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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 6  |  Page : 1005-1009
Urological complications of renal transplantation: Reducing the risk


Directorate of Surgery & Renal Services, Plymouth Hospitals NHS Trust, Derriford Hospital, Plymouth PL6 8DH, United Kingdom

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Date of Web Publication27-Oct-2009
 

   Abstract 

Urological complications can have a significant effect on the outcome of renal trans­plantation including the loss of the graft. The aims of this study were to determine the incidence of urological complications occurring after kidney transplantation at our unit, and how the risk of com­plications can be reduced. All 398 renal transplantations performed at Derriford Hospital, Plymouth between August 1997 and December 2006 were reviewed. Twenty nine (7.3%) urological com­plications were noted with a median time to diagnosis of 8.5 days (range 1-950 days) following transplantation; 81% occurring within two weeks. Fourteen (48.3%) of these patients had iden­tifiable risk factors; 10 patients required ureteric reimplantation, 6 had Boari flap reconstruction, and 3 underwent transurethral resection prostatectomy. One graft was lost to severe ureteric nec­rosis. Steps to reduce the risk of complications include avoiding damage to organs during retrieval, meticulous bench preparation including hydrodilating ureters to exclude ureteric injury and vigi­lance during the transplant procedure. Prompt and appropriate corrective surgery can diminish the effect of urological complications on graft survival.

How to cite this article:
Akoh JA, Opaluwa AS, Weller D. Urological complications of renal transplantation: Reducing the risk. Saudi J Kidney Dis Transpl 2009;20:1005-9

How to cite this URL:
Akoh JA, Opaluwa AS, Weller D. Urological complications of renal transplantation: Reducing the risk. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2019 Dec 7];20:1005-9. Available from: http://www.sjkdt.org/text.asp?2009/20/6/1005/57254

   Introduction Top


Since the first successful renal transplantation from one twin to another in 1954, significant improvements in the techniques of renal trans­plantation and the use of immunosuppressive agents have resulted in better outcomes for re­nal transplant recipients. Effort is now being concentrated on ways to improve the quality of life of transplant recipients by reducing the com­plications of immunosuppressive drugs, decrea­sing post-transplant morbidity and length of stay in hospital, and intervening to prevent early or late graft loss.

Urological complications can have a signifi­cant effect on the outcome of renal transplan­tation and may lead to the loss of the graft. At a time when organ shortage is still the most im­portant factor limiting transplantation with in­creasing usage of extended criteria kidneys, efforts must be made to maximize the use of these scarce resources.

The aim of this study is to evaluate the inci­dence of urological complications in consecu­tive transplants and determine how the risk of urological complications can be lowered.


   Patients and Methods Top


All recipients of kidney transplantation at the South West Transplant Centre (SWTC), Derri­ford Hospital, Plymouth between August 1997 and December 2006 were included in the study. The patients were identified using the renal com­puter database (PROTON Information System, Clinical Computing, PLC, London, England). Their discharge summaries were retrieved, and patients who had urological complications were identified. Patients who developed significant urological complications in the allografts were included in the analysis. We entered into pro­forma sheets and analyzed relevant data that in­cluded age, type and date of transplant, and re­cognized risk factors for urological complica­tions such as skeletonized/stripped ureters, da­maged or short ureters, damaged renal arte­ries/bench surgery, multiple renal arteries, base­line immunosuppression, prolonged cold ische­mic time (CIT) greater than 24 hours, and lower urinary tract obstruction and bladder abnorma­lity.


   Statistical analysis Top


The association of risk factors with urological complications was evaluated using Pearson's Chi square test (P≤ 0.05 was regarded as sig­nificant). Patients with perirenal collections not compromising renal function, hematuria (not re­quiring operative intervention) and urinary tract infection were excluded from the study. The duration of follow-up of these patients ranged from 8 to 120 months, with none lost to follow­up.


   Results Top


A total of 398 renal transplant procedures (355 deceased and 43 living donors) were carried out in 394 patients during the study period with a male to female ratio of 2:1. The mean age of the recipients was 46.2 ± 1.71 compared to 45.5 ± 1.77 (range, 12-75 years) for donors. Urological complications were encountered in 29 (7.3%) patients [Table 1]. Risk factors for urological complications were identified in 14 of 29 pa­tients with complications compared to 24 of 369 who did not develop any urological compli­cations (x 2 = 54.323; P = 0.000). In our series 5 kidneys were reported to have ureteric damage. Four patients had prolonged cold ischemia time (CIT) of greater than 24 hours. Other risk fac­tors included delayed graft function in 2, mul­tiple renal arteries in 2 (one of these had 4 renal arteries with 2 of these transected) and one pa­tient with bladder abnormality who had several reconstructive operations prior to transplantation.

