British Journal of Urology (1992), 70, 139-143 0 1992 British Journal of Urology
Ureteric Complications of Renal Transplantation S. H. KASHI, J. P. A. LODGE, G. R. GILES and H. C. IRVING University Department of Surgery and Department of Radiology, St James's University Hospital, Leeds
Summary-Of 507 consecutive recipients of renal allografts, 45 developed a urological complication. In 39 patients (7.7%) ureteric problems were implicated and these comprised 30 cases of obstruction and 9 cases of ureteric necrosis presenting as urinary leakage. In 7 patients ureteric obstruction resolved following a period of nephrostomy decompression; 10 patients were reconstructed surgically and this was successful in 8, with 2 patients requiring further surgical procedures. Ten patients were successfully treated by percutaneous stenting after dilatation of the stricture. Stenting failed in 4 patients and in 1 patient caused rupture of a calix. All 10 stents have now been removed and there is no recurrence of stricture (follow-up 32.0 k 8.6 months). Of the remaining 3 grafts, 2 were removed and the other graft had percutaneous removal I of a ureteric calculus. The 1-year survival rate of allografts in the ureteric complication group was 84.6%; in the recipients without a urological complication it was 81%. It was concluded that an active approach to ureteric problems following renal transplantation results in the rescue of the majority of allografts.
Ureteric complications of renal transplantation have been reported in 5 to 12.5%of renal transplants (Anderson et al., 1972; Salvatierra et al., 1977; Smolev et al., 1977; Mundy et al., 1981; Hunter, 1986). It is essential that these complications are diagnosed early and differentiated from rejection, which is the commonest cause of deterioration in allograft function. Delay in accurate diagnosis and inappropriate anti-rejection therapy may result in the loss of the transplanted kidney and is also associated with increased morbidity and mortality (Weil et al., 1971; Becker and Kutcher, 1978). We have reviewed the records of 507 consecutive renal transplants carried out over a 6-year period at St James's University Hospital, Leeds, to record the incidence of ureteric complications in the era since the introduction of cyclosporin as an immunosuppressive agent and to assess the long-term results of surgical and radiological methods of management.
Accepted for publication 29 August 1991
Patients and Methods Between January 1984 and April 1990, 507 allografts were transplanted consecutively into 495 patients. The study group consisted of 325 males and 170 females, with 12 patients undergoing 2 transplant procedures. The mean age in the female population was 36.8 years (range 2-67) and 38.6 years (range 3-71) in the male recipients. The right kidney was transplanted in 248 cases and 259 recipients received the left kidney. Throughout the series the usual technique of urinary tract reconstruction was an internal tunnelled ureteroneocystostomy (transvesical). If the bladder was found to be too small to allow the creation of a submucosal tunnel, an external ureteroneocystostomy (extravesical) was carried out. The extravesical technique involved the creation of a l-cm cystotomy and direct anastomosis of the ureter to the edge of the bladder mucosa using interrupted 3/0 catgut sutures. Ureteroneocystostomy was performed on 50 1 occasions. In 485 operations the transvesical nipple technique was used. The extravesical method was
139
140 employed in 16 cases and in 3 patients the allograft ureter was implanted into an ileal conduit. In 3 other cases, owing to special circumstances, continuity of the urinary tract was established using pyeloureterostomy or ureteroureterostomy. Stents or splints were not used in the transvesical group, although 4 of the extravesical anastomoses were stented. Urethral catheter drainage was maintained for at least 5 days in all patients, with the period extended to 7 days in cases where the bladder was considered to be thin-walled or small. Allograft function was monitored daily with measurement of serum creatinine, urea and electrolytes and daily urine output. Deteriorating renal function was investigated by ultrasonography, isotope renography, renal biopsy or fine needle aspiration cytology as appropriate. At present the recipients at this centre undergo regular ultrasonic examination as a screening procedure with a baseline scan within 3 days after transplantation. Suspected urinary extravasation is investigated by cystography followed by antegrade pyelography under ultrasound guidance if further information is required. Suspected ureteric obstruction is investigated by antegrade pyelography and in doubtful cases pressure flow studies are undertaken to clarify the significance of a radiologically demonstrated narrowing. Cyclosporin monotherapy was administered to all transplant recipients initially in a dose of 15 mg/ kg/day in 2 divided doses and the dose adjusted to reduce plasma cyclosporin level to the therapeutic range for the assay used and presently to less than 1200 ng/ml. Latterly, the plasma cyclosporin level has been estimated every third day using Abbotts TDX system (Abbotts Diagnostics Ltd) by a fluorescent competition technique with polyclonal antisera. In patients with pre-formed cytotoxic antibodies the immunosuppressive therapy was altered to triple therapy with azathioprine 1 mg/ kg, prednisolone EC 0.3 mg/kg and cyclosporin 610 mg/kg. Statistical analysis of the results was performed using the x2 test and the Mann-Whitney U test with correction for large numbers.
