British Journalof Urology (1975), 41, 424 0
Short Case Report
Occurrence of Vesical Calculus following Renal Transplantation The development of a calculus at the site of ureteroneocystostomy after renal transplantation has not been previously reported to our knowledge. Below is described our experience with such a case.
Case Report A 58-year-old woman with end-stage renal failure due to chronic glomerulonephritis began haemodialysis in August 1972. She had no history of urinary tract infections or urinary calculous disease. Complete urological investigation was normal except for bilaterally small kidneys commensurate with chronic glomerulonephritis. The serum calcium concentration was 9.2 mg/dl and the serum phosphorus concentration, 9.9 mg/dl. She underwent bilateral nephrectomy in September 1972 and received a living-related-donor renal allograft 6 weeks later. Transplantation was uncomplicated. The allograft ureter was reimplanted into the bladder, a submucosal tunnel and ureteral cuff technique being used, as previously described (DeWeerd, Woods and Leary, 1973). All suture material used in the urinary tract was 4-0 chromic catgut. No splints were used. The Foley urethral catheter was removed on the 5th posttransplant day and voiding was normal. The serum creatinine concentration stabilised at 0.8 mg/dl. The urine was sterile throughout her hospital course. She was dismissed on the 10th postoperative day on a regimen of azathioprine (Imuran) 75 mg daily and prednisone 20 mg and 17.5 mg on alternate days. Follow-up evaluations at 1 month and 6 months were normal. At the 12-month follow-up she stated that she had been “passing some gravel” in her urine 1 week previously. She had no other symptoms and urine culture was sterile. The renal allograft appeared normal on the excretory urogram. However, an irregularly oval density ( I by 2 cm) having a nonopaque centre was present in the bladder (Fig.). The serum concentrations of calcium and phosphorus were 10.7 and 3.2 mg/dl, respectively. Cystoscopy revealed a smooth yellow-white calculus (1 by 2 cm) tenuously attached to the site of the previous ureteroneocystostomy. The slender attachment of the calculus appeared to be at the site of the prior suture line uniting the posterior edge of the ureteral cuff to the bladder mucosa. The ureteral orifice itself appeared normal. Litholapaxy was performed and the patient was dismissed 3 days later. Histological examination of the calcareous material
removed showed a fibrous connective tissue nidus with a calcified outer surface correlating well with its radiographic appearance. Analysis of the calculus showed that it was composed of calcium phosphate.
Comment We feel that the calculus resulted from dystrophic calcification of an ischaemic portion of the cuff of the allograft ureter. Isolated rejection of such a small portion of tissue seems highly unlikely, and there was no evidence of urinary infection. It seems most likely that the ureteroneocystostomy rendered a small area of ureteral mucosa ischaemic and that this resulted in calcification. Meticulous attention to detail in performing all aspects of renal allograft surgery should keep such complications to a minimum. MICHAELJ. O’DEA,HORSTZINCKE. THOMAS A. RIVERS AND FRANK J. LEAKY Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55901 U.S.A.
Reference DEWEERD, J. H., WOODS, J. E. and LEAKY,F. J. ( 1973). The allograft ureter. Joiirnal of Urology, 109, 958-963. 424
Short Case Report
Occurrence of Vesical Calculus following Renal Transplantation The development of a calculus at the site of ureteroneocystostomy after renal transplantation has not been previously reported to our knowledge. Below is described our experience with such a case.
Case Report A 58-year-old woman with end-stage renal failure due to chronic glomerulonephritis began haemodialysis in August 1972. She had no history of urinary tract infections or urinary calculous disease. Complete urological investigation was normal except for bilaterally small kidneys commensurate with chronic glomerulonephritis. The serum calcium concentration was 9.2 mg/dl and the serum phosphorus concentration, 9.9 mg/dl. She underwent bilateral nephrectomy in September 1972 and received a living-related-donor renal allograft 6 weeks later. Transplantation was uncomplicated. The allograft ureter was reimplanted into the bladder, a submucosal tunnel and ureteral cuff technique being used, as previously described (DeWeerd, Woods and Leary, 1973). All suture material used in the urinary tract was 4-0 chromic catgut. No splints were used. The Foley urethral catheter was removed on the 5th posttransplant day and voiding was normal. The serum creatinine concentration stabilised at 0.8 mg/dl. The urine was sterile throughout her hospital course. She was dismissed on the 10th postoperative day on a regimen of azathioprine (Imuran) 75 mg daily and prednisone 20 mg and 17.5 mg on alternate days. Follow-up evaluations at 1 month and 6 months were normal. At the 12-month follow-up she stated that she had been “passing some gravel” in her urine 1 week previously. She had no other symptoms and urine culture was sterile. The renal allograft appeared normal on the excretory urogram. However, an irregularly oval density ( I by 2 cm) having a nonopaque centre was present in the bladder (Fig.). The serum concentrations of calcium and phosphorus were 10.7 and 3.2 mg/dl, respectively. Cystoscopy revealed a smooth yellow-white calculus (1 by 2 cm) tenuously attached to the site of the previous ureteroneocystostomy. The slender attachment of the calculus appeared to be at the site of the prior suture line uniting the posterior edge of the ureteral cuff to the bladder mucosa. The ureteral orifice itself appeared normal. Litholapaxy was performed and the patient was dismissed 3 days later. Histological examination of the calcareous material
removed showed a fibrous connective tissue nidus with a calcified outer surface correlating well with its radiographic appearance. Analysis of the calculus showed that it was composed of calcium phosphate.
Comment We feel that the calculus resulted from dystrophic calcification of an ischaemic portion of the cuff of the allograft ureter. Isolated rejection of such a small portion of tissue seems highly unlikely, and there was no evidence of urinary infection. It seems most likely that the ureteroneocystostomy rendered a small area of ureteral mucosa ischaemic and that this resulted in calcification. Meticulous attention to detail in performing all aspects of renal allograft surgery should keep such complications to a minimum. MICHAELJ. O’DEA,HORSTZINCKE. THOMAS A. RIVERS AND FRANK J. LEAKY Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55901 U.S.A.
Reference DEWEERD, J. H., WOODS, J. E. and LEAKY,F. J. ( 1973). The allograft ureter. Joiirnal of Urology, 109, 958-963. 424
