Long-term comparative outcomes between 2 common ureteroneocystostomy techniques for renal transplantation

PURPOSE: We compared the incidence of ureteral complications between the classic (Lich-Gregoir) technique and the recently popularized single stitch (Shanfield) technique in renal transplantation. MATERIALS AND METHODS: The charts of 721 consecutive transplant recipients from May 1999 to July 2002 were retrospectively reviewed. Ureteral and nonureteral complications were reviewed at 3 to 5-year followup. RESULTS: Of the 721 recipients evaluated 713 were included in the study. There were 360 recipients in the Lich-Gregoir group and 353 in the Shanfield group. A significantly higher rate of ureteral complications occurred in the Shanfield group compared to the Lich-Gregoir group (15.6% vs 3.9%, p <0.0001). The Shanfield group consisted of 20 patients with ureteral leakage, 21 with hematuria, 11 with strictures and 3 who had ureteral stones. The Lich-Gregoir group had 8 patients with ureteral leakage, 5 with hematuria and 1 with a stricture. In comparison, urinary tract infections, delayed graft function and rejection rates were not significantly different between the 2 groups (p = 0.76, 0.12 and 0.19, respectively). CONCLUSIONS: In contrast to other reports, the Shanfield group had significantly more ureteral complications. In particular the Shanfield technique may predispose patients to higher rates of hematuria and stone formation. Based on this large series and published meta-analyses we believe that the stented Lich-Gregoir anastomosis is the superior ureteroneocystostomy technique in renal transplantation.     

Surgical treatment of urologic complications after renal transplantation

AIM: The incidence of urologic complications after renal transplantation has been reported to be between 2.5% and 27%. The aim of this study was to evaluate urologic complications of and their surgical treatment in our series of renal transplantations. MATERIALS AND METHODS: We retrospectively evaluated urologic complications among 395 renal transplant recipients in our institute. RESULTS: The urologic complications were ureteral leakage (n = 8), stricture of ureteral anastomosis (n = 3), hydronephrosis secondary to stone (n = 2) and bladder outlet obstruction (n = 2), recurrent urinary infection because of vesicoureteral reflux to native kidney (n = 2), renal tumor in native kidney (n = 1), hydroceles (n = 3), technical complications (n = 2), and clot retention (n = 1). CONCLUSION: Major urologic complications following renal transplantation are ureteral leakage and stricture resulting from disrupture of the distal ureteral blood supply during the donor operation. Extravesical ureteroneocystostomy over a JJ stent seems feasible to minimize urologic complication. Early diagnosis and endourologic techniques are the mainstays of treatment.     

Ex vivo ureteroscopic treatment of calculi in donor kidneys at renal transplantation

PURPOSE: We evaluated the safety and efficacy of ex vivo ureteroscopy (ExURS) as a means of rendering the donated kidney stone-free at live donor renal transplantation. MATERIALS AND METHODS: A total of 10 suitable kidney donors with small, unilateral nonobstructive calculi underwent live donor nephrectomy (8 open flank, 2 hand assisted transperitoneal). Immediately after cold perfusion, ExURS was performed in an iced saline solution. Access to the collecting system was via the ureteral stump. Calculi were either removed with endoscopic baskets and/or completely fragmented with Holmium laser lithotripsy. RESULTS: Access to the renal collecting system was technically successful in all cases. A total of 10 stones, ranging in largest diameter from 1 to 8 mm (average 5.2) were visualized. Of the kidneys 6 had solitary stones, 2 had 2 stones and 1 had no stone. Of 10 stones 9 were successfully removed and/or fragmented with an average procedure time of 6.5 minutes (range 3 to 28). Indwelling ureteral stents were placed at transplantation in 5 of 10 kidneys. There were no intra-operative or postoperative ureteral complications. At 1 month after transplant serum creatinine ranged from 0.9 to 2.7 mg/dl (average 1.5). At a mean followup of 33.2 months new stones have not formed in any recipients and at mean 36.4-month followup no new calculi have formed in the remaining kidney of any donors. CONCLUSIONS: ExURS is a technically feasible means of rendering a stone bearing kidney stone-free without compromising ureteral integrity or renal allograft function.     

