Terence A. S. Matalon, MD • Michael J. Thompson, MD • Suresh K. Patel, MD • Marcus V. Ramos, MD • Stephen C. Jensik, MD • Frederick K. Merkel, MD
Percutaneous Treatment of Urine Leaks in Renal Transplantation Patients' The data on post-renal transplantation urine leaks in 23 patients were retrospectively reviewed to assess the role of percutaneous urine-diverting procedures in their treatment. The leaks were confirmed by means of antegrade pyelography, and either a nephrostomy catheter or a nephroureteral stent was placed. Nephrostography was performed frequently to evaluate leak closure. Urinary diversion was continued for an average of 68 days. Leak closure was documented in 20 of 23 (87%) cases. In four patients, concomitant infection or multiorgan failure precluded adequate therapy. One patient developed a ureteral stricture after the urine-diverting procedure and required surgical correction. The results suggest that percutaneous urine-diverting procedures are a definitive treatment for post-renal transplantation urine leaks. Index terms: Catheters and catheterization. • Genitourinary system, interventional procedure, 80.1299 • Kidney, interventional procedure, 813.1299 • Kidney transplantation, 81.4559 • Ureter, interventional procedure, 82.1299 Radiology 1990; 174:1049-1051
1 From the Departments of Diagnostic Radiology and Nuclear Medicine (T.A.S.M., M.J.T., S.K.P., M.V.R.) and Surgery (S.C.J., F.K.M.), Rush-Presbyterian-St Luke's Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612. Received April 3, 1989; revision requested June 6; final revision received August 22; accepted August 28. Address reprint requests to T.A.S.M. RSNA, 1990
leaks are an uncommon but serious complication of renal transplantation. If the leak is not treated, the mortality is 50% (1). Despite appropriate treatment, the morbidity and mortality in transplantation patients with urine leaks are two to three times higher than in those without leaks (2). Recently investigators have reported that percutaneous urine-diverting procedures are a temporizing treatment and that surgical repair is the definitive therapy (3). A review of the data on 23 urine leaks in 23 patients was performed to evaluate the role of percutaneous procedures in the treatment of postrenal transplantation urine leaks.
U
RINE
PATIENTS AND METHODS In a retrospective review, 23 leaks were identified in 23 patients who were treated from 1984 through 1988. All leaks were confirmed by means of antegrade pyelography. Of the 23 patients, eight were women. The mean patient age was 38 years (range, 19-68 years). Four leaks originated at the level of the renal pelvis, two from the midportion of the ureter, and 17 from the distal ureter. Six leaks were treated with nephrostomy alone, and 17 were treated with placement of a nephroureteral stent. The patients were followed up clinically, and nephrostography was performed frequently. Nephrostomy catheters and stents were removed 6 weeks after documentation of leak closure. The period 6 weeks was chosen on the basis of the experience of our urologic colleagues in treatment of ureteral injuries. Antegrade pyelography was performed in the special procedures suite with use of real-time ultrasound (US). The US probe was draped in standard fashion and was used within the sterile field. When some dilatation of the collecting system was
present, real-time US was used to confirm needle placement within the collecting system. Subsequent injection of contrast material under fluoroscopic guidance confirmed the placement. In situations in which the collecting system had been totally decompressed by the urine leak, the needle was placed within the central echo system, and multiple small-volume injections of contrast material were made under fluoroscopic guidance. After fluoroscopic confirmation of placement of the needle in the collecting system, a 0.018-inch platinum-tipped guide wire was advanced through the antegrade pyelography needle, and subsequent tract dilation was performed in standard fashion. If the site at which the needle entered was inappropriate for tube placement, a second puncture was made under fluoroscopic guidance. At the time of antegrade pyelography, the presence of a leak within the renal pelvis or ureter was observed. Most ureteral leaks were treated with placement of a nephroureteral stent with a pigtail within the bladder and side holes within the renal pelvis. Pelvic and calyceal leaks were treated simply with nephrostomy catheters with a pigtail in the renal pelvis. All leaks were treated with purely external drainage until closure of the leak had been demonstrated. The external drainage catheter was then capped, and internal drainage was used in patients with nephroureteral stents. Drainage was continued for 6 weeks after documentation of leak closure. Prophylactic therapy with a variety of antibiotics was given. Currently Bactrim (trimethoprim-sulfamethoxazole; Roche Laboratories, Nutley, NJ) is used unless a specific organism is found, in which case antibiotic coverage is tailored to the sensitivity of the organism. Urinary tract infection was common after the patients' hospital dis1049
c. b. a. Figure 1. (a) Antegrade nephrostogram reveals marked extravasation of contrast material, apparently originating from an upper pole calyx. (b) Steep oblique view reveals that leak is actually from the renal pelvis. (c) Nephrostogram obtained 7 weeks after nephrostomy was performed reveals no leak. The catheter was removed, and the patient did well.
