Vol. 115,'March Printed in U.S.A.
THE JOURNAL OF UROLOGY Copyright © 1976 by The Williams & Wilkins Co.
MANAGEMENT OF URINARY FISTULAS AFTER RENAL TRANSPLANTATION MARTIN SCHIFF, JR., EDWARD J. MCGUIRE, ROBERT M. WEISS
AND
BERNARD LYTTON
From the Section of Urology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
ABSTRACT
Urinary fistulas developed in 13 of 134 patients after renal transplantation. Bladder fistulas originating from the anterior suture line in 6 patients were satisfactorily managed by urethral or paravesical drainage. Fistulas arising from the donor ureter were best treated by surgical repair using the recipient's own ureter. Caliceal fistulas in 3 patients were successfully treated with nephrostomy drainage. A favorable outcome was achieved in 11 of the 13 patients, with closure of the fistula and preservation of renal function. Renal transplantation has become a well established procedure but urological complications remain a major problem. Urinary fistulas comprise a significant proportion of these complications with a reported incidence of 3 to 23 per cent in recent series, many being associated with a mortality rate of between 14 and 60 per cent (table l). 1• 14 The anterior bladder suture line is the most frequent site of urinary extravasation but fistulas may originate at the ureterovesical anastomosis or more proximally at any point along the urinary collecting system of the transplanted kidney. The long-standing uremia and anemia common to transplant recipients, the high doses of steroids required in the immediate postoperative period and the relative vascular insufficiency of the distal allograft ureter are all factors that may contribute to urological problems. A review of the experience with urinary fistulas after renal transplantation at our hospital during the last 7 years revealed 13 such cases out of 134 transplants, an incidence of 9.7 per cent. The etiology and management of these fistulas are reported herein. CLINICAL MATERIAL
Bladder fistulas. Urinary fistulas arising from the anterior bladder suture line developed in 6 patients despite a meticulous 3-layer closure. Although living related donors accounted for only 23 per cent of the total transplants performed (31 of 134) 4 of the 6 patients with vesical fistulas received a living donor transplant and had experienced an immediate, brisk diuresis (table 2). All vesical fistulas were evident by 12 days after the onset of urinary excretion. The diagnosis was readily apparent in all instances and fistulas became manifest following diminution in voided urine and the appearance of urinary drainage through the wound. The drainage was distinguished from serum or lymph by simultaneous determinations of sodium, potassium and urea from peripheral blood, voided urine and wound drainage. Diagnosis was confirmed by cystography (fig. 1). Of the 6 vesical fistulas 5 closed spontaneously within 2 to 12 weeks. Two patients were managed solely by an indwelling urethral catheter. The fistulas in these 2 cases were small and all urinary drainage from the wound ceased completely after catheter drainage was instituted. Cystography prior to catheter removal confirmed closure of the fistula. Urethral catheters were managed by a strict closed-system technique without prophylactic antibacterials. 15 They were left indwelling for up to 3 weeks. In 3 patients in whom the extravasation was Accepted for publication June 13, 1975. Read at annual meeting of American Urological Association, Miami Beach. Florida, May 11-15, 1_975.
251
pronounced surgical paravesical drainage was effected. These fistulas took longer to heal but the patients remained well and were managed outside the hospital. The single patient with a bladder fistula in whom all treatment failed was an 18-year-old man with renal failure secondary to congenital, bilateral ureterovesical obstruction. He had undergone multiple, unsuccessful attempts at reconstructive operations as a child and after development of renal insufficiency when he was 15 years old he underwent bilateral nephroureterectomy. Renal transplantation was thus complicated by the extensive prior pelvic operative procedures and the bladder was markedly thickened and distorted. Diuresis began 7 days postoperatively but 3 days later a cutaneous urinary fistula developed. On cystography extravasation occurred from the anterior bladder suture line. Initial treatment was with a urethral catheter but 3 weeks after transplantation there was no improvement and surgical wound drainage was performed. A gapping defect in the bladder was resutured and a cystostomy tube was inserted. Since urinary leakage persisted the bladder was re-explored and the fistula was reclosed 2 months after transplantation. The patient remained well and renal function was excellent but the fistula persisted. An extensive bladder mobilization and repair were performed 8 months after transplantation but this also failed. Another repair was undertaken 15 months post-transplantation, using a pedicled omental graft to reinforce closure of the bladder wall, but was unsuccessful. An ileocystoplasty was performed 20 months post-transplantation but the fistula reappeared within 5 days. A cutaneous urinary fistula persisted until chronic rejection developed 3 years after the transplantation and the patient returned to dialysis. Ureteral fistulas. Ureteral fistulas occurred in 4 patients (table 2). One was in the first transplant performed at this institution and represented the sole instance in which a primary ureteropyelostomy was performed. Extravasation occurred at the site of the anastomosis and was successfully treated by repair over a silastic stent. In all succeeding renal transplants continuity of the urinary collecting system was re-established by primary ureteroneocystostomy with the ureter being implanted low in the bladder through a short submucosal tunnel. In 3 patients fistulas arising from the donor ureter developed 10, 23 and 24 days after transplantation. In 2 cases repair was successful, using the recipient's own ipsilateral ureter for secondary repair. The ipsilateral recipient kidney was left in situ with ligation of the proximal ureter without untoward effects. In 1 patient the entire donor ureter and renal pelvis became ischemic. The recipient ureter was, therefore, anastomosed to a flap of renal capsule.