One of the seven patients with a urine leak was the recipient of a living related donor kid­ney who failed to pass urine after the operation. An ultrasound scan revealed a fluid collection around the transplant and at exploration urine was found to be draining from a freely floating ureter. The gonadal vein, mistaken for the ure­ter, had been anastomosed to the bladder. Ano­ther patient leaked urine from an unrecognized cut to the renal pelvis. Fifty percent of the com­plications were diagnosed during the first and 31% in the second week. The procedures used in treating the 29 patients with complications are shown in [Table 2]. The only case of graft loss due to urological complication in this series resulted from extensive necrosis of the ureter extending from the lower end to the anterior portion of the renal pelvis. Of the two patients managed by permanent stenting, one suffered necrosis of the lower transplant ureter, but had an adequate length of a well vasculized ureter to allow re-implantation; this was complicated by a stricture. Further attempts at corrective sur­gery were deemed too hazardous. A stent was inserted during a combined antegrade and retro­grade approach. The second patient developed a stricture 2 years post transplant. Following a failed attempt to dissect the ureter due to severe fibrotic adhesions, a stent was inserted with a plan to change every 4-6 months.


   Discussion Top


The 7.3% incidence of urological complica­tions reported in our study compares favorably with 2.9 to 21% reported in large series. [1],[2],[3],[4],[5] It is noteworthy that 81% of the complications occurred within the first 2 weeks of transplan­tation. Vigilance and methodical assessment of post transplant patients are essential in order to identify correctable causes of graft dysfunction at any point in the survival curve.

Our study shows that urological complications are more likely to develop in patients with re­cognized risk factors. However, given the num­ber of transplants and the variety and numbers of risk factors seen, it is difficult to determine whether there are any independent risk factors in our study. Reek et al [1] identified two major etiological factors responsible for urinary leak and early ureteric obstruction to be technical (poor techniques of organ retrieval and ureteric re-implantation) and ureteric ischemia. Injury du-ring retrieval was reported in 1726 of 9014 (19%-7% vascular, 12% non vascular) retrieved kidneys in the UK. [6] Both the vascular and non vascular injuries contribute to the risk of uro­logical complications.

We are not aware of any previous reports of failure to anastomose the ureter, and advocate that the gonadal vein, which serves as a useful anatomical guide to the renal vein during living donor nephrectomy, should be ligated and divi­ded close to the renal vein. This case also high­ lights the need for vigilance throughout the en­tire transplant procedure. The preferred method of uretero-neocystostomy in our centre was the extravesical technique with stenting when indi­cated. This is in agreement with Butterworth et al [7] who reported that both stented and non sten­ted extravesical technique were associated with a lower complication rate than the Leadbetter­Politano technique for vesico-ureteric anasto­mosis.

Though ureteric necrosis was said to be rare in some reports, 5 were recorded in our study. Emiroglu et al [8] experienced 6/1275 patients with distal ureteric necroses. They all required ure­teric re-implantation for restoration of function as in our patients. Ureteric ischemia may be due to denudation of the fragile arterial supply to the ureter. In the retroperitoneal position, the ure­ter receives segmental blood supply from the renal, common iliac, middle rectal, gonadal, su­perior and inferior vesical arteries. These arte­ries anastomose with each other in the adven­titia. Following kidney retrieval and transplan­tation, the ureter depends on the renal artery or arteries until a new vascularization from the vesicular arteries is established. This tenuous blood supply makes the transplant ureter, par­ticularly the lower end, vulnerable to the effects of ischemia-stenosis/stricture and necrosis, the commonest complications observed in our pa­tients. Acute rejection reaction can also cause ischemia of the ureter. [9] Minnee et al [10] identified acute rejection and delayed graft function as the only independent risk factors for a urological complication. Furthermore, Karam et al [11] ana­lyzed the course of 1629 kidney transplants and showed that the independent risk factors for ureteric necrosis included donor age, delayed graft function, cytomegalovirus, high dose ste­roids and short ureteric length. Our experience of one graft loss in a patient with necrosis of the ureter is similar to that of Chmura et al. [5] Great care should be exercised during retrieval and bench preparation of the donor kidney to pre­serve its tenuous arterial blood supply.

Complete obstruction of the renal artery re­sulting in total renal infarction has been repor­ted in patients with fibromuscular dysplasia, [12] which tends to affect the mid or distal renal ar­tery and may result in stenosis of a branch renal artery. Moreover, CsA is known to cause chro­nic fibrosis due to its ability to increase the pro­duction of transforming growth factor β1 . [13]

Stented ureteric re-implantation is often suffi­cient to treat urine leaks and anastomotic ste­nosis of the lower ureter. However, in the pre­sence of necrosis or a long stricture of the trans­plant ureter, the challenge remains to ensure an adequate length of well vascularised ureter to anastomose to the bladder. Although the native ureter can be used to provide a tension free con­duit from the residual transplant ureter to the bladder, frequently this requires mobilization of the native ureter with the attendant risk of stric­ture of the uretero-ureteric anastomosis. Due to its rich blood supply, a pedicled flap of bladder wall (Boari flap) can be used to bridge a 10-15 cm defect in the ureter without tension. [14] A flap length to breadth ratio of 3:1 will ensure the apex is well vascularised. During the mobili­zation of the ureter, care is taken to preserve its adventitia. The ureter is spatulated and anasto­mosed to the flap ensuring that the anastomosis is free of tension and watertight. Tension-free anastomosis is important to avoid stricture, the most common complication in Boari flap re­construction. One of our patients who had ure­teric necrosis received a kidney with a damaged arterial patch. In the United Kingdom, marginal or suboptimal donors account for about 30% of kidneys transplanted, [15] and will continue as a source for the ever increasing demand for organs.

