Surgical complications in kidney transplantation in nonhuman primates

Surgical complications are important causes of graft loss in the nonhuman primate kidney transplantation model. We reviewed the incidence and intervention methods in 182 kidney transplantations performed in our lab recently 2 years in Cynomolgus monkeys. There were six renal artery thromboses (3.3%), eight urine leakages (4.4%), and five ureteral stenoses (2.7%). All renal artery thrombosis cases were found within 3 days after surgery. Urine leakage appeared from the 5th to 12th day after surgery and all cases were caused by ureter rupture. Reexploration was performed in five cases to reanastomose ureter with stent. Four cases reached long‐term survival. The rest one died of graft rejection. Ureteral stenoses were found in long‐term survival cases. Ureter reanastomoses with stent were performed in two cases. The postoperative renal functions of these two monkeys recovered to normal and they survived until study termination. From this large number of study, our experience indicated that kidney transplantation in the nonhuman primate is a safe procedure with low complications. Reexploration is recommended for salvage of the graft with urine leakage and ureteral stenosis. © 2010 Wiley‐Liss, Inc. Microsurgery, 2010.     

The use of long-term defunctionalized bladder in renal transplantation: is it safe?

OBJECTIVE: Evaluation of the use of defunctionalized bladder in renal transplantation, concerning surgical complications. METHODS: In order to assess the complication rate of ureteral reimplantation in long-term defunctionalized bladder, we compared 20 patients on haemodialysis for more than 15 years (group I) with another 20 patients on haemodialysis for less than 5 years (group II). None of these patients had renal failure due to urological causes or neurogenic bladder. Non-stented extravesical ureteroneocystostomy was done routinely in all patients except 1 in group II who underwent Politano-Leadbetter ureteroneocystostomy and 7 patients in group I who underwent Politano-Leadbetter (3 patients) and pyelo-ureteral anastomosis using the recipient's native ureter (4 patients). The amount of residual urine was insignificant (<100 cm(3)) in both groups. RESULTS: The mean postoperative bladder catheterization period was 7.8 days in group I and 4.2 days in group II. Postoperative urinary tract infections were observed in 9 cases of group I and in 4 cases of group II. No surgical complications occurred in patients of group II, while there were 6 patients with surgical complications in group I: stenosis after a pyelo-ureteral anastomosis (1 case), stenosis after a ureterovesical anastomosis with Politano-Leadbetter technique (1 case), urinary fistulae (3 cases; 1 with Politano-Leadbetter ureteroneocystostomy and 2 cases with pyelo-ureteral anastomosis), and vesico-ureteral reflux (1 case with Politano-Leadbetter ureteroneocystostomy). These 6 cases had the lowest bladder capacity (30-150 cm(3)) among our 40 patients. Graft losses were comparable between the two groups and were not due to surgical complications. CONCLUSION: Small defunctionalized bladders can be used in kidney transplantation, but it may represent an increased surgical risk due to difficulty in performing ureteral reimplantation.     

双J管在上尿路梗阻性疾病中的应用及其并发症

目的　探讨双J管在上尿路梗阻性疾病中应用效果。　方法　回顾性分析1986年以来1422例病人使用双J管的资料。　结果　开放手术使用双J管者术后住院时间平均(7.99±0.93)d,未置双J管者的术后住院时间平均(13.56±7.53)d,两者差别有极显著性意义,P<0.01。吻合口漏尿和伤口感染发生率双J管组为0.1%和2.3%,而未置双J管组为5.1%和5.7%,两者比较差别有极显著性意义,P<0.01。　结论　双J管的应用对防止上尿路手术后漏尿和狭窄,术后病情恢复具有重要作用,为一些特殊类型的上尿路梗阻治疗提供了有效手段。双J管应用并发症较轻者有管壁尿盐沉着、血尿、膀胱刺激症状、腰胁部疼痛,严重者有双J管移位、尿路感染、管腔阻塞、取管困难。     

