Urological Complications in Kidney Transplantation Urol Int 1992;49:99-103
Department of Urology and Department of Nephrology. Radboud University Hospital. Nijmegen, The Netherlands
Diagnosis and Treatment of Urological Complications in Kidney T ransplantation
Keyw ords
Abstract
Kidney transplantation Complications, urologie Treatment, surgical and endourologic
Between January 1973 and January 1990 we carried out 1,038 kidney trans plantations using a transvesical end-to-side implantation of the ureter in the bladder without an antireflux mechanism. Moreover, 30 transplantations were done in 26 patients with a urinary diversion. We examined the urological complications in these 1,068 consecutive transplants. Urinary leakage and obstruction were the two main urological posttransplant complications. Se vere leakage occurred in 21 patients (2.0%), and was treated by open surgery; 2 patients had a urinary diversion. The treatment of choice is a pyeloureterostomy (anastomosis between the transplant renal pelvis and the native ureter). There were 35 patients (3.3%) with severe ureteral obstruction of whom 5 had a urinary diversion. In 30 patients open surgical treatment of the obstruction was necessary and in 7 patients a percutaneous endourologic treatment was done (dilatation of a confined ureteral stricture in 6 patients and percutaneous stone treatment in 1). The postoperative mortality in the patients treated for leakage or obstruction was low: 4 patients (7%) died. 3 of septicemia due to leakage and 1 of pulmonary embolism after repair of the obstruction. The results of surgical treatment were good. The graft survival after 2 years in the group of urologically complicated transplants was 68% for the patients with leakage and 80% for those with obstruction. The 2-year graft survival in the patients without complications was 67% and 71 % for the patients with a uri nary diversion. We conclude from these results that urological complications after renal transplantation can be treated successfully by surgical (or percuta neous) correction.
Introduction
Kidney transplantation is a well-standardized method of treatment in patients with end-stage renal failure. The technique of anastomosis between the transplant ureter
and the bladder is now widely used. In the beginning we carried out a pyeloureterostomy as a first-choice anasto mosis. However, because of the high complication rate of this technique, especially involving leakage, we have used since 1973 a direct transvesical end-to-side ureter-bladder
G.O.N. Oosterhof. MI) Department of Urology St. Radboud University Hospital Postbox 9101.6500 HB Nijmegen (The Netherlands)
© 1992 S. Karger AG. Base! 0042-1138/92/0492-0099 $2.75/0
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G.O.N. Oosterhof'1 A.J. Hoitsmab J.A. Witjesa F.M.J. Debmynea
Table 1. Causes and sites of leakage, necessitating surgery in renal transplant recipients without a urinary diversion (n = 19)
Table 2. Causes and sites of obstruction, necessitating surgery in renal transplant recipients without a urinary diversion (n = 30)
Number
Number
5 1 3 1 8 1
Stenosis of the ureter-bladder anastomosis Retroperitoneal fibrosis whole ureter proximal ureter midureteral distal ureter
Table 3. Graft and patient survival in 1.068 consecutive transplantations
Graft survival, %
Leakage(n = 19) Obstruction (n = 30) Diversion (n = 30) No urological complications (n = 989) Pyeloureterostomy (n = 43)
anastomosis without an antireflux tunnel [1]. Other fre quently used techniques are the transvesical implantation of the ureter with an antireflux tunnel (Politano-Leadbetter) or the external ureteroneocystostomy described by Lich-Gregoir. Severe urological complications necessitating surgical treatment are seen in 5-13 % of the patients, and a mortal ity of 5-32% has been reported [2, 3. 5.8.9, 13], The most frequent urological complications seen after kidney trans plantation are obstruction and leakage. Treatment of both conditions is mainly surgical [2, 13]. In selected cases of confined ureteral stricture a percutaneous endourologic treatment is also possible [4, 6, 11].
Patients and Methods Between January 1973 and January 1990 we performed 1.068 kidney transplants, including 84 living-rclatcd-donor transplanta tions. There were 30 transplantations carried out in 26 patients with a urinary diversion. In all the patients with a normal bladder (n = 1.038) a transvesical ureteroneocystostomy without an antireflux mechanism was established. The ureter was implanted in the fixed (trigonal) part of the bladder; the bladder was then closed in three layers and a ureteral stent and bladder catheter were left in place for 5 and 7 days, respectively.
