|Year : 2010 | Volume
| Issue : 2 | Page : 251-257
|Surgical complications in pediatric and adolescent renal transplantation
Rabih El Atat1, Amine Derouiche1, Sabra Guellouz2, Tahar Gargah2, Rachid Lakhoua2, Mohamed Chebil1
1 Department of Urology, Charles Nicolle Hospital, Tunis, Tunisia
2 Department of Pediatric, Charles Nicolle Hospital, Tunis, Tunisia
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|Date of Web Publication||9-Mar-2010|
| Abstract|| |
To report the surgical complications among our pediatric and adolescent renal transplants and to compare these results with other reported series in the literature. A total of 50 pediatric and adolescent renal transplants were included in this study. There were 30 boys and 20 girls with a mean age of 13 years (range 6 - 18 years). 70% of patients received their kidneys from living donors. Two patients underwent renal re-transplantation. Among the 52 transplantations, 17 surgical complications were encountered in 15(30%) patients. The incidence of urological and vascular complications was respectively 13.2% and 18.9%. These complications included vesicoureteral reflux (9.4%), urinary leakage (3.8%), lymphocele (5.8%), peri-renal hematoma (1.9%), renal artery stenosis (3.7%), and thrombosis of the allograft (7.5%). The patients with vesicoureteral reflux were treated by antibiotic prophylaxis. In four recipients, thrombosis of the allograft with subsequent graft loss occurred. The graft survival rate was 90% in 1 year, 77% in 5 years and 40% in 10 years follow-up. The patient survival rate was 94.4% in 1 year and 84% after 8 years follow-up. We conclude that surgical complications can be minimized if basic principles of careful transplant techniques are used. Prompt identification and treatment of any complication are critical for graft and patient survival.
|How to cite this article:|
El Atat R, Derouiche A, Guellouz S, Gargah T, Lakhoua R, Chebil M. Surgical complications in pediatric and adolescent renal transplantation. Saudi J Kidney Dis Transpl 2010;21:251-7
|How to cite this URL:|
El Atat R, Derouiche A, Guellouz S, Gargah T, Lakhoua R, Chebil M. Surgical complications in pediatric and adolescent renal transplantation. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2020 Feb 28];21:251-7. Available from: http://www.sjkdt.org/text.asp?2010/21/2/251/60062
| Introduction|| |
Renal transplantation is the therapy of choice in end-stage renal failure in children. Although rejection is the main cause of graft failure, surgical complications can also play a role in graft loss and even patient mortality.
The incidence of surgical complications after kidney transplantation has been reported to range from 1 to 33%, ,,, data are not really comparable because some author include only major surgical complications, whereas others even include urinary tract infections.
We performed a retrospective study of surgical complications in our pediatric transplant patients and compared these results with other reported series.
| Subjects and Methods|| |
From June 1986 to December 2007, 409 kidney transplantations were performed in our institution, including 50 children and adolescents who comprised the study group. There were 30 boys and 20 girls with a mean age of 13 years (range 6 - 18 years). Their weights ranged from 15 to 59 Kg (mean of 32 kg). Thirty-five (70%) patients received their kidneys from living donors, and 2 patients underwent re-transplantation. All patients were treated with dialysis prior to transplantation.
We used the standard open surgical technique with a right pararectal incision with an extraperitoneal approach. We used the common iliac for arterial anastomosis in 50 cases, and the hypogastric artery in 2 cases. The venous anastomosis was performed with the external iliac vein in all the cases. There were no cases of bladder enlargement previous to transplantation. The uretero-vesical re-implant in all the cases was extra-vesical through the LichGregoir technique associated with ureteral stent.
| Results|| |
Among the 52 transplantations, 17 surgical complications occurred in 15 patients. The overall rate of surgical complication was 32%. These complications included are shown in the [Table 1]. The incidence of urological complications and vascular complications were respectively 13.2% and 18.9%.