小儿腹腔镜下巨输尿管成形术

目的 探讨小儿腹腔镜下输尿管铲状乳头膀胱再植术的可行性和临床效果.方法采用经膀胱外途径行腹腔镜下输尿管铲状乳头膀胱再植术治疗先天性梗阻性巨输尿管症患儿11例.年龄11个月～13岁,平均(5.3±3.9)岁.左侧4例,右侧7例.其中输尿管出口闭锁1例、单纯性输尿管出口狭窄9例、开放输尿管膀胱再植术后(Cohen手术)输尿管出口狭窄1例.B超和IVU示重度肾积水7例、中度肾积水4例. 结果 11例手术均获成功.手术时间70～190 min,平均(103.O±35.3)min.术中出血10～40 ml,平均(18.0±9.5)ml.术后住院时间7～10 d,平均(8.0±1.4)d.无尿漏发生.术后6周拔除双J管,膀胱镜或输尿管镜下见膀胱输尿管吻合口已黏膜化,乳头收缩抗反流效果满意;11例平均随访6(3～24)个月,B超复查患侧肾积水减轻;IVU示成形输尿管排尿好,无梗阻,症状基本消失;膀胱造影未见膀胱输尿管反流. 结论 在熟练掌握腹腔镜操作技术后,应用经膀胱外途径腹腔镜下输尿管铲状乳头膀胱再植术治疗小儿梗阻性巨输尿管症创伤小、抗反流效果好,是治疗小儿梗阻性巨输尿管症的微创新途径.     

Influencia del catéter doble J en las complicaciones de la anastomosis vesicoureteral realizada durante el trasplante renal

IntroductionComplications arising from ureterovesical anastomosis in kidney transplantation have an important influence on the success of the procedure. The most serious and frequent complications are fistula and stenosis of the ureterovesical junction. The placement of double J stents in anastomosis is currently recommended to reduce these complications.ObjectiveThe aim of the study is to evaluate whether the placement of a DJ stent affects complications of anastomosis.Material and methodsRetrospective analysis of 697 patients treated with cadaveric donor renal transplant in our center from 1999 to 2018 was performed. Results were compared according to double J stent placement and the surgical technique employed for anastomosis.ResultsTransplantation was performed without DJ placement in 51.7% of the patients, compared to 48.3% who were treated with DJ stent placement. The most commonly used technique was Lich-Gregoir. Ureterovesical fistula occurred in 5% of cases, and ureterovesical stenosis in 4.2%. DJ stent behaved as a protective factor for ureterovesical fistula but did not significantly influence the development of stenosis. The Taguchi technique greatly increased the risk of developing both ureterovesical fistula and stenosis. The incidence of stenosis and fistula was significantly higher when the Taguchi technique was combined with no DJ stent placement.ConclusionDJ stent placement acts as a protective factor for ureterovesical stenosis complications. The results of our study seem to agree with current literature.     

输尿管镜下气压弹道碎石术近期并发症的预防及处理

目的总结输尿管镜下气压弹道碎石术并发症的处理经验。方法回顾性分析2002年5月～2007年12月660例经尿道输尿管镜取石术中发生25例并发症的临床资料。结果输尿管穿孔22例：13例顺利将结石击碎并将双J管越过穿孔处一端置入肾盂内;4例手术取石并修补输尿管;5例拒绝开放手术,术后出现不同程度的发热、腰痛、血尿等症状,3例经皮肾穿刺造瘘后症状好转,2例经皮穿刺肾造瘘失败待病情稳定后行开放手术治疗。输尿管撕断2例,术中开放行输尿管端端吻合术。输尿管下段穿孔至盆腔卵巢静脉血管出血1例,术中开放手术结扎破裂的血管。25例经积极对症处理后均痊愈出院。术后2个月顺利拔除双J管,术后1年行静脉肾盂造影检查无输尿管狭窄、梗阻。结论输尿管镜下气压弹道碎石术后近期输尿管损伤通过输尿管内支架引流管或经皮穿刺肾造瘘改道处理,可降低再次手术发生率;果断及时的开放手术可以避免更为严重并发症的发生。     

Perfect outcome of kidney recipients with ureteral stenosis after treatment with open surgery under magnetic resonance urography localization