charge, but the infection usually responded to oral antibiotic therapy. Parenteral therapy was used when positive cultures were associated with symptoms of sepsis. RESULTS
All patients with documented leaks underwent a urine-diverting procedure. All procedures were technically successful. Urinary diversion was continued for an average of 68 days (range, 6-130 days). Leak closure was documented after an average of 41 days. The interval between leak closure and stent removal is less than our recommended 6 weeks because in some cases early in the review period the catheter was removed sooner than 6 weeks. All patients were followed up regularly with nephrostography; an average of 4.0 studies were performed (range, 2-8). Closure of 20 of 23 (87%) leaks was documented (Fig 1). In four patients, concomitant infection or multiorgan failure precluded adequate therapy. In one patient with a distal ureteral leak and sepsis due to gram-negative organisms despite a functioning stent, renal function continued to deteriorate. Antibiotic therapy failed to eradicate the underlying infection, and 6 days after stent placement a transplant nephrectomy was performed. A second patient developed 1050 • Radiology
a wound infection in the early posttransplantation period. Subsequent antegrade pyelography revealed a ureteral leak in the middle to distal portion. Nephroureterograms obtained 19 and 28 days after stent placement revealed a persistent leak. On the 40th postprocedure day, the patient died of overwhelming sepsis. A third failure occurred in a patient who initially had a perinephric fluid collection. Antegrade pyelography revealed a leak originating at the renal pelvis. The patient was treated with a nephrostomy catheter. He developed bilateral pneumonia and multiple pneumothoraces. His compromised pulmonary status precluded follow-up nephrography. Seventy-two days after the drainage procedure, the patient died of respiratory collapse. One patient required surgical correction despite adequate leak closure. In this case a distal ureteral leak had been treated with placement of a nephroureteral stent (Fig 2). Fiftyfive days after stent placement, closure of the leak was documented. The stent was removed 2 weeks later because of sepsis. A stricture eventually developed. Multiple attempts to dilate the stricture with a balloon catheter were unsuccessful, and surgical correction was eventually necessary. One leak was produced iatrogenically in a patient with a ureteral stric-
ture. The stricture was successfully dilated percutaneously. The use of a nephroureteral stent for 42 days was successful in closing the leak. The patients have been followed up clinically for 6-58 months (average, 32.7 months). Sixteen (70%) currently have functioning transplants and have required no further procedures or surgery, three (13%) have rejected their transplant and are currently undergoing dialysis, and four (17%) have died. Our overall leak closure rate was 87%. Of the three (13%) patients in whom a leak failed to close, two died (9%) and one (4%) required transplant nephrectomy. One patient (4%) required surgical intervention to correct a stricture that developed in response to the presence of a drainage catheter. No patient required surgical closure of a leak. DISCUSSION
Urologic complications are a serious threat to renal transplantation patients. While complication rates have decreased, major complications are still reported in 8%-12% of patients after renal transplantation (1,4,5). Approximately half of these complications (3%-10%) are urine leaks (4-6). The majority of urine leaks occur at the distal ureter just proximal to the level of the ureteroneocystostomy. In our series, 74% of March 1990 • Part 2
only one of 12 urine leaks was successfully treated percutaneously. In the largest previously reported series, success was seen in only five of eight patients (14). Our results differ dramatically from those of earlier studies. Twenty of 23 urine leaks closed without surgical reconstruction. Thus, we have found percutaneous urine-diverting procedures to be the simplest, but nevertheless effective, therapy for posttransplantation urine leaks. It seems likely that the previously reported poor experience may have been a result of premature surgical correction of urine leaks. It is our opinion that all posttransplantation urine leaks that are given an adequate trial of urinary diversion will close. We believe that these percutaneous procedures should be the treatment of choice for the renal transplantation patient with a urine leak and that the use of a stent should be continued for at least 6 weeks after the leak appears to have closed. n References b. a. Figure 2. (a) Antegrade nephrostogram reveals a moderately large leak from the distal ureter. Subsequent nephrostogram showed closure of the leak; however, the catheter was removed prematurely because of infection. (b) Nephrostogram obtained 2 weeks after premature removal of catheter reveals complete obstruction of distal ureter in the area of the previously seen leak.