Urinary leakage was observed in 2 patients, ureteral in one case and calyceal in the other case; the interval to diagnosis was 2 weeks, and symptoms included sudden oliguria and an increasing serum creatinine level. The leakage was treated by antegrade fixation of a ureteric stent.
The calyceal fistula was secondary to an accidental ligation of polar vessels; the upper pole of the graft was infracted. Upper polar partial nephrectomy was performed and the repair was reinforced by an omental patch.
The characteristics and the management of the patient with vesico-ureteral reflux are shown in the [Table 2].
Asymptomatic lymphocele was diagnosed in 3 patients. The diagnosis was made with ultrasonography and confirmed by needle aspiration of the lymphocele content and estimation of the creatinine concentration. The treatment was conservative in the 3 cases due to the small volume of the collections.
Renal artery stenosis was reported in 2 of our patients. Both patients presented with hypertension had a normal serum creatinine level and were successfully treated with antihypertensive medications.
In 4 recipients, thrombosis of the allograft with subsequent graft loss occurred. One patient had a significant peri-renal hematoma, which presented in the immediate postoperative period with a decreasing hematocrit and hypotension requiring blood transfusion.
During the follow-up period, 10 grafts were lost due to chronic rejection and 4 patients died. There were 4 losses of grafts due to surgical complications. The patient survival rate [Figure 1] was 94.4% in 1 year, and 84% after 8 years follow-up. The graft survival rate [Figure 2] was 90% in 1 year, 77% in 5 years and 40% in 10 years follow-up.
| Discussion|| |
Surgical complications represent the most common complication after pediatric renal transplantation and may be associated with significant morbidity.
A summary of urological complications in pediatric patients reported in the literature and our own series is given in [Table 3].
Urological complications can be a real threat to the graft and even patient survival. In the literature especially urinary leakage and obstruction have a considerable mortality rate. In our study, no patient died because of urological complications.
Ureteric obstruction may occur in either the early or the late postoperative period, while ureteral fistula is generally evident early after transplantation. Technical problems can induce ureteric vascular insufficiency, such as transient hypotension with vascular declamping compromising the already marginal ureteral blood supply and failure to preserve ureteral blood supply during procurement by not adhering to principles of proper dissection.
The use of graft percutaneous nephrostomy in the initial management of ureteral complications significantly improved graft survival and function and reduced the incidence of posttreatment complications.  Patients initially treated by graft percutaneous nephrostomy, endourologic procedures (ureteral stent, antegrade balloon dilatation) provided definitive management in 40% of case with small ureteral fistula and in 28% of cases with ureteral obstruction. Surgery is required for the leaks associated with ureteral necrosis and for the late and severe cases of ureteral obstruction.
Calyceal fistula is serious sequelae of renal transplantation occurring in approximately 3% of allografts. The urinary leak is usually secondary to infarction due to ligation of polar vessels or damage during retrieval or bench surgery. Early intervention is mandatory to avoid wound infection and systemic infection which could be fatal. 
In a series of 543 renal transplants, 6 patients suffered a post transplant renal segmental infarct and developed calyceal fistulas between 9 and 17 days.  They were treated by partial (25 to 40%) transplant nephrectomy, followed by closure and tissue coverage.
The frequency of post-transplant vesico-ureteral reflux (VUR) in children and the factors that favor the development of VUR are poorly known, and studies published to date have yielded contradictory findings. The higher occurrence of post-transplant VUR (34 - 36%) in children has been reported in some studies, ,,, while the occurrence of surgery for post-transplant VUR in pediatric patients is 5.5%. In our study, we did not screen systematically for post-transplant VUR. The appearance of VUR may depend on the time elapsed between transplantation and diagnostic studies to detect this complication, and the type of uretero-vesical anastomosis used. , In an earlier prospective, randomized trial,  VUR was less frequent when the Leadbetter-Politano technique was used. However, like most transplant teams, we used an extra-vesical approach because it is associated with lower rates of post-surgical complications, and requires shorter segments of ureters and less operating time to perform. A number of authors ,,,,,,, have noted that the presence of VUR is not associated with an increase in the frequency of post-transplant urinary tract infection. According to French and Fontana et al, , VUR did not affect graft function in the short and long-term. The surgical treatment was performed only when UTI appeared despite antibiotic prophylaxis, or after antibiotics were withdrawn 6 months after transplantation. In some patients, a less invasive endoscopic technique may be useful. Cloix et al  and Mallet et al,  reported success rates of 30% and 53%, respectively.