Results Thirty-five episodes of ureteric obstruction were demonstrated by antegrade pyelography in 30 transplants. Of the 15 patients who presented with a urinary leak, 9 were found to have developed ureteric necrosis and in 6 cases the leaks came from the bladder closure. The true overall incidence of
BRITISH JOURNAL OF UROLOGY
ureteric problems in the study group was, therefore, 7.7% (39 patients). Factors which may affect ureteric healing were analysed for each of the 2 populations (no urological complication and ureteric complication) but there was no obvious correlation with any factors other than delayed primary function of the graft for the first 5 posttransplant days (Table 1). In 21 patients the site of ureteric obstruction was a stricture at the vesicoureteric junction and in 5 transplants mid to distal ureteric stenosis impeded urine flow. The other cases comprised idiopathic pelviureteric junction obstruction (l), external compression of renal pelvis by tumour (l), calculus obstruction (l), and obstruction at the pyeloureterostomy (1). Ureteric obstruction was managed in the earlier part of the study by preliminary insertion of a percutaneous nephrostomy catheter followed by surgical reimplantation. Eight of the 10 surgical procedures were successful but 2 patients required further surgery. In 1 case the stricture persisted after a second procedure involving per-operative dilatation of the stenosed section but was successfully treated with percutaneous balloon dilatation and placement of a double-pigtail stent (Medi-Tech Inc, Watertown, USA). Two transplant nephrectomies were carried out in the group with ureteric obstruction because of a lymphoma compressing the renal pelvis in 1 patient and arterial thrombosis in the other. The obstruction resolved spontaneously in 7 allografts after a period of nephrostomy catheter drainage. Of 14 more recent patients, 10 have been successfully treated with dilatation of the stricture and insertion of a double-pigtail ureteric stent after nephrostomy drainage had allowed recovery of renal function. However, stenting failed in 4 transplants because of the presence of a long, tight stricture in the ureter (l), technical difficulties in gaining satisfactory access to an upper pole calix (2) and the rupture of a calix on guide wire manipulation (1). All of these allografts were salvaged with surgical reconstruction. All recipients with a ureteric double-pigtail stent were placed on low dose co-trimoxazole and regularly examined ultrasonically to ensure satisfactory drainage was continued. Two patients have been treated for bacterial urinary infection and 2 other recipients have suffered urinary Candida spp. infection. One of these patients required ureteric reimplantation because the stent was blocked with fungal growth. All of the percutaneously placed stents in the patients included in this series were
141
URETERIC COMPLICATIONSOF RENAL TRANSPLANTATION
Table 1 Donor and Recipient Data No. of complications ( n = 468)
Ureteric problems ( n = 39)
C 100% 0 1-2 3-4 5-6
37.8 & 15 2.0: 1 32.4+ 15 1.3: 1 1.05:l 76.2% 20.2% 3.6% 8 1.O% 13.0% 6.0% 4.7% 42.0% 49.5% 3.8%
40.7 & 14 1.5: 1 40.7 k 16 2.0: 1 1.2:l 79.5% 20.5% 0.0% 76.9% 7.7% 15.4% 7.7% 43.7% 46.0% 2.6%
Storage time (h)
20.4 & 6.5
18.9k4.8
Type Of Perfusion
E/Collins HOC PBS 140 Others Others 24.0% 1.18k1.5
9.2% 70.0% 15.4% 5.4% 5.4% 46.0% 1.46& 1.2
Recipient Donor Kidney No. of Arteries Panel Reactive Antibody Total no. of mismatch loci
Fluid Delayed function* Rejection episodes
Age (years) M:F Age (years) M:F
L:R 1 2 23 0%
c 50%
8.0% 72.0% 20.0% 0.0%
Values are mean & standard deviation. Percentages are for the total in each group. *(P=0.005, ,yz test).