the leaks were from the distal ureter. These leaks are probably secondary to ischemia of the distal ureter at the time of graft procurement or a technically incomplete anastomosis of the distal ureter and the bladder (1-4). The normal ureter receives its blood supply both from the renal artery and from small branches of the internal iliac artery. When the donor kidney is removed, the latter vessels are interrupted, which causes impingement on the ureteral blood supply. Thus, the need for reliance on the blood supply from the kidney makes it good practice to use transplantation methods that allow for as short a ureter as possible (7). Additionally, normal swelling at the ureteroneocystostomy with mild obstruction further stresses the compromised area. One may contend that an ischemic ureter will remain ischemic once the stent is removed, leading to scarring and stricture formation. This has not been our experience. Perhaps the prolonged presence of the stent after leak closure (6 weeks) allowed extenVolume 174 • Number 3 • Part 2
sive fibrosis at the site, which was then resistant to further scarring once the stent was removed. Calyceal leaks secondary to segmental infarction have been reported in patients who have accessory renal arteries or who have undergone ligation of a polar artery (8). This occurred in one of our patients. The treatment of post-renal transplantation urine leaks remains controversial. In the past, early surgical intervention was considered the only viable treatment (9,10). Fear of infection or parenchymal damage restrained the use of percutaneous procedures of these leaks. In the early 1980s, reports of definitive treatment of leaks with percutaneous procedures appeared in the literature (11). The results in several small series, with success rates ranging from 40% to 100% and low complication rates, increased confidence in these procedures (2,11-14). Nevertheless, in the most recent series in the radiology literature, Smith et al (3) asserted that percutaneous procedures are only temporizing measures. In that report
1. Becker JA, Kutcher R. Urologic complications of renal transplantation. Semin Roentgenol 1978; 13:341-351. 2. Hunter D, Castaneda-Zuniga W, Coleman C, Herrera M, Amplatz K. Percutaneous techniques in the management of urologic complications in renal transplant patients. Radiology 1983; 148:407-412. 3. Smith T, Hunter D, Letourneau J, et al. Urine leaks after renal transplantation. AJR 1988; 151:511-513. 4. Mindy AR, Podesta MC, Bewick M, Rudge CJ, Ellis FG. The urologic complications of 1000 renal transplants. Br J Urol 1981; 53:357-402. 5. Loughlin KR, Tilney NI, Richie JP. Urologic complications in 718 renal transplant patients. Surgery 1984; 95:297-301. 6. Goldstein I, Chi SI, Olsson CA. Nephrostomy drainage for renal transplant complications. J Urol 1981; 126:159-163. 7. Merkel FK, Matalon TAS. Intraperitoneal placement of renal transplant. Transplant Proc 1988; 20:370-374. 8. Schiff M, McGuire EJ, Webster J. Successful management of calyceal fistulas following renal transplantation. Arch Surg 1975; 110:1129-1132. 9. Gregory J, Grace A, Anderson C, Codd J, Graff R, Newton W. Aggressive management of genitourinary complications in renal transplantation. Urology 1976; 7:349-354. 10. Bewick M, Collins R, Saxton H, Ellis F, McColl I, Ogg C. The surgery and problems of the ureter in human renal transplantation. Br J Urol 1974; 46:493-510. 11. Lieberman R, Glass N, Crummy A, Sollinger H, Belzer F. Non-operative percutaneous management of urinary fistulas and strictures in renal transplants. Surg Gynecol Obstet 1982; 155:667-672. 12. Curry N, Cochran S, Barbaric Z, et al. Interventional radiologic procedures in the renal transplant. Radiology 1984; 152:647-653. 13. Druy E, Gharib M, Finder C. Percutaneous nephroureteral drainage and stenting for postsurgical ureteral leaks. AJR 1983; 141:389-394. 14. Bennett L, Voegeli D, Crummy A, McDermott J, Jensen S, Sollinger H. Urologic complications following renal transplantations: role of interventional radiologic procedures. Radiology 1986; 160:531-536.
