the follow-up of the study patients, renal ultrasound and renal function tests did not disclose any urological complications. We conclude that the new technique is effective and safe and enabled better retrograde handling of the allograft ureter than the conventional ureteroneo-cystostomy. Advantages of the new technique included the need for a shorter ureter, the normally appearing orifice of the allograft ureter in the bladder, and the unproblematic retrograde vesical approach for the posterolateral ureter.

Keywords: Renal Transplantation, Ureteroneocystostomy, Ureters, Urological

How to cite this article:
Zomorrodi A, Buhluli A. New technique for allograft ureteroneocystomy for better transvesical endoscopic handling of allograft urological complications. Saudi J Kidney Dis Transpl 2007;18:365-9

How to cite this URL:
Zomorrodi A, Buhluli A. New technique for allograft ureteroneocystomy for better transvesical endoscopic handling of allograft urological complications. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2020 May 26];18:365-9. Available from: http://www.sjkdt.org/text.asp?2007/18/3/365/33753

   Introduction Top

Transplantation has revolutionized treat­ment of end-stage renal disease by proving more cost effective than hemodialysis with a lower morbidity and better quality of life. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11]

Despite the advancement in the care of the renal transplant patients, the surgical technique for renal transplantation has been only minimally modified since the original description of the pelvic opera­tion by Kuss et al in 1951. [12] The standard placement of the transplanted kidney has been extraperitoneally, in the right iliac fossa. [13],[14]

After the vascular anastomosis is completed and the kidney is perfused, urinary continuity is secured by a number of methods. The most common techni­ques are the posterior Leadbetter-Politano, the anterior multi-stitch (Litch), and the anterior single-stitch. [15] Regardless of the technique used, the anastomosis must be tension-free and protected by at least a 1 centimeter submucosal tunnel to provide protection against reflux during voiding. The extravesical ureteroneocystostomy has been shown to have a lower incidence of obstruction than the intravesical techni­que. [16],[17] This is especially true when ureteral stenting is employed with the extravesical technique.

In evaluation and treatment of urologic complications in renal transplantation, the invasive percutaneous approach is usually advised, since the less invasive transvesical approach is very difficult due to the position of ureteral orifice in the anterior aspect of the dome of the bladder. [18] In order to enable a better transvesical approach, we designed a new position for the uretero­neocystomy in the deep lateral aspect of the dome of the bladder.

The aim of this study is to evaluate the safety and efficacy of the newly designed insertion site of the ureter on the outcome of our transplant grafts and the incidence of urologic complications.

   Methods and materials Top

We studied 30 consecutive renal trans­plant recipients (25 males and five females with ages between 15-50 years) on whom we applied the new technique of extra­vesical ureteroneocystostomy. The donors of the renal grafts were living donors. After anastomosing the renal artery to the internal iliac artery (end to end) and the renal vein to external iliac vein (end to side), the graft's ureter was tunneled on the lateral deep aspect of the bladder's dome where the bladder mucosa was exposed and a small vesicostomy was performed; then, a cobra head of the ureter was anastomosed to the bladder mucosa as shown in [Figure - 1], in contrast to the conventional method in which the ureter is usually anastomosed to anterio-lateral aspect of the bladder, as shown in [Figure - 2]. In all of the study patients, double J (DJ) stents were inserted in the ureters.

All of the patients were followed with ultrasound and renal function parameters for at least one year. Four weeks after the operation, all of the recipients were cysto­scoped and the DJ stents were removed; then, the orifices of the ureters were negotiated with transvesical stents to evaluate the transvesical approach for evaluation of the ureters. Some patients even under-went ureteroscopy.

   Results Top

In all of the 30 study patients, the transvesical ureteral stents could be easily passed. One patient developed a urinary leak that was secondary to necrosis of the upper calyx due to upper pole artery ligation, which was managed by inserting a DJ stent in the ureter during evaluation by uretero­scopy. In comparison, transvesical stenting and urteroscopy were impossible in 30 recipients who underwent conventional ureteroneocystostomy.

   Discussion Top

The prevalence of urologic complications following renal transplantation is 2.6%-13%.[19],[20] Ureteral extravasation producing uri­noma can be caused by graft rejection, ureteral necrosis due to ischemia, or inade­quate surgical technique. The majority of urological complications result from techni­cal error. [19] Urine leaks usually occur in the 2nd or 3rd postoperative week and require surgical or percutaneous intervention.[21] Urine leaks and fistulae account for half of the urologic complications. [22] Urologic complications in renal transplants are asso­ciated with mortality rates of up to 22%. [23] Death or transplant loss is more common when urologic complications occur within three weeks of surgery.[24]

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, which results in 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. [25] Trauma to the renal artery during donor nephrectomy, as caused by excessive traction on the renal vessels during removal or damage from the perfusion cannula can cause distal ureteral ischemia.

To reduce ureteral complications, the transplant surgeons should follow a proce­dure that includes the utmost care to keep the transplanted ureteral artery intact during the donor's nephrectomy, the ureter as short as possible, the ureter anastmosis tension free and easily performed, and the tissue hand­ling atraumatic. Advantages of our new technique included the use of a short ureter, and the easier retrograde vesicoureteral stenting and ureteroscopy after transplantation.

We conclude that our new method of anastomosis of the transplanted ureter proved safe and effective in our transplant patients and enabled better retrograde handling of the allograft ureter than the conventional ureteroneocystostomy.

