Percutaneous treatment of urologic complications following renal transplantation

Summary Urologic complications continue to occur in renal transplant recipients. Furthermore, standard, secondary operative intervention for these problems has been associated with high morbidity and even mortality. Currently, percutaneous techniques are being used with increasing frequency for these patients to temporize or even avoid the need for subsequent operative procedures. The indications, techniques, and results of such intervention are reviewed.     

Transplant ureteral obstruction masquerading as recurrent rejection episodes: management by percutaneous antegrade balloon dilatation

We report a 52-year-old male renal transplant recipient who had three "rejection episodes." The first of these responded to conventional antirejection therapy; however, the next two episodes showed incomplete responses to treatment for rejection. At subsequent presentation with deteriorating renal function, ureteral obstruction was evident and was relieved with percutaneous antegrade balloon dilatation with a return of his plasma creatinine to normal. Obstruction of the ureter was a major component in our patient's course given the lack of response to conventional antirejection therapy and the normalization of renal function with relief of the documented ureteral stenosis. This case illustrates that ureteral obstruction can mimic rejection in the renal transplant recipient. Management of ureteral stenosis in transplant patients with percutaneous antegrade balloon dilatation appears to be an effective procedure and can supplant the need for open surgical procedures.     

Percutaneous management of benign ureteral strictures and fistulas

The percutaneous methods of management of benign ureteral strictures or fistulas have developed as a natural evolution of percutaneous nephrostomy and angiographic techniques. We review our 5-year experience, which includes 18 patients with 19 benign ureteral strictures and 12 patients with ureteral fistulas. In the majority of the patients the ureteral strictures occurred at sites of surgical reconstruction or endoscopic manipulation. All fistulas resulted from surgical injury. In 10 of the 12 patients (82 per cent) the fistulas healed without development of a stricture or need for further intervention. Patients with short ureteral strictures had a high incidence of success and they usually were the best candidates for percutaneous manipulation. The long strictures usually were of longer duration and they were less likely to be managed successfully percutaneously. Failure of percutaneous dilation did not impede subsequent surgical management. Percutaneous management often is a reasonable initial step in the treatment of ureteral strictures and fistulas.     

Primary extracorporeal shock wave lithotripsy of staghorn renal calculi.

186 patients with partial and 55 patients with complete renal staghorn calculi were treated with primary extracorporeal shock wave lithotripsy (ESWL) at the Department of Urology, University of Würzburg Medical School. Partial staghorn calculi required an average of 1.4, complete staghorn calculi an average of 2.2 treatment sessions using the Dornier HM 3 lithotriptor. 55% of all patients and 46% of the patients with complete staghorn calculi were rendered stone-free within 1 year after ESWL. Pretreatment urinary tract infections present in 50.6% of all patients could be reduced to 22.5% 1 year after ESWL. The most frequent complications after ESWL were ureteral obstruction caused by 'steinstrasse' (41.4%), fever (38.4%), and renal colics (29.4%). Severe complications needing open operative procedures or blood transfusions did not occur. 50% of all patients underwent auxiliary procedures (e.g. insertion of indwelling ureteral stents: 25.3%, percutaneous nephrostomy: 20.3%, percutaneous nephrolithotripsy: 2.9%). Pretreatment insertion of an indwelling ureteral stent was found to reduce posttreatment complications as well as the need for percutaneous nephrostomy only in patients with partial staghorn calculi. The data presented in this study demonstrate that primary ESWL therapy can be safely and successfully performed in the majority of patients with renal staghorn calculi. In patients requiring complete removal of all stone fragments, a percutaneous lithotripsy can be performed following ESWL.     

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.     

Prolonged ureteral stenting in obstruction after renal transplantation: long-term results

BACKGROUND: Renal transplantation is an effective treatment for end-stage renal disease. Ureteral stenosis is the most frequent urologic complication. We report our long-term follow-up results concerning endourologic treatment of ureteral obstruction after renal transplantation. METHODS: Between May 1997 and September 2000, 15 patients with renal transplant obstructive uropathy were managed with percutaneous nephrostomy and prolonged ureteral stenting. RESULTS: Percutaneous nephrostomies were performed successfully in all 15 kidneys. In 13 patients, antegrade ureteral stenting was attempted, which was successful in 11 patients (85%). After prolonged ureteral stenting (mean duration 15 months), the stent was removed in all patients, 90% of whom had no recurrence. During follow-up (36 to 71 months; mean 51), urea, creatinine, sodium, and potassium determinations and ultrasound scans were performed. Success was defined as a reduction in hydronephrosis. No major complications were observed. CONCLUSIONS: Modern endourologic procedures have replaced open reconstructive surgery in most patients with ureteral obstruction after renal transplantation, because they may offer a definitive treatment with low morbidity.     