Radiology • 1051
Percutaneous Treatment of Urine Leaks in Renal Transplantation Patients' The data on post-renal transplantation urine leaks in 23 patients were retrospectively reviewed to assess the role of percutaneous urine-diverting procedures in their treatment. The leaks were confirmed by means of antegrade pyelography, and either a nephrostomy catheter or a nephroureteral stent was placed. Nephrostography was performed frequently to evaluate leak closure. Urinary diversion was continued for an average of 68 days. Leak closure was documented in 20 of 23 (87%) cases. In four patients, concomitant infection or multiorgan failure precluded adequate therapy. One patient developed a ureteral stricture after the urine-diverting procedure and required surgical correction. The results suggest that percutaneous urine-diverting procedures are a definitive treatment for post-renal transplantation urine leaks. Index terms: Catheters and catheterization. • Genitourinary system, interventional procedure, 80.1299 • Kidney, interventional procedure, 813.1299 • Kidney transplantation, 81.4559 • Ureter, interventional procedure, 82.1299 Radiology 1990; 174:1049-1051
1 From the Departments of Diagnostic Radiology and Nuclear Medicine (T.A.S.M., M.J.T., S.K.P., M.V.R.) and Surgery (S.C.J., F.K.M.), Rush-Presbyterian-St Luke's Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612. Received April 3, 1989; revision requested June 6; final revision received August 22; accepted August 28. Address reprint requests to T.A.S.M. RSNA, 1990
leaks are an uncommon but serious complication of renal transplantation. If the leak is not treated, the mortality is 50% (1). Despite appropriate treatment, the morbidity and mortality in transplantation patients with urine leaks are two to three times higher than in those without leaks (2). Recently investigators have reported that percutaneous urine-diverting procedures are a temporizing treatment and that surgical repair is the definitive therapy (3). A review of the data on 23 urine leaks in 23 patients was performed to evaluate the role of percutaneous procedures in the treatment of postrenal transplantation urine leaks.
U
RINE
PATIENTS AND METHODS In a retrospective review, 23 leaks were identified in 23 patients who were treated from 1984 through 1988. All leaks were confirmed by means of antegrade pyelography. Of the 23 patients, eight were women. The mean patient age was 38 years (range, 19-68 years). Four leaks originated at the level of the renal pelvis, two from the midportion of the ureter, and 17 from the distal ureter. Six leaks were treated with nephrostomy alone, and 17 were treated with placement of a nephroureteral stent. The patients were followed up clinically, and nephrostography was performed frequently. Nephrostomy catheters and stents were removed 6 weeks after documentation of leak closure. The period 6 weeks was chosen on the basis of the experience of our urologic colleagues in treatment of ureteral injuries. Antegrade pyelography was performed in the special procedures suite with use of real-time ultrasound (US). The US probe was draped in standard fashion and was used within the sterile field. When some dilatation of the collecting system was
present, real-time US was used to confirm needle placement within the collecting system. Subsequent injection of contrast material under fluoroscopic guidance confirmed the placement. In situations in which the collecting system had been totally decompressed by the urine leak, the needle was placed within the central echo system, and multiple small-volume injections of contrast material were made under fluoroscopic guidance. After fluoroscopic confirmation of placement of the needle in the collecting system, a 0.018-inch platinum-tipped guide wire was advanced through the antegrade pyelography needle, and subsequent tract dilation was performed in standard fashion. If the site at which the needle entered was inappropriate for tube placement, a second puncture was made under fluoroscopic guidance. At the time of antegrade pyelography, the presence of a leak within the renal pelvis or ureter was observed. Most ureteral leaks were treated with placement of a nephroureteral stent with a pigtail within the bladder and side holes within the renal pelvis. Pelvic and calyceal leaks were treated simply with nephrostomy catheters with a pigtail in the renal pelvis. All leaks were treated with purely external drainage until closure of the leak had been demonstrated. The external drainage catheter was then capped, and internal drainage was used in patients with nephroureteral stents. Drainage was continued for 6 weeks after documentation of leak closure. Prophylactic therapy with a variety of antibiotics was given. Currently Bactrim (trimethoprim-sulfamethoxazole; Roche Laboratories, Nutley, NJ) is used unless a specific organism is found, in which case antibiotic coverage is tailored to the sensitivity of the organism. Urinary tract infection was common after the patients' hospital dis1049
c. b. a. Figure 1. (a) Antegrade nephrostogram reveals marked extravasation of contrast material, apparently originating from an upper pole calyx. (b) Steep oblique view reveals that leak is actually from the renal pelvis. (c) Nephrostogram obtained 7 weeks after nephrostomy was performed reveals no leak. The catheter was removed, and the patient did well.
