UROLOGIC COMPLICATIONS

IN

RENAL TRANSPLANTATION STUART HOLDEN,

M.D.

DAVID P. O’BRIEN,

III, M.D.

ERNEST

L. LEWIS,

M.D.

G. GREEN,

M.D.

BRUCE

KENNETH

N. WALTON,

M.D.

From the Division of Urology, Department Emory University and Affiliated Hospitals, Atlanta, Georgia

of Surgery,

ABSTRACT - Our ten-year experience with 141 kidney transplants is reported. Fifty per cent of the grafts are presently functioning, and 22 patients have been followed more thanjive years. A urologic complication rate of 13 per cent occurred, but 84 per cent of those patients retained their grafts. Only 1.3 per cent of patients with urologic complications died. Improved results can be achieved by good operative technique and aggressive management of complications.

The morbidity and mortality of renal transplantation have been gradually reduced over the past two decades. Although allograft rejection remains the major cause of transplant failure, technical problems account for most graft losses in the immediate postoperative period. Urinary tract reconstruction is the leading technical problem. This report contains an analysis of the authors’ experience with 141 consecutive renal transplants over ten years. It emphasizes the incidence and types of complications we encountered and how they were managed.

went nephroureterectomy. Two patients underwent bilateral nephrectomies and creation of ileal conduits prior to transplantation. With a few early exceptions, we employ a modified Paquin-type ureteroneocystostomy as described by Woodard and Keats.l No ureteral stent is used. A urethral Foley catheter is inserted along with hemovac drainage of the iliac fossa. The minimum follow-up in this series is two months. We are currently following 22 patients who have had satisfactorily functioning grafts for between five and ten years.

Clinical Material

Results

From 1964 to 1973, 127 patients received 141 renal transplants. There were 87 (62 per cent) living related donor kidneys and 54 (38 per cent) cadaveric grafts. Eight patients received both living related and cadaveric grafts. In the vast majority of cases the entire operative procedure was carried out by the urology service. Bilateral nephrectomy prior to transplantation was electively performed in patients with calculus disease, polycystic kidneys, or hyperreninemic hypertension. Patients with vesicoureteral reflux under-

Of 127 patients receiving one or more grafts, 85 or 67 per cent are alive today. Of 141 grafts, 74 or 50 per cent are presently functioning. Thirtythree per cent of cadaver grafts and 65 per cent of related donor grafts are presently intact. Major operative complications following renal transplantation are either vascular or urologic. A discussion of the multitude of minor complications is beyond the scope of this report. In our series vascular complications occurred in 9 patients and resulted in the salvage of four kidneys

182

UROLOGY

/ FEBRUARY

1975 / VOLUME

V, NUMBER 2

TABLE

I.

Vascular complications following 141 transplants

Complication

Number of Grafts

Number of Patient Survivals

Number of Graft Survivals

3 4

3 4

2 2

1

1

0

1

0

0

g/141 (6.3 per cent)

(88 per cent)

Renal vein thrombosis Renal artery stenosis Arterial hemorrhage Ruptured iliac artery above anastomosis TOTALS

and in one death. These are tabulated in Table I. The predominant complications were renal vein thrombosis and renal artery stenosis. Major urologic complications occurred in 19 transplants or 13 per cent of all grafts. The incidence of complications in cadaveric and living related grafts was identical. A summary of our urologic complications and results of therapy can be seen in Table II. They fall into the four categories as shown. Urinary fistulas developed in 8 patients. Five had vesical fistulas, three of which closed spontaneously and two were closed surgically. No graft loss occurred in this group. In 2 patients pyeloureteral leaks developed. One of these closed spontaneously, and the second patient died of sepsis following nephrostomy. In 1 patient a calyceal fistula developed following thrombosis of an upper pole renal artery. This graft was lost following nephrostomy. Ureteral necrosis occurs when ureteral blood supply is surgically compromised, usually at the time of nephrectomy. Five patients in our series underwent varying degrees of ureteral necrosis. Three patients had distal ureteral sloughs. TWO were successfully treated by pyeloureterostomy (utilizing the patient’s own ureter) while the third died following nephrectomy. One patient lost his entire ureter and was treated by cutaneous pyeloileostomy. The fifth TABLE