100
1-year
2-year
4-year
74 90 87 72 86
68 80 71 67 79
56 62 66 58 61
5 4 5 7 9
Patient survival (4-ycar). % 84 88 92 83 91
Patients with a Ureteroneocystostomy
In the 1,038 patients with a ureteroneocystostomy. urinary leak age was seen in 53 patients (5.1%). In 36 patients the leakage occurred at the cystostomy or at the site of the ureteroneocystostomy and conservative treatment by draining the bladder or kidney was sufficient. In 19 patients (1.8%) surgical treatment was necessary. Leakage occurred early, a mean of 2 weeks after transplantation and immediate drainage of the kidney and urinoma was done. The cause of leakage in these patients was necrosis due to vascular disorders of the renal pelvis or calyx (n = 5), ureter (n = 13), or disruption of the ureteroneocystostomy (n = 1). Table 1 shows the causes and exact sites of leakage. The final treatment of the 19 patients with persistent leakage consisted of pyelourctcrostomy (n = 17). Boari-plasty (n = 1) and open closure of the site of leakage (n = 1). The 103 patients (9.9%) with obstruction after implantation of the ureter in a bladder can be divided into those with a mild obstruc tion which was easily repaired with a minor intervention and those w'ith severe obstruction which threatened the graft. In 40 patients (3.8%) percutaneous drainage of a lymphocele was sufficient to relieve the obstruction. In another 33 patients (3.2%) the temporary obstruction could be treated by nephrostomy drainage. Thus, there were 30 patients (2.9%) with ureteral obstructions that necessitated surgical or endourologic treatment. The causes of obstruction (ta ble 2) were retroperitoneal fibrosis (n = 25) or stenosis of the urete roneocystostomy (n = 5). Open reconstructive surgery was necessary in 26 cases and percutaneous endourologic dilatation of a confined ureteral stricture was carried out 6 times, 2 patients being treated by endourologic dilatation and open surgery. Ureteral obstruction oc curred later than leakage, a mean of 11 months after transplanta tion.
Oosterhof/Hoitsma/W itjes/Debruy ne
Diagnosis and Treatment of Urological Complications in Kidney Transplantation
Downloaded by: Nagoya University 133.6.82.173 - 1/22/2018 5:15:02 PM
Necrosis of the renal pelvis or calyx Necrosis of the ureter whole ureter proximal ureter midurcteral distal ureter Disruption of the ureter-bladder anastomosis
Patients with a Urinary Diversion
In the 30 transplants with implantation of the ureter in a urinary diversion, urinary' leakage was encountered at the site of the ileal con duit in 2 patients. Open closure of the site of leakage (n = 1) and ureterocutaneostomy (n = 1) were carried out. Obstruction was seen in 11 patients. Open surgical treatment was necessary in 5 patients and consisted of neourcteroileostomy (n = 2), correction of the length of the ileal loop (n = 2), and pyclolithotomy (n = 1). Technique o f Pyeloureterostomy
The technique of pyeloureterostomy (fig. 1) consists of an anasto mosis between the transplant renal pelvis and the native ureter. Exci sion of the maximum possible length of the transplant ureter is man datory in order to maximize the blood supply to the transplant pelvis. The host ureter is spatulatcd medially to provide a wide anastomosis. The end-to-end anastomosis is completed with Dexon 5-0 sutures, and a Gil Vernet ureteral stent is left in place for 10-14 days, Proxi mal ligation of the ureter might be sufficient, but we prefer the exci sion of the host kidney. Fig. 1. The technique of pyeloureterostomy.
Results Discussion
Patients with a Urinary Diversion Of the 2 patients with urinary leakage 1 died 2 years after transplantation from liver failure and the other is alive with a well-functioning graft. The results of the open surgical treatment in the 5 patients with obstruction were good: there was no mortality and the 1- and 2-year graft survival of the 26 patients with a urinary diversion was 87 and 71%, respectively, and the 4-year patients survival was 92%.
