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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
REVIEW ARTICLE  
Year : 2019  |  Volume : 30  |  Issue : 3  |  Page : 564-570
Perinephric transplant fluid collection approach and management


1 Division of Nephrology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates; Faculty of Health and Science, Institute of Learning and Teaching, University of Liverpool, Liverpool, England
2 Faculty of Health and Science, Institute of Learning and Teaching, University of Liverpool; Renal Transplantation Department, Royal Liverpool University Hospitals, Liverpool, England
3 Faculty of Health and Science, Institute of Learning and Teaching, University of Liverpool, Liverpool, England; Nephrology and Transplantation Department, Sheffield Teaching Hospitals, Sheffield, UK

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Date of Submission25-Sep-2018
Date of Acceptance31-Oct-2018
Date of Web Publication26-Jun-2019
 

   Abstract 


Renal transplant is the treatment of choice for end-stage renal disease. Perirenal fluid collections are a common surgical complication postrenal transplant that may lead to early graft loss, considerable morbidity, and excess financial loss, if not diagnosed and managed early. The causes of posttransplant fluid collections are urinary leak, lymphocele, hematoma, and seroma, which can be further complicated by abscess formation if becomes infected. Urine leak is considered the most common urological complication postrenal transplant. Diagnosis can be made by biochemical analysis of the fluid drainage with the simultaneous comparison to that of serum. Radiological imaging is also essential for confirming the diagnosis of urinary leak that may not necessarily identify the site of the leak. The management of urinary leak is usually surgical unless the leak is small. The choice of surgery depends on the location of the leak, the vascularization of the involved ureter, and the presence of any complications caused by the leak. This article reviews the differential diagnoses of perirenal fluid collections in postrenal transplant period and focuses on the clinical assessment of urinoma and management options according to the latest evidence-based medicine.

How to cite this article:
Alshamsi I, Alshamsi H, Al Falahi S, Sharma A, Halawa A. Perinephric transplant fluid collection approach and management. Saudi J Kidney Dis Transpl 2019;30:564-70

How to cite this URL:
Alshamsi I, Alshamsi H, Al Falahi S, Sharma A, Halawa A. Perinephric transplant fluid collection approach and management. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Jul 16];30:564-70. Available from: http://www.sjkdt.org/text.asp?2019/30/3/564/261328



   Introduction Top


Renal transplantation is the treatment of choice for patients with end-stage renal disease. The surgical techniques have evolved since the first successful renal transplant in 1954, and the procedure gained great success over the years. Perirenal fluid collections are the most common surgical complication post renal transplant and occur in 2.5%–30% of recipients. Delay in recognizing and management can lead to graft loss, morbidity, and mortality to the recipient. In this review, we shall discuss the differential diagnosis of fluid collection postrenal transplant, the clinical presentation of urinoma, and its management.[1]


   Differential Diagnosis of Perinephric Fluid Collection Postrenal Transplant Top


The clinical presentation of postoperative peri-graft fluid collection ranges from asympto-matic to potential graft threatening [Figure 1]. Patients may present with pain at the surgical site, decreased urine output, symptoms of lower-limb venous obstruction, scrotal or labial swelling, or fluid leak from the surgical wound. The fluid may accumulate immediately post-operatively or a few months later. The differential diagnosis of such collection includes hematoma, urinoma, seroma, lympho-cele, and abscess. Although imaging may be useful in identifying the location and measuring the size of the collection, fluid aspiration and analysis are crucial for reaching a diagnosis.[1],[2],[3]
Figure 1: Asymptomatic fluid collection at the upper pole of the graft found on routine.