BackgroundTo evaluate the outcome of kidney recipients with ureteral stenosis after treatment with open surgery under magnetic resonance urography (MRU) localization.MethodsWe assessed 2,256 consecutive kidney transplant recipients between October 2010 and December 2018. Ureteral stenosis was detected by ultrasound, confirmed and positioned by Magnetic Resonance Urography. All patients underwent open ureteral reconstruction. The ureteral stenosis was located according to the location on the MRU during the operation. Surgical complications and recurrence rate were recorded in the stenosis group. Outcomes were compared with those of a matched control group of transplant recipients with no history of ureteric stenosis.ResultsThe incidence of ureteral stenosis in our center was 3.1% (70/2,256). Sixty-four cases (91.4%) were confirmed to have distal stenosis and were reconstructed with ureterovesical re-implantation; six cases (8.6%) were confirmed to have mid-distal stenosis and were subjected to ureteroureterostomy with the use of native ureter. The overall success rate was 100% and the graft function was salvaged in all cases. There was no recurrence of stenosis after a mean follow-up of 38.9±26.3 months. The complication rate was 5.7%. The 110-month graft survival and patient survival were not significantly different between the stenosis and control groups.ConclusionsMRU is an effective method for non-invasive and accurate diagnosis of ureteral stenosis in kidney transplant recipients. Open ureteral reconstruction surgery under MRU localization for treatment of ureter stenosis after kidney transplantation had a high success rate, low recurrence rate and high safety.     

Minilaparoscopic nerve-sparing extravesical ureteral reimplantation for primary vesicoureteral reflux: a preliminary report

Abstract Background: To validate its safety and efficacy, we evaluated our preliminary results of the three-port minilaparoscopic nerve-sparing extravesical ureteral reimplantation for patients with vesicoureteral reflux (VUR). Methods: Between July 2005 and February 2007, 9 consecutive patients (4 girls and 5 boys) with a mean age of 3.4 years (range, 7 months to 5 years) underwent a minilaparoscopic nerve sparing extravesical ureteral reimplantation for VUR. A 30-degree 3-mm telescope and two 3-mm trocars were used for the reimplantation. Minimal handling and dissection of the ureter and ureterovescial junction was adhered to spare the nerves. Results: A total of 14 ureters were reimplanted (4 unilateral and 5 bilateral). Mean follow-up period was 8.7 months. The mean operative time was 170 minutes in unilateral reimplantations and 218 minutes in the bilateral one. There was no intraoperative complication. All patients resumed oral intake in the first postoperative morning. The Foley catheters were removed within 24-36 hours after surgery. None of them had urinary retention after catheter removal. Voiding cystourethrography was done 3-4 months after surgery. A complete resolution of reflux was identified in 11 of 14 units, a downgrading of reflux in 2 of 14 units, and ureterovesical junction stenosis in 1 of 14. Open reimplantation was done for the ureter with postoperative ureterovesical junction stenosis. Conclusions: The three-port minilaparoscopic nerve-sparing extravesical ureteral reimplantation was a safe, effective techinique for the treatment of VUR.     

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.     

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。     

气膀胱腹腔镜输尿管前移术

目的:探讨气膀胱腹腔镜输尿管前移术的安全性及有效性。方法:分析6例建立气膀胱行腹腔镜输尿管前移术患者的临术资料。结果:手术均获成功,手术时间70~140m in,平均95m in,出血量30~50m l,术后2d下床活动,术后1周拔导尿管,住院7~10d,平均7.8d,术后1个月膀胱镜下拔双“J”管,无尿漏发生。随访3~8个月,症状消失,B-us肾积水减轻,IVU吻合口无狭窄,膀胱造影无返流。结论:气膀胱腹腔镜输尿管前移术是治疗输尿管下段狭窄、输尿管返流、输尿管囊肿、巨输尿管症安全有效的微创手术方式。     

Double J stent with antireflux device in the prevention of short-term urological complications after cadaveric kidney transplantation: single-center prospective randomized study

The placement of a double J stent to protect a uretero-vesical anastomosis in a kidney transplant is a widespread procedure performed to reduce the incidence of fistula and stenosis at the anastomosis. However, the presence of a double J stent may cause vesicoureteral reflux (VUR), predisposing one to urinary tract infections (UTIs), which may be a significant source of morbidity for the graft. We evaluated whether a ureteral stent incorporating an antireflux device can reduce the incidence of ureteral reflux and UTIs. From January to December 2003, 44 kidney transplant recipients were randomized to receive a 14-cm 4.8-F double J stent with (group A) or without an anti-reflux device (group B). Primary end points were the reduction of the incidence of VUR and of UTIs. The secondary end point was the graft function, on the basis of mean serum creatinine level at 3, 6, and 12 months. We failed to observe statistically significant differences in terms of either the incidence of VUR and UTIs, or the short-term outcomes of the grafts. We concluded that the anti-reflux device does not have an impact on the incidence of stent-related side effects.     