Severe urological complications, especially urinary leakage, were common in the early years of transplanta tion, when a pyeloureterostomy was carried out as a first choice anastomosis. In 17 primary pyeloureterostomies carried out before 1973, 7 urinary fistulas were observed and two kidney grafts were lost [1]. Urinary leakage is very often associated with rejection and (urinary tract) infection. Antirejection therapy carried out in the pres ence of infection may lead to systemic infection and sub sequent septicemia, threatening not only the graft but also the patient. Rejection has become less common since the selection of patients has been made more accurate by newer matching techniques and since the introduction of ciclosporin as a new antirejection agent [2], On the other hand, we carry out increasingly more living-related-donor transplantations instead of cadaveric kidney transplants. Urinary leakage is likely to occur more frequently in these patients because the vascularization of the ureter is more easily damaged during donor nephrectomy. Moreover, several risk factors such as diabetes mellitus or age over 55 years (associated with atherosclerosis) or under 16 years are no longer contraindications for transplantation. Table 4 summarizes the patients at risk for urological complications since the opening of our transplantation center in 1968. Urinary leakage and obstruction are the most impor tant urological complications following kidney transplan-
101
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Patients with a Ureteroneocystostomy The results of the surgical intervention in the 19 patients with a urinary fistula were good in 16 patients. Three patients died postoperatively of septicemia. Patient survival was 84% (16/19) and the 1- and 2-year graft sur vival was 74 and 68%, respectively. In patients with uri nary leakage there is often concomitant infection and rejection of the graft; patient and graft survival depend largely on the outcome of the anti-infection and antirejec tion therapy. In the group with obstruction, 1 patient died of pulmonary embolism. The 1- and 2-year graft survival in this group was 90 and 80%, respectively. The 4-year patient survival was 88%. The results of the 989 implan tations in a ureteroneocystostomy without urological complications or with mild complications that could be treated conservatively were 1- and 2-year graft survival, 72 and 67%, respectively, and 4-year patient survival, 83%. These results are summarized in table 3.
Number Living related donor Diabetes mellitus Over 55 years of age U nder 16 years of age Urinary' diversion
84 60 135 85 30
Total
394(36.9%)
lation. In our patients with a ureteroneocystostomy surgi cal treatment was performed for leakage in 1.8% and for obstruction in 2.9%. Independent of the technique used for implantation of the ureter (extravesical or transvesi cal, with or without an antireflux mechanism), the per centages in the literature vary between 1.3 and 10% for the occurrence of a fistula and between 1.0 and 10.7% for obstruction [7, 9, 12-14], Urinary leakage may be due to necrosis of the ureter or to leakage from the ureter-blad der anastomosis or the cystotomy. The latter condition can mostly be treated conservatively by bladder drainage. Necrosis of the ureter may occur when an impaired vascu larization of the ureter is still worsened by (acute) vascular rejection [2], Immediate percutaneous drainage of the kidney and the urinoma is mandatory to prevent septic complications. At a later stage, open reconstructive sur gery, especially pyeloureterostomy, can be done. We agree with Waltzer et al. [14] that a pyeloureterostomy is the method of choice in reconstructing the ureter after leak age or obstruction. The causes of ureteral obstruction are retroperitoneal fibrosis or stricture of the ureteroneocystostomy. The former is mostly generalized and affects the whole ureter. The cause of this retroperitoneal fibrosis may be an impaired vascularization of the ureter, eventually related to rejection. When the vascularization is completely dam aged necrosis will occur, while in a chronic, noncomplete impairment of the blood vessels fibrosis of the ureter may occur. Obstruction can be diagnosed by ultrasound exam ination of the kidney, a rise in serum creatinine, and renal scanning. First wc usually carry out a percutaneous kid ney drainage. Once renal function has been restored, the cause, site, and degree of obstruction are confirmed by antegrade pyelography and Whitaker perfusion test. If there is obstruction over a long distance due to retroperi
102
toneal fibrosis, a pyeloureterostomy is indicated. In cases of confined ureteral obstruction, especially stricture of the ureter-bladder anastomosis, a percutaneous antegrade di lation or incision of the strictured area may be done. Our limited experience with 6 patients was good in 4, with now a mean follow-up of 24 months [11]. The 2-year graft survival in the group of patients surgi cally treated for leakage was 68%, and for obstruction 80%. The mortality was 15.8% for leakage and 3% for obstruction. In the literature, mortality between 1 and 32% has been reported [3, 5, 8, 9, 14]. In the 52 patients with severe urological complica tions, we carried out a pyeloureterostomy in 43 cases (26 obstructions and 17 urinary fistula); our results indicate that it is a safe procedure with few complications. In these 43 patients the 1- and 2-year graft survival was 86 and 79%, respectively, and the 4-year patient survival was 91%. There were no early surgical complications and 1 patient developed a stone at the site of the pyeloureteros tomy 9 years after surgery. Many patients with lower urinary tract abnormalities have previously been considered poor candidates for kid ney transplantation. In these patients the bladder is often unsuitable for the implantation of a ureter. Before a deci sion is made to implant the ureter in an intestinal conduit, the unsuitability of the bladder should be irrefutably established, even if a diversion has already been con structed. In our series of 30 transplantations on a urinary diversion, 13 patients (43%) had severe complications and were treated for obstruction (n = 9), leakage (n = 2) or nephrolithiasis (n = 2). Open surgical treatment was nec essary in 7 patients (23%). The graft survival in these patients after 2 and 4 years is very good: 71 and 66%, respectively. In conclusion, our data indicate that severe urological complications, threatening the graft or the life of the patient, are rare. However, urinary leakage, which mostly occurs within 2 weeks following the transplantation, should be surgically treated as an emergency. Drainage of the kidney and urinoma should be carried out immediate ly, followed at a later stage by the bridging of the leakage site, preferably by a pyeloureterostomy. Urinary obstruc tion should be treated as well surgically, by a pyelourete rostomy if there is a generalized retroperitoneal fibrosis, or by percutaneous endourologic techniques if a very short stricture is involved. Patients with a urinary diver sion have a higher risk of urological complications, espe cially obstruction. However, by performing adequate open surgical or endourologic correction a good graft and patient survival can be obtained in these patients.