252
SCHIFF AND ASSOCIATES
The single failure in this group (case 10) is interesting because of the unusual manner in which the presence of the fistula became apparent. The patient was a 37-year-old man who received a cadaveric renal transplant and had an immediate, brisk diuresis. The postoperative course was entirely uncomplicated and the man was discharged from the hospital 13 days after transplantation with a serum creatinine level of 1.3 mg. per cent. However, he was rehospitalized 10 days later because if the sudden onset of acute right lower quadrant pain, which occurred after voiding. The serum creatinine level was 1.1 mg. per cent. Excretory urography (IVP) and cystography revealed no evidence of extravasation. Since the abdominal pain persisted exploratory laparotomy was undertaken but no abnormalities were found. A cutaneous urinary fistula became evident a week later and a discrete hole in the mid portion of the donor ureter was discovered at another exploration 5 weeks after transplantation. Dense inflammatory tissue prevented adequate dissection of the ipsilateral recipient ureter for secondary repair. A silastic stent was inserted and a nephrostomy was established. A nephrostogram 3 weeks later demonstrated the ureteral fistula with passage of contrast medium beyond it into the bladder (fig. 2, A). Five weeks after the repair a nephrostogram showed all contrast medium to extravasate at the fistula (fig. 2, B). We decided to remove the kidney because of persistent infection. Caliceal fistulas. Caliceal fistulas developed in 3 patients
TABLE
(table 2). In 2 cases the fistulas were associated with segmental renal infarction in cadaveric kidneys and were noted 3 and 5 weeks after the transplantation. In 1 patient (case 12) severe, transient hypertension developed in the immediate postoperative period and renal scans ( 99mtechnetium diethylenetriaminepentaacetic acid) demonstrated a small area of diminished perfusion in the upper, medial portion of the graft (fig. 3, A). Several weeks later the patient had acute abdominal pain, and extravasation originating from the poorly perfused area of the graft was seen on a followup scan (fig. 3, B). During exploration this patient and patient 13 were found to have segmental renal infarcts communicating directly with an open calix. Treatment in each instance was by nephrostomy drainage, resulting in spontaneous closure of the fistulas with preservation of renal function. Periodic nephrostograms were performed until no further extravasation was noted, after which the nephrostomy tubes were removed (fig. 3, C). Urinary drainage persisted for a number of weeks thereafter but both fistulas eventually closed completely (fig. 3, D). One patient (case 11) sustained blunt abdominal trauma in an automobile accident almost a year after the transplantation. He had gross hematuria and a falling hematocrit. An initial IVP showed only poor visualization of the graft but massive caliceal extravasation with a urinoma above the upper pole was demonstrated on pyelography 10 days later (fig. 4, A). Nephrostomy drainage resulted in closure of the fistula in 4 weeks (fig. 4, B).
1. Incidence of urinary fistulas after transplantation No. Transplants
Source
234 158 220 147 200 125 72 94 238 130 85 126 173 200 134
Starzl and associates' Williams and associates' Belzer and associates 3 Robson and Caine• Weil and associates' Anderson and associates 6 Morehouse and associates 7 Malek and associates' Hricko and associates 9 O'Donoghue and associates" Marx and associates 11 Colfry and associates" Barry and associates 13 Bewick and associates u Present study
Urinary Fistulas (%) No. 9 23 6 8 16 11 6 6 54 16 3 11 14 14 13
(3.8) (14.8) (2.7) (5.4) (8.0) (8.8) (8.3) (6.4) (22.7) (12.3) (3.5) (8.8) (8.1) (7.0) (9.7)
TABLE
Mortality After Fistula (%)
33 39 0 25 62.5 ?
0 16 18.7 0 36 14 21 0
DISCUSSION
Urinary extravasation in the immediate post-transplant period is a potentially lethal complication and requires prompt diagnosis and management. Presently, in the vast majority of transplant recipients continuity of the urinary collecting system is achieved by ureteroneocystostomy. The preponderance of urinary fistulas, therefore, arises from either the anterior bladder suture line or the donor ureter. The importance of preservation of ureteral vascularity and the meticulous care in bladder closure have been stressed in the literature but with the exception of a few reports 1 • 3 • 11 the incidence of urinary fistulas continues to be substantial. It should be pointed out that after ureteropyelostomy, which has been used as an alternative to ureteroneocystostomy, there is a similar incidence of urinary fistulas and the added disadvantage that
2. Patients with urinary fistulas
Onset (day) Case No.
Treatment
Donor Diuresis
Fistula
Result
1 2 3 4 5 6
Brother Cadaver Cadaver Mother Brother Father
1 7 10 1 1 1
Vesical fistulas 1 10 19 4 11 12
Urethral catheter Multiple procedures Wound drainage Wound drainage Urethral catheter Wound drainage
Closed, Failed Closed, Closed, Closed, Closed,
7 8
Cadaver* Mother Brother Cadaver
12 1 1 1
Ureteral fistulas 18 24 10 23
Reanastomosis Ureteropyelostomy Ureteroureterostomy Nephrostomy and stent
Closed, 18 wks. Closed, 20 w ks. Closed, 6 wks. Failed
Cadaver Cadaver Cadaver
11 8 12
Caliceal fistulas 335 35 23
Nephrostomy Nephrostomy Nephrostomy
Closed, 4 wks. Closed, 10 wks. Closed, 21 wks.