机器人辅助腹腔镜黏膜下隧道法输尿管再植术的临床疗效分析

目的:介绍黏膜下隧道法机器人辅助腹腔镜治疗1例医源性输尿管下段狭窄患者和1例单侧重复肾重复巨输尿管合并肾积水患者的学习经验和手术疗效.方法:回顾性分析机器人辅助腹腔镜治疗1例膀胱肿瘤电切术后左侧输尿管下段狭窄、左肾积水,患者抗反流输尿管膀胱吻合采用黏膜下隧道包埋法;1例(左侧)原发性梗阻重复肾重复巨输尿管症患者,首先分离巨输尿管前面和两侧面,保留输尿管和腹壁间系膜先不离断,测量输尿管,剪裁,放入F7双J管,缝合成形后再离断系膜,采用黏膜下隧道包埋法与膀胱再吻合.结果:2例患者手术均成功,无中转开放,手术时间分别为165.8min、176.2min,其中机器人定位时间30min;出血量分别为12.4ml、20.8ml;术后引流管拔除时间第1例5d,第2例6d,2例患者均无明显漏尿,术后尿管拔除时间为14d.术后随访6个月,复查CT和彩超显示肾积水明显减轻,未见输尿管吻合口狭窄和输尿管反流.结论:机器人辅助腹腔镜黏膜下隧道法输尿管膀胱再植术治疗复杂的输尿管下段狭窄和复杂的巨输尿管症安全有效.     

Common sheath reimplantation with ureteral plication: A useful technique for the management of ectopic ureterocele

BACKGROUND: When salvaging the upper pole kidney in duplex ectopic ureterocele, primary bladder level surgery with common sheath ureteral reimplantation has the definite advantage of allowing the reconstruction of the entire collecting system through a single lower abdominal incision. However, there are several complications associated with a common sheath reimplantation in a child with a very dilated upper pole ureter, such as vesicoureteral reflux or ureterovesical stenosis. METHODS/RESULTS: To avoid these complications, ureteral plication over the common ureteral sheath in two children with duplex ectopic ureterocele was used. Postoperatively, neither child showed reflux or recurrent urinary tract infection and both showed a marked improvement of the upper pole collecting system. CONCLUSION: This technique allows for a simple and definitive reconstruction in cases of duplex ectopic ureterocele, particularly with dilated upper pole ureter.     

肾移植中供肾输尿管异常的处理

目的：探讨肾移植术中供肾输尿管异常的手术处理方法。方法：回顾性分析18例供。肾输尿管异常的肾移植术中处理,包括损伤致输尿管过短8例,完全型双输尿管4例,不完全型双输尿管2例,输尿管结石2例,巨输尿管2例。根据具体情况采用输尿管膀胱吻合术、供受者输尿管端端吻合术和膀胱腰大肌悬吊术等方法再植输尿管。结果：术后恢复顺利,未发生移植肾功能延迟恢复和尿漏。随访3～8年,发生输尿管梗阻1例,行经皮。肾造口输尿管镜切开后治愈。发生尿路感染5例（其中2例为反复感染）。未见膀胱输尿管返流。结扎输尿管的原肾未出现胀痛和不适,B超检查未见肾积水。带输尿管结石移植肾未见结石复发。巨输尿管供肾移植后输尿管管径稳定,无明显增大。结论：供肾输尿管损伤和异常时采用不同的技术修复和再植输尿管,可减少并发症的发生。     

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.     