Oosterhof/Hoitsma/Witjes/Debruyne
Diagnosis and Treatment of Urological Complications in Kidney Transplantation
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Table 4. Risk factors for urological com plications in 1,068 consecutive kidney trans plantations (1973-1990)
References 5 Kinnaert. P.: Hall. M.: Janssen. F.; Verecrstraeten. P.: Toussaint. C.: Van Geertruyden J.: Ureteral stenosis after kidney transplantation: true incidence and long-term follow-up after surgical correction. J. Urol 133: 17-20(1985). 6 Lewi, H.J.E.; McMillan, I.: Bramwell, S.: Kyle, F.: Percutaneous pvelolysis: a new approach to post-transplant ureteric obstruction. Br. J. Urol. 57:354-355 (1985). 7 Löbermann. H.: Dotal G.; Schreiber. B.: Eigler. F.W.: Frühe Ureterkomplikationen nach Nie rentransplantation. Arch. Klin. Chir. 348: 269275(1979). 8 Malek, G.H.: Uchling. D.T.; Daouk. A.A.; Kisken. W.A.: Urological complications of re nal transplantation. J. Urol 109: 173-176 (1973). 9 Mundy. A.R.: Podesta. M.L.: Bewick. M.: Rudge. C.J.: Ellis, F.G.: The urological compli cations of 1000 renal transplants. Br. J. Urol. 53:397-402(1981).
10 Oosterhof, G.O.N.; Hoitsma, A.J.: Arendsen. H.J.: Debruyne. F.M.J.: Kidney transplanta tion in patients with a urinary diversion. Wld J. Urol 6:91-94(1988). 11 Oosterhof. G.O.N.; Hoitsma. A.J.: Debruyne, F.M.J.: Antegrade percutaneous dilation of ureteral strictures after kidney transplantation. Transplant, int. 2:36-39(1989). 12 Presto A.J. Ill: Midlcton, R.G.; Bateman, J.M.: Secondary pyeloureterostomy in renal trans plant patients. J. Urol 110: 166-168(1973). 13 Smith. R.B.; Ehrlich. R.M.: The surgical com plications of renal transplantation. Urol dins N. Am. 3:621-646(1979). 14 Waltzer. W.C.: Zincke. H.; Leary. F.J.; Sterioff, S.: Woods. J.E.; De Weerd. J.H.: Myers. R.P.: Urinary tract reconstruction in renal transplan tation. Urology 26:233-241 (1980).
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1 Debruync. F.M.J.; Wijdeveld. P.G.A.B.: Moonen. W.A.; Urinclekkage na nicrtransplantatie. Ned. Tijdschr. Geneesk. 123: 283-288 (1979). 2 Dcbruyne. F.M.J.; Hoitsma. A.J.; Arendsen. H.J.: Oosterhof. G.O.N.: Surgical treatment of urologie complications in kidney transplanta tion. Wld J. Urol. 6:75-77 ( 1988). 3 Dreikorn. K.; Röhl. L.: Horsch. R.: Behand lung von Harnleiterobstruktionen und Urinfi steln nach Nierentransplantation. Helv. chir. Acta 46: 357-364 (1979). 4 Jarowcnko. M.V.: Flcchncr. S.M.: Sandler. C.M.: van Buren, C.T.: Kahan. B.D.: Salvage of difficult transplant complications by percuta neous techniques. J. Urol. 133: 840-842 (1985).