removed cystoscopicallyat 3 to 6 months and there has been no evidence of recurrence of the strictures with a mean follow-up period of 32.0 months (SD f 8.6 months). It is our practice to allow for the recovery of renal function before attempting percutaneous or surgical treatment of urological complications. This was achieved by percutaneous placement of a nephrostomy catheter under ultrasound guidance as the initial treatment. Following placement of a nephrostomy (n = 21), the median serum creatinine decreased from 485 to 396 pmol/l at 48 h and the improvement continued to provide a median serum creatinine level of 229 pmol/l 2 weeks after intervention (Fig.). Of the 9 patients with lower ureteric/vesicoureteric junction urinary leakage, 5 underwent surgical procedures, 1 resolved on continued bladder catheter drainage and 2 transplants were managed with the placement of a double-pigtail stent across the site of leakage. One graft was lost in this group owing to overwhelming sepsis. Table 2 summarises graft survival and median and interquartile ranges for serum creatinine for
those grafts presenting a ureteric complication and the allografts without a urological complication. There was no difference in graft survival at 12 months ; however, renal function was significantly worse in the transplants with a ureteric problem (P=0.01). The success of aggressive management of ureteric complications is demonstrated by Table 3, which indicates a 12-month graft survival rate of Table 2 Graft Survival and Serum Creatinine at 12 Months (all kidneys) Graft survival
(%) Ureteric complication (n = 39) No ureteric complication (n =468)
84.6 81
Serum creatinine (wolil) 175 (135-197) (n = 33) 139 (106163) (n = 375)
Values for serum creatinine are median with interquartile ranges for allografts surviving at 12 months. (P=0.01, Mann-Whitney U test).
142
BRITISH JOURNAL OF UROLOGY S e r u m creatinine (pmol/l)
' O o 0 /MEDIAN
U P P E R AND LOWER Q U A R T I L E S
1 600
j
I
i
AT AT AT PRESENTATION 2 DAYS 2 WEEKS Fig. Serum creatinine following nephrostomy catheter drainage.
100% in the stented group and 87% in those managed surgically. Both methods, however, failed to reverse the damage suffered by the allograft during the period of obstruction, as shown by the higher median serum creatinine at 12 months when compared with that of the non-complicated grafts.
Discussion In this series of 507 consecutive renal transplanta-
tions the incidence of ureteric complications was 7.7%, with ureteric obstruction at the vesicoureteric junction the commonest complication (4.7%). The cause of ureteric stenosis or necrosis remains uncertain, although the blood supply of the terminal ureter is clearly vulnerable as it is entirely derived from the main renal artery. Although there has been speculation that unwanted vasoactivity associated with the use of cyclosporin might be associated with increased ureteric problems, a ureteric complication rate of 7.7%using cyclosporin is little different from the 10% reported by Mundy et al. (1981) in 1,000 patients transplanted in the pre-cyclosporin period. In addition, there is no evidence that multiple renal arteries are associated with increased risk to the ureter, as suggested by Hricko et al. (1973). However, necrosis of the distal ureter must be related to vascular insufficiency due either to deficient proximal supply or to the effects on the vasculature by drug action, preservation injury or rejection. Analysis of the data in this series does not indicate a significantly higher number of rejection episodes in those patients with ureteric stenosis or leak, nor are the kidneys transplanted in the patients with pre-formed cytotoxic antibodies more prone to ureteric damage. Similarly, we found no association with the degree of matching on the HLA loci (Table 1). However, delayed primary function was significantlymore predominant in the group with ureteric complications, which would suggest that damage during organ harvesting or the preservation period played a definite role (P= 0.005). Ultrasonography of renal allografts is highly sensitive for the exclusion of obstruction, as in the absence of pelvicaliceal dilatation the likelihood of ureteric obstruction is very low. Further investiga-
Table 3 12-month Allograft Survival and Function (ureteric complication) Graft survival
Serum creatinine
*No.