输尿管镜下逆行球囊扩张术治疗良性输尿管狭窄的临床研究

目的分析影响输尿管镜下逆行球囊扩张术治疗良性输尿管狭窄（US）预后的相关因素。 方法回顾性分析我科2012年10月至2016年10月期间行输尿管镜逆行球囊扩张术治疗的单侧单发的良性输尿管狭窄患者临床资料,总共40例患者,其中男、女各20例,年龄25～76岁,输尿管狭窄段位置位于盂管交界处12例,输尿管上段8例,中段3例,下段17例。输尿管狭窄段的长度0.2～2 cm。均应用U30球囊扩张器扩张,所有患者术后常规留置双J管或者海马管6个月至1年,每3个月更换一次,术后随访1年。 结果手术时间45～90 min,平均60 min。术后2～3 d出院,平均住院日2.5 d,无严重并发症,血尿及尿路刺激征并发症发生率较高,术后随访1年,有效患者25例（62.5%）,无效患者15例（37.5%）。单因素χ²检验及多因素Logistic回归分析显示输尿管狭窄段的长度及术前患侧肾积水程度是影响输尿管镜球囊扩张术预后的主要因素（P<0.05）,而患者的性别、年龄及输尿管狭窄的位置以及狭窄的原因对手术治疗预后无显著影响（P>0.05）。 结论输尿管镜下逆行球囊扩张术是治疗良性输尿管狭窄安全、有效的手术方法。     

Modified extravesical ureteral reimplantation and routine stenting in kidney transplantation

In the past, extravesical ureteroneocystostomy has been technically modified several times, with varying results. In this study, we evaluate our experience with modified extravesical re-implantation and routine stenting. From January 1988 to September 2001, 411 consecutive renal transplantations (220 LRD/LUD, 191 CAD) were performed at our institutions. Of 220 kidneys utilized for living related transplantation, 39 were retrieved laparoscopically and 181 were retrieved by open nephrectomy. The ureteroneocystostomy performed was a modified Lich-Gregoir re-implantation with routine stenting, using the upper transplant ureter. A double ureter was encountered in 11 patients and was managed with a conjoint ureteral ostium-to-mucosa anastomosis, using two stents. In two patients with graft ureteropelvic junction (UPJ) stenosis, a double ipsilateral drainage was performed, applying modified extravesical reimplantation with concomitant ureteroneocystostomy. There were no ureteral leaks. Five (1.22%) patients developed temporary ureterovesical junction (UVJ) obstruction/edema following stent removal, which necessitated re-stenting for 4-6 weeks. Two patients (0.49%) developed delayed stenosis and were successfully treated with retrograde balloon dilatation.(One at the UPJ of a pediatric kidney, and one at UVJ). All patients with functioning grafts in this series are currently stent-free. We conclude that the modified extravesical reimplantation with routine stenting is an effective and safe technique in renal transplantation, associated with almost no complications.     

Fluoroscopy guided retrograde ureteral stent insertion in patients with a ureteroileal urinary conduit: method and results

PURPOSE: We evaluated retrograde double pigtail stent placement in patients with ureteroileal anastomosis. MATERIALS AND METHODS: Procedures were performed under digital C-arm fluoroscopic guidance and the patient under sedation analgesia. Radiography of the conduit was done to delineate urinary diversion anatomy and identify ureteral reflux. A purpose designed, angled tip catheter was used to direct a straight glide wire across the ureteroileal anastomosis. The glide wire was exchanged for a stiff guide wire for stent placement. We retrospectively evaluated the clinical records of 7 men and 5 women with a mean age of 54.3 years in a 7-year period. In 11 patients a new stent was placed because of ureteroileal stricture in 5, anastomotic leakage in 3, ureterolithiasis in 2 and recurrent malignancy in 1. RESULTS: New stent placement was successful in 10 of the 11 patients (90.9%, 13 of 16 ureters or 81.3%). Stent placement was successful in the 8 ureters in which reflux was noted on radiography of the conduit and in 5 of the 9 (55.6%) in which no reflux was noted. Stent replacement was accomplished in all 22 ureters (6 patients) in which it was attempted. Mean radiological screening time for new stent placement was 13.3 minutes (range 4.7 to 19.7), while for exchange it was 6.4 minutes (range 0.8 to 15.1). There were no immediate complications. CONCLUSIONS: This technique represents a useful approach to the ureter and should be considered an alternative to percutaneous nephrostomy and surgical revision. The approach is also useful for other ureteral procedures, including stone or migrated stent retrieval.     

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.