Year : 2010 | Volume
: 21 | Issue : 2 | Page : 310--313
Unusual causes of obstruction to transplant ureter
Subodh R Shivde, Jaydeep Date, Tushar A Dighe, Pankaj M Joshi
Department of Urology, Deenanath Mangeshkar Hospital, Erendawane, Pune, Maharashtra, India
Subodh R Shivde
Consultant Uro-Oncosurgeon Department of Urology Deenanath Mangeshkar Hospital, Erendawane, Pune, Maharashtra
Surgical complications remain a significant clinical problem following renal transplantation. Ureteral obstruction following transplantation is not uncommon. Persistent obstruction of the ureterovesical anastomosis is the most common urologic complication. Obstruction occurring beyond the first post operative month remains frequent (2-7.5%) and mostly related to ureteral stenosis. We report here a case of Ureteral stenosis due to an unusual cause and review the literature.
|How to cite this article:|
Shivde SR, Date J, Dighe TA, Joshi PM. Unusual causes of obstruction to transplant ureter.Saudi J Kidney Dis Transpl 2010;21:310-313
|How to cite this URL:|
Shivde SR, Date J, Dighe TA, Joshi PM. Unusual causes of obstruction to transplant ureter. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2020 Jul 7 ];21:310-313
Available from: http://www.sjkdt.org/text.asp?2010/21/2/310/60201
Renal transplantation has dramatically improved throughout the last decade. However, medical and surgical complications still occur. Ureteral obstruction following transplantation is not uncommon. Persistent obstruction of the ureterovesical anastomosis is the most common urologic complication. Approximately two thirds of the early urologic complications are apparent in the first month after transplantation. 
Early obstruction is usually rare and is generally related to a technical defect such as narrow anti reflux tunnel or compression due to hematoma or lymphocoele. In contrast obstruction occurring beyond the first post operative month remains frequent (2-7.5%) and mostly related to ureteral stenosis besides some other unusual causes for ureteral obstruction.  We here by report an unusual cause of ureteric obstruction along with review of literature for unusual causes.
A 32 year male underwent live related kidney transplant. A modified Gibsons incision was used for exposure. Upon transplantation a modified Gregoir Lich ureteroneocystostomy was done. A 4 French diameter with 16 centimeters length Double J stent was inserted. His immediate postoperative recovery was uneventful. 3 weeks later the DJ stent was removed due to recurrent urinary tract infections due to E. Coli. One and half month later he presented with rising serum creatinine levels. An ultrasonography of the transplant kidney and ureter showed hydronephrosis and hydroureter. Initial percutaneous nephrostomy was followed by diagnostic antegrade pyelography. This contrast trast study showed narrowing of the ureter at 6 cm from the pelviureteric junction [Figure 1]. Balloon dilatation was done for the transplanted ureter with Cook (TM) Balloon dilator (5 French diameter with Max pressure of 40 psi) [Figure 2]. This was followed by antegrade stenting. The percutaneous nephrostomy was removed and the patient was discharged. After 3 weeks patient underwent stent removal with a retrograde ureterography. There was persistence of previously seen ureteral narrowing suggestive of recurrent stricture [Figure 3].
Considering it to be a ureteral stricture patient was posted for exploration. Intraoperatively, dense scar tissue encasing the transplanted ureter was observed which was released till the extravesical ureterocystostomy. To our surprise there was no mural or luminal narrowing of the ureter on gross inspection [Figure 4]. The transplanted ureter was in fact obstructed due to its encasement by dense scar tissue from the abdominal wound. In the post operative follow up the renal parameters normalized and there were no further incidences of urinary tract infection.
Ischemia is the most common cause of distal ureteral stricture formation often involving the ureterovesical junction. This compromised blood supply can be due to problems in operative technique during harvesting or high dose of immunosuppresion. 
Other risk factors for ureteral stenosis are enlisted in [Table 1]. ,,,,,,,,
Detailed review of reported cases around the globe highlighted some unusual causes of ureteric obstruction including the one we encountered.
After the diagnosis of ureteral obstruction percutaneous nephrostomy remains the procedure of choice for temporarily relieving the obstruction.  In early 1980's, endoscopic treatment of transplant ureter strictures was described. Although initial reports of endoscopic balloon dilatation demonstrated success rates between 78 - 100%.  The success of subsequent series fell to 60%.  The factors that predicted success with stenting and balloon dilatation were:
1) Short length (less than 2 cms)
2) Duration less than 3 months
Significant controversy exists whether treatment should be by open surgery or endourologically.  The increasing popularity in the endoscopic techniques of minimally invasive nature is best reserved for cases of short segment stenosis treated within 3 months.  As for open surgery the results are more consistent with a global success rate of 85%.  Open surgery is reserved for ureteral obstructions which are lengthy and of long duration or that recur after endoscopic failures. 
To our knowledge this is the first reported case of ureteral compression caused by fibrosis by the incision site scar. The method to avoid such obstructions is to use shortest possible ureter length, use the most direct route for the ureter up to the point of anastomosis. This would guarantee the best ureteric vascularization and avoid possible stenosis.
This unusual etiology should be kept in mind when conventional endourologic methods fail to relieve the ureteral obstruction and reimplantation can be avoided.
In conclusion, ureteric obstruction is a well known surgical complication in a renal allograft and refinements in the operative technique have decreased the rate of ureteric obstruction. There should be low threshold for open surgical repairs in cases of recurrence, failure of balloon dilatation, proximal or long segment strictures.
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