9
10
11
12 13
* Primary ureteropyelostomy.
3 wks. 8 wks. 12 wks. 2 wks. 10 wks.
I MANAGEMENT OF FISTULAS AFTER RENAL TRANSPLANTATION
there is no remaining ureter with which to effect a secondary repair. 1 Most urinary fistulas become manifest within several weeks after the onset of renal function and are heralded by the appearance of wound drainage. All 6 patients in our series with vesical fistulas presented in this fashion. Simultaneous urea and electrolyte determinations from wound drainage, serum and voided urine can be helpful in initially distiriguishing the drainage as urine rather than lymph. 16 Conventional uroradiographic studies should then be performed (cystography, IVP and retrograde pyelography) to localize the site and magnitude of the fistula. Occasionally, the use of renal scans may be of benefit diagnostically, especially if renal function is not adequate to permit good visualization on an IVP. 11 Two patients (cases 8 and 13) with supravesical fistulas had extravasation first documented renal scan after an apparently normal IVP. Serial studies may also prove helpful in patients who have signs of acute abdominal distress in the first
Fm. 1. Cystography demonstrates vesical fistula
253
few weeks after the transplantation and in whom no extravasation of contrast medium is seen on routine uroradiographic studies. Two of our patients underwent emergency abdominal exploration prior to discovery of a urinary fistula. Bladder fistulas frequently can be managed solely by urethral catheter drainage. 10 In female subjects the insertion of a large Malecot catheter can be performed easily, providing optimum drainage. Antibacterials are not used in the presence of an indwelling catheter, since this may lead to the emergence of resistant bacterial strains or development of fungal infection. 18 If the fistula is large or if urethral catheter drainage fails to control cutaneous urinary leakage, paravesical drainage should be instituted and can be accomplished under local anesthesia without disturbance of the graft or vascular anastomosis. Fistulas arising proximal to the ureterovesical require more aggressive management. Those involving the donor ureter are best treated prompt, repair using the recipient's own ipsilateral ureter. 1 The 2 patients in our series (cases 8 and 9) who were treated in this fashion achieved a satisfactory result despite a prolonged period of drainage from the anastomotic site. Although Desai and associates successfully treated 2 patients with ureteral fistulas by nonoperative means, 19 the severe ischemia usually responsible for this type of lesion makes spontaneous healing unlikely, Our patient (case 10) treated by wound and nephrostomy drainage had an increase in the size of the fistula during a 5-week period and required nephrectomy, Caliceal fistulas are usually related to segmental renal infarction resulting from failure to recognize or inability to reanastomose an accessory renal artery. Since approximately 25 per cent of kidneys have multiple renal arteries, 20 these must be carefully sought and preserved during donor nephrectomy. With the proliferation of organ-sharing networks now in use in renal transplantation, cadaveric kidneys frequently are not removed by the transplant surgeon. The surgeon performing the cadaveric nephrectomy must, therefore, accurately assess and report the vascular anatomy. Caliceal fistulas have been treated by nephrostomy drainage, 2 segmental resection with closure 8 and with the aid of an omental patch graft.2 1 When complications arise after renal transplantation a constant dilemma is how vigorous the attempt to save the graft should be while incurring a risk to the patient's life. This is
Fm. 2. Case 10. A, nephrostogra.m 3 weeks after attempted repair of ureternl fistula with stent and nephrostomy demonstrates c01,u,1ut,0J1 extravasation. B: nephrostogram_ 5 weeks after attempted repair demonstrates increased extravasation without visualization of ureter.
254
SCHIFF AND ASSOCIATES
FIG. 3. Case 12. A, renal scan 1 day after transplantation shows diminished perfusion in upper, medial portion of kidney. B, renal scan 5 weeks after transplantation shows extravasation originating from upper, medial portion of kidney. C, nephrostogram 10 weeks after transplantation continues to show urinary extravasation from calix. D, IVP 1 year after transplantation demonstrates well functioning kidney without extravasation.
MANAGEMENT OF FISTULAS AFTER RENAL TRANSPLANTATION
FIG. 4. Case 11. A, IVP 10 days after blunt trauma to kidney transplanted 1 year previously demonstrates massive extravasation originating from upper pole calix. B, IVP 1 month after nephrostomy drainage shows no further extravasation.
particularly true with urinary extravasation in which mortality rates of more than 40 per cent have been reported. 5 • 22 • 23 Moreover, it is now well documented that second and third grafts are almost as successful as the primary one 24 • 25 so that loss of the original graft does not necessarily jeopardize the patient's chances of eventually having a successful transplant. However, with a well functioning graft and an otherwise healthy patient, some effort to save the transplant is worthwhile. Our data would indicate that with proper management a favorable outcome can be achieved in the majority of transplant recipients in whom a urinary fistula develops. -
13.
REFERENCES
14.