Ureteral Complications in Renal Transplant Recipients Successfully Treated With Interventional Radiology

Introduction

Ureteral complications in renal transplantation occur in approximately 8% of renal transplant recipients, occasionally leading to graft loss. This retrospective study presents a single-center experience in managing ureteral complications with interventional radiology as well as the long-term graft function and recipient survival.

Patients and Methods

We analyzed 21 renal transplant recipients with ureteral problems.

Results

Nine patients experienced urinary leak, six patients had ureteric obstruction, and six patients had obstruction preceded by leak. Median recipient age was 48 (range, 20-63) years; 71% (15/21) of the patients were male and 66.6% (14/21) of transplants were derived from cadaveric donors. Ureteral complications were diagnosed at a mean of 18 days (range, 12-47) after renal transplantation. Initially a percutaneous nephrostomy was performed, followed by antegrade placement of a nephroureteral stent. In cases with ureteral obstruction, ureteral balloon dilation was performed prior to placement of the stent. Median time to the procedure was 53 days, and median follow-up for the purposes of this study was 57 months. Renal graft function improved following treatment of the ureteral complication. Mean serum creatinine values prior to and after the intervention were 4.8 ± 2.12 and 1.79 ± 0.58 mg/dL, respectively (P<.0001). Functional renal grafts were observed at the first, third, and fifth posttransplantation year among 100%, 95.2% and 80.9% of patients, respectively. It should be further noted that no graft was lost due to a ureteral complication.

Conclusions

Interventional radiology was successful in treating immediate and long-term ureteral problems among renal transplant recipients with preservation of good renal function and patient survival.     

O'Brien peel-away sheath: an alternative for allograft percutaneous nephroscopy

Percutaneous access and antegrade intervention remains the gold standard in the management of renal and ureteral complications in the renal transplant recipient. Current techniques with large nephrostomy sheaths and instrumentation carry significant morbidity in this patient population. We present our experience with a modification of the standard nephroscopic approach using a smaller (16F) O'Brien suprapubic peel-away introducer and sheath to access the allograft renal pelvis and allow manipulation with a smaller-caliber endoscope, with the purpose of attaining similar treatment outcomes with less morbidity in this subset of patients. Fourteen renal transplant patients with indications for antegrade management of renal or proximal ureteral complications had successful endoscopic intervention through the smaller sheaths without suffering any intraoperative or postoperative complications at a mean follow-up of 22 months (range 8-37 months). The mean operative time was 140 minutes (33-190 minutes), which is not significantly different from our operative time using standard instrumentation.     

The surgical approach to urological complications in renal allotransplant recipients.

Urinary extravasation or ureteral obstruction occurred in 22 patients who received 30 transplants in a series of 290 renal transplants. This incidence represent 10.3 per cent of the entire transplant experience at The Johns Hopkins Hospital and Baltimore City Hospitals from 1968 to the present time. Ureteroneocystostomy was used as the primary form of urinary tract reconstruction in all but 1 patient who had urinary complications. These 22 patients received 30 renal transplants: 6 from living related donors and 24 from cadaver sources. There were 15 instances of urinary extravasation and 14 instances of obstruction. All but 2 fistulas were diagnosed within 30 days of the original transplant. Obstruction occurred later, with 4 cases of ureterovesical obstruction being diagnosed 3 to 5 years after the transplant procedure. The ureterovesical junction or bladder was the site of complication in 17 of the 29 instances. Surgical management in these cases was highly individualized, with successful outcomes more commonly attained in those cases characterized by obstruction. Ureteral stents were used in all but 1 secondary procedure involving the ureter and these stents were not associated with an increased incidence of urinary tract infection. Death directly related to the urological complications occurred in 2 cases, 5 patients underwent transplant nephrectomy and 2 patients died of rejection and infection more than 6 months after the urinary fistulas were successfully managed. From the original series, there are 15 of the 22 patients who have stable renal function after secondary or tertiary urological procedures on the transplanted kidney. Four patients underwent surgical correction of hydronephrosis associated with infection or diminishing renal function more than 3 years after the transplantation and 3 of these had good results.     