Post-op. days on treatment (mean + S D )
(%)
( W O W
Stenting
12
40+ 12
100
Reconstruction
15
27+5
87
Nephrostomy/ catheter drainage
8
23+11
88
182 (1 34-231) (n = 12) 177 (1 35-3 17) (n=13) 172 (95-1 78) (n=7)
*=Exclusions 3 allograft nephrectomy. 1 percutaneousremoval of stone. Values for serum creatinine are median and interquartile ranges for allografts surviving to 12 months.
URETERIC COMPLICATIONS OF RENAL TRANSPLANTATION
tion of these recipients with antegrade pyelography to exclude obstruction as a cause of deterioration in graft function is unlikely to be beneficial (Kashi et al., 1991). In the earlier part of this study the majority of cases of ureteric obstruction were managed surgically. Latterly, however, with our increasing experience of percutaneous techniques, percutaneous dilatation with placement of a double-pigtail stent has become our first line of treatment, thus reducing the morbidity associated with surgical remedial procedures. Neither surgical nor radiological procedures for the treatment of obstruction were attended by graft loss or patient mortality. This comparesfavourably with other previously reported surgical experience (Smolev et al., 1977; Mundy et al., 1981). We elect to remove the stents after 3 to 6 months, though this may be unduly conservative because it is recognised that in the non-transplant patient population in whom double-pigtail stents had been placed as the primary treatment for urinary leaks, complete ureteric healing was observed within 2 to 7 weeks (Narasimham et al., 1990). Thus there may be a case for removing stents sooner than we have done to date. It is clear that an aggressive policy of investigation and treatment can significantly reduce patient morbidity and mortality as well as allowing the salvage of the allografts. We recommend that all renal transplant recipients undergo routine ultrasound monitoring of the allograft and that any suspected urological complication is actively and urgently investigated and appropriately treated. Percutaneous placement of a nephrostomy catheter under ultrasound guidance is a simple and effective method which allows recovery of renal function and provides time for further evaluation and formulation of a plan of definitive management. The use of a percutaneously placed ureteric double-
143
pigtail stent, with or without balloon dilatation of any strictures, has become an acceptable and effective alternative to surgical management. References Anderson, E. E., Glenn, J. F., Siegler, H. F. et el.(1972). Ureteral implantation in renal transplantation. Surg. Gynecol. Obstet., 134,494-496. Becker, J. and Kutcher, R. (1978). Urological complications of renal transplantation. Semin. Roentgeml., 13,341-351. Hricko, G. M., Birtch, A. G., Bennett, A. H. et el. (1973). Factors responsible for urinary fistula in the renal transplant recipient. Ann. Surg., 178,609-615. Hunter, D. W. (1986). Evaluation and treatment of non-vascular problems of the transplanted kidney. Semin. Intervent. Radiol., 3 , 1 0 4 1 14. Kashi, S. H., Lodge, J. P. A., Giles, G. R. et el. (1991). Ultrasonography of renal allografts : collecting system dilatation and its clinical significance. Nephrol. Dial. Transplant., 6, 358-362. Mundy, A. R., Podesta, M. L., Bewick, M. et al. (1981). The urological complications of 1000 renal transplants. Br. J . Urol., 53, 397402. Narasimham, D. L., Jacobson, B., Nyman, U. et el. (1990). Primary double pigtail stenting as treatment of upper urinary tract leaks. J. Urol., 143,234236. Salvatierra,O., Olcott, C., Amend, W. J. et el. (1977). Urological complications of renal transplantation can be prevented or controlled. J . Urol., 117,421429, Smolev, J. K., McLougNin, M. G., Rolley, R. et d (1977). The surgical approach to urological complications in renal recipients. J. Urol., 117, 10-12. We& R., Simmons,R. L., Tallent, M. B. et el. (1971). Prevention of urological complications after kidney transplantation. Ann. Surg., 174, 154-160.
The Authors S. H. Kashi, FRCSE, Tutor in Surgery. J. P. A. Lodge, FRCS, Lecturer in Surgery. G. R. Giles, MD, FRCS, Professor of Surgery. H. C. Irving, FRCR, DMRD, Consultant Radiologist. Requests for reprints to: G. R. Giles, Department of Surgery, St James’s University Hospital, Beckett Street, Leeds LS9 7TF.