1. Starzl, T. E., Groth, C. G., Putnam, C. W., Penn, I., Halgrimson, C. G., Flatmark, A., Gecelter, L., Brettschneider, L. and Stonington, 0. G.: Urological complications in 216 human recipients of renal transplants. Ann. Surg., 172: 1, 'i970. 2. Williams, G., Birtch, A. G., Wilson, R. E., Harrison, J. H. and Murray, J. E.: Urological complications of renal transplantation. Brit. J. Urol., 42: 21, 1970. 3. Belzer, F. 0., Kountz, S. L., Najarian, J. S., Tanagho, E. A. and Hinman, F., Jr.: Prevention of urological complications after renal allotransplantation. Arch. Surg., 101: 449, 1970. 4. Robson, A. J. and Caine, R. Y.: Complications of urinary drainage following renal transplantation. Brit. J. Uro( 43: 586, 1971. 5. Weil, R., III, Simmons, R. L., Tallent, M. B., Lillehei, R. C., Kjellstrand, C. M. and Najarian, J. S.: Prevention of urological complications after kidney transplantation. Ann. Surg., 174: 154, 1971. 6. Anderson, E. E., Glenn, J. F., Seigler, H. F. and Stickel, D. L.: Urologic complications in renal transplantation. J. Urol., HJ7: 187, 1972. 7. Morehouse, D. D., Macramalla, E. A., Guttmann, R. D., Beaudoin, J-G., Farrer, P. A. and MacKinnon, K. J.: The conservative management of urinary fistulas following renal allografts. J. Urol., HO: 502, 1973. 8. Malek, G. H., Uehling, D. T., Daouk, A. A. and Kisken, W. A.: Urological complications of renal transplantation. J. Urol., Hl9: 173, 1973o 9. Hricko, G. M., Birtch, A. G., Bennett, A. H. and Wilson, R. E.:
10.
11.
12.
15.
16.
17.
18.
19.
20.
21.
22. 23.
Factors responsible for urinary fistula in the renal transplant recipient. Ann. Surg., 178: 609, 1973. O'Donoghue, E. P. N., Chisholm, G. D. and Shackman, R.: Urinary fistulae after renal transplantation. Brit. J. Urol., 45: 28, 1973. Marx, W. L., Halasz, N. A., McLaughlin, A. P. and Gittes, R. F.: Urological complications in renal transplantation. J. Urol., H2: 561, 1974. Colfry, A. J., Jr., Schlegel, J. U., Lindsey, E. S. and McDonald, J. C.: Urological complications in renal transplantation. J. Urol., 112: 564, 1974. Barry, J. M., Lawson, R. K., Strong, D. and Hodges, C. V.: Urologic complications in 173 kidney transplants. J. Urol., H2: 567, 1974. Bewick, M., Collins, R. E. C., Saxton, H. M., Ellis, F. G., McColl, I. and Ogg, C. S.: The surgery and problems of the ureter in human renal transplantation. Brit. J. Urol., 46: 493, 1974. Kunin, C. M. and McCormack, R. C.: Prevention of catheterinduced urinary-tract infections by sterile closed drainage. New Engl. J. Med., 274: 1155, 1966. Banowsky, L. H., Francis, J., Braun, W. E. and Magnusson, M. 0.: Renal transplantation. II. Lymphatic complications. Urology, 4: 650, 1974. Freedman, G. S., Schiff, M., Jr., Lange, R. C., Brown, R. S., Weiss, R. M., Treves, S. and Lytton,-B.: Functional assessment of renal homografts by means of ,,mTc-DTPA and a gamma scintillation camera. Invest. Urol., 9: 490, 1972. Thornton, G. F., Lytton, B. and Andriole, V. T.: Bacteriuria during indwelling catheter drainage. Effect of constant bladder rinse. J.A.M.A., 195: 179, 1966. Desai, S. G., McRoberts, J. W., Hellebusch, A. A. and Luke, R. G.: Conservative non-operative management of ureteral fistulas following renal allografts. J. Urol., 112: 572, 1974. Ross, J. A., Samuel, E. and Millar, D.R.: Variations in the renal vascular pedicle. (An anatomical and radiological study with particular reference to renal transplantation.) Brit. J. Urol., 33: 478, 1961. Fox, M. and Tottenham, R. C.: Urinary fistula from segmental infarction in a transplanted kidney: recovery following surgical repair. Brit. J. Urol., 44: 336, 1972. Dossetor, J.B., MacKinnon, K. J., Gault, M. H. and MacLean, L. D.: Cadaver kidney transplants. Transplantation, 5: 844, 1967. MacLean, L. D., MacKinnon, K. J., Inglis, F, G. and Dossetor, J.
256
SCHIFF AND ASSOCIATES
B.: When should renal allografts be removed? Arch. Surg., 99: 269, 1969. 24. Advisory Committee of the Renal Transplant Registry: The 12th report of the Human Renal Transplant Registry. J.A.M.A., 233: 787, 1975. 25. Opelz, G., Mickey, M. R. and Terasaki, P. I.: Prolonged survival of second human kidney transplants. Science, 178: 617, 1972.
high incidence of bladder leaks as opposed to ureteral leaks in this series is different from our series. We believe that if there is any extravasation surgical exploration should be done and the use of closed bladder drainage may result in delay of correction of the leak with resultant infection and possibly secondary rejection. The wide use of sonography at our institution has aided in the diagnosis of extravasation urinoma and fistula formation.