Symptoms in patients with lower urinary tract obstruction manifest usually after renal trans­plantation. This is not unexpected because most patients with chronic renal failure pass little or no urine. There is no agreement with regard to the timing of evaluation and surgical interven­tion of patients with bladder outlet obstruction (BOO) undergoing renal transplantation. Instru­mentation prior to transplantation may predis­pose patients to urethral strictures. [2] Some advo­cate early intervention following renal trans­plantation. Streeter et al [2] reported that only 2% of patients with lower urinary tract obstruction are likely to require surgical intervention within 6 months after transplantation. Three patients in our study who required transurethral resection of the prostate (TURP) had their procedures within 6 months of renal transplantation. It is still controversial whether to evaluate the lower urinary tract of asymptomatic patients before transplantation in order to avoid or reduce symptomatic bladder outlet obstruction (BOO) after surgery. Given the low incidence of BOO (1.3% in our study), such a practice would not be cost effective.

In conclusion, our analysis shows that patients with risk factors are more likely to develop uro­logical complications. We can reduce the risk of these complications by avoidance of damage to organs during retrieval, meticulous bench pre­paration including hydrodilating ureters to ex­clude lacerations, and vigilance throughout the entire transplant procedure. Furthermore, early diagnosis and prompt and appropriate correc­tive surgery can diminish the effect of com­plications on graft function and prevent graft loss.



 
   References Top

1.Reek C, Noster M, Burmeister D, Wolff JM, Seiter H. Urological complications of renal trans­plantation: A series of 900 cases. Transplant Proc 2003;35:2106-7.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Streeter EH, Little DM, Cranston DW, Morris PJ. The urological complications of renal trans­plantation: A series of 1535 patients. BJU Int 2002;90:627-34.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Sert S, Gulay E, Hamaloglu E, Haberal M. Urological complications in 350 consecutive renal transplants. Br J Urol 1990;66:568-71.  Back to cited text no. 3      
4.Mundy 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. 4      
5.Chmura A, Rowinski W, Walaszewski J, Czaplicki M, Kwiatkowski A, Trzebicki J. Treat­ment of early and late urinary complications after kidney transplantation. Transplant Int 2007;20(suppl 2):189.  Back to cited text no. 5      
6.Wigmore SJ, Seeney FM, Pleass HC, Praseedom RK, Forsythe JL. Kidney damage during organ retrieval: Data from UK National Transplant Database. Kidney Advisory Group. Lancet 1999;354:1136-7.  Back to cited text no. 6      
7.Butterworth PC, Horsburgh T, Veitch PS, Bell PRF, Nicholson ML. Urological Complications in renal transplantation: Impact of a change of technique. Br J Urol 1997;79:499-502.  Back to cited text no. 7      
8.Emiroglu R, Karakayall H, Sevmis S, Akkoc H, Bilgin N, Haberal M. Urologic complications in 1275 consecutive renal transplantations. Transplant Proc 2001;33:2016-7.  Back to cited text no. 8      
9.Jaskowski A, Jones RM, Murie JA, Morris PJ. Urological complications in 600 consecutive renal transplants. BMJ 1987;74:922-5.  Back to cited text no. 9      
10.Minnee RC, Surachno S, Kox C, ten berge IJ, Aronson DC, Idu MM. Is a selective splinted ureterocystostomy protocol feasible in renal transplantation? An analysis of 475 renal transplantations. Transplant Int 2006;19:558-62.  Back to cited text no. 10      
11.Karam G, Maillet F, Parant S, Soulillou JP, Girat-Classe M. Ureteral necrosis after kidney transplantation: Risk factors and impact on graft and patient survival. Transplantation 2004;78: 725-9.  Back to cited text no. 11      
12.Goncharenko V, Gerlock AJ, Shaff MI, Hollifield JW. Progression of renal artery fibromuscular dysplasia in 42 patients as seen on angiography. Radiology 1981;139:45-51.  Back to cited text no. 12      
13.Waiser J, Dell K, Bohler T, et al. Cyclosporine A up regulates the expression of TGF- beta 1 and its receptors type I and type II in rat mesangial cells. Nephro1 Dial Transplant 2002; 17:1568.  Back to cited text no. 13      
14.Hsu TH, Stream SB, Nakada SY. Management of upper urinary tract obstruction. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds). Campbel-Walsh UROLOGY Vol 3, 9th edn. Saunders, Philadelphia 2007;1262-4.  Back to cited text no. 14      
15.Andrews PA. Recent developments: Renal transplantation. BMJ 2002;324:530-4.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
Jacob A Akoh
Consultant General and Transplant Surgeon, Level 04 Derriford Hospital Plymouth PL6, 8DH
United Kingdom
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PMID: 19861861

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    Abstract
    Introduction
    Patients and Methods
    Statistical analysis
    Results
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