Diagnosis and treatment of urological complications in kidney transplants

ObjectiveTo analyze the incidence of urological complications, like fistula and stenosis in our series of 282 renal transplants and their management.Materials and methodsBetween December 1995 and October 2005, 282 adult recipients underwent renal transplant.The most common urological complication was urinary fistula. This complication was observed in 24 cases (8.5%), ureteral stenosis in 18 cases (6.4%) and both of them in 5 (1.7%). The items recorded on these patients included the time to diagnosis, the image technique, the type of ureteral stents and the clinical evolution.ResultsEndourologic treatment with percutaneos nefrostomy, double-J catheter and metalic endoprotesis was performed successfully in 76.4% of urinary fistula, in 66.7% of ureteral obstruction and in 60% of patients who developed both of them.ConclusionEndourologic procedures have replaced open reconstructive surgery in most patients with ureteral obstruction or urinary fistula after renal transplant, because they may offer a definitive treatment with low morbidity.     

Endoscopic management of ureteral complications following renal transplantation

Management of ureteral complications after kidney transplantation can be done with a surgical, percutaneous, or endoscopic approach. The aim of this study was to determine the success rate of the endoscopic retrograde approach for the management of these complications following renal transplantation. We reviewed the records of 25 patients who underwent endoscopic management of ureteral complications after renal transplant between 1995 and 2005. Variables examined included timing of event following transplant, type of ureteral complication, equipment implemented in the procedure, operating time, success in stent placement, and complications. Initial approach was via rigid cystoscopy followed by flexible cystoscopy if needed. Initial attempts to intubate the ureteral orifice were by a flexible-tipped guide wire, and occasionally an angiocatheter guide was used for ultimate wire placement. Stents were positioned with fluoroscopic and direct visual guidance. Of 25 patients evaluated, five had a ureteral anastomotic leak with a mean time of presentation of 16.8 days. The remaining 20 patients suffered from ureteral obstruction revealed by hydronephrosis on a renal ultrasound prompted by a rising creatinine. Mean time of onset was 48 months. Although each was initially approached with rigid cystoscopy, 12 were converted to flexible cystoscopy for easier access to the ureteral orifice. Twenty of the 25 patients had successful stent placement with three failures in the ureteral obstruction group and two failures in the leakage group. Average operative time was 42 minutes. No intraoperative complications were experienced. Resolution of hydronephrosis in those with preoperative obstruction was noted and all stented urinary leaks resolved.     

经皮肾穿刺顺行球囊扩张治疗移植肾输尿管梗阻

目的探讨经皮肾穿刺顺行球囊扩张治疗移植肾输尿管梗阻的安全性和疗效。方法回顾性分析2007年至2011年华中科技大学附属协和医院6例接受经皮肾穿刺顺行球囊扩张治疗移植肾输尿管梗阻的患者资料。所有患者先行B超引导移植肾穿刺造瘘,顺行造影确定梗阻的具体位置,顺行球囊扩张输尿管狭窄段,术后留置双J管和肾造瘘管,无效则改开放手术。结果6例患者中1例输尿管狭窄段〉1cm,球囊扩张失败,1例合并尿瘘,尿囊肿,扩张治疗无效,此2例均经开放手术治愈;其余4例一次扩张治愈,随访16～38个月,肾功能正常,无梗阻复发。结论经皮肾穿刺顺行球囊扩张安全、损伤小,可作为治疗移植肾输尿管梗阻的首选方法,对于合并有其他外科并发症或扩张治疗失败的患者,需开放手术治疗。     

Diagnosis and treatment of urological complications in kidney transplantation.

Between January 1973 and January 1990 we carried out 1,038 kidney transplantations using a transvesical end-to-side implantation of the ureter in the bladder without an antireflux mechanism. Moreover, 30 transplantations were done in 26 patients with a urinary diversion. We examined the urological complications in these 1,068 consecutive transplants. Urinary leakage and obstruction were the two main urological posttransplant complications. Severe leakage occurred in 21 patients (2.0%), and was treated by open surgery; 2 patients had a urinary diversion. The treatment of choice is a pyeloureterostomy (anastomosis between the transplant renal pelvis and the native ureter). There were 35 patients (3.3%) with severe ureteral obstruction of whom 5 had a urinary diversion. In 30 patients open surgical treatment of the obstruction was necessary and in 7 patients a percutaneous endourologic treatment was done (dilatation of a confined ureteral stricture in 6 patients and percutaneous stone treatment in 1). The postoperative mortality in the patients treated for leakage or obstruction was low: 4 patients (7%) died, 3 of septicemia due to leakage and 1 of pulmonary embolism after repair of the obstruction. The results of surgical treatment were good. The graft survival after 2 years in the group of urologically complicated transplants was 68% for the patients with leakage and 80% for those with obstruction. The 2-year graft survival in the patients without complications was 67% and 71% for the patients with a urinary diversion. We conclude from these results that urological complications after renal transplantation can be treated successfully by surgical (or percutaneous) correction.     