Department of Urology and Department of Nephrology. Radboud University Hospital. Nijmegen, The Netherlands
Diagnosis and Treatment of Urological Complications in Kidney T ransplantation
Keyw ords
Abstract
Kidney transplantation Complications, urologie Treatment, surgical and endourologic
Between January 1973 and January 1990 we carried out 1,038 kidney trans plantations using a transvesical end-to-side implantation of the ureter in the bladder without an antireflux mechanism. Moreover, 30 transplantations were done in 26 patients with a urinary diversion. We examined the urological complications in these 1,068 consecutive transplants. Urinary leakage and obstruction were the two main urological posttransplant complications. Se vere leakage occurred in 21 patients (2.0%), and was treated by open surgery; 2 patients had a urinary diversion. The treatment of choice is a pyeloureterostomy (anastomosis between the transplant renal pelvis and the native ureter). There were 35 patients (3.3%) with severe ureteral obstruction of whom 5 had a urinary diversion. In 30 patients open surgical treatment of the obstruction was necessary and in 7 patients a percutaneous endourologic treatment was done (dilatation of a confined ureteral stricture in 6 patients and percutaneous stone treatment in 1). The postoperative mortality in the patients treated for leakage or obstruction was low: 4 patients (7%) died. 3 of septicemia due to leakage and 1 of pulmonary embolism after repair of the obstruction. The results of surgical treatment were good. The graft survival after 2 years in the group of urologically complicated transplants was 68% for the patients with leakage and 80% for those with obstruction. The 2-year graft survival in the patients without complications was 67% and 71 % for the patients with a uri nary diversion. We conclude from these results that urological complications after renal transplantation can be treated successfully by surgical (or percuta neous) correction.
Introduction
Kidney transplantation is a well-standardized method of treatment in patients with end-stage renal failure. The technique of anastomosis between the transplant ureter
and the bladder is now widely used. In the beginning we carried out a pyeloureterostomy as a first-choice anasto mosis. However, because of the high complication rate of this technique, especially involving leakage, we have used since 1973 a direct transvesical end-to-side ureter-bladder
G.O.N. Oosterhof. MI) Department of Urology St. Radboud University Hospital Postbox 9101.6500 HB Nijmegen (The Netherlands)
© 1992 S. Karger AG. Base! 0042-1138/92/0492-0099 $2.75/0
Downloaded by: Nagoya University 133.6.82.173 - 1/22/2018 5:15:02 PM
G.O.N. Oosterhof'1 A.J. Hoitsmab J.A. Witjesa F.M.J. Debmynea
Table 1. Causes and sites of leakage, necessitating surgery in renal transplant recipients without a urinary diversion (n = 19)
Table 2. Causes and sites of obstruction, necessitating surgery in renal transplant recipients without a urinary diversion (n = 30)
Number
Number
5 1 3 1 8 1
Stenosis of the ureter-bladder anastomosis Retroperitoneal fibrosis whole ureter proximal ureter midureteral distal ureter
Table 3. Graft and patient survival in 1.068 consecutive transplantations
Graft survival, %
Leakage(n = 19) Obstruction (n = 30) Diversion (n = 30) No urological complications (n = 989) Pyeloureterostomy (n = 43)
anastomosis without an antireflux tunnel [1]. Other fre quently used techniques are the transvesical implantation of the ureter with an antireflux tunnel (Politano-Leadbetter) or the external ureteroneocystostomy described by Lich-Gregoir. Severe urological complications necessitating surgical treatment are seen in 5-13 % of the patients, and a mortal ity of 5-32% has been reported [2, 3. 5.8.9, 13], The most frequent urological complications seen after kidney trans plantation are obstruction and leakage. Treatment of both conditions is mainly surgical [2, 13]. In selected cases of confined ureteral stricture a percutaneous endourologic treatment is also possible [4, 6, 11].
Patients and Methods Between January 1973 and January 1990 we performed 1.068 kidney transplants, including 84 living-rclatcd-donor transplanta tions. There were 30 transplantations carried out in 26 patients with a urinary diversion. In all the patients with a normal bladder (n = 1.038) a transvesical ureteroneocystostomy without an antireflux mechanism was established. The ureter was implanted in the fixed (trigonal) part of the bladder; the bladder was then closed in three layers and a ureteral stent and bladder catheter were left in place for 5 and 7 days, respectively.