Percutaneous techniques for the management of urological renal transplant complications

Percutaneous techniques were used to manage 13 renal transplant recipients with urological complications and long-term followup now is available. Three patients had urinary fistulas and 10 had ureteral obstruction. In 2 of the patients with ureteral fistulas and 5 with ureteral obstruction the percutaneous procedures provided definitive management and obviated the need for an open operation. In the 6 other patients the percutaneous procedures proved to be valuable adjuncts to subsequent planned open operative reconstruction. While there were 4 significant complications related to the percutaneous procedures, none resulted in graft loss or patient death. We conclude that percutaneous techniques provide valuable alternatives to immediate open operative intervention in renal transplant recipients with ureteral obstruction or fistula formation. Furthermore, these techniques may obviate entirely the need for subsequent operative intervention.     

Intermediate outcomes of dual renal allografts: the University of Washington experience

PURPOSE: The increased survival advantage of renal transplantation with end stage renal disease combined with an increasing incidence of renal disease fuel an increasing disparity between supply and demand for transplantable kidneys. Despite efforts to increase cadaveric organ donation through education and publicity, the number of cadaveric kidneys transplanted has not increased and in the last year was surpassed by kidneys transplanted from living donors. In an effort to maximize cadaver organ donors use of kidneys from expanded criteria donors has been investigated. In select cases both donor kidneys have been transplanted into a single recipient, which is called dual renal transplant. We report on the 4-year dual renal transplant graft and patient outcomes and compare these to age matched single cadaver kidney transplants. MATERIALS AND METHODS: A retrospective review of 10 dual renal transplant recipients and 10 age matched single cadaver kidney recipients was performed. All patients underwent transplantation at our university between January 1996 and February 1998. Mean followup was 4.1 years (range 2.5 to 5.1) for the dual kidney recipients and 3.6 (0.0 to 5.5) years for the control group. RESULTS: Of the 10 dual renal transplant recipients 7 remain alive and 3 died of nontransplant related causes. Of the 10 single recipients 8 are alive, 1 died of postoperative complications and 1 died of nontransplant related causes. When censored for death with a functioning graft, 7 of 10 dual grafts are functioning at followup with a mean creatinine clearance of 39.4 ml. per minute (range 16.1 to 65.9) and mean serum creatinine of 2.0 mg./dl. (1.1 to 3.9). If not censored for death with a functioning graft, 50% of dual grafts are functioning. Of the 3 graft losses 2 were due to recurrent disease and 1 was attributed to chronic rejection. In the control group 8 of 10 grafts are functioning at current followup (regardless of censoring for death with a functioning graft) with a mean creatinine clearance of 48.7 ml. per minute (range 23.4 to 66.5) and mean serum creatinine of 1.6 mg./dl. (1.2 to 2.4). Of the 2 graft losses 1 resulted from postoperative complications and 1 was due to chronic rejection. CONCLUSIONS At the 4-year followup patients undergoing dual renal transplant have comparable graft function, incidence of graft loss and survival compared to the control group. However, because of our small sample size, differences in the 2 groups may be significant in a larger study. Additional studies need to be conducted to determine if this practice represents an acceptable use of kidneys from expanded criteria donors.     

Urological complications in 210 consecutive simultaneous pancreas-kidney transplants with bladder drainage.

OBJECTIVE: The urological complications of 210 patients who underwent simultaneous pancreas-kidney (SPK) transplantation over a 7-year period were reviewed. SUMMARY BACKGROUND DATA: Worldwide, bladder drainage has become the accepted method of exocrine drainage after pancreas transplantation. With the increasing use of bladder drainage, the surgical post-transplant complications have shifted from intra-abdominal complications to urological complications. METHODS: Two hundred ten diabetic patients received SPK transplants with bladder drainage. A retrospective review was conducted to analyze the incidence, type, and management of urological complications. RESULTS: The most frequent urological complications were hematuria, leak from the duodenal segment, recurrent urinary tract infections, urethritis, and ureteral stricture and disruption. Complications related to the renal transplant included ureteral stricture and leaks, as well as lymphoceles. CONCLUSIONS: Despite the high incidence of urological complications, 5-year actuarial patient and graft survival are excellent. Only one graft and one patient were lost secondary to urological complications.     

