Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
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

Correspondence Address:
Mirza Anzar Baig
Renal Transplant Unit, Nephrology Department, Riyadh Armed Forces Hospital, P.O. Box 7897, Riyadh 11159, Kingdom of Saudi Arabia

Abstract

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


Full Text

 Introduction



Ureteral obstruction occurs in 2.5%-12.5% of renal transplant patients. [1],[2] 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.

 Case Report



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].

 Discussion



Ureteral obstruction occurs in 2.5%-12.5% [1],[2] of renal transplant patients and in some series upto 27%.[3] Ischemia is the most common cause of ureteral stenosis and is the result of excessive hilar dissection and poor anastomotic technique.[3] 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 [4],[5] ,as well as uretero-pelvic and ureterocalyceal anastomosis. [6],[7],[8] 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, [9] 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.

References

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