100
1-year
2-year
4-year
74 90 87 72 86
68 80 71 67 79
56 62 66 58 61
5 4 5 7 9
Patient survival (4-ycar). % 84 88 92 83 91
Patients with a Ureteroneocystostomy
In the 1,038 patients with a ureteroneocystostomy. urinary leak age was seen in 53 patients (5.1%). In 36 patients the leakage occurred at the cystostomy or at the site of the ureteroneocystostomy and conservative treatment by draining the bladder or kidney was sufficient. In 19 patients (1.8%) surgical treatment was necessary. Leakage occurred early, a mean of 2 weeks after transplantation and immediate drainage of the kidney and urinoma was done. The cause of leakage in these patients was necrosis due to vascular disorders of the renal pelvis or calyx (n = 5), ureter (n = 13), or disruption of the ureteroneocystostomy (n = 1). Table 1 shows the causes and exact sites of leakage. The final treatment of the 19 patients with persistent leakage consisted of pyelourctcrostomy (n = 17). Boari-plasty (n = 1) and open closure of the site of leakage (n = 1). The 103 patients (9.9%) with obstruction after implantation of the ureter in a bladder can be divided into those with a mild obstruc tion which was easily repaired with a minor intervention and those w'ith severe obstruction which threatened the graft. In 40 patients (3.8%) percutaneous drainage of a lymphocele was sufficient to relieve the obstruction. In another 33 patients (3.2%) the temporary obstruction could be treated by nephrostomy drainage. Thus, there were 30 patients (2.9%) with ureteral obstructions that necessitated surgical or endourologic treatment. The causes of obstruction (ta ble 2) were retroperitoneal fibrosis (n = 25) or stenosis of the urete roneocystostomy (n = 5). Open reconstructive surgery was necessary in 26 cases and percutaneous endourologic dilatation of a confined ureteral stricture was carried out 6 times, 2 patients being treated by endourologic dilatation and open surgery. Ureteral obstruction oc curred later than leakage, a mean of 11 months after transplanta tion.
Oosterhof/Hoitsma/W itjes/Debruy ne
Diagnosis and Treatment of Urological Complications in Kidney Transplantation
Downloaded by: Nagoya University 133.6.82.173 - 1/22/2018 5:15:02 PM
Necrosis of the renal pelvis or calyx Necrosis of the ureter whole ureter proximal ureter midurcteral distal ureter Disruption of the ureter-bladder anastomosis
Patients with a Urinary Diversion
In the 30 transplants with implantation of the ureter in a urinary diversion, urinary' leakage was encountered at the site of the ileal con duit in 2 patients. Open closure of the site of leakage (n = 1) and ureterocutaneostomy (n = 1) were carried out. Obstruction was seen in 11 patients. Open surgical treatment was necessary in 5 patients and consisted of neourcteroileostomy (n = 2), correction of the length of the ileal loop (n = 2), and pyclolithotomy (n = 1). Technique o f Pyeloureterostomy
The technique of pyeloureterostomy (fig. 1) consists of an anasto mosis between the transplant renal pelvis and the native ureter. Exci sion of the maximum possible length of the transplant ureter is man datory in order to maximize the blood supply to the transplant pelvis. The host ureter is spatulatcd medially to provide a wide anastomosis. The end-to-end anastomosis is completed with Dexon 5-0 sutures, and a Gil Vernet ureteral stent is left in place for 10-14 days, Proxi mal ligation of the ureter might be sufficient, but we prefer the exci sion of the host kidney. Fig. 1. The technique of pyeloureterostomy.
Results Discussion
Patients with a Urinary Diversion Of the 2 patients with urinary leakage 1 died 2 years after transplantation from liver failure and the other is alive with a well-functioning graft. The results of the open surgical treatment in the 5 patients with obstruction were good: there was no mortality and the 1- and 2-year graft survival of the 26 patients with a urinary diversion was 87 and 71%, respectively, and the 4-year patients survival was 92%.