Successful long-term outcome using existing native cutaneous ureterostomy for renal transplant drainage

PURPOSE: We report our long-term experience with a preexisting native cutaneous ureterostomy via an ipsilateral transplant ureteral native ureterostomy for transplant drainage without native nephrectomy. MATERIALS AND METHODS: Between 1993 and 1998, 5 patients without a usable bladder had undergone previously urinary diversion via cutaneous ureterostomy. All patients had a well functioning cutaneous ureterostomy for a mean plus or minus standard deviation of 18+/-12 years before renal transplantation. No patient had a history of stomal stenosis, recent urinary tract infection or pyelonephritis. RESULTS: All 5 patients continued to have a functioning renal transplant at last mean followup of 36+/-6.6 months. Complications included stomal retraction due to postoperative weight gain requiring revision in 2 cases and ureteroureteral anastomotic stenosis treated with endopyelotomy in 1. Mean serum creatinine at last followup was 1.5+/-0.6 mg./dl. CONCLUSIONS: Of the complications that we present only 1 may be attributed to the singularity of our procedure. Our experience suggests that a preexisting native cutaneous ureterostomy may serve as a receptacle for transplant ureteral drainage in select patients with excellent long-term function.     

Enterocystoplasty and renal transplantation

PURPOSE: We report on our experience with renal transplantation in patients with severe chronic bladder contracture who underwent prior intestinal bladder augmentation, and assess the safety of the procedure. MATERIALS AND METHODS: A total of 7 patients with severe alterations to the lower urinary tract and renal insufficiency underwent enterocystoplasty before renal transplantation. The etiologies of the bladder dysfunction were bladder contraction secondary to urinary tuberculosis in 4 cases, neurogenic bladder secondary to myelomeningocele in 1, chronic cystitis secondary to intravesical instillation of glutaraldehyde in 1 and hyperreflexic, contracted bladder in 1. Mean patient age was 38.4 years (range 19 to 57). The intestinal segment used was ileal conduit in 6 cases and an ileocaecal segment in 1. All 7 patients have received renal transplant from cadaveric donors. RESULTS: Graft survival rate was 100% and graft function was good after a mean followup of 48 months (range 8 to 97). Of the patients 6 are continent and void spontaneously and 1 requires intermittent self-catheterization. CONCLUSIONS: In our experience bladder augmentation is an acceptable method, although not exempt from complications, for patients with alterations to the lower urinary tract and who are candidates for renal transplantation.     

Is ureteroscopy first line treatment for pediatric stone disease?

PURPOSE: We report our current outcomes for ureteroscopic management of pediatric stone disease. MATERIALS AND METHODS: We carried out a retrospective review of all ureteroscopic procedures for kidney or ureteral calculi performed between 2001 and 2005. Stone location and size, preoperative and postoperative stenting, intraoperative dilation, use of ureteral access sheath, stone-free rates and complications were noted. RESULTS: A total of 100 patients (58% female, mean age 13.2 years) underwent 115 procedures. Stones were located in the renal pelvis in 6% of patients, upper pole in 10%, mid ureter in 11%, lower pole in 17%, proximal ureter in 19% and distal ureter in 37%. Mean stone size was 8.3 mm (median 7.0), with a mean of 1.5 stones per patient. Preoperative stenting was used in 54% of patients, and a stent was placed postoperatively in 76%. Ureteral coaxial dilators and ureteral access sheaths were used in 70% and 24% of patients, respectively. There were no major intraoperative complications, although 5 patients required stent placement for ureteral perforation or extravasation. One patient had a ureteral stricture requiring ureteral reimplantation. Mean followup was 10.1 months (median 2.6). Stone-free rate was 91% on followup ultrasound, abdominal radiography or computerized tomography. Seven patients required staged ureteroscopic procedures to achieve stone-free status. While the number of percutaneous nephrolithotomy and shock wave lithotripsy cases remained stable, the number of ureteroscopic cases increased 7-fold during this period. CONCLUSIONS: Improved ureteroscopic access to stones throughout the pediatric urinary tract and stone-free rates that are comparable to the adult population have led to the adoption of ureteroscopy as first line therapy in children at our institution.     