Ureteral stent – help or hindrance? In healing of post traumatic nephrocutaneous fistula

Nephrocutaneous fistulas are rare complications of blunt or penetrating renal trauma. The majority are managed conservatively, some may require percutaneous drainage or ureteral stenting and some require operative intervention. Diversion of the urine by a ureteral stent usually aids in the healing of the fistula. We present an unusual case of nephrocutaneous fistula following blunt renal trauma which persisted as long as a stent was in place but healed immediately after the stent was removed.     

Endourological management is better in early-onset ureteral stenosis in kidney transplantation

INTRODUCTION: The incidence of ureteral stenosis in kidney transplant recipients is 3%-8%. The treatment of ureteral stenosis has been traditionally operative reconstruction, although such intervention is associated with high rates of serious complications, including graft loss and even perioperative mortality. More recently, endourological treatment has been proposed due to its low morbidity. OBJECTIVE: The objective of this study was to assess the usefulness of balloon percutaneous dilatation as a treatment technique for ureteral stenosis in kidney transplant recipients. PATIENTS AND METHODS: Among 1000 kidney transplantations performed between 1980 and 2004, the coexistence of high creatinine values and urinary tract dilatation in the postoperative period, after discarding concomitant causes, was managed with a percutaneous nephrostomy. Once renal function recovered, antegrade pyelography was performed to confirm the presence and determine the location of ureteral stenosis. Ureteral dilatation was performed using a 5-French balloon-fitted angioplasty catheter. RESULTS: Fifty-six patients were diagnosed with ureteral stenosis during follow-up, an incidence of 5.6%. Transluminal balloon dilatation was the first therapeutic option in 45 cases, whereas surgery was performed directly on 11 patients. Disappearance of the stenosis as well as maintenance of an improved creatinine level was verified in 45% of cases (20 patients). Two patients experienced graft loss. Both a short time to diagnosis after transplantation (P = .06) and the presence of a previous acute rejection episode (P < .05) were good prognosis factors for the endourologic solution of a ureteral stricture. CONCLUSIONS: Balloon dilatation may be considered the definitive procedure for treatment of ureteral stenosis in selected cases. Percutaneous nephrostomy should be used for initial diagnosis and improvement in the renal function before attempting an open procedure.     

开放手术治疗肾移植术后输尿管梗阻的技术探讨

目的探讨肾移植术后移植肾输尿管狭窄的开放手术技巧与效果。方法首都医科大学附属北京友谊医院泌尿外科于2019年1月—2020年1月共行166例单肾移植,共发生5例肾移植术后输尿管狭窄,根据梗阻部位的不同采用了不同的开放手术术式进行治疗,回顾性分析这组患者的临床资料及预后。结果5例患者中,男性3例,女性2例,平均年龄42.6岁。其中2例患者原发病为Ⅱ型糖尿病,3例患者为肾小球肾炎。输尿管梗阻确诊的平均时间为肾移植术后143.8 d,行开放手术平均时间为肾移植术后209.8 d,确诊梗阻时平均血肌酐水平为271.94μmol/L。所有患者均因出现移植肾积水合并血肌酐进行性升高经影像学检查确诊,首先采取内支架或经皮肾造瘘紧急挽救肾功能。待肾功能恢复稳定后,根据梗阻段位置,3例患者行移植输尿管-膀胱再吻合术,1例患者行原输尿管-移植肾输尿管端端吻合术,1例患者行膀胱皮瓣翻转代输尿管术。5例患者开放手术平均时间为2.6 h,术中平均出血量为32 ml。开放手术后,5例患者均预后良好,开放手术后平均血清肌酐恢复至111.5μmol/L,尿量正常,无外科并发症发生。随访半年后,5例患者均未再发生输尿管梗阻。结论移植肾输尿管梗阻是肾移植术后常见外科并发症之一,腔内治疗中远期效果有限,根据不同梗阻部位选择不同术式进行开放手术,是治疗移植肾输尿管狭窄的有效方案。     