Severe urological complications, especially urinary leakage, were common in the early years of transplanta tion, when a pyeloureterostomy was carried out as a first choice anastomosis. In 17 primary pyeloureterostomies carried out before 1973, 7 urinary fistulas were observed and two kidney grafts were lost [1]. Urinary leakage is very often associated with rejection and (urinary tract) infection. Antirejection therapy carried out in the pres ence of infection may lead to systemic infection and sub sequent septicemia, threatening not only the graft but also the patient. Rejection has become less common since the selection of patients has been made more accurate by newer matching techniques and since the introduction of ciclosporin as a new antirejection agent [2], On the other hand, we carry out increasingly more living-related-donor transplantations instead of cadaveric kidney transplants. Urinary leakage is likely to occur more frequently in these patients because the vascularization of the ureter is more easily damaged during donor nephrectomy. Moreover, several risk factors such as diabetes mellitus or age over 55 years (associated with atherosclerosis) or under 16 years are no longer contraindications for transplantation. Table 4 summarizes the patients at risk for urological complications since the opening of our transplantation center in 1968. Urinary leakage and obstruction are the most impor tant urological complications following kidney transplan-
101
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Patients with a Ureteroneocystostomy The results of the surgical intervention in the 19 patients with a urinary fistula were good in 16 patients. Three patients died postoperatively of septicemia. Patient survival was 84% (16/19) and the 1- and 2-year graft sur vival was 74 and 68%, respectively. In patients with uri nary leakage there is often concomitant infection and rejection of the graft; patient and graft survival depend largely on the outcome of the anti-infection and antirejec tion therapy. In the group with obstruction, 1 patient died of pulmonary embolism. The 1- and 2-year graft survival in this group was 90 and 80%, respectively. The 4-year patient survival was 88%. The results of the 989 implan tations in a ureteroneocystostomy without urological complications or with mild complications that could be treated conservatively were 1- and 2-year graft survival, 72 and 67%, respectively, and 4-year patient survival, 83%. These results are summarized in table 3.
Number Living related donor Diabetes mellitus Over 55 years of age U nder 16 years of age Urinary' diversion
84 60 135 85 30
Total
394(36.9%)
lation. In our patients with a ureteroneocystostomy surgi cal treatment was performed for leakage in 1.8% and for obstruction in 2.9%. Independent of the technique used for implantation of the ureter (extravesical or transvesi cal, with or without an antireflux mechanism), the per centages in the literature vary between 1.3 and 10% for the occurrence of a fistula and between 1.0 and 10.7% for obstruction [7, 9, 12-14], Urinary leakage may be due to necrosis of the ureter or to leakage from the ureter-blad der anastomosis or the cystotomy. The latter condition can mostly be treated conservatively by bladder drainage. Necrosis of the ureter may occur when an impaired vascu larization of the ureter is still worsened by (acute) vascular rejection [2], Immediate percutaneous drainage of the kidney and the urinoma is mandatory to prevent septic complications. At a later stage, open reconstructive sur gery, especially pyeloureterostomy, can be done. We agree with Waltzer et al. [14] that a pyeloureterostomy is the method of choice in reconstructing the ureter after leak age or obstruction. The causes of ureteral obstruction are retroperitoneal fibrosis or stricture of the ureteroneocystostomy. The former is mostly generalized and affects the whole ureter. The cause of this retroperitoneal fibrosis may be an impaired vascularization of the ureter, eventually related to rejection. When the vascularization is completely dam aged necrosis will occur, while in a chronic, noncomplete impairment of the blood vessels fibrosis of the ureter may occur. Obstruction can be diagnosed by ultrasound exam ination of the kidney, a rise in serum creatinine, and renal scanning. First wc usually carry out a percutaneous kid ney drainage. Once renal function has been restored, the cause, site, and degree of obstruction are confirmed by antegrade pyelography and Whitaker perfusion test. If there is obstruction over a long distance due to retroperi
102
toneal fibrosis, a pyeloureterostomy is indicated. In cases of confined ureteral obstruction, especially stricture of the ureter-bladder anastomosis, a percutaneous antegrade di lation or incision of the strictured area may be done. Our limited experience with 6 patients was good in 4, with now a mean follow-up of 24 months [11]. The 2-year graft survival in the group of patients surgi cally treated for leakage was 68%, and for obstruction 80%. The mortality was 15.8% for leakage and 3% for obstruction. In the literature, mortality between 1 and 32% has been reported [3, 5, 8, 9, 14]. In the 52 patients with severe urological complica tions, we carried out a pyeloureterostomy in 43 cases (26 obstructions and 17 urinary fistula); our results indicate that it is a safe procedure with few complications. In these 43 patients the 1- and 2-year graft survival was 86 and 79%, respectively, and the 4-year patient survival was 91%. There were no early surgical complications and 1 patient developed a stone at the site of the pyeloureteros tomy 9 years after surgery. Many patients with lower urinary tract abnormalities have previously been considered poor candidates for kid ney transplantation. In these patients the bladder is often unsuitable for the implantation of a ureter. Before a deci sion is made to implant the ureter in an intestinal conduit, the unsuitability of the bladder should be irrefutably established, even if a diversion has already been con structed. In our series of 30 transplantations on a urinary diversion, 13 patients (43%) had severe complications and were treated for obstruction (n = 9), leakage (n = 2) or nephrolithiasis (n = 2). Open surgical treatment was nec essary in 7 patients (23%). The graft survival in these patients after 2 and 4 years is very good: 71 and 66%, respectively. In conclusion, our data indicate that severe urological complications, threatening the graft or the life of the patient, are rare. However, urinary leakage, which mostly occurs within 2 weeks following the transplantation, should be surgically treated as an emergency. Drainage of the kidney and urinoma should be carried out immediate ly, followed at a later stage by the bridging of the leakage site, preferably by a pyeloureterostomy. Urinary obstruc tion should be treated as well surgically, by a pyelourete rostomy if there is a generalized retroperitoneal fibrosis, or by percutaneous endourologic techniques if a very short stricture is involved. Patients with a urinary diver sion have a higher risk of urological complications, espe cially obstruction. However, by performing adequate open surgical or endourologic correction a good graft and patient survival can be obtained in these patients.
