|Year : 2019 | Volume
| Issue : 3 | Page : 564-570
|Perinephric transplant fluid collection approach and management
Iman Alshamsi1, Hefsa Alshamsi1, Salamah Al Falahi1, Ajay Sharma2, Ahmed Halawa3
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 Submission||25-Sep-2018|
|Date of Acceptance||31-Oct-2018|
|Date of Web Publication||26-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 20];30:564-70. Available from: http://www.sjkdt.org/text.asp?2019/30/3/564/261328
| Introduction|| |
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.
| Differential Diagnosis of Perinephric Fluid Collection Postrenal Transplant|| |
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.,,
|Figure 1: Asymptomatic fluid collection at the upper pole of the graft found on routine.|
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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. Risk factors include receiving anticoagulants and antiplatelets, induction with thymoglobulin, or plasmapheresis.
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.”
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.
Hematomas are usually self-limiting; however, aspiration may be required to exclude an underlying abscess.
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., 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.
|Figure 3: An ultrasound image showing a multiloculated collection. Chemical analysis of an aspirated sample was consistent with a lymphocele (reproduced, with permission).|
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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.,
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.
Ultrasound shows an anechoic collection and it can form septations. They might become infected and develop a more complex appearance.
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,,. 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.,
Abscess formation usually occurs around the first few weeks posttransplantation. The signs and symptoms are fever and pain at the site of transplantation. It can occur as a postoperative complication, due to protracted pyelonephritis, or as a secondary infection of other fluid collections.
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.
Treatment of abscess is either radiology-guided drain or surgical drainage with antibiotic coverage.
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. These complications are usually related to ureteral ischemia or technique failure.
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].
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. Nonmodifiable risk factors related to the recipient include male gender and being of African-American origin.
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.,
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.,,
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.,, A higher incident of urological complications is known to be associated with laparoscopic procurement of a kidney with multiple arteries.
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., A study that looked into the timing of stent removal found that early removal of stents (by day 5) reduces the incidence of UTI.
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.
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.
Biochemically: Fluid drained shows high creatinine and potassium level compared to that simultaneously drawn from serum.
- 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
- CT contrast may show isodense collection and urine extravasation although avoidance of nephrotoxic contrast is highly recommended
- Simple retrograde urethrocystography
- Antegrade nephrostogram if hydroneph-rosis is present
- Renal scintigraphy if patient has adequate renal function.,
| Evidence-Based Management of Urinary Leaks|| |
- 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.
- 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.
- 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.,,,
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.,,
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. 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
- 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.
| Conclusion|| |
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.
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Sheffield Teaching Hospitals, Sheffield - University of Liverpool
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