Urological complications after renal transplantation using ureteroureteral anastomosis in children

PURPOSE: Ureterovesical reimplantation is most often performed for renal transplantation in children. We reviewed our experience to evaluate the safety and efficacy of ureteroureteral reimplantation in pediatric renal transplantation. MATERIALS AND METHODS: We retrospectively evaluated the charts of 92 boys and 72 girls who underwent a total of 166 ureteroureteral anastomoses for renal transplantation from January 1990 to December 1999. Spatulated end-to-end anastomosis was performed between recipient and graft ureters without stenting and with a bladder catheter for at least 10 days. RESULTS: Mean patient age at transplantation was 11.2 years (range 1 to 21.5). There were 22 living related donor and 144 cadaveric grafts. Urological anomalies and nephropathy were the cause of end stage renal disease in 146 and 20 patients, respectively. Urological complications were noted in 14 of the 166 transplantations (8.4%) in 10 boys and 4 girls, including 12 initial and 2 repeat grafts from 2 living related and 12 cadaveric donors. Five of these patients had undergone previous urological surgery. The 2 children (1.2%) with acute ureteral obstruction underwent repeat intervention after stent failure. Anastomotic leakage in 7 cases (4.2%) was treated conservatively in 1 and with a Double-J stent (Medical Engineering Corp., New York, New York) only required in 3. Reoperation was required in 3 cases. One patient (0.6%) with late ureteral stenosis underwent repeat anastomosis, 1 (0.6%) required reimplantation for recurrent pyelonephritis due to vesicoureteral reflux in the graft, 1 (0.6%) with a valve bladder required bladder augmentation and ureteral reimplantation, and 1 (0.6%) with lymphocele and 1 (0.6%) with lithiasis were successfully treated conservatively. Complications were associated with acute rejection in 6 cases. Mean followup without graft loss in patients who presented with versus without complications was 58.3 months (range 1 to 112) versus 75 (range 1 to 118). In the former patients with a mean age of 16 years 9 months versus those without urological complications mean serum creatinine was 116 and 108 mol./l., respectively. Two grafts were lost in patients with urological complications, including 1 who died of pulmonary embolism and 1 with refractory chronic rejection. Seven patients were lost to followup after 54 months (range 12 to 113) of adequate graft function. CONCLUSIONS: Ureteroureteral anastomosis is a safe and effective technique for pediatric renal transplantation with a low complication rate, which may be due to better vascularization of the shorter ureteral end of the graft. Our results should encourage the use of this technique in pediatric renal transplantation. Efforts to preserve the recipient ureters should be made at nephrectomy.     

460例次肾移植术后尿路并发症分析

本文报告我院460例次肾移植术后尿路并发症,共45例次,其中42例原发性(占9.13％),3例继发性,包括输尿管梗阻18例,输尿管或膀胱瘘26例,肾输尿管结石1例。除1例因行移植肾造瘘并发感染死亡外,余均经手术或非手术治愈。我们认为多数尿路并发症为外科技术所致,需要开放手术治疗。仔细的取肾、规范植肾手术操作和及早诊断是减少肾移植后尿路并发症发生的重要因素。     