____~

UROLOGY

/ FEBRUARY1975

patient, a twenty-six-year-old black man, received his brother’s kidney and did well until the eighth postoperative day when he became anuric, distended, and septic. Surgical exploration revealed the loss of the entire ureter and extrarenal pelvis. Because the tissue match was good and there was no evidence of rejection, it was elected to try to preserve the kidney. A nephrostomy was inserted and the wound closed. Figure 1 shows a nephrostogram done recently, almost three years later. The patient’s creatinine clearance is 55 cc. per minute. Of the 5 patients with ureteral necrosis, there was one fatality. Ureteral obstruction occurred in 4 patients. In 1 patient a retrograde pyelogram dislodged a blood clot, and in the second the obstruction cleared following insertion of a ureteral stent. Two patients required reoperation. In 1 an obstructing suture was remove& and the second underwent reimplantation. No graft loss occurred in this group. Spontaneous rupture of the kidney, a rarely reported complication of unknown cause,’ occurred in 2 of our patients. Both occurred in the oliguric phase following cadaveric transplants and were temporally related to dialysis. The clinical presentation was characterized by the acute onset of pain over the graft, shock, falling hematocrit, and the appearance of a flank mass. Exploration revealed linear cortical tears which were packed

Number of Grafts

Patient Survivals

Number of Graft Survivals

8 4 5 2

7 4 4 2

6 4 4 2

19/141 (13 per cent)

17/19

16/19

(89 per cent)

(84 per cent)

fistula obstruction necrosis of kidney

TOTALS

419

(44 per cent)

II. Major urologic complications following 141 transplants

Complication Urinary Ureteral Ureteral Rupture

819

/ VOLUMEV.

NUMBER2

Number of

183

FIGURE 1. Nephrostogram three years after insertion of nephrostomy tube following necrosis of the entire ureter and renal pelvis.

Improved methods of tissue typing and lower surgical complication rates are responsible for higher graft survival. An additional factor is the early recognition and improved management of complications. Our experience has taught us to be extremely aggressive when any change in the patient’s clinical status occurs. Most urologic complications occur between the eighth and tenth postoperative days. The diagnosis is established just as in nontransplant patients, by systematic application of routine urologic tests including intravenous pyelogram, cystogram, cystoscopy, retrograde pyelogram, and finally renal arteriography. We have become increasingly reliant on renal scans as a noninvasive high-yield procedure. We disagree with earlier teachings that the best treatment for urologic complications is the removal of the graft to save the patient. If reoperation occurs before urine or infection destroys tissue planes, satisfactory secondary procedures are feasible. In our series, 16 of 19 (84 per cent) of grafts were retained despite urologiccomplications. Our mortality from urologic complications was 1.3 per cent. Emory University Clinic 1365 Clifton Road, N. E. Atlanta, Georgia 30322 (DR. WALTON)

with a gelatin sponge (Gelfoam) and over-sewn. Of interest is that both kidneys began to function almost immediately after surgery. Comment In kidney transplantation, as in any surgical discipline, complication rates vary inversely with experience. Earlier series have reported urologic complication rates as high as 35 per cent.3 Our rate of urologic complications of 13 per cent compares favorably with a 1971 report of 1,108 transplants from ten centers with an over-all complication rate of 14 per cent.4

184

References 1. WOODARD,J. R., and Keats, G. K.: Ureteral reimplantation: Paquin’s procedure after 12 years, J. Urol. 109: 891 (1973). 2. O’BRIEN, D. P., and LEWIS, E. L.: Spontaneous rupture of renal transplants; in preparation. 3. STAFFRON, R. A., et al. : Four years’ clinical experience with 138 kidney transplants, J. Urol. 99: 479 (1968). 4. WEIL, R., et al. : Prevention of urological complication after kidney transplantation, Ann. Surg. 174: 154 (1971).

UROLOGY /

FEBRUARY 1975 /

VOLUME V. NUMBER 2

Urologic complications in renal transplantation.

Our ten-year experience with 141 kidney transplants is reported. Fifty per cent of the grafts are presently functioning, and 22 patients have been fol...
589KB Sizes 0 Downloads 0 Views