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Hematoma

Hematomas are common after kidney transplantation. A small hematoma usually resolves spontaneously. A large hematoma can lead to compression of the kidney or ureter, leading to obstruction and hydronephrosis.[2] Risk factors include receiving anticoagulants and antiplatelets, induction with thymoglobulin, or plasmapheresis.[1]

Ultrasound examination of hematoma reveals a complex appearance. A recent hematoma is echogenic that evolves into less echogenic appearance with time [Figure 2]a. Subsequently, the hematoma appears anechoic, and septations may form. Computed tomography (CT) shows recent hematoma to have high-attenuation components, whereas chronic hematoma contains liquefied and serous portions of intermediate attenuation [Figure 2]b. On scintigraphy, hematoma presents as a “cold defect.”[2]
Figure 2:

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Perinephric hematomas can be large enough to compress the transplanted kidney, leading to page kidney phenomenon. Page kidney means the development of hypertension postsevere compression of kidney tissue, leading to activation of the renin–angiotensin–aldosterone system.[3]

Management

Hematomas are usually self-limiting; however, aspiration may be required to exclude an underlying abscess.[2]

Lymphocele

Lymphoceles are caused by damage of the lymphatic channels around the iliac vessels, leading to leakage of lymphatic fluid [Figure 3]. Risk factors to develop lymphoceles are failure to ligate lymphatic channels properly, lower-limb edema leading to increased lymphatic flow, and obesity.[2],[4] Medications such as ATG or mammalian target of rapamycin inhibitors have been linked to this problem. The presence of symptomatic lymphoceles is associated with a higher rejection risk and lower graft survival.[5]
Figure 3: An ultrasound image showing a multiloculated collection. Chemical analysis of an aspirated sample was consistent with a lymphocele (reproduced, with permission).[2]

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Diagnosis

Diagnosis is made by analysis of the fluid aspirate which shows electrolyte content similar to the blood but with low protein level. Aspirated fluid should have a cell count, and its differential may show relatively few white blood cells with a predominance of lymphocytes. The result of the Gram stain and culture of the fluid is negative.[2],[6]

Complications

Lymphoceles might cause hydronephrosis of the transplanted kidney. Patients can develop ipsilateral lower-extremity edema as it could compress the femoral vein. Rarely, lymphoceles may form in the scrotum, and lymphatic drainage may occur through the wound.[2]

Imaging

Ultrasound shows an anechoic collection and it can form septations. They might become infected and develop a more complex appearance.[2]

Management

Ultrasound can monitor small lymphoceles. Large lymphoceles can lead to hydronephrosis and should be drained. Recurrence was reported in up to 20% of cases after sclerotherapy of lymphocele. Ethanol, povidone-iodine, and tetracycline have been used for sclero-therapy,[2],[6]. In case of infected lymphocele, percutaneous drainage and antibiotics are required. Laparoscopic marsupialization or fenestration into the peritoneal cavity is the mainstay of treatment of large lymphoceles.[7],[8]

Abscess

Abscess formation usually occurs around the first few weeks posttransplantation. The signs and symptoms are fever and pain at the site of transplantation.[2] It can occur as a postoperative complication, due to protracted pyelonephritis, or as a secondary infection of other fluid collections.[3]

Imaging

Ultrasound imaging shows variable appearances. Focal pyelonephritis appears as focal areas of increased or decreased echogenicity. The differential diagnosis of this finding is infarction or rejection. Abscesses have a complex, cystic, nonspecific appearance on ultrasound imaging. CT scan can help diffe rentiate an abscess from other pathologies as it may have an air–fluid level.[2]

Treatment

Treatment of abscess is either radiology-guided drain or surgical drainage with antibiotic coverage.[2]

Urine leak

A meta-analysis reported postrenal transplantation urological complications to be about 6%. The breakdown of this percentage includes 2.8% with ureteral strictures, 1.7% with both urinary leak and ureteral strictures, and a 1.6% with urinary leaks only.[9] These complications are usually related to ureteral ischemia or technique failure.[10]

Risk factors

Risk factors that may predispose to a urinary leak can be divided into preoperative, intraoperative, and postoperative and include both donors and recipients [Table 1].
Table 1: Urine leak risk factors.