Lymphocele represents an extraperitoneal collection of lymph created by division of lymphatic vessels, and it is best prevented by meticulous sequential lymphatic ligation during recipient vessel exposure, and by limiting the extent of dissection to that needed for safe proximal and distal vascular control.  Shokeir  treated his patients with symptomatic lymphocele successfully with percutaneous catheter drainage and sclerotherapy with an overall success rate of 50%. Should catheter drainage fail, laparoscopic marsupialization is usually effective .
Renal artery stenosis was reported in only two of our patients. Both patients presented with hypertension and were successfully treated with antihypertensive medications. Zaontz et al  summarized the etiological factors of renal artery stenosis as faulty surgical technique, trauma to the donor kidney from the perfusion canula or intimal tears from overstretching the artery, or artery angulation secondary to excessive length from end-to-end anastomosis with the hypogastric artery.  Surgical correction of renal artery stenosis may be indicated in patients with either intractable hypertension and/ or deteriorating renal function. Radiographic angioplasty to relieve renal artery/segmental stenosis is especially difficult in children. 
Renovascular thrombosis developed in 4 of our pediatric recipients. Sheldon et al reported no renovascular thrombosis in the small number of living donor transplants.  They speculated that kidney allografts from live donors may have less vascular resistance and provide better graft perfusion than deceased grafts. They also mentioned that the risk of deceased allograft thrombosis in young recipients is high, necessitating aggressive preventive measures. They strongly recommended the use of living related donors in young recipients; all our patients received kidneys from living related donors.
In the Shokeir series,  the type of primary urinary continuity was the only factor that affectted the incidence of surgical complications on multivariate analysis, with the best results achieved with the use of the extravesical Lich-Gregoir technique. He observed a high complication rate with the uretero-ureteral anastomosis. This observation is different from a recent report on a large number of children with uretero-ureteral anastomosis by Lapointe et al who concluded that uretero-ureteral anastomosis is a safe and effective technique for pediatric renal transplantation with a low complication rate (8.4%).  This difference could be attributed to the fact that the vast majority of the patients in the Lapointe  series (144 of 166) received kidneys from deceased donors, while all of Shokeir  patients received live donor transplants. Several authors reported that the incidence of urological complications is more common with living donor transplants in comparison with deceased grafts because of the different technique of kidney retrieval. Another reason for the difference in the results is the limited number of our patients who were subjected to uretero-ureteral anastomosis in comparison to the series of Lapointe et al. 
Although rejection has been implicated as a possible mechanism in the development of ureteral leaks, analysis of the data in our study and in others ,, failed to confirm this view. Moreover, there is no evidence that multiple renal arteries are associated with an increased risk to the ureteral complications, as suggested by Hricko et al.  Finally, the incidence of ureteral complications did not differ in recipients receiving cyclosporine compared with those given conventional immunotherapy. This finding is not consistent with the speculation that unwanted vasoactivity associated with cyclosporine could be associated with increased ureteral problems.
We conclude that kidney transplantation in children is a viable treatment option for terminal kidney disease presenting success and surgical complication rate similar to kidney transplantation in adults. Surgical complications in pediatric and adolescent renal transplant recipients can be minimized if basic principles of careful transplant techniques are used. Prompt identification and treatment of any complication are critical to graft and patient survival.
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Rabih El Atat
Charles Nicolle Hospital, Service Urology 138 Boulevard 9 Avril, 1006 Tunis
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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