COMMENT These authors support our view that urinary fistulas after a renal transplantation should be surgically corrected as early as possible. The
Martin G. McLaughlin The Johns Hopkins Hospital Baltimore, Maryland
THE JOURNAL OF UROLOGY Copyright © 1976 by The Williams & Wilkins Co.
MANAGEMENT OF URINARY FISTULAS AFTER RENAL TRANSPLANTATION MARTIN SCHIFF, JR., EDWARD J. MCGUIRE, ROBERT M. WEISS
AND
BERNARD LYTTON
From the Section of Urology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
ABSTRACT
Urinary fistulas developed in 13 of 134 patients after renal transplantation. Bladder fistulas originating from the anterior suture line in 6 patients were satisfactorily managed by urethral or paravesical drainage. Fistulas arising from the donor ureter were best treated by surgical repair using the recipient's own ureter. Caliceal fistulas in 3 patients were successfully treated with nephrostomy drainage. A favorable outcome was achieved in 11 of the 13 patients, with closure of the fistula and preservation of renal function. Renal transplantation has become a well established procedure but urological complications remain a major problem. Urinary fistulas comprise a significant proportion of these complications with a reported incidence of 3 to 23 per cent in recent series, many being associated with a mortality rate of between 14 and 60 per cent (table l). 1• 14 The anterior bladder suture line is the most frequent site of urinary extravasation but fistulas may originate at the ureterovesical anastomosis or more proximally at any point along the urinary collecting system of the transplanted kidney. The long-standing uremia and anemia common to transplant recipients, the high doses of steroids required in the immediate postoperative period and the relative vascular insufficiency of the distal allograft ureter are all factors that may contribute to urological problems. A review of the experience with urinary fistulas after renal transplantation at our hospital during the last 7 years revealed 13 such cases out of 134 transplants, an incidence of 9.7 per cent. The etiology and management of these fistulas are reported herein. CLINICAL MATERIAL
Bladder fistulas. Urinary fistulas arising from the anterior bladder suture line developed in 6 patients despite a meticulous 3-layer closure. Although living related donors accounted for only 23 per cent of the total transplants performed (31 of 134) 4 of the 6 patients with vesical fistulas received a living donor transplant and had experienced an immediate, brisk diuresis (table 2). All vesical fistulas were evident by 12 days after the onset of urinary excretion. The diagnosis was readily apparent in all instances and fistulas became manifest following diminution in voided urine and the appearance of urinary drainage through the wound. The drainage was distinguished from serum or lymph by simultaneous determinations of sodium, potassium and urea from peripheral blood, voided urine and wound drainage. Diagnosis was confirmed by cystography (fig. 1). Of the 6 vesical fistulas 5 closed spontaneously within 2 to 12 weeks. Two patients were managed solely by an indwelling urethral catheter. The fistulas in these 2 cases were small and all urinary drainage from the wound ceased completely after catheter drainage was instituted. Cystography prior to catheter removal confirmed closure of the fistula. Urethral catheters were managed by a strict closed-system technique without prophylactic antibacterials. 15 They were left indwelling for up to 3 weeks. In 3 patients in whom the extravasation was Accepted for publication June 13, 1975. Read at annual meeting of American Urological Association, Miami Beach. Florida, May 11-15, 1_975.
251
pronounced surgical paravesical drainage was effected. These fistulas took longer to heal but the patients remained well and were managed outside the hospital. The single patient with a bladder fistula in whom all treatment failed was an 18-year-old man with renal failure secondary to congenital, bilateral ureterovesical obstruction. He had undergone multiple, unsuccessful attempts at reconstructive operations as a child and after development of renal insufficiency when he was 15 years old he underwent bilateral nephroureterectomy. Renal transplantation was thus complicated by the extensive prior pelvic operative procedures and the bladder was markedly thickened and distorted. Diuresis began 7 days postoperatively but 3 days later a cutaneous urinary fistula developed. On cystography extravasation occurred from the anterior bladder suture line. Initial treatment was with a urethral catheter but 3 weeks after transplantation there was no improvement and surgical wound drainage was performed. A gapping defect in the bladder was resutured and a cystostomy tube was inserted. Since urinary leakage persisted the bladder was re-explored and the fistula was reclosed 2 months after transplantation. The patient remained well and renal function was excellent but the fistula persisted. An extensive bladder mobilization and repair were performed 8 months after transplantation but this also failed. Another repair was undertaken 15 months post-transplantation, using a pedicled omental graft to reinforce closure of the bladder wall, but was unsuccessful. An ileocystoplasty was performed 20 months post-transplantation but the fistula reappeared within 5 days. A cutaneous urinary fistula persisted until chronic rejection developed 3 years after the transplantation and the patient returned to dialysis. Ureteral fistulas. Ureteral fistulas occurred in 4 patients (table 2). One was in the first transplant performed at this institution and represented the sole instance in which a primary ureteropyelostomy was performed. Extravasation occurred at the site of the anastomosis and was successfully treated by repair over a silastic stent. In all succeeding renal transplants continuity of the urinary collecting system was re-established by primary ureteroneocystostomy with the ureter being implanted low in the bladder through a short submucosal tunnel. In 3 patients fistulas arising from the donor ureter developed 10, 23 and 24 days after transplantation. In 2 cases repair was successful, using the recipient's own ipsilateral ureter for secondary repair. The ipsilateral recipient kidney was left in situ with ligation of the proximal ureter without untoward effects. In 1 patient the entire donor ureter and renal pelvis became ischemic. The recipient ureter was, therefore, anastomosed to a flap of renal capsule.