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Preoperative The use of cadaveric kidneys is more associated with urological complications as compared with using a kidney from a living donor. Dinckan et al reported a 7.27% versus 5.53% risk.[11] Nonmodifiable risk factors related to the recipient include male gender and being of African-American origin.[9]

Intraoperative

A randomized controlled trial that addressed the issue of postrenal transplant urological complications in patients who had intravesical versus extravesical anastomosis techniques found no difference in postoperative nephros-tomy tube insertion among the two groups. There was, however, a higher rate of urinary tract infections (UTIs) in the intravesical anastomosis group and the procedure took a longer operative time.[12],[13]

Periureteric adipose tissue should be preserved to preserve blood supply to the ureter that comes from the renal hilum rather than segmental in the native ureter. A long ureter is predisposed to ischemia, and a short ureter predisposes to tension at the anastomosis site. In addition, ligation of an inferior polar artery predisposes to ureteral ischemia, whereas any segmental infarction may lead to a caliceal leak.[3],[14],[15]

While literature in the 1990s report a higher risk of urological complications with the use of laparoscopic donor nephrectomy due to too much traction on ureter during explanation operation, more recent literature reports no increased risk when comparing open versus laparoscopic techniques. This can be explained with surgeons being more familiar with laparoscopic techniques.[9],[14],[16] A higher incident of urological complications is known to be associated with laparoscopic procurement of a kidney with multiple arteries.[1]

The routine use of ureteric stents has been shown to reduce major urological complications including ureteric strictures and leaks; however, there is an increase in the postoperative UTI with the use of stents.[18],[19] A study that looked into the timing of stent removal found that early removal of stents (by day 5) reduces the incidence of UTI.[10]

Postoperative

Outflow obstruction may predispose to a urinary leak. An example is a blocked Foley’s catheter. Delayed graft function may delay the recognition of a leak.[3]

Diagnosis of urinary leak

Clinically: increased fluid drainage early post surgery decreased urine output and impaired renal function. If the drain has been removed, it can present as wound fluid drainage, scrotal edema, graft site inflammatory changes, and pain. Perinephric abscess or hydronephrosis can occur if the diagnosis is delayed.[20]

Biochemically: Fluid drained shows high creatinine and potassium level compared to that simultaneously drawn from serum.

Imaging:

  1. Ultrasound will show well-defined anechoic collections without septations and allows measurement of size and progression and the diagnosis of any obstructive complications such as hydronephrosis from large-sized leaks and extravasation
  2. CT contrast may show isodense collection and urine extravasation although avoidance of nephrotoxic contrast is highly recommended
  3. Simple retrograde urethrocystography
  4. Antegrade nephrostogram if hydroneph-rosis is present
  5. Renal scintigraphy if patient has adequate renal function.[3],[16]



   Evidence-Based Management of Urinary Leaks Top


Prevention

  1. Using the shortest ureter as possible and preserving the tissues between the lower pole of transplanted kidney and the ureter (the golden triangle) to prevent ureteral necrosis.
  2. According to Cochrane database reviewed in 2005 and 2013, double-J stent placement reduces major urinary complications but is associated with high risk of infections and excess surgical cost.
  3. AUsing Lich-Gregoir technique for uretero–vesical anastomosis showed lower urolo-gical complication rate with or without double-J stent according to a meta-analysis by Albertset al.[18],[19],[20],[21]


Treatment of urinary leaks

Treatment of urinary leaks depends on causes, site, and presence of complications caused by the leak.

1. Conservative management

- Foley catheter placement is suggested once urinary leak is suspected. This is usually enough to control a small anastomotic leak due to incomplete bladder healing by reducing intravesical pressure

- Endoscopic placement of double-J stent for ureteric fistulas is considered if not placed at the time of transplantation

- Percutaneous antegrade nephrostomy tube placement is suggested if leak is relatively small and associated with hydronephrosis. It is used to maximally decompress and divert urine away from the leak site to allow healing. This procedure can also be used to diagnose the site and severity of the fistula and guide further management. The short-term success rate is 69%, whereas the long-term success of this procedure is 58% due to recurrence of stenosis. This concludes that surgical repair remains the best treatment for ureteric fistulas.[15],[22],[23]

2. Surgical management

The type of surgical repair depends on the level of leak and the viability of the tissues.

