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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 2  |  Page : 232-236
Frequency of occurrence of vesico-ureteral reflux in kidney transplanted patients with the new technique of uretero-neo­ cystostomy (Barry-Taguchi)


Urmia University of Medical Sciences, Department of Transplantation, Imam Khomeini Training Hospital, Urmia, Iran

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Date of Web Publication9-Mar-2010
 

   Abstract 

There are several ways of performing vesico-ureteral anastomosis in kidney trans­plantation (Tx); they are broadly classified into two categories: extra-vesical and intra-vesical. Extra-vesical methods are preferred in kidney transplantation. In this study, we attempt to integ­rate two extra-vesical techniques of Barry and Taguchi and to evaluate the frequency of occu­rrence of vesico-ureteral reflux (VUR) with this technique. Also, an attempt is made to compare the results with other techniques reported in the literature. Fifty consecutive transplant recipients, who underwent uretero-neo-cystostomy (uretero-vesical anastomosis) by the new technique of Barry-Taguchi were evaluated for VUR by sonography and cystoureterography, six months after Tx. The mean age of the study subjects was 34.8 years; there were 33 males and 17 females. The mean time between Tx and evaluating for VUR was 6.6 months. Two cases of asymptomatic VUR (4%) were detected at the end of the study period. The occurrence of 4% asymptomatic VUR suggests that this technique is more acceptable compared to others. Because of the simple nature of the procedure as well as the short time required, this technique could be a suitable choice in kidney transplantation.

How to cite this article:
Mohammadi Fallah MR, Afshari AT, Estifayi K, Ghafari A, Sepehrvand N, Hatami S. Frequency of occurrence of vesico-ureteral reflux in kidney transplanted patients with the new technique of uretero-neo­ cystostomy (Barry-Taguchi). Saudi J Kidney Dis Transpl 2010;21:232-6

How to cite this URL:
Mohammadi Fallah MR, Afshari AT, Estifayi K, Ghafari A, Sepehrvand N, Hatami S. Frequency of occurrence of vesico-ureteral reflux in kidney transplanted patients with the new technique of uretero-neo­ cystostomy (Barry-Taguchi). Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 May 21];21:232-6. Available from: http://www.sjkdt.org/text.asp?2010/21/2/232/60058

   Introduction Top


Kidney transplantation is the preferred replace­ment therapy among patients with end-stage renal disease (ESRD). Since the first success­ful experience of kidney transplantation in hu­mans, many attempts have been made in order to decrease the complications of transplanta­tion, which can threaten the allograft. [1],[2],[3],[4],[5]

Having an appropriate choice among vascular and vesico-ureteral anastomosis techniques could prevent most of the surgical complications, es­pecially vesico-ureteral reflux (VUR), the pre­sence of which, can increase the probability of developing pyelonephritis due to lower urinary infection by eight-fold. [6]

Numerous innovations have been developed to circumvent uretero-vesical anastomotic fai­lure. [7] Several different techniques have been suggested to perform anastomosis of the allo­graft ureter to the bladder. These techniques are classified into two general categories: extra­vesical and intra-vesical methods. The first group is more accepted. Some of the advantages of extra-vesical uretero-neo-cystostomy include: shorter operation time, avoidance of a separate cystotomy, virtually no hematuria, ability to use short ureters, no need for splints or stents, shor­tened foley's catheter drainage, and no inter­ference with native ureteral function. [8]

Techniques with anti-reflux mechanism are more common among extra-vesical methods. Among these techniques, Barry, Lich-Gregoir and Taguchi methods are frequently used. The Barry method has an excellent anti-reflux me­chanism due to the creation of a suitable sub­mucosal tunnel. [9] The Taguchi method attracts more attention because of simplicity, short duration and good results. These techniques were used earlier, in the transplantation center of the Imam-Khomeini Hospital in Urmia. In this study, we attempt to integrate two diffe­rent techniques to extract the advantages of both. This method was suggested earlier by Capparos in a study in 1996; [10] unfortunately, there are no studies since then. Also, evalua­tion of the frequency of occurrence of VUR with this method has not been studied earlier, hence this study.