252
SCHIFF AND ASSOCIATES
The single failure in this group (case 10) is interesting because of the unusual manner in which the presence of the fistula became apparent. The patient was a 37-year-old man who received a cadaveric renal transplant and had an immediate, brisk diuresis. The postoperative course was entirely uncomplicated and the man was discharged from the hospital 13 days after transplantation with a serum creatinine level of 1.3 mg. per cent. However, he was rehospitalized 10 days later because if the sudden onset of acute right lower quadrant pain, which occurred after voiding. The serum creatinine level was 1.1 mg. per cent. Excretory urography (IVP) and cystography revealed no evidence of extravasation. Since the abdominal pain persisted exploratory laparotomy was undertaken but no abnormalities were found. A cutaneous urinary fistula became evident a week later and a discrete hole in the mid portion of the donor ureter was discovered at another exploration 5 weeks after transplantation. Dense inflammatory tissue prevented adequate dissection of the ipsilateral recipient ureter for secondary repair. A silastic stent was inserted and a nephrostomy was established. A nephrostogram 3 weeks later demonstrated the ureteral fistula with passage of contrast medium beyond it into the bladder (fig. 2, A). Five weeks after the repair a nephrostogram showed all contrast medium to extravasate at the fistula (fig. 2, B). We decided to remove the kidney because of persistent infection. Caliceal fistulas. Caliceal fistulas developed in 3 patients
TABLE
(table 2). In 2 cases the fistulas were associated with segmental renal infarction in cadaveric kidneys and were noted 3 and 5 weeks after the transplantation. In 1 patient (case 12) severe, transient hypertension developed in the immediate postoperative period and renal scans ( 99mtechnetium diethylenetriaminepentaacetic acid) demonstrated a small area of diminished perfusion in the upper, medial portion of the graft (fig. 3, A). Several weeks later the patient had acute abdominal pain, and extravasation originating from the poorly perfused area of the graft was seen on a followup scan (fig. 3, B). During exploration this patient and patient 13 were found to have segmental renal infarcts communicating directly with an open calix. Treatment in each instance was by nephrostomy drainage, resulting in spontaneous closure of the fistulas with preservation of renal function. Periodic nephrostograms were performed until no further extravasation was noted, after which the nephrostomy tubes were removed (fig. 3, C). Urinary drainage persisted for a number of weeks thereafter but both fistulas eventually closed completely (fig. 3, D). One patient (case 11) sustained blunt abdominal trauma in an automobile accident almost a year after the transplantation. He had gross hematuria and a falling hematocrit. An initial IVP showed only poor visualization of the graft but massive caliceal extravasation with a urinoma above the upper pole was demonstrated on pyelography 10 days later (fig. 4, A). Nephrostomy drainage resulted in closure of the fistula in 4 weeks (fig. 4, B).
1. Incidence of urinary fistulas after transplantation No. Transplants
Source
234 158 220 147 200 125 72 94 238 130 85 126 173 200 134
Starzl and associates' Williams and associates' Belzer and associates 3 Robson and Caine• Weil and associates' Anderson and associates 6 Morehouse and associates 7 Malek and associates' Hricko and associates 9 O'Donoghue and associates" Marx and associates 11 Colfry and associates" Barry and associates 13 Bewick and associates u Present study
Urinary Fistulas (%) No. 9 23 6 8 16 11 6 6 54 16 3 11 14 14 13
(3.8) (14.8) (2.7) (5.4) (8.0) (8.8) (8.3) (6.4) (22.7) (12.3) (3.5) (8.8) (8.1) (7.0) (9.7)
TABLE
Mortality After Fistula (%)
33 39 0 25 62.5 ?
0 16 18.7 0 36 14 21 0
DISCUSSION
Urinary extravasation in the immediate post-transplant period is a potentially lethal complication and requires prompt diagnosis and management. Presently, in the vast majority of transplant recipients continuity of the urinary collecting system is achieved by ureteroneocystostomy. The preponderance of urinary fistulas, therefore, arises from either the anterior bladder suture line or the donor ureter. The importance of preservation of ureteral vascularity and the meticulous care in bladder closure have been stressed in the literature but with the exception of a few reports 1 • 3 • 11 the incidence of urinary fistulas continues to be substantial. It should be pointed out that after ureteropyelostomy, which has been used as an alternative to ureteroneocystostomy, there is a similar incidence of urinary fistulas and the added disadvantage that
2. Patients with urinary fistulas
Onset (day) Case No.
Treatment
Donor Diuresis
Fistula
Result
1 2 3 4 5 6
Brother Cadaver Cadaver Mother Brother Father
1 7 10 1 1 1
Vesical fistulas 1 10 19 4 11 12
Urethral catheter Multiple procedures Wound drainage Wound drainage Urethral catheter Wound drainage
Closed, Failed Closed, Closed, Closed, Closed,
7 8
Cadaver* Mother Brother Cadaver
12 1 1 1
Ureteral fistulas 18 24 10 23
Reanastomosis Ureteropyelostomy Ureteroureterostomy Nephrostomy and stent
Closed, 18 wks. Closed, 20 w ks. Closed, 6 wks. Failed
Cadaver Cadaver Cadaver
11 8 12
Caliceal fistulas 335 35 23
Nephrostomy Nephrostomy Nephrostomy
Closed, 4 wks. Closed, 10 wks. Closed, 21 wks.
