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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2011  |  Volume : 22  |  Issue : 1  |  Page : 72-74
Management of ureteral complications in renal transplantation: Prevention and treatment


Department of Urology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran

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Date of Web Publication30-Dec-2010
 

   Abstract 

Urinary anastomotic complications following renal transplantation cause significant patient morbidity. In ureteric reconstruction, different techniques are used to reduce complications (such as leakage or obstruction). In this study, we suggested two aspects of management of the complications of ureteral anastamosis: ureteral spatulation more than 10 mm for prevention and percutaneous nephrostomy and balloon dilatation as the first steps of treatment. A sequential double-blind random trial with 170 kidney transplant recipients was performed, dividing the patients into two groups: group 1 patients had ureteral spatulation length ≤10 mm (70 recipients) and group 2 patients had ureteral spatulation ≥10 mm (100 recipients). In patients with ureteral stenosis, percutaneous nephrostomy (PCN) and balloon dilatation were used as the first step of treatment. The mean age was 44 ± 4.2 years. Before and after removing the double J stent, ure­teral complications that needed surgical intervention occurred in 16/70 recipients in group 1 (20.3%) and in eight/100 recipients in group 2 (8%). There is a significant difference between the two groups (P < 0.05). PCN and balloon dilatation were performed in 24 patients with ureteral stenosis. Eleven patients had a good response and 13 patients underwent surgical procedures (in four of theses patients, ileal interposition was used for repairing the ureteral defects). In con­clusion, ureteral spatulation more than 10 mm in prevention of ureteral stenosis and use of PCN and balloon dilatation in the first step of treatment of ureteral obstruction should be the manage­ment choice for these patients.

How to cite this article:
Asadpour A, Molaei M, Yaghoobi S. Management of ureteral complications in renal transplantation: Prevention and treatment. Saudi J Kidney Dis Transpl 2011;22:72-4

How to cite this URL:
Asadpour A, Molaei M, Yaghoobi S. Management of ureteral complications in renal transplantation: Prevention and treatment. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Nov 18];22:72-4. Available from: http://www.sjkdt.org/text.asp?2011/22/1/72/74353

   Introduction Top


Renal transplantation is the best choice in the treatment of end-stage renal disease. Urinary anastomotic complications following renal trans­ plantation cause significant patient morbidity. In ureteric reconstruction, different techniques are used to reduce complications after ureteral reimplantation, such as leakage or obstruction. [1],[2]

Standard treatment of these complications is repeat ureteroneocystostomy or ureterourete­rostomy with the recipient ureter. [3] Open sur­gical treatment of ureteral stenosis is techni­cally difficult.

Some factors make this procedure more dif­ficult, such as compromised ureteral blood sup­ply, ureteral necrosis and post-surgical fibrosis. [4]

In this study, we report the ureteral compli­cations based on urologist's experience for ure­teral reimplantation with two different spatu­lation lengths to reduce these complications and subsequent difficult surgical procedures.


   Subjects and Methods Top


From September 2004 to June 2008, 170 kid­ney transplant recipients were studied and their ureteral complications were analyzed. In all patients, the ureter was extravesically implan­ted by the Lich-Gregoir technique with reten­tion of the double J stent for at least six weeks.

Patients were divided into two groups: group 1 had patients with ureteral spatulation length less than 10 mm (70 recipients) and group 2 had patients with ureteral spatulation 10 mm or more (100 recipients). During follow-up, ure­teral complications were evaluated and com­pared between the two groups.

In patients with ureteral stenosis, percutaneous nephrostomy (PCN) was performed and, after two weeks, antegrade pyelography was also performed. Balloon dilatation and insertion of a double J stent for at least two months was used for significant stricture. After this period, if there was any obstruction shown in the ultra­sonography or retrograde pyelography after re­moval of the double J stent, open surgery was performed.

The T-test was used for comparing quanti­tative variables among patients of two cate­gories. A P-value less than 0.05 was considered significant.


   Results Top


The mean age of our patients was 44 ± 4.2 years (36-58), and 120 were males and 50 were females. The most common causes of end­stage renal disease were hypertension, diabetes mellitus and chronic urinary infections.

Before and after removing the double J stent (six weeks later), ureteral complications that needed surgical intervention (open or percuta­neous) occurred in 16/70 recipients in group 1 (20.3%) and in eight/100 recipients in group 2 (8%) (P < 0.05).

Urine leakage and ureteral stenosis were the most frequent complications.

PCN and balloon dilatation were performed in 24 patients with ureteral stenosis. Eleven pa­tients had a good response to these treatments and, in the follow-up period, had no recurrence.

Thirteen patients underwent surgical proce­dures and, in four of them, ileal interposition was used for repairing the ureteral defects. No mortality related to any of the urological com­plication was reported during the follow-up (mean time, 13 months).


   Discussion Top


In different transplant centers, the incidence of ureteral complications following renal trans­plant varies from 2% to 20%. [6]

There are four causes for complications after transplantation: donor-related, recipient-related, medical management and surgical technique. [4] These complications include urinary leakage, urinary obstruction, ureteral necrosis, fistulas, malignancies and calculi. [7] Poor techniques with destruction of a lower polar artery, stripping the ureter or surgical problems at the time of implantation are the main reasons for ureteral problems. High-dose steroid therapy [8] and chro­nic rejection [9] have been mentioned as further risk factors.