charge, but the infection usually responded to oral antibiotic therapy. Parenteral therapy was used when positive cultures were associated with symptoms of sepsis. RESULTS
All patients with documented leaks underwent a urine-diverting procedure. All procedures were technically successful. Urinary diversion was continued for an average of 68 days (range, 6-130 days). Leak closure was documented after an average of 41 days. The interval between leak closure and stent removal is less than our recommended 6 weeks because in some cases early in the review period the catheter was removed sooner than 6 weeks. All patients were followed up regularly with nephrostography; an average of 4.0 studies were performed (range, 2-8). Closure of 20 of 23 (87%) leaks was documented (Fig 1). In four patients, concomitant infection or multiorgan failure precluded adequate therapy. In one patient with a distal ureteral leak and sepsis due to gram-negative organisms despite a functioning stent, renal function continued to deteriorate. Antibiotic therapy failed to eradicate the underlying infection, and 6 days after stent placement a transplant nephrectomy was performed. A second patient developed 1050 • Radiology
a wound infection in the early posttransplantation period. Subsequent antegrade pyelography revealed a ureteral leak in the middle to distal portion. Nephroureterograms obtained 19 and 28 days after stent placement revealed a persistent leak. On the 40th postprocedure day, the patient died of overwhelming sepsis. A third failure occurred in a patient who initially had a perinephric fluid collection. Antegrade pyelography revealed a leak originating at the renal pelvis. The patient was treated with a nephrostomy catheter. He developed bilateral pneumonia and multiple pneumothoraces. His compromised pulmonary status precluded follow-up nephrography. Seventy-two days after the drainage procedure, the patient died of respiratory collapse. One patient required surgical correction despite adequate leak closure. In this case a distal ureteral leak had been treated with placement of a nephroureteral stent (Fig 2). Fiftyfive days after stent placement, closure of the leak was documented. The stent was removed 2 weeks later because of sepsis. A stricture eventually developed. Multiple attempts to dilate the stricture with a balloon catheter were unsuccessful, and surgical correction was eventually necessary. One leak was produced iatrogenically in a patient with a ureteral stric-
ture. The stricture was successfully dilated percutaneously. The use of a nephroureteral stent for 42 days was successful in closing the leak. The patients have been followed up clinically for 6-58 months (average, 32.7 months). Sixteen (70%) currently have functioning transplants and have required no further procedures or surgery, three (13%) have rejected their transplant and are currently undergoing dialysis, and four (17%) have died. Our overall leak closure rate was 87%. Of the three (13%) patients in whom a leak failed to close, two died (9%) and one (4%) required transplant nephrectomy. One patient (4%) required surgical intervention to correct a stricture that developed in response to the presence of a drainage catheter. No patient required surgical closure of a leak. DISCUSSION
Urologic complications are a serious threat to renal transplantation patients. While complication rates have decreased, major complications are still reported in 8%-12% of patients after renal transplantation (1,4,5). Approximately half of these complications (3%-10%) are urine leaks (4-6). The majority of urine leaks occur at the distal ureter just proximal to the level of the ureteroneocystostomy. In our series, 74% of March 1990 • Part 2
only one of 12 urine leaks was successfully treated percutaneously. In the largest previously reported series, success was seen in only five of eight patients (14). Our results differ dramatically from those of earlier studies. Twenty of 23 urine leaks closed without surgical reconstruction. Thus, we have found percutaneous urine-diverting procedures to be the simplest, but nevertheless effective, therapy for posttransplantation urine leaks. It seems likely that the previously reported poor experience may have been a result of premature surgical correction of urine leaks. It is our opinion that all posttransplantation urine leaks that are given an adequate trial of urinary diversion will close. We believe that these percutaneous procedures should be the treatment of choice for the renal transplantation patient with a urine leak and that the use of a stent should be continued for at least 6 weeks after the leak appears to have closed. n References b. a. Figure 2. (a) Antegrade nephrostogram reveals a moderately large leak from the distal ureter. Subsequent nephrostogram showed closure of the leak; however, the catheter was removed prematurely because of infection. (b) Nephrostogram obtained 2 weeks after premature removal of catheter reveals complete obstruction of distal ureter in the area of the previously seen leak.