Ureteric Complications of Renal Transplantation S. H. KASHI, J. P. A. LODGE, G. R. GILES and H. C. IRVING University Department of Surgery and Department of Radiology, St James's University Hospital, Leeds
Summary-Of 507 consecutive recipients of renal allografts, 45 developed a urological complication. In 39 patients (7.7%) ureteric problems were implicated and these comprised 30 cases of obstruction and 9 cases of ureteric necrosis presenting as urinary leakage. In 7 patients ureteric obstruction resolved following a period of nephrostomy decompression; 10 patients were reconstructed surgically and this was successful in 8, with 2 patients requiring further surgical procedures. Ten patients were successfully treated by percutaneous stenting after dilatation of the stricture. Stenting failed in 4 patients and in 1 patient caused rupture of a calix. All 10 stents have now been removed and there is no recurrence of stricture (follow-up 32.0 k 8.6 months). Of the remaining 3 grafts, 2 were removed and the other graft had percutaneous removal I of a ureteric calculus. The 1-year survival rate of allografts in the ureteric complication group was 84.6%; in the recipients without a urological complication it was 81%. It was concluded that an active approach to ureteric problems following renal transplantation results in the rescue of the majority of allografts.
Ureteric complications of renal transplantation have been reported in 5 to 12.5%of renal transplants (Anderson et al., 1972; Salvatierra et al., 1977; Smolev et al., 1977; Mundy et al., 1981; Hunter, 1986). It is essential that these complications are diagnosed early and differentiated from rejection, which is the commonest cause of deterioration in allograft function. Delay in accurate diagnosis and inappropriate anti-rejection therapy may result in the loss of the transplanted kidney and is also associated with increased morbidity and mortality (Weil et al., 1971; Becker and Kutcher, 1978). We have reviewed the records of 507 consecutive renal transplants carried out over a 6-year period at St James's University Hospital, Leeds, to record the incidence of ureteric complications in the era since the introduction of cyclosporin as an immunosuppressive agent and to assess the long-term results of surgical and radiological methods of management.
Accepted for publication 29 August 1991
Patients and Methods Between January 1984 and April 1990, 507 allografts were transplanted consecutively into 495 patients. The study group consisted of 325 males and 170 females, with 12 patients undergoing 2 transplant procedures. The mean age in the female population was 36.8 years (range 2-67) and 38.6 years (range 3-71) in the male recipients. The right kidney was transplanted in 248 cases and 259 recipients received the left kidney. Throughout the series the usual technique of urinary tract reconstruction was an internal tunnelled ureteroneocystostomy (transvesical). If the bladder was found to be too small to allow the creation of a submucosal tunnel, an external ureteroneocystostomy (extravesical) was carried out. The extravesical technique involved the creation of a l-cm cystotomy and direct anastomosis of the ureter to the edge of the bladder mucosa using interrupted 3/0 catgut sutures. Ureteroneocystostomy was performed on 50 1 occasions. In 485 operations the transvesical nipple technique was used. The extravesical method was
139
140 employed in 16 cases and in 3 patients the allograft ureter was implanted into an ileal conduit. In 3 other cases, owing to special circumstances, continuity of the urinary tract was established using pyeloureterostomy or ureteroureterostomy. Stents or splints were not used in the transvesical group, although 4 of the extravesical anastomoses were stented. Urethral catheter drainage was maintained for at least 5 days in all patients, with the period extended to 7 days in cases where the bladder was considered to be thin-walled or small. Allograft function was monitored daily with measurement of serum creatinine, urea and electrolytes and daily urine output. Deteriorating renal function was investigated by ultrasonography, isotope renography, renal biopsy or fine needle aspiration cytology as appropriate. At present the recipients at this centre undergo regular ultrasonic examination as a screening procedure with a baseline scan within 3 days after transplantation. Suspected urinary extravasation is investigated by cystography followed by antegrade pyelography under ultrasound guidance if further information is required. Suspected ureteric obstruction is investigated by antegrade pyelography and in doubtful cases pressure flow studies are undertaken to clarify the significance of a radiologically demonstrated narrowing. Cyclosporin monotherapy was administered to all transplant recipients initially in a dose of 15 mg/ kg/day in 2 divided doses and the dose adjusted to reduce plasma cyclosporin level to the therapeutic range for the assay used and presently to less than 1200 ng/ml. Latterly, the plasma cyclosporin level has been estimated every third day using Abbotts TDX system (Abbotts Diagnostics Ltd) by a fluorescent competition technique with polyclonal antisera. In patients with pre-formed cytotoxic antibodies the immunosuppressive therapy was altered to triple therapy with azathioprine 1 mg/ kg, prednisolone EC 0.3 mg/kg and cyclosporin 610 mg/kg. Statistical analysis of the results was performed using the x2 test and the Mann-Whitney U test with correction for large numbers.