- If ureteric leak is caused by simple anastomotic leak, resection of distal ureter and reimplantation to the urinary bladder are recommended

- If ureteric necrosis is the cause of the urinary leak, necrotic ureter resection is required and the ureteral implantation depends on the length of the ureter and adequacy of blood supply. If ureteric length and blood supply of ureter are sufficient, then the preserved transplant ureter is reimplanted into the bladder.[3] If length of the transplanted ureter is insufficient and vascularity is poor, then the native ureter, not the bladder, is used for anastomosis or alternatively, the bladder is fixed superiorly by a psoas hitch or extended by Boari flap. If no native ureter is available in case of bilateral nephrectomy, the ileal conduit may be used as neoureter[24]

- Caliceal leak is treated by the removal of the obstructive cause and conservative management if leak is caused from segmental renal infarction secondary to ligation of the polar artery. Partial nephrec-tomy is rarely needed for management.[25]


   Conclusion Top


Urinary leak is the most common urological complication postrenal transplant and can result in, decreased urine output and worsening graft function. Delay in recognizing and management of these complications can lead to graft loss, morbidity, and mortality to the recipient.. Biochemical analysis of fluid is essential for diagnosis and should be compared to that of serum. Imaging is also crucial to confirm the presence, location, and severity of the leak. Conservative management by percutaneous drainage is the first-line treatment for small, uncomplicated leaks. Surgical management is the best option. The type of surgery depends on the site of the leak, anastomosis site, and the blood supply of the ureter.



 
   References Top

1.
Inci MF, Ozkan F, See TC, Tatli S. Renal transplant complications: Diagnostic and therapeutic role of radiology. Can Assoc Radiol J 2014;65:242-52.  Back to cited text no. 1
    
2.
Akbar SA, Jafri SZ, Amendola MA, Madrazo BL, Salem R, Bis KG. Complications of renal transplantation. Radiographics 2005;25:1335-56.  Back to cited text no. 2
    
3.
Knechtle S, Morris P. Kidney Transplantation. Edinburgh [U.A.]: Saunders Elsevier; 2014.  Back to cited text no. 3
    
4.
Ranghino A, Segoloni GP, Lasaponara F, Biancone L. Lymphatic disorders after renal transplantation: New insights for an old complication. Clin Kidney J 2015;8:615-22.  Back to cited text no. 4
    
5.
Benedetti E, Hakin N, Perez E, Matas A. Current topics in medicine: Renal transplantation. Acad Radiol 1995;2:159-99.  Back to cited text no. 5
    
6.
Banner M. Uroradiology. Baltimore [U.A.]: Williams & Wilkins; 1998.  Back to cited text no. 6
    
7.
Ebadzadeh MR, Tavakkoli M. Lymphocele after kidney transplantation: Where are we standing now? Urol J 2008;5:144-8.  Back to cited text no. 7
    
8.
Bailey SH, Mone MC, Holman JM, Nelson EW. Laparoscopic treatment of post renal transplant lymphoceles. Surg Endosc 2003;17: 1896-9.  Back to cited text no. 8
    
9.
Englesbe MJ, Dubay DA, Gillespie BW, et al. Risk factors for urinary complications after renal transplantation. Am J Transplant 2007; 7:1536-41.  Back to cited text no. 9
    
10.
Patel P, Rebollo-Mesa I, Banga N, et al. TrUST (transplant ureteric stent trial): Early versus standard removal. A randomized controlled trial. Transplantation 2014;98:638.  Back to cited text no. 10
    