9
10
11
12 13
* Primary ureteropyelostomy.
3 wks. 8 wks. 12 wks. 2 wks. 10 wks.
I MANAGEMENT OF FISTULAS AFTER RENAL TRANSPLANTATION
there is no remaining ureter with which to effect a secondary repair. 1 Most urinary fistulas become manifest within several weeks after the onset of renal function and are heralded by the appearance of wound drainage. All 6 patients in our series with vesical fistulas presented in this fashion. Simultaneous urea and electrolyte determinations from wound drainage, serum and voided urine can be helpful in initially distiriguishing the drainage as urine rather than lymph. 16 Conventional uroradiographic studies should then be performed (cystography, IVP and retrograde pyelography) to localize the site and magnitude of the fistula. Occasionally, the use of renal scans may be of benefit diagnostically, especially if renal function is not adequate to permit good visualization on an IVP. 11 Two patients (cases 8 and 13) with supravesical fistulas had extravasation first documented renal scan after an apparently normal IVP. Serial studies may also prove helpful in patients who have signs of acute abdominal distress in the first
Fm. 1. Cystography demonstrates vesical fistula
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few weeks after the transplantation and in whom no extravasation of contrast medium is seen on routine uroradiographic studies. Two of our patients underwent emergency abdominal exploration prior to discovery of a urinary fistula. Bladder fistulas frequently can be managed solely by urethral catheter drainage. 10 In female subjects the insertion of a large Malecot catheter can be performed easily, providing optimum drainage. Antibacterials are not used in the presence of an indwelling catheter, since this may lead to the emergence of resistant bacterial strains or development of fungal infection. 18 If the fistula is large or if urethral catheter drainage fails to control cutaneous urinary leakage, paravesical drainage should be instituted and can be accomplished under local anesthesia without disturbance of the graft or vascular anastomosis. Fistulas arising proximal to the ureterovesical require more aggressive management. Those involving the donor ureter are best treated prompt, repair using the recipient's own ipsilateral ureter. 1 The 2 patients in our series (cases 8 and 9) who were treated in this fashion achieved a satisfactory result despite a prolonged period of drainage from the anastomotic site. Although Desai and associates successfully treated 2 patients with ureteral fistulas by nonoperative means, 19 the severe ischemia usually responsible for this type of lesion makes spontaneous healing unlikely, Our patient (case 10) treated by wound and nephrostomy drainage had an increase in the size of the fistula during a 5-week period and required nephrectomy, Caliceal fistulas are usually related to segmental renal infarction resulting from failure to recognize or inability to reanastomose an accessory renal artery. Since approximately 25 per cent of kidneys have multiple renal arteries, 20 these must be carefully sought and preserved during donor nephrectomy. With the proliferation of organ-sharing networks now in use in renal transplantation, cadaveric kidneys frequently are not removed by the transplant surgeon. The surgeon performing the cadaveric nephrectomy must, therefore, accurately assess and report the vascular anatomy. Caliceal fistulas have been treated by nephrostomy drainage, 2 segmental resection with closure 8 and with the aid of an omental patch graft.2 1 When complications arise after renal transplantation a constant dilemma is how vigorous the attempt to save the graft should be while incurring a risk to the patient's life. This is
Fm. 2. Case 10. A, nephrostogra.m 3 weeks after attempted repair of ureternl fistula with stent and nephrostomy demonstrates c01,u,1ut,0J1 extravasation. B: nephrostogram_ 5 weeks after attempted repair demonstrates increased extravasation without visualization of ureter.
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FIG. 3. Case 12. A, renal scan 1 day after transplantation shows diminished perfusion in upper, medial portion of kidney. B, renal scan 5 weeks after transplantation shows extravasation originating from upper, medial portion of kidney. C, nephrostogram 10 weeks after transplantation continues to show urinary extravasation from calix. D, IVP 1 year after transplantation demonstrates well functioning kidney without extravasation.
MANAGEMENT OF FISTULAS AFTER RENAL TRANSPLANTATION
FIG. 4. Case 11. A, IVP 10 days after blunt trauma to kidney transplanted 1 year previously demonstrates massive extravasation originating from upper pole calix. B, IVP 1 month after nephrostomy drainage shows no further extravasation.
particularly true with urinary extravasation in which mortality rates of more than 40 per cent have been reported. 5 • 22 • 23 Moreover, it is now well documented that second and third grafts are almost as successful as the primary one 24 • 25 so that loss of the original graft does not necessarily jeopardize the patient's chances of eventually having a successful transplant. However, with a well functioning graft and an otherwise healthy patient, some effort to save the transplant is worthwhile. Our data would indicate that with proper management a favorable outcome can be achieved in the majority of transplant recipients in whom a urinary fistula develops. -
13.
REFERENCES
14.