Results Thirty-five episodes of ureteric obstruction were demonstrated by antegrade pyelography in 30 transplants. Of the 15 patients who presented with a urinary leak, 9 were found to have developed ureteric necrosis and in 6 cases the leaks came from the bladder closure. The true overall incidence of
BRITISH JOURNAL OF UROLOGY
ureteric problems in the study group was, therefore, 7.7% (39 patients). Factors which may affect ureteric healing were analysed for each of the 2 populations (no urological complication and ureteric complication) but there was no obvious correlation with any factors other than delayed primary function of the graft for the first 5 posttransplant days (Table 1). In 21 patients the site of ureteric obstruction was a stricture at the vesicoureteric junction and in 5 transplants mid to distal ureteric stenosis impeded urine flow. The other cases comprised idiopathic pelviureteric junction obstruction (l), external compression of renal pelvis by tumour (l), calculus obstruction (l), and obstruction at the pyeloureterostomy (1). Ureteric obstruction was managed in the earlier part of the study by preliminary insertion of a percutaneous nephrostomy catheter followed by surgical reimplantation. Eight of the 10 surgical procedures were successful but 2 patients required further surgery. In 1 case the stricture persisted after a second procedure involving per-operative dilatation of the stenosed section but was successfully treated with percutaneous balloon dilatation and placement of a double-pigtail stent (Medi-Tech Inc, Watertown, USA). Two transplant nephrectomies were carried out in the group with ureteric obstruction because of a lymphoma compressing the renal pelvis in 1 patient and arterial thrombosis in the other. The obstruction resolved spontaneously in 7 allografts after a period of nephrostomy catheter drainage. Of 14 more recent patients, 10 have been successfully treated with dilatation of the stricture and insertion of a double-pigtail ureteric stent after nephrostomy drainage had allowed recovery of renal function. However, stenting failed in 4 transplants because of the presence of a long, tight stricture in the ureter (l), technical difficulties in gaining satisfactory access to an upper pole calix (2) and the rupture of a calix on guide wire manipulation (1). All of these allografts were salvaged with surgical reconstruction. All recipients with a ureteric double-pigtail stent were placed on low dose co-trimoxazole and regularly examined ultrasonically to ensure satisfactory drainage was continued. Two patients have been treated for bacterial urinary infection and 2 other recipients have suffered urinary Candida spp. infection. One of these patients required ureteric reimplantation because the stent was blocked with fungal growth. All of the percutaneously placed stents in the patients included in this series were
141
URETERIC COMPLICATIONSOF RENAL TRANSPLANTATION
Table 1 Donor and Recipient Data No. of complications ( n = 468)
Ureteric problems ( n = 39)
C 100% 0 1-2 3-4 5-6
37.8 & 15 2.0: 1 32.4+ 15 1.3: 1 1.05:l 76.2% 20.2% 3.6% 8 1.O% 13.0% 6.0% 4.7% 42.0% 49.5% 3.8%
40.7 & 14 1.5: 1 40.7 k 16 2.0: 1 1.2:l 79.5% 20.5% 0.0% 76.9% 7.7% 15.4% 7.7% 43.7% 46.0% 2.6%
Storage time (h)
20.4 & 6.5
18.9k4.8
Type Of Perfusion
E/Collins HOC PBS 140 Others Others 24.0% 1.18k1.5
9.2% 70.0% 15.4% 5.4% 5.4% 46.0% 1.46& 1.2
Recipient Donor Kidney No. of Arteries Panel Reactive Antibody Total no. of mismatch loci
Fluid Delayed function* Rejection episodes
Age (years) M:F Age (years) M:F
L:R 1 2 23 0%
c 50%
8.0% 72.0% 20.0% 0.0%
Values are mean & standard deviation. Percentages are for the total in each group. *(P=0.005, ,yz test).