Oosterhof/Hoitsma/Witjes/Debruyne
Diagnosis and Treatment of Urological Complications in Kidney Transplantation
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Table 4. Risk factors for urological com plications in 1,068 consecutive kidney trans plantations (1973-1990)
References 5 Kinnaert. P.: Hall. M.: Janssen. F.; Verecrstraeten. P.: Toussaint. C.: Van Geertruyden J.: Ureteral stenosis after kidney transplantation: true incidence and long-term follow-up after surgical correction. J. Urol 133: 17-20(1985). 6 Lewi, H.J.E.; McMillan, I.: Bramwell, S.: Kyle, F.: Percutaneous pvelolysis: a new approach to post-transplant ureteric obstruction. Br. J. Urol. 57:354-355 (1985). 7 Löbermann. H.: Dotal G.; Schreiber. B.: Eigler. F.W.: Frühe Ureterkomplikationen nach Nie rentransplantation. Arch. Klin. Chir. 348: 269275(1979). 8 Malek, G.H.: Uchling. D.T.; Daouk. A.A.; Kisken. W.A.: Urological complications of re nal transplantation. J. Urol 109: 173-176 (1973). 9 Mundy. A.R.: Podesta. M.L.: Bewick. M.: Rudge. C.J.: Ellis, F.G.: The urological compli cations of 1000 renal transplants. Br. J. Urol. 53:397-402(1981).
10 Oosterhof, G.O.N.; Hoitsma, A.J.: Arendsen. H.J.: Debruyne. F.M.J.: Kidney transplanta tion in patients with a urinary diversion. Wld J. Urol 6:91-94(1988). 11 Oosterhof. G.O.N.; Hoitsma. A.J.: Debruyne, F.M.J.: Antegrade percutaneous dilation of ureteral strictures after kidney transplantation. Transplant, int. 2:36-39(1989). 12 Presto A.J. Ill: Midlcton, R.G.; Bateman, J.M.: Secondary pyeloureterostomy in renal trans plant patients. J. Urol 110: 166-168(1973). 13 Smith. R.B.; Ehrlich. R.M.: The surgical com plications of renal transplantation. Urol dins N. Am. 3:621-646(1979). 14 Waltzer. W.C.: Zincke. H.; Leary. F.J.; Sterioff, S.: Woods. J.E.; De Weerd. J.H.: Myers. R.P.: Urinary tract reconstruction in renal transplan tation. Urology 26:233-241 (1980).
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1 Debruync. F.M.J.; Wijdeveld. P.G.A.B.: Moonen. W.A.; Urinclekkage na nicrtransplantatie. Ned. Tijdschr. Geneesk. 123: 283-288 (1979). 2 Dcbruyne. F.M.J.; Hoitsma. A.J.; Arendsen. H.J.: Oosterhof. G.O.N.: Surgical treatment of urologie complications in kidney transplanta tion. Wld J. Urol. 6:75-77 ( 1988). 3 Dreikorn. K.; Röhl. L.: Horsch. R.: Behand lung von Harnleiterobstruktionen und Urinfi steln nach Nierentransplantation. Helv. chir. Acta 46: 357-364 (1979). 4 Jarowcnko. M.V.: Flcchncr. S.M.: Sandler. C.M.: van Buren, C.T.: Kahan. B.D.: Salvage of difficult transplant complications by percuta neous techniques. J. Urol. 133: 840-842 (1985).
