Year : 2010 | Volume
: 21 | Issue : 3 | Page : 504--506
Post transplant ureteric stenosis causing allograft hydronephrosis and calyceal rupture: Salvage side to side ureteroneocystostomy
Mirza Anzar Baig1, Taqi Khan1, Dujana Mousa2,
1 Department of Renal Transplant Surgery, Riyadh Armed Forces Hospital Riyadh, Kingdom of Saudi Arabia
2 Department of Nephrology, Riyadh Armed Forces Hospital Riyadh, Kingdom of Saudi Arabia
Mirza Anzar Baig
Renal Transplant Unit, Nephrology Department, Riyadh Armed Forces Hospital, P.O. Box 7897, Riyadh 11159, Kingdom of Saudi Arabia
A 26 years old lady with End Stage Renal Disease who received a cadaveric renal transplant, presented with ureteral stenosis as well as calyceal rupture due to hydronephrosis that was unresponsive to balloon dilation and the allograft was salvaged by a side to side ureteroneocystostomy. The symptoms and renal function improved and patency of the side to side uretroneocystostomy was confirmed post operatively and also at seventeen month follow-up. It may be reasonable to treat post-transplant ureteral stenosis resistant to balloon dilation with this technique. However, long-term follow-up is required to evaluate the efficacy of this treatment.
|How to cite this article:|
Baig MA, Khan T, Mousa D. Post transplant ureteric stenosis causing allograft hydronephrosis and calyceal rupture: Salvage side to side ureteroneocystostomy.Saudi J Kidney Dis Transpl 2010;21:504-506
|How to cite this URL:|
Baig MA, Khan T, Mousa D. Post transplant ureteric stenosis causing allograft hydronephrosis and calyceal rupture: Salvage side to side ureteroneocystostomy. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2020 Aug 4 ];21:504-506
Available from: http://www.sjkdt.org/text.asp?2010/21/3/504/62688
Ureteral obstruction occurs in 2.5%-12.5% of renal transplant patients. , The developments of balloon catheters, stents and advances in interventional radiology have offered safe and effective management in these cases. However the management of ureteral stenosis unresponsive to balloon dilatations pose a difficult situation. We report the successful surgical treatment of a tight distal ureteral stenosis resistant to balloon dilatations with a side to side ureteroneocystostomy, performed proximal to the stenosis.
A 26 year old lady with End Stage Renal Disease of unknown etiology received a cadaveric renal transplant in April 2006 and was discharged with serum creatinine of 74 mmoL. During the next three months her renal function deteriorated because of recurrent Urinary Tract Infections (UTI) and hydronephrosis from a distal ureteral stenosis. The stricture was dilated and stented for five weeks with improvement in renal function. Symptoms recurred with positive blood and urine culture following stent removal. Ultrasound confirmed hydronephrosis and the patient underwent a second dilatation and stenting.. Symptoms improved as did renal function but did not reach the baseline. The stent was removed after four weeks following which she presented with serum creatinine of 311 umol/L and positive blood and urine cultures. Ultrasound confirmed gross hydronephrosis, antegrade nephrogram showed severe hydroureter and rupture of upper pole calyx [Figure 1]. On a previous kidney biopsy there was no evidence of rejection but showed changes compatible with chronic obstruction. With poor results from dilatation and stenting and worsening of her renal function, it was decided to correct the distal ureteric stenosis surgically.
At surgery, a 2 cm long side to side ureteroneocystostomy was fashioned just proximal to the stenotic ureteroneocystostomy. The indwelling DJ Stent was removed and no attempt was made to repair the calyces. She recovered well and an antegrade nephrogram [Figure 2] showed prompt flow into the bladder She was discharged home with a serum creatinine of 130 umol/L.
She was followed-up regularly and her serum creatinine stabilized at 140 umol/L with no further episodes of UTI. Ultrasound did not reveal hydronephrosis and since there was no access for an antegrade nephrogram, we performed a scintigraphic examination 17 months after surgery which demonstrated normal excretion of isotope into the bladder [Figure 3].
Ureteral obstruction occurs in 2.5%-12.5% , of renal transplant patients and in some series upto 27%. Ischemia is the most common cause of ureteral stenosis and is the result of excessive hilar dissection and poor anastomotic technique. Urinary leakage and subsequent formation of periureteral fibrosis may also lead to ureteral stenosis. Percutaneous antegrade balloon dilation and endoscopic placement of a temporary stent for benign ureteral stenosis following renal transplantation are usually the mainstay of post transplant ureteral stenosis. The length of the stenosis, time after transplantation and ureteral vascular supply are the main factors affecting balloon dilation procedures. However for the resistant cases, a number of options had been tried including self expanding metallic stent placements , ,as well as uretero-pelvic and ureterocalyceal anastomosis. ,, In our case the simple technique of side to side anastomosis was technically feasible and proved effective in the relief of symptoms and recovery of allograft function. The calyceal rupture in our patient was secondary to the unrelenting tight stenosis at the uretro-vesical anastomosis and healed once the obstruction was relieved. It was not considered prudent to explore the area of the ruptured calyx unless a pelvicalyceal anastomosis was contemplated. The long term use of stents in ureteral stenosis is generally not recommended because of progressive intimal hyperplasia and ultimate occlusion. We did not mobilize the ureter to prevent further devascularization and used the adjacent bladder to create a wide anastomosis to the dilated ureter proximal to the stenosis. A stenosis of more than 2 cm is considered unresponsive to dilatation and constitutes an indication for surgical repair,  in our case, besides being resistant to dilatation, the stenosis was also the source of recurrent sepsis and had resulted in worsening of renal function. We have termed the surgery a salvage procedure because inevitable graft loss was prevented with significant improvement in renal function.
In conclusion, treating post-transplant ureterovesical stenosis resistant to balloon dilatation with side to side anastomosis is a viable option as illustrated in our patient and may be a better alternative to permanent self-expanding metallic stents.
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