11.
Dinckan A, Tekin A, Turkyilmaz S, et al. Early and late urological complications corrected surgically following renal transplantation. Transpl Int 2007;20:702-7.  Back to cited text no. 11
    
12.
Slagt IK, Klop KW, Ijzermans JN, Terkivatan T. Intravesical versus extravesical ureteroneo-cystostomy in kidney transplantation: A systematic review and meta-analysis. Transplantation 2012;94:1179-84.  Back to cited text no. 12
    
13.
Slagt IK, Dor FJ, Tran TC, et al. A randomized controlled trial comparing intravesical to extravesical ureteroneocystostomy in living donor kidney transplantation recipients. Kidney Int 2014;85:471-7.  Back to cited text no. 13
    
14.
Hamouda M, Sharma A, Halawa A. Urine leak after kidney transplant: A review of the literature. Exp Clin Transplant 2018;16:90-5.  Back to cited text no. 14
    
15.
Philosophe B, Kuo PC, Schweitzer EJ, et al. Laparoscopic versus open donor nephrectomy: Comparing ureteral complications in the recipients and improving the laparoscopic technique. Transplantation 1999;68:497-502.  Back to cited text no. 15
    
16.
Srivastava A, Kumar J, Upadhyaya R, Ansari MS, Kapoor R. Impact of open vs. laparoscopic kidney harvesting and routine use of double j stent on longterm outcome of ureteral complications in renal transplants. World J Nephrol Urol 2012;1:73-8.  Back to cited text no. 16
    
17.
Carter JT, Freise CE, McTaggart RA, et al. Laparoscopic procurement of kidneys with multiple renal arteries is associated with increased ureteral complications in the recipient. Am J Transplant 2005;5:1312-8.  Back to cited text no. 17
    
18.
Wilson CH, Rix DA, Manas DM. Routine intraoperative ureteric stenting for kidney transplant recipients. Cochrane Database Syst Rev 2013;4:CD004925.  Back to cited text no. 18
    
19.
Danovitch G. Handbook of Kidney Transplantation. 5th ed. Philadelphia: Lippincott Williams & Wilkins & Wolters Kluwer; 2010.  Back to cited text no. 19
    
20.
Alberts VP, Idu MM, Legemate DA, Laguna Pes MP, Minnee RC. Ureterovesical anasto-motic techniques for kidney transplantation: A systematic review and meta-analysis. Transpl Int 2014;27:593-605.  Back to cited text no. 20
    
21.
Duty BD, Barry JM. Diagnosis and management of ureteral complications following renal transplantation. Asian J Urol 2015;2:202-7.  Back to cited text no. 21
    
22.
Alcaraz A, Bujons A, Pascual X, et al. Percutaneous management of transplant ureteral fistulae is feasible in selected cases. Transplant Proc 2005;37:2111-4.  Back to cited text no. 22
    
23.
Haberal M, Boyvat F, Akdur A, Kırnap M, Özçelik Ü, Yarbuğ Karakayalı F. Surgical complications after kidney transplantation. Exp Clin Transplant 2016;14:587-95.  Back to cited text no. 23
    
24.
Shokeir AA, Shamaa MA, Bakr MA, el-Diasty TA, Ghoneim MA. Salvage of difficult trans-plant urinary fistulae by ileal substitution of the ureter. Scand J Urol Nephrol 1993;27:537-40.  Back to cited text no. 24
    
25.
Gutiérrez-Calzada JL, Ramos-Titos J, González-Bonilla JA, Garcia-Vaquero AS, Martin-Morales A, Burgos-Rodrıguez R. Caliceal fistula formation following renal transplantation: Management with partial nephrectomy and ureteral replacement. J Urol 1995;153:612-4  Back to cited text no. 25
    

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Correspondence Address:
Ahmed Halawa
Sheffield Teaching Hospitals, Sheffield - University of Liverpool

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DOI: 10.4103/1319-2442.261328

PMID: 31249219

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