Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
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

Correspondence Address:
Subodh R Shivde
Consultant Uro-Oncosurgeon Department of Urology Deenanath Mangeshkar Hospital, Erendawane, Pune, Maharashtra
India

Abstract

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


Full Text

 Introduction



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. [1]

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. [2] We here by report an unusual cause of ureteric obstruction along with review of literature for unusual causes.

 Case Report



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.

 Discussion



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. [3]

Other risk factors for ureteral stenosis are en­listed in [Table 1]. [4],[5],[6],[7],[8],[9],[10],[11],[12]

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. [12] 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%. [13] The success of subsequent series fell to 60%. [13] 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. [2] The increasing popularity in the en­doscopic techniques of minimally invasive na­ture is best reserved for cases of short segment stenosis treated within 3 months. [2] As for open surgery the results are more consistent with a global success rate of 85%. [2] Open surgery is reserved for ureteral obstructions which are lengthy and of long duration or that recur after endoscopic failures. [2]

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.

References

1Park SB, Kim JK, Cho SK. Complications of renal transplantation. J Ultrasound Med 2007; 26:615-33.
2Karam G, Hetet JF, Maillet F, et al. Late ureteral stenosis following renal transplantation:Risk factors and impact on patient and graft sur­vival. Am J Transplant 2006;6:352-6.
3Al-Saher, Al-Midani A. The management of urological complications in renal transplant pa­tients. Saudi J Kidney Dis Transpl 2005;16:176-80.
4Kamath S, Moody MP, Hammonds JC, Wells IP. Papillary necrosis causing hydronephrosis in renal allograft treated by percutaneous retrieval of sloughed papilla. Br J Radiol 2005;78:346­-8.
5Smets S, Oyen R, Coosemans W, Dirk RJ Kuypers. An unusual cause of ureteral obs­truction in a renal allograft. Nephrol Dial Transplant 2006;21(12):3593-4.
6Cohn, Deborah A, Gruenewald, Simon MB, Postural renal transplant obstruction: A case report and review of literature. Clin Nucl Med 2001;26(8):673-6.
7Pelestrant AM, De Wolf WC. The pseudostric­ture of transplant ureteral torsion. Radiology 1982;145:49-50.
8Osman Y, Ali El Dein B, Eleithy R, Shokeir A. Sliding hernia containing the ureter: A rare cause of graft hydroureteronephrosis. Transplant Proc 2004;36:1042-4.
9Singh SK, Sakhuja V, Sharma SK, et al. Unusual causes of ureteral obstruction in renal allo­grafts. Transplant Proc 2003;35:337-8.
10Bernie JE, Hart M. Ureteral obstruction in a transplant kidney caused by an ovarian tumor. Transplantation 1997;71(3):485-6.
11Leikis MJ, Denford AJ, Pidgeon GB, Hatfield PJ. Post renal transplant obstruction caused by cytomegalovirus ureteritis. Nephrol Dial Transplant 2000;15:2063-4.
12Juaneda B, Alcaraz A, Bujons A, et al. Endouro­logical management is better in early onset ureteral stenosis in kidney transplantation. Transplant Proc 2005;37:3825-7.
13Kristo B, Phelan MW, Gritisch AH, Schulam PG. Treatment of renal transplant ureterovesical anastomotic strictures using antegrade balloon dilation with or without Holmium:Yag laser endoureterotomy. Urology 2003;62:831-4.