removed cystoscopicallyat 3 to 6 months and there has been no evidence of recurrence of the strictures with a mean follow-up period of 32.0 months (SD f 8.6 months). It is our practice to allow for the recovery of renal function before attempting percutaneous or surgical treatment of urological complications. This was achieved by percutaneous placement of a nephrostomy catheter under ultrasound guidance as the initial treatment. Following placement of a nephrostomy (n = 21), the median serum creatinine decreased from 485 to 396 pmol/l at 48 h and the improvement continued to provide a median serum creatinine level of 229 pmol/l 2 weeks after intervention (Fig.). Of the 9 patients with lower ureteric/vesicoureteric junction urinary leakage, 5 underwent surgical procedures, 1 resolved on continued bladder catheter drainage and 2 transplants were managed with the placement of a double-pigtail stent across the site of leakage. One graft was lost in this group owing to overwhelming sepsis. Table 2 summarises graft survival and median and interquartile ranges for serum creatinine for
those grafts presenting a ureteric complication and the allografts without a urological complication. There was no difference in graft survival at 12 months ; however, renal function was significantly worse in the transplants with a ureteric problem (P=0.01). The success of aggressive management of ureteric complications is demonstrated by Table 3, which indicates a 12-month graft survival rate of Table 2 Graft Survival and Serum Creatinine at 12 Months (all kidneys) Graft survival
(%) Ureteric complication (n = 39) No ureteric complication (n =468)
84.6 81
Serum creatinine (wolil) 175 (135-197) (n = 33) 139 (106163) (n = 375)
Values for serum creatinine are median with interquartile ranges for allografts surviving at 12 months. (P=0.01, Mann-Whitney U test).
142
BRITISH JOURNAL OF UROLOGY S e r u m creatinine (pmol/l)
' O o 0 /MEDIAN
U P P E R AND LOWER Q U A R T I L E S
1 600
j
I
i
AT AT AT PRESENTATION 2 DAYS 2 WEEKS Fig. Serum creatinine following nephrostomy catheter drainage.
100% in the stented group and 87% in those managed surgically. Both methods, however, failed to reverse the damage suffered by the allograft during the period of obstruction, as shown by the higher median serum creatinine at 12 months when compared with that of the non-complicated grafts.
Discussion In this series of 507 consecutive renal transplanta-
tions the incidence of ureteric complications was 7.7%, with ureteric obstruction at the vesicoureteric junction the commonest complication (4.7%). The cause of ureteric stenosis or necrosis remains uncertain, although the blood supply of the terminal ureter is clearly vulnerable as it is entirely derived from the main renal artery. Although there has been speculation that unwanted vasoactivity associated with the use of cyclosporin might be associated with increased ureteric problems, a ureteric complication rate of 7.7%using cyclosporin is little different from the 10% reported by Mundy et al. (1981) in 1,000 patients transplanted in the pre-cyclosporin period. In addition, there is no evidence that multiple renal arteries are associated with increased risk to the ureter, as suggested by Hricko et al. (1973). However, necrosis of the distal ureter must be related to vascular insufficiency due either to deficient proximal supply or to the effects on the vasculature by drug action, preservation injury or rejection. Analysis of the data in this series does not indicate a significantly higher number of rejection episodes in those patients with ureteric stenosis or leak, nor are the kidneys transplanted in the patients with pre-formed cytotoxic antibodies more prone to ureteric damage. Similarly, we found no association with the degree of matching on the HLA loci (Table 1). However, delayed primary function was significantlymore predominant in the group with ureteric complications, which would suggest that damage during organ harvesting or the preservation period played a definite role (P= 0.005). Ultrasonography of renal allografts is highly sensitive for the exclusion of obstruction, as in the absence of pelvicaliceal dilatation the likelihood of ureteric obstruction is very low. Further investiga-
Table 3 12-month Allograft Survival and Function (ureteric complication) Graft survival
Serum creatinine
*No.