Postrenal transplantation urologic complications

OBJECTIVES: We sought to explore the incidence, risk factors, clinical presentation, management options, and outcomes of post renal transplant urologic complications. PATIENTS AND METHODS: Between November 1993 and December 2005, we performed 646 renal transplantation procedures in 373 males and 273 females, of whom 81 were children. Kidney grafts were obtained from 461 living and 185 cadaveric donors. The medical records were retrospectively reviewed for urologic complications. Affected patients presented clinically with impaired kidney function: the diagnosis was confirmed by ultrasound scanning, isotope renal scanning, magnetic resonance urography, and/or antegrade urography. Ureteric stricture was managed by percutaneous antegrade ureteric dilatation and stenting, or by surgical reconstruction. Urine leak was treated by prolonged bladder drainage or surgical reconstruction. Renal stones were treated with extracorporeal shockwave lithotripsy. RESULTS: Urologic complications were detected in 31 recipients (4.8%), including 21 males and 10 females, among whom 4 were children. They had received kidney grafts from 19 living and 12 cadaveric donors. Urologic complications were ureteric strictures in 15 (2.58%), urine leaks in 15 (2.58%), and ureteric stone in 1 (0.17%) recipients. There was no graft loss to urologic complications. CONCLUSIONS: The incidence of post-kidney transplant urologic complications was 4.8%. They were more common among male recipients and after cadaveric kidney transplantation. Although ureteric stricture presented late posttransplantation and was more common among children (4.23%), urine leak presented early and was more common in the elderly (4.69%). All urologic complications were successfully managed, with no graft loss.     

Urological complications after living-donor renal transplantation

OBJECTIVE: To determine the incidence and management of urological complications after 1200 consecutive live-donor renal transplantations, all of which were carried out in one centre; the possible risk factors and the effect on patient and graft survival were also assessed. PATIENTS AND METHODS: Data were retrieved from an electronic database; the incidence of urological complications was determined, and correlated with relevant risk factors by univariate and multivariate analysis. The effect on patient and graft survival was assessed using Kaplan-Meier statistics. RESULTS: There were 100 complications in 96 patients (8%); urinary leaks occurred in 37, ureteric strictures in 23 and lymphoceles causing ureteric obstruction in 17. Percutaneous needle biopsy was complicated by haematuria and clot anuria in six patients. Late complications included 11 cases of stones, four of bladder malignancy and two of haemorrhagic cystitis. There was evidence that the age of the recipients (< 10 years), method of establishing urinary continuity (uretero-ureteric anastomosis) and a high dose of steroids had an independent positive effect on the incidence of urological complications. However, their development did not influence graft or patient survival. CONCLUSION: When there is meticulous attention to the technical details, renal transplantation should incur few urological complications. Early intervention with percutaneous drainage reduces morbidity and the likelihood loss of graft function. Proper and prompt management should not affect the graft and/or the patient's survival.     

Impact of stents on urological complications and health care expenditure in renal transplant recipients: results of a prospective, randomized clinical trial

PURPOSE: We performed a randomized, prospective trial to compare the incidence of early urological complications and health care expenditures in renal transplant recipients with or without ureteral stenting. MATERIALS AND METHODS: Patients receiving a renal transplant at a single center were randomized preoperatively to undergo Double-J stent or no-stent ureterovesical anastomosis from November 1998 to October 2001. Early urological mechanical complications were recorded, including urinary leakage or obstruction, or urinary tract infections within 3 months of transplantation. Direct health care costs associated with stenting, urological complications and urinary tract infection management were also collected. RESULTS: A total of 201 patients were randomized to a stent (112) and a no-stent (89) group. In the no-stent group 11 patients received a stent due to intraoperative findings and were excluded from study. At 3 months there were significantly more cases of urinary leakage (8.9% vs 0.9%, p <0.008) and ureteral obstruction (7.7 % vs 0%, p <0.004) in the no-stent than in the stent group. Mean time of stent removal was 74.3 days. A significant increase in urinary tract infections was observed when stent was left greater than 30 days after transplantation compared to the rate in the no-stent group (p <0.02). An additional cost of 151 UK pounds per patient was incurred in the no-stent group vs the stent group. CONCLUSIONS: Using a ureteral stent at renal transplantation significantly decreases the early urinary complications of urine leakage and obstruction. However, there is a significant increase in urinary tract infections, primarily beyond 30 days after transplantation. Stent removal within 4 weeks of insertion appears advisable.     