   References Top

1.Hansen M. Disorders of renal and urinary function, Pathophysiology: Foundations of Disease and Clinical Intervention. Philadelphia, Pa: W B Saunders Company; 1998.  Back to cited text no. 1    
2.US Renal Data System: Excerpts from the USRDS 2001 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. Am J Kidney Dis. 2001;38:S1-S248.  Back to cited text no. 2    
3.Fauci AS, Braunwald C, Isselbacher KJ, et al, eds. Dialysis and Transplantation in the Treatment of Renal Failure (14th ed). New York, NY: McGraw-Hill;1998.  Back to cited text no. 3    
4.US Renal Data System. USRDS 2001 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Bethesda, Md; 2001. Available at: http://www.usrds.org/atlas.htm. Accessed August 30, 2002.  Back to cited text no. 4    
5.Ray T. Chronic and acute renal failure: primary care issues. United States Renal Disease System (1999). USRDS 1999 Annual Data Report. Adv Nurse Pract 2000;8:69-73.  Back to cited text no. 5    
6.Kiberd BA, Clase CM. Cumulative risk for developing end-stage renal disease in the US population. J Am Soc Nephrol 2002;13:1635-44.  Back to cited text no. 6    
7.Blommers T, Schabacher B, Corry RJ. Transplant and Dialysis: The cost/benefit question. Iowa Med 1984;74:15-7.  Back to cited text no. 7    
8.Landsberg DN, Shackleton CR, Keown PA, Cameron EC, Manson D. Renal Transplantation. BC Med J 1993;35:801-4.  Back to cited text no. 8    
9.United Network for Organ Sharing (UNOS), Division of Organ Transplantation USD. 1993 Annual Report of the U.S. Scientific Registry for Transplant Recipients and the Organ Procurement and Transplantation Network - Transplant Data 1988-1991. Richmond,VA: UNOS, 1993.  Back to cited text no. 9    
10.Frei U, Brunkhorst R, Schindler R, et al. Present status of kidney transplantation. Clin Nephrol 1992;38 suppl 1:S46-52.  Back to cited text no. 10    
11.Aguilo J, Rodriguez O, Gaete J, Galleguillos I. Vascular anastomosis techniques in renal transplants. Int Angiol 1991;10:39-43.  Back to cited text no. 11    
12.Koss R, Teinturier J, Millize P. Quelques essais de greffe de rein chez l'homme. Mem Acad Chir 77:755(1951) ?????????  Back to cited text no. 12    
13.Perryman JP, Stillerman PU. Kidney transplantation. In: Smith SL (ed). Tissue and Organ Transplantation. St. Louis, Mo: Mosby Year Book; 1990: 176-209.  Back to cited text no. 13    
14.NIDDK National Kidney and Urologic Diseases Information Clearinghouse. End-stage renal disease: choosing a treatment that's right for you. 1997. Available at: http://www.niddk.nih.gov/health/kidney/nk udic.htm Accessed August 30, 2002.  Back to cited text no. 14    
15.Matas AJ, Tellis VA, Karwa GL. Comparison of posttransplant urologic complications following extravesical ureteroneocystostomy by a "single-stitch" or "mucosal" anastomosis. Clin Transplant 1987;1:159-163 (1987).  Back to cited text no. 15    
16.Heron S, O'Brien D III, Welchel JD, Neylan 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 patient. J Urol 1995;153:1210-3.  Back to cited text no. 16    
17.Butterworth PC, Horsburgh T, Veitch PS, Bell PR, Nicholson MR. Urological complications in renal transplantation: impact of a change in technique. Br J Urol 1997;79(4):499-502.  Back to cited text no. 17    
18.B. Yig" it, C. Aydin, I'. Titiz, I' Berber, O. Sinanog" lu, and G. Altaca, Stone Disease in Kidney Transplantation, Transplantation Proceedings, 36, 187_189 (2004)  Back to cited text no. 18    
19.Shoskes DA, Hanbury D, Cranston D, Morris PJ. Urological complications in 1000 consecutive renal transplant recipients. J Urol 1995;153:18-21.  Back to cited text no. 19    
20.Makisalo H, Eklund B, Salmela K, et al. Urological complications after 2084 consecutive kidney transplantations. Transplant proc 1997;29(1-2):152-3.  Back to cited text no. 20    
21.Fontaine AB, Nijjar A, Rangaraj R. Update on the use of percutaneous nephrostomy/balloon dilation for the treatment of renal transplant leak/obstruction. J Vasc Intervent Radiol 1997;8:649-53.  Back to cited text no. 21    
22.Voegeli DR, Crummy AB, McDermott JC, Jensen SR, Montague TL. Percutaneous management of the urologic complications of renal transplantation. Radiographics 1986;6:1007-22.  Back to cited text no. 22    
23.Mundy AR, Podesta ML, Bewick M, Rudge CJ, Ellis FG. The urologic complications of 1000 renal transplants. Br J Urol 1981;53:397-402.  Back to cited text no. 23    
24.Palmer JM, Chatterjee SN. Urologic complications in renal transplantation. Surg Clin North Am 1978;58:305-19.  Back to cited text no. 24    
25.Foster MC, Wenham PW, Rowe PA, et al. The use of older patients as cadaveric kidney donors. Br J Surg 1988;75:767.  Back to cited text no. 25    

Correspondence Address:
Afshar Zomorrodi
Transplant Ward, Imam Hospital, Tabriz Medical University, Tabriz
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PMID: 17679747

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