the leaks were from the distal ureter. These leaks are probably secondary to ischemia of the distal ureter at the time of graft procurement or a technically incomplete anastomosis of the distal ureter and the bladder (1-4). The normal ureter receives its blood supply both from the renal artery and from small branches of the internal iliac artery. When the donor kidney is removed, the latter vessels are interrupted, which causes impingement on the ureteral blood supply. Thus, the need for reliance on the blood supply from the kidney makes it good practice to use transplantation methods that allow for as short a ureter as possible (7). Additionally, normal swelling at the ureteroneocystostomy with mild obstruction further stresses the compromised area. One may contend that an ischemic ureter will remain ischemic once the stent is removed, leading to scarring and stricture formation. This has not been our experience. Perhaps the prolonged presence of the stent after leak closure (6 weeks) allowed extenVolume 174 • Number 3 • Part 2
sive fibrosis at the site, which was then resistant to further scarring once the stent was removed. Calyceal leaks secondary to segmental infarction have been reported in patients who have accessory renal arteries or who have undergone ligation of a polar artery (8). This occurred in one of our patients. The treatment of post-renal transplantation urine leaks remains controversial. In the past, early surgical intervention was considered the only viable treatment (9,10). Fear of infection or parenchymal damage restrained the use of percutaneous procedures of these leaks. In the early 1980s, reports of definitive treatment of leaks with percutaneous procedures appeared in the literature (11). The results in several small series, with success rates ranging from 40% to 100% and low complication rates, increased confidence in these procedures (2,11-14). Nevertheless, in the most recent series in the radiology literature, Smith et al (3) asserted that percutaneous procedures are only temporizing measures. In that report
1. Becker JA, Kutcher R. Urologic complications of renal transplantation. Semin Roentgenol 1978; 13:341-351. 2. Hunter D, Castaneda-Zuniga W, Coleman C, Herrera M, Amplatz K. Percutaneous techniques in the management of urologic complications in renal transplant patients. Radiology 1983; 148:407-412. 3. Smith T, Hunter D, Letourneau J, et al. Urine leaks after renal transplantation. AJR 1988; 151:511-513. 4. Mindy AR, Podesta MC, Bewick M, Rudge CJ, Ellis FG. The urologic complications of 1000 renal transplants. Br J Urol 1981; 53:357-402. 5. Loughlin KR, Tilney NI, Richie JP. Urologic complications in 718 renal transplant patients. Surgery 1984; 95:297-301. 6. Goldstein I, Chi SI, Olsson CA. Nephrostomy drainage for renal transplant complications. J Urol 1981; 126:159-163. 7. Merkel FK, Matalon TAS. Intraperitoneal placement of renal transplant. Transplant Proc 1988; 20:370-374. 8. Schiff M, McGuire EJ, Webster J. Successful management of calyceal fistulas following renal transplantation. Arch Surg 1975; 110:1129-1132. 9. Gregory J, Grace A, Anderson C, Codd J, Graff R, Newton W. Aggressive management of genitourinary complications in renal transplantation. Urology 1976; 7:349-354. 10. Bewick M, Collins R, Saxton H, Ellis F, McColl I, Ogg C. The surgery and problems of the ureter in human renal transplantation. Br J Urol 1974; 46:493-510. 11. Lieberman R, Glass N, Crummy A, Sollinger H, Belzer F. Non-operative percutaneous management of urinary fistulas and strictures in renal transplants. Surg Gynecol Obstet 1982; 155:667-672. 12. Curry N, Cochran S, Barbaric Z, et al. Interventional radiologic procedures in the renal transplant. Radiology 1984; 152:647-653. 13. Druy E, Gharib M, Finder C. Percutaneous nephroureteral drainage and stenting for postsurgical ureteral leaks. AJR 1983; 141:389-394. 14. Bennett L, Voegeli D, Crummy A, McDermott J, Jensen S, Sollinger H. Urologic complications following renal transplantations: role of interventional radiologic procedures. Radiology 1986; 160:531-536.
Radiology • 1051