   Materials and Methods Top


Study Population

Fifty consecutive transplant recipients in the department of transplantation at the Imam-Kho­meini Hospital of Urmia, Iran who underwent uretero-neo-cystostomy (uretero-vesical anas­tomosis) by the new technique of Barry-Ta­guchi during 2005-2006 were enrolled in our study. Our exclusion criteria included presence of bladder anomalies, neurogenic bladder, his­tory of cystoplasty, urethral stricture, patients who did not give consent to participate in the study, as well as those who expired, and those who underwent graft nephrectomy. The patients were enrolled in our study after explaining the procedure and obtaining informed consent.

The Barry-Taguchi Technique

At the beginning of surgery, the recipients' bladder was filled with 150-200 mL of antibio­tic solution through the foley's catheter follo­wing which, the catheter was clamped. After vascular anastomosis and urinary flow through the transplanted ureter were established, the distal one centimeter of the ureter was dissec­ted from the peripheral tissues and accurate homeostasis was established. The posterior sur­face of the ureter was then spatulated for 0.5 cm. The bladder was then exposed, and its fat tissue pooled over from the antero-lateral sur­face. Two transverse and parallel incisions, one cm in length and 2-3 cm apart, were made on the antero-lateral surface of the detrusor muscle and the vesical mucosa was exposed. After that, a sub-mucosal tunnel was created between these two incisions and the ureter was passed through this tunnel.

In this step, a transient Double J ureteral stent was placed in the ureter and pelvis of kidney. When the distal tunnel mucosa was incised, we inserted the distal part of the stent into the bladder. The distal ureter was inserted and fixed to the bladder with a U-shaped single absor­bable stitch (Vicryl 3.0) placed four cm from the cystostomy site. The distal detrusor incision was sutured by an absorbable stitch (3.0 vicryl). The indwelling ureteral stent was pulled out by cystoscope about 2-3 weeks after transplan­tation under local anesthesia.

Data Collection

The patients were followed-up for approxi­mately six months after transplantation. During these six months, urine analysis (U/A) and urine culture (U/C) were checked monthly and in symptomatic cases, when needed. Ultrasono­graphy was performed on all patients. After antibiotic prophylaxis, patients underwent voi­ding cysto-urethrography (VCUG) with urethral catheter. Sonography and VCUG were per­formed on all patients to evaluate probable re­flux. If there was any reflux into the trans­planted kidney, grading was determined accor­ding to the international classification. Data such as time taken for ureteric anastomosis were collected from medical records.


   Statistical Analysis Top


We analyzed the data using SPSS software version 11.5. The results are presented in gra­phical form.


   Results Top


The mean age of the study-group was 34.82 years (range, 6-59 years) [Figure 1]. There were 33 male patients (66%) and 17 females (34%). The time taken for uretero-vesical anastomosis using the new technique of Barry-Taguchi with stent implantation was between 6 and 30 mi­nutes, with a mean time of 17.26 minutes. Ure­teral stent (DJ) was removed with cystoscopic guidance 10-18 days (mean time of 13.6 days) after transplantation, as outpatient and under local anesthesia.

The mean period between performing VCUG and ultrasonography and transplantation was 6.6 months (range, 4 to 8 months). Among 50 patients studied, 16 cases (32%) had mild sta­sis in the urinary collecting system of the trans­planted kidney [Figure 2] . In one case, there was moderate hydronephrosis; however, no obstruction was detected. Of the 50 cases that underwent VCUG, VUR was found in two cases (4%); one was a 20-year-old female pa­tient who had grade-IV reflux, and the other was a 13-year-old male who had grade-III VUR into the transplanted kidney. Ultrasonography showed mild urinary stasis in the pyelocalyceal system. Several studies have indicated that in the presence of VUR, if we have lower UTI, the probability of pyelonephritis increases, particularly in kidney transplanted patients. During the study period, four patients were evaluated for fever associated with UTI with positive urine culture for E. Coli. None of them had VUR.


   Discussion Top


The aim of kidney transplantation is to a­chieve satisfactory survival for patient and graft with minimal morbidity, and ultimately returning to a normal life. To achieve such goals, the technique of transplantation has pro­gressed over the last century, especially in the last three decades. Now, renal transplantation is the renal replacement therapy of choice for patients with chronic renal failure.