Urinary calculi in renal transplant recipients

Urinary calculi are an uncommon complication in renal transplant recipients. During a 15-year period, in 544 cases of kidney transplantation with a functioning allograft for more than 3 months, and a long-term follow-up, we have observed 9 cases (1.7%) of urinary calculi. Calculi occurred in 6 male and 3 female patients, 6 patients were recipients of living related and 3 of cadaveric kidneys. Calculi were diagnosed as early as 3 months and as late as 3.5 years after transplantation, but most were detected within the first year. The location of the calculi was the bladder in 4 cases, the transplant in 3, and indeterminant in 2. Crystallographic analysis of retrieved stones revealed calcium oxalate and/or phosphate in 4 cases, triple phosphate in 2, and uric acid in 1. All patients had one or more stone-predisposing factors, such as obstructive uropathy and recurrent urinary tract infection (4 cases), hyperoxaluria (3), or hypercalciuria (2). During long-term follow-up (mean 60 months), only one patient lost the renal graft, 14.5 years after transplantation, primarily from causes unrelated to urinary calculi. One instance of stone recurrence was noted. In conclusion: (1) urinary calculi after renal transplantation are relatively uncommon; (2) predisposing factors and crystallographic composition of the calculi are identical in type, but not frequency, to those of nontransplant patients; and (3) with proper medical and surgical management, post-transplant urolithiasis does not appear to affect graft prognosis.     

The manifestation and management of late urological complications in renal transplant recipients: use of the urological armamentarium

The incidence of urological complications in renal transplant patients is well documented. The majority of these complications occur in the early postoperative period; late occurrences (more than 3 months) are much less common. We have had experience with 7 patients who presented with late complications 3 months to 7 years after transplantation: ureteral obstruction occurred in 4 patients, ureteral disruption or laceration in 2 and neurogenic bladder with hydronephrosis in 1. Management of these patients has been varied and has included cystoscopic stent placement, Boari flap, ureteropyelostomy, ureteroneocystostomy, bladder augmentation and urinary undiversion. Grafts have been salvaged in 6 of 7 patients. Transplant patients who present with late urological complications can be challenging. However, the potential for intervention and graft salvage is excellent.     

Experiences in kidney transplantation with duplicated ureters

INTRODUCTION: The purpose of this study was to evaluate the complications of duplicated ureters in renal transplant recipients. METHODS: Between 1983 and 2004, 12 patients (median age 34 years) received renal transplants from donors with duplicated ureters. In four patients the ureter to bladder anastomoses were performed separately according to the method described by MacKinnon, including two cases transplanted with ureteral catheters because of narrow widths. In the following cases of eight duplicated ureters an anastomosis was performed between the distal part of each ureter to form a common ureteral ostium, which was connected to the urinary bladder. A ureteral catheter was used to the splint ureterovesical anastomosis. RESULTS: No graft loss to ureteral complications was observed. There was no ureteral necrosis in the postoperative period. No clinical symptoms of ureteral junction obstruction were revealed after removing the ureteral catheter. By ultrasound examination four patients showed a slight temporary pyelocaliectasis was observed and four patients developed temporary urinary fistulas. CONCLUSION: Our ureterocystoneostomy procedures with duplicated ureters were safe and useful in kidney transplantation.     

Increased incidence of gastrointestinal surgical complications in renal transplant recipients with polycystic kidney disease

BACKGROUND: We had the impression that, although our renal transplant recipients with polycystic kidney disease (PKD) had excellent long-term renal graft function, they had an increased incidence of postoperative gastrointestinal (GI) complications. METHODS: Over a 10-year period (1987 through 1996), 1467 renal transplants were performed in 1417 patients; 145 of these transplants involved PKD recipients. In the PKD group, 18 patients (12.4%) developed a posttransplant complication necessitating GI surgery (PKD-GI), an incidence twice that in the non-PKD recipients (73 patients or 6.2%, non-PKD-GI). RESULTS: PKD and non-PKD recipients displayed no significant difference in mortality. The PKD patients had better long-term renal graft survival than the non-PKD patients (P=0.08). There was no difference in mortality (P>0.6) or renal graft survival (P>0.6) between the PKD-GI and PKD-non-GI groups. The PKD-GI group had no increased mortality over the non-PKD-GI patients (P>0.6), despite a higher incidence of GI surgical complications in the PKD group versus the non-PKD group (overall: 12.4 vs. 6.2%, P<0.01; within 90 days of transplant: 7.6 vs. 3.3%, P<0.02) and a greater propensity for small and large bowel complications (overall: 9.0 vs. 2.6%; P< 0.001; less than 90 days: 6.9 vs. 2.0%, P<0.002). The PKD-GI recipients tended toward less long-term graft loss than their non-PKD-GI counterparts (11.1 vs. 27.4%; P=.22). The PKD-GI recipients suffered no acute rejection episodes within 90 days after their GI operation versus 11 of 73 non-PKD-GI recipients (O vs. 15.1%; P=0.075). CONCLUSIONS: PKD recipients of renal grafts should be watched closely early after transplant because of their increased risk of GI complications. These complications resulted in no increase in mortality or graft loss compared to non-PKD recipients with GI complications despite the PKD group's higher incidence of bowel perforation and increased age at time of transplant.     