1. Starzl, T. E., Groth, C. G., Putnam, C. W., Penn, I., Halgrimson, C. G., Flatmark, A., Gecelter, L., Brettschneider, L. and Stonington, 0. G.: Urological complications in 216 human recipients of renal transplants. Ann. Surg., 172: 1, 'i970. 2. Williams, G., Birtch, A. G., Wilson, R. E., Harrison, J. H. and Murray, J. E.: Urological complications of renal transplantation. Brit. J. Urol., 42: 21, 1970. 3. Belzer, F. 0., Kountz, S. L., Najarian, J. S., Tanagho, E. A. and Hinman, F., Jr.: Prevention of urological complications after renal allotransplantation. Arch. Surg., 101: 449, 1970. 4. Robson, A. J. and Caine, R. Y.: Complications of urinary drainage following renal transplantation. Brit. J. Uro( 43: 586, 1971. 5. Weil, R., III, Simmons, R. L., Tallent, M. B., Lillehei, R. C., Kjellstrand, C. M. and Najarian, J. S.: Prevention of urological complications after kidney transplantation. Ann. Surg., 174: 154, 1971. 6. Anderson, E. E., Glenn, J. F., Seigler, H. F. and Stickel, D. L.: Urologic complications in renal transplantation. J. Urol., HJ7: 187, 1972. 7. Morehouse, D. D., Macramalla, E. A., Guttmann, R. D., Beaudoin, J-G., Farrer, P. A. and MacKinnon, K. J.: The conservative management of urinary fistulas following renal allografts. J. Urol., HO: 502, 1973. 8. Malek, G. H., Uehling, D. T., Daouk, A. A. and Kisken, W. A.: Urological complications of renal transplantation. J. Urol., Hl9: 173, 1973o 9. Hricko, G. M., Birtch, A. G., Bennett, A. H. and Wilson, R. E.:
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Factors responsible for urinary fistula in the renal transplant recipient. Ann. Surg., 178: 609, 1973. O'Donoghue, E. P. N., Chisholm, G. D. and Shackman, R.: Urinary fistulae after renal transplantation. Brit. J. Urol., 45: 28, 1973. Marx, W. L., Halasz, N. A., McLaughlin, A. P. and Gittes, R. F.: Urological complications in renal transplantation. J. Urol., H2: 561, 1974. Colfry, A. J., Jr., Schlegel, J. U., Lindsey, E. S. and McDonald, J. C.: Urological complications in renal transplantation. J. Urol., 112: 564, 1974. Barry, J. M., Lawson, R. K., Strong, D. and Hodges, C. V.: Urologic complications in 173 kidney transplants. J. Urol., H2: 567, 1974. Bewick, M., Collins, R. E. C., Saxton, H. M., Ellis, F. G., McColl, I. and Ogg, C. S.: The surgery and problems of the ureter in human renal transplantation. Brit. J. Urol., 46: 493, 1974. Kunin, C. M. and McCormack, R. C.: Prevention of catheterinduced urinary-tract infections by sterile closed drainage. New Engl. J. Med., 274: 1155, 1966. Banowsky, L. H., Francis, J., Braun, W. E. and Magnusson, M. 0.: Renal transplantation. II. Lymphatic complications. Urology, 4: 650, 1974. Freedman, G. S., Schiff, M., Jr., Lange, R. C., Brown, R. S., Weiss, R. M., Treves, S. and Lytton,-B.: Functional assessment of renal homografts by means of ,,mTc-DTPA and a gamma scintillation camera. Invest. Urol., 9: 490, 1972. Thornton, G. F., Lytton, B. and Andriole, V. T.: Bacteriuria during indwelling catheter drainage. Effect of constant bladder rinse. J.A.M.A., 195: 179, 1966. Desai, S. G., McRoberts, J. W., Hellebusch, A. A. and Luke, R. G.: Conservative non-operative management of ureteral fistulas following renal allografts. J. Urol., 112: 572, 1974. Ross, J. A., Samuel, E. and Millar, D.R.: Variations in the renal vascular pedicle. (An anatomical and radiological study with particular reference to renal transplantation.) Brit. J. Urol., 33: 478, 1961. Fox, M. and Tottenham, R. C.: Urinary fistula from segmental infarction in a transplanted kidney: recovery following surgical repair. Brit. J. Urol., 44: 336, 1972. Dossetor, J.B., MacKinnon, K. J., Gault, M. H. and MacLean, L. D.: Cadaver kidney transplants. Transplantation, 5: 844, 1967. MacLean, L. D., MacKinnon, K. J., Inglis, F, G. and Dossetor, J.
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B.: When should renal allografts be removed? Arch. Surg., 99: 269, 1969. 24. Advisory Committee of the Renal Transplant Registry: The 12th report of the Human Renal Transplant Registry. J.A.M.A., 233: 787, 1975. 25. Opelz, G., Mickey, M. R. and Terasaki, P. I.: Prolonged survival of second human kidney transplants. Science, 178: 617, 1972.
high incidence of bladder leaks as opposed to ureteral leaks in this series is different from our series. We believe that if there is any extravasation surgical exploration should be done and the use of closed bladder drainage may result in delay of correction of the leak with resultant infection and possibly secondary rejection. The wide use of sonography at our institution has aided in the diagnosis of extravasation urinoma and fistula formation.
COMMENT These authors support our view that urinary fistulas after a renal transplantation should be surgically corrected as early as possible. The
Martin G. McLaughlin The Johns Hopkins Hospital Baltimore, Maryland