Urological complications of allogenic kidney transplantation include VUR, which can result in graft threatening UTI. In the study of Praz et al, two consecutive vesico-renal refluxes led to the loss of the kidney graft in the long-term. [4] To prevent this complication, several uretero­vesical anastomosis techniques have been de­veloped. [1],[2],[3],[4],[5],][11],[12],[13],[14]

Reconstruction of the urinary system during renal transplantation is usually performed with anti-reflux uretero-neo-cystostomy techniques and extra-vesical methods are usually preferred. [3] In the study of Mastrosimone, the frequency of VUR among kidney transplanted patients who underwent extra-vesical ureteral anastomosis was reported to be 86.4%. [6]

Ostrowski et al presented a comparison of three different techniques in their study: extra­vesical without anti-reflux mechanism, extra­vesical Witzel-Lich with anti-reflux mechanism and intra-vesical Leadbetter-Politano with anti­reflux mechanism. The incidence of VUR va­ried from 13.3 to 50%, depending on the anas­tomosis technique. No correlation was found between type of anastomosis and occurrence of UTI. [15]

In their study, Secin et al compared the in­cidence of urological and anastomotic compli­cations, and the duration of ureteral re-implan­tation for the Taguchi and Lich-Gregoir tech­niques. There were no cases of symptomatic reflux in the Taguchi group. They reported that the Taguchi uretero-neo-cystostomy proved to be a more rapid method without increasing the incidence of urological or anastomotic compli­cations. The Lich-Gregoir cohort was at grea­ter risk for urological complications following live donor transplantation. [16]

Conlin et al reported the occurrence of Grade-I VUR in 3% of 182 unstented allograft ureters and five of 13 (46%) stented allograft ureters. [17] In another study by Gutierrez Baflos et al, among 79 renal transplants with extra-vesical uretero­neo-cystostomy, no cases of VUR were repor­ted. [18]

Gutierrez Baflos et al in another study, com­pared two extra-vesical methods of Campos Freire with the Taguchi technique. Although both techniques achieved good results, they advocated the use of the Taguchi technique because it is easy to perform and the operating time is shorter. [19]

Lee et al performed a comparative outcome study of the standard Lich-Gregoir technique and the Taguchi technique, which resulted in dramatically higher complication rates with the Taguchi technique (23%) than with the modi­fied Lich-Gregoir technique (7%). [2]

On the other hand, Moreira et al compared these techniques and reported that both tech­niques showed similar results; however, the Taguchi technique was reported to be simpler and quicker to perform. [20] In a study by Zargrar et al, the complication rate was less among pa­tients in whom the Lich-Gregoir technique was used (P < .02) compared to the Taguchi tech­nique. [7]

In the study of Nane et al using the Lich­Gregoir technique, post-operative VUR to the transplanted kidney was seen in 2.9% of the cases. [3] Whang et al reported less than 1% rate of VUR among 1083 ureteral re-implant ope­rations using the Lich-Gregoir technique. [5]

By reviewing all these studies, it seems that the new technique of Barry-Taguchi for uretero­vesical anastomosis is a suitable method be­cause it is extra-vesical, needs less time and yields good results. The frequency of VUR was 4% by using this technique, which is in accep­table range compared with other methods re­ported in the literature. Further studies are nee­ded to evaluate other complications of anasto­mosis such as stricture, urinary leakage, ure­teral necrosis, etc.


   Acknowledgement Top


The authors would like to thank Urmia Uni­versity of Medical sciences for the grants pro­vided for our study.