Urological complications in renal transplantation from cadaveric donor grafts: a retrospective analysis of 20 years

INTRODUCTION: This study is a retrospective analysis of ureteral complications and their management from a monocenter series of 277 consecutive renal transplantations. MATERIALS AND METHODS: From September 1979 to June 1999, 277 renal transplantations (cadaveric origin) were performed in 241 patients. The ureter from the kidney graft was inserted into the bladder according to the technique of extravesical implantation described by Lich-Gregoir and Campos-Freire. The study analyzed the time of occurrence and the type of complications observed. The different procedures to restore the transplanted urinary tract are presented. RESULTS: Complications occurred in 43/277 renal transplantations (15.5%). Anastomotic urine leakage or ureteral stricture were the most frequent. The time to appearance of these complications was either short (<1 month) or late (>1 month) in a similar number of cases. Most cases were managed surgically: 33/43 cases (76.7%). The most frequent surgical repair was ureterovesical reimplantation (n=13), followed by: ureteroureteral end-to-end anastomosis (native ureter-ureter transplant, n=5); pyeloureteral anastomosis (native ureter-renal pelvis transplant, n=5); simple revision of ureterovesical implantation (n=4); resection and end-to-end anastomosis of the transplant ureter (n=2); calico-vesicostomy (graft-bladder, n=1); implantation according to Boari (n=1); pyelovesicostomy with bipartition of bladder (n=1), and pyeloileocystoplasty with detubularized ileal graft (n=1). No deaths related to any of the urological complications were reported. However, 2 consecutive vesico-renal refluxes led to the loss of the kidney graft in the long-term. CONCLUSION: The rate of complications observed in this retrospective analysis is similar to the experience of other studies, ranging from 2 to 20%. If the classical extravesical ureteral bladder implantation is to remain an attractive technique due to its simplicity, the surgical team at the training center should be aware of all the means to prevent any ureteral complications, such as the choice of another implantation technique and/or insertion of a transient ureteral stent.     

Diagnosis, Management, and Outcome of Late Duodenal Complications in Portal–Enteric Pancreas Transplantation: Case Reports

Background: Enteric drainage (ED) of pancreas allografts is an alternative to the bladder drainage (BD) technique and eliminates unique metabolic complications seen in the BD pancreas transplant recipients. Little longterm data has been reported in ED pancreas transplants.

Study Design: Of 53 patients who underwent pancreas transplantations performed with ED drainage of the exocrine secretion to a Roux-en-Y limb, who had more than 6 months graft function, four patients were identified with late duodenal segment complications (more than 6 months after transplantation) and are presented as case reports.

Results: The duodenal segment complications occurred between 8 and 48 months after simultaneous pancreas–kidney transplantation. Three patients were diagnosed with leakage from the duodenal segment. All were managed operatively. The fourth patient developed a distal stricture of the transplant duodenum occluding the anastomosis between the duodenum and the Roux-en-Y limb and also had a pancreatic pseudocyst. Drainage via a cyst-jejunostomy resulted in graft salvage. The mean followup after operative management of the duodenal-related complications was 15 months (range, 3–24 months). The patient, pancreas and kidney graft survival are 100%.

Conclusions: Late duodenal complications occurred in 8% of pancreas transplant recipients with ED. Operative intervention in all four patients resulted in excellent graft and patient outcome and is recommended for these complications.