Surgical treatment of urologic complications in kidney transplantation

Summary Between January 1973 and December 1987 we carried out 846 kidney transplants using a transvesical end-to-side implantation of the ureter in the bladder without an antireflux mechanism. Moreover, 22 transplantations were carried out in 19 patients with a urinary diversion. We examined the urologic complications in these 868 consecutive transplants. Urinary leakage and obstruction were the two main urologic posttransplant complications. Severe leakage occurred in 17 patients (1.9%) and was treated by open surgery; the treatment of choice is a pyeloureterostomy (anastomosis between the transplant renal pelvis and the native ureter). There were 33 patients (3.8%) with severe ureteral obstructions. In 28 patients, open surgical treatment of the obstruction was necessary, and 5 patients required percutaneous endourologic treatment (dilitation of a confined ureteral stricture in 4 patients and percutaneous stone treatment in 1). The postoperative mortality was low: three patients (6%) died, two of septicemia due to leakage and one of pulmonary embolism after repair of the obstruction. The results of surgical treatment were good. The graft survival after 2 years in the group of urologically complicated transplants was 69.2% for the patients with leakage and 82.4% for those with obstructions. We conclude from these results that urologic complications after renal transplantation can be successfully treated by surgical (or percutaneous) correction.     

Treatment of ureteral stone disease: the role of ESWL and endourology

Summary In recent years, extracorporeal shockwave lithotripsy (ESWL) has proved a safe and easily reproducible method for the treatment of calculi in the upper urinary tract above the iliac crest. Current indications for ESWL as single therapy encompass approximately 60%–70% of all stones. The use of endourological methods as auxiliary procedures can enhance the range of indications to 95% of all renal stones and 85% of all ureteral stones. In the last year, 1340 patients have been successfully treated for urinary calculi at our department. Evaluation of all stone cases shows that ESWL alone, ESWL combined with percutaneous techniques, or percutaneous techniques alone were performed on 93% of all patients. Only 7% of patients had to undergo open surgical treatment, 1% for renal stones and 15% for ureteral stones. Ureteral stones are still among the problem stones for ESWL, in many cases requiring time-consuming combined procedures with either of the percutaneous methods. Furthermore, ureteral obstruction caused by stone particles as a complication after ESWL-treatment of large renal stones has to be relieved using percutaneous techniques. In this report we describe our approach in detail and discuss our results.     

Modified extravesical ureteral reimplantation technique for kidney transplants

Purpose We describe a modification and evaluate a technique of extravesical ureteral reimplantation for kidney transplant. Materials and methods We reviewed the records of 120 kidney transplant recipients who underwent ureteral reimplantation via a modified extravesical technique. Follow-up evaluation included renal ultrasonography. Because reflux is not routinely assessed in transplant cases, only symptomatic reflux was considered a complication and accessed with voiding cystourethrography (VCUG). The urological complications evaluated included urinary fistula, ureteral stenosis and symptomatic vesicoureteral reflux. Results The modified extravesical technique produced a successful result in 93.4% of patients with no symptomatic reflux or anastomotic obstruction. Anastomotic complications included stenosis in four patients, prolonged leakage and fistula in three patients, and symptomatic vesicoureteral reflux in one patient. Other urologic complications included complicated hematuria in three patients, postoperative urosepsis in one patient, and ureteral stenosis caused by extrinsic compression in three patients due to lymphocele (two patients) and by adhesions (one patient). Conclusions The modified extravesical ureteral reimplantation is a reliable procedure with predictable results comparable to those of more-traditional techniques and proved to be efficient without increasing the incidence of urological or anastomotic complications. This modified technique offers two advantages; removal of the ureteral stent with the urethral catheter without the need for a postoperative cystoscopy and facilitation of postoperative endoscopic maneuvers if needed.     

Distal ureteral obstruction complicating percutaneous nephrolithotomy

Endourologic techniques for the treatment of surgical stone disease have proved cost-effective and safe with results comparable to open surgical procedures. Because these are new procedures, unexpected complications are going to occur. We have had 3 cases of complete distal ureteral obstruction unrelated to a ureteral calculus following a percutaneous nephrolithotomy. The obstruction resolved after extended nephrostomy tube drainage. These 3 cases and their treatment and pathogenesis are presented.