Post-op. days on treatment (mean + S D )
(%)
( W O W
Stenting
12
40+ 12
100
Reconstruction
15
27+5
87
Nephrostomy/ catheter drainage
8
23+11
88
182 (1 34-231) (n = 12) 177 (1 35-3 17) (n=13) 172 (95-1 78) (n=7)
*=Exclusions 3 allograft nephrectomy. 1 percutaneousremoval of stone. Values for serum creatinine are median and interquartile ranges for allografts surviving to 12 months.
URETERIC COMPLICATIONS OF RENAL TRANSPLANTATION
tion of these recipients with antegrade pyelography to exclude obstruction as a cause of deterioration in graft function is unlikely to be beneficial (Kashi et al., 1991). In the earlier part of this study the majority of cases of ureteric obstruction were managed surgically. Latterly, however, with our increasing experience of percutaneous techniques, percutaneous dilatation with placement of a double-pigtail stent has become our first line of treatment, thus reducing the morbidity associated with surgical remedial procedures. Neither surgical nor radiological procedures for the treatment of obstruction were attended by graft loss or patient mortality. This comparesfavourably with other previously reported surgical experience (Smolev et al., 1977; Mundy et al., 1981). We elect to remove the stents after 3 to 6 months, though this may be unduly conservative because it is recognised that in the non-transplant patient population in whom double-pigtail stents had been placed as the primary treatment for urinary leaks, complete ureteric healing was observed within 2 to 7 weeks (Narasimham et al., 1990). Thus there may be a case for removing stents sooner than we have done to date. It is clear that an aggressive policy of investigation and treatment can significantly reduce patient morbidity and mortality as well as allowing the salvage of the allografts. We recommend that all renal transplant recipients undergo routine ultrasound monitoring of the allograft and that any suspected urological complication is actively and urgently investigated and appropriately treated. Percutaneous placement of a nephrostomy catheter under ultrasound guidance is a simple and effective method which allows recovery of renal function and provides time for further evaluation and formulation of a plan of definitive management. The use of a percutaneously placed ureteric double-
143
pigtail stent, with or without balloon dilatation of any strictures, has become an acceptable and effective alternative to surgical management. References Anderson, E. E., Glenn, J. F., Siegler, H. F. et el.(1972). Ureteral implantation in renal transplantation. Surg. Gynecol. Obstet., 134,494-496. Becker, J. and Kutcher, R. (1978). Urological complications of renal transplantation. Semin. Roentgeml., 13,341-351. Hricko, G. M., Birtch, A. G., Bennett, A. H. et el. (1973). Factors responsible for urinary fistula in the renal transplant recipient. Ann. Surg., 178,609-615. Hunter, D. W. (1986). Evaluation and treatment of non-vascular problems of the transplanted kidney. Semin. Intervent. Radiol., 3 , 1 0 4 1 14. Kashi, S. H., Lodge, J. P. A., Giles, G. R. et el. (1991). Ultrasonography of renal allografts : collecting system dilatation and its clinical significance. Nephrol. Dial. Transplant., 6, 358-362. Mundy, A. R., Podesta, M. L., Bewick, M. et al. (1981). The urological complications of 1000 renal transplants. Br. J . Urol., 53, 397402. Narasimham, D. L., Jacobson, B., Nyman, U. et el. (1990). Primary double pigtail stenting as treatment of upper urinary tract leaks. J. Urol., 143,234236. Salvatierra,O., Olcott, C., Amend, W. J. et el. (1977). Urological complications of renal transplantation can be prevented or controlled. J . Urol., 117,421429, Smolev, J. K., McLougNin, M. G., Rolley, R. et d (1977). The surgical approach to urological complications in renal recipients. J. Urol., 117, 10-12. We& R., Simmons,R. L., Tallent, M. B. et el. (1971). Prevention of urological complications after kidney transplantation. Ann. Surg., 174, 154-160.
The Authors S. H. Kashi, FRCSE, Tutor in Surgery. J. P. A. Lodge, FRCS, Lecturer in Surgery. G. R. Giles, MD, FRCS, Professor of Surgery. H. C. Irving, FRCR, DMRD, Consultant Radiologist. Requests for reprints to: G. R. Giles, Department of Surgery, St James’s University Hospital, Beckett Street, Leeds LS9 7TF.