 
   References Top

1.Gibbons WS, Barry JM, Hefty TR. Compli­cations following unstented parallel incision extravesical ureteroneocystostomy in 1,000 kid­ney transplants. J Urol 1992;148(1):38-40.  Back to cited text no. 1      
2.Lee RS, Bakthavatsalam R, Marsh CL, Kuhr CS. Ureteral complications in renal transplan­tation: A comparison of the Lich-Gregoir versus the Taguchi technique. Transplant Proc 2007;39(5):1461-4.  Back to cited text no. 2      
3.Nane I, Kadioglu TC, Tefekli A, Kocak T, Ander H, Koksal T. Urologic complications of extravesical ureteroneocystostomy in renal trans­plantation from living related donors. Urol Int 2000;64(1):27-30.  Back to cited text no. 3      
4.Praz V, Leisinger HJ, Pascual M, Jichlinski P. Urological complications in renal transplanta­tion from cadaveric donor grafts: a retrospec­tive analysis of 20 years. Urol Int 2005;75 (2):144-9.  Back to cited text no. 4      
5.Whang M, Geffner S, Baimeedi S, Bonomini L, Mulgaonkar S. Urologic complications in over 1000 kidney transplants performed at the Saint Barnabas healthcare system. Transplant Proc 2003;35(4):1375-7.  Back to cited text no. 5      
6.Mastrosimone S, Pignata G, Maresca MC, et al. Clinical significance of vesicoureteral reflux after kidney transplantation. Clin Nephrol 1993; 40(1):38-45.  Back to cited text no. 6      
7.Zargar MA, Shahrokh H, Mohammadi Fallah MR, Zargar H. Comparing Taguchi and anterior Lich-Gregoir ureterovesical reimplan­tation techniques for kidney transplantation. Transplant Proc 2005;37(7):3077-8.  Back to cited text no. 7      
8.Cos LR, Light JA, Stutzman RE. External ure­teroneocystostomy in renal transplantation. Urology 1985;26(4):362-7.  Back to cited text no. 8      
9.Barry JM, Hatch DA. Parallel incision, unsten­ted extravesical ureteroneocystostomy: follow­up of 203 kidney transplants. J Urol 1985;134 (2):249-51.  Back to cited text no. 9      
10.Caparros J, Regalado RI, Sanchez-Martin F, Villavicencio H. A simplified technique for ureteroneocystostomy in renal transplantation. World J Urol 1996;14(4):236-8.  Back to cited text no. 10      
11.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(4):499-502.  Back to cited text no. 11      
12.Fuller TF, Deger S, Buchler A, et al. Ureteral complications in the renal transplant recipient after laparoscopic living donor nephrectomy. Eur Urol 2006;50(3):535-40.  Back to cited text no. 12      
13.Kocak T, Nane I, Ander H, Ziylan O, Oktar T, Ozsoy C. Urological and surgical complications in 362 consecutive living related donor kidney transplantations. Urol Int 2004;72(3):252-6.  Back to cited text no. 13      
14.Ranchin B, Chapuis F, Dawhara M, et al. Vesi­coureteral reflux after kidney transplantation in children. Nephrol Dial Transplant 2000;15(11): 1852-8.  Back to cited text no. 14      
15.Ostrowski M, Wlodarczyk Z, Wesolowski T, et al. Influence of ureterovesical anastomosis tech­nique on the incidence of vesicoureteral reflux in renal transplant recipients. Ann Transplant 1999;4(1):54-8.  Back to cited text no. 15      
16.Secin FP, Rovegno AR, Marrugat RE, Virasoro R, Lautersztein GA, Fernandez H. Comparing Taguchi and Lich-Gregoir ureterovesical re­implantation techniques for kidney transplants. J Urol 2002;168(3):926-30.  Back to cited text no. 16      
17.Conlin MJ, Lemmers MJ, Barry JM. Postope­rative cystography is unnecessary following renal transplantation with parallel incision extravesical ureteroneocystostomy. Tech Urol 2001;7(1):55-6.  Back to cited text no. 17      
18.Gutierrez Banos JL, Portillo Martin JA, Correas Gomez MA, Monge Mirallas JM, Roca Edreira A. Single-stitch extravesical ureteroneocystos­tomy in kidney transplantation (Taguchi's technic). Actas Urol Esp 1994;18(5):569-72.  Back to cited text no. 18      
19.Gutierrez Banos JL, Portillo Martin JA, Correas Gomez MA, Monge Mirallas JM, Roca Edreira A. Extravesical ureteroneocystostomy in renal transplantation. Comparative study of the Campos Freire's and the Taguchi's techniques (single point). Arch Esp Urol 1994;47(4):393-­8.  Back to cited text no. 19      
20.Moreira P, Parada B, Figueiredo A, et al. Com­parative study between two techniques of ure­teroneocystostomy: Taguchi and Lich-Gregoir. Transplant Proc 2007;39(8):2480-2.  Back to cited text no. 20      

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Correspondence Address:
Nariman Sepehrvand
Students' Research Committee, Urmia University of Medical Sciences, Urmia, West-Azerbaijan
Iran
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    Abstract
    Introduction
    Materials and Me...
    Statistical Analysis
    Results
    Discussion
    Acknowledgement
    References
    Article Figures
 

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