Ureteral stenosis occurs in 2-10% of renal transplant recipients, [10] which presents with nausea, vomiting, decreased urine output and increased creatinine. [11] The most common loca­tion of obstruction is at the distal ureter and the ureterovesical junction. [12] Ureteral stenosis of the distal ureter is a frequent late compli­cation. [6] Surgical technique for vesicoureteral anastomosis is an important factor in determi­ning ureteral complications after renal trans­plantation. [13],[14] A variety of methods have been used for vesicoureteral anastomosis. Studies have demonstrated that extravesical reimplan­tation techniques are superior to intravesical reimplantation with respect to operative times and decreased complication rates. [15],[16]

Ureteral spatulation length is an important factor in ureteral anastomosis for reducing the distal ureteral stenosis. In our study, we de-monstrated that ureteral spatulation more than 10 mm is an effective method in decreasing this complication.

The standard method of treating transplant ureteral strictures is open surgical techniques. [17] Traditional therapy is still ureterocystostomy or a ureteroureterostomy using the recipient's ipsilateral ureter. In the failure of this treat­ment, an ileal interposition can be used. [18]

For the treatment of ureteral stenosis, we recommend the following staged procedures: first, PCN. After two weeks, antegrade pyelo­graphy should be performed and if significant stricture is still present, balloon dilatation is our recommendation. Open sur-gery is the last step in failure of this primary process.

In conclusion, ureteral spatulation more than 10 mm in the prevention of ureteral stenosis and use of PCN and balloon dilatation as the first steps of treatment of ureteral obstruction are our recommendation in the management of these patients.

 
   References Top

1.Gu YL, Dahmen U, Dirsch O, Broelsch CE. Improved renal transplantation in the rat with a nonsplinted ureteroureterostomy. Microsurgery 2002;22(5):204-10.  Back to cited text no. 1
    
2.Oesterwitz H, Althaus P. Orthotopic kidney transplantation in the rat with non-splinted end-to-end ureteric anastomosis: Details of a technique. Urol Res 1982;10(3):149-52.  Back to cited text no. 2
    
3.Shoskes DA, Hanbury D, Cranston D, Morris PJ. Urological complications in 1,000 conse­cutive renal transplant recipients. J Urol 1995; 153(1):18-21.  Back to cited text no. 3
    
4.Lojanapiwat B, Mital D, Fallon L, et al. Ma­nagement of ureteral stenosis after renal trans­plantation. J Am Coll Surg 1994;179(1):21.  Back to cited text no. 4
    
5.Samhan M, Al-Mousawi M, Hayati H, Abdul­halim M, Nampoory MR. Urologic complica­tions after renal transplantation. Transplant Proc 2005;37(7):3075-6.  Back to cited text no. 5
    
6.Praz V, Leisinger HJ, Pascual M, Jichlinski P. Urologic 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. 6
    
7.Palmer JM, Chatterjee SN. Urologic complica­tions in renal transplantation. Surg Clin North Am 1978;58(2):305-19.  Back to cited text no. 7
    
8.Shoskes DA, Hanbury D, Cranston D, Morris PJ. Urological complications in 1000 consecutive renal transplant recipients. J Urol 1995;153(1): 18-21.  Back to cited text no. 8
    
9.Keller H, Noldge G, Wilms H, Kirste G. Inci­dence, diagnosis and treatment of ureteric stenosis in 1298 renal transplant patients. Transplant Int 1994;7(4):253-7.  Back to cited text no. 9
    
10.Lojanapiwat B, Mital D, Fallon L, et al. Ma­nagement of ureteral stenosis after renal trans­plantation. J Am Coll Surg 1994;179(1):21-4.  Back to cited text no. 10
    
11.Gerrard ER Jr, Burns JR, Young CJ, et al. Retrograde stenting for obstruction of the renal transplant ureter. Urology 2005;66(2):256-60.  Back to cited text no. 11
    
12.Bhagat VJ, Gordon RL, Osorio RW, et al. Ureteral obstructions and leaks after renal transplantation. Outcome of percutaneous ante­grade ureteral stent placement in 44 patients: Radiology 1998;209(1):159-67.  Back to cited text no. 12
    
13.Krol R, Ziaja J, Chudek J, et al. Surgical treat­ment of urologic complications after kidney transplantation. Transplant Proc 2006;38(1): 127-30.  Back to cited text no. 13
    
14.Murray JE, Merrill JP, Harrison JH. Renal homotransplantations in identical twins. J Am Soc Nephrol 2001;12(1):201-4.  Back to cited text no. 14
    
15.Lich R Jr, Howerton LW, Davis LA. Ureteral reflux, its significance and correction. South Med J 1962;55:633-5.  Back to cited text no. 15
[PUBMED]  [FULLTEXT]  
16.Gregoir W, Vanregemorter G. Congenital Vesico-Ureteral reflux. Urol Int 1964;18:122.  Back to cited text no. 16
[PUBMED]    
17.Debruyne FM, Hoitsma AJ, Arendsen EH, et al. Surgical treatment of urologic complications in kidney transplantation. World J Urol 1988; 6:75.  Back to cited text no. 17
    
18.Lojanapiwat B, Mital D, Fallon L. Manage­ment of ureteral stenosis after renal transplant­tation. J Am Coll Surg 1994;179(1):21-4.  Back to cited text no. 18
    

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Correspondence Address:
Mahmood Molaei
Department of Urology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad
Iran
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PMID: 21196616

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    Abstract
    Introduction
    Subjects and Methods
    Results
    Discussion
    References
 

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