Ureteral complications in the renal transplant recipient after laparoscopic living donor nephrectomy

OBJECTIVES: We report on ureteral and surgical complications in our first 110 consecutive recipients of kidneys procured with laparoscopic living donor nephrectomy (LLDN). METHODS: The records of all living donor transplants with LLDN performed between February 1999 and December 2004, including 10 pediatric transplants, were reviewed retrospectively. Three urologists performed LLDN using a pure laparoscopic non-hand-assisted transperitoneal technique. Kidney transplantation was performed in a standard fashion. For ureteroneocystostomy, the intravesical Politano-Leadbetter (P-L) technique was used. RESULTS: Two-year patient and graft survival was 99% and 98%, respectively. Serum creatinine at 12 months was 1.36+/-0.1mg/dl in adult and 0.99+/-0.23 mg/dl in pediatric recipients. Nineteen right donor kidneys were transplanted into adult recipients. Surgical complications included three symptomatic lymphoceles, one peritransplant haematoma and one kinking of a lower pole artery. All five (4.5%) ureteral complications occurred in adult recipients with a mean age of 33.2+/-2.8 years. The incidence of ureteral complications was not clustered around the early phase of our LLDN experience. Of the three (2.7%) patients diagnosed with ureteral obstruction, two required ureteral reimplantation, and one was managed conservatively. Another two patients (1.8%) with a urinary leak received a double J stent and a cystostomy catheter for 3 and 5 months, respectively. Of the five patients with a ureteral complication, three had received a donor kidney with more than one renal artery. CONCLUSIONS: LLDN combined with the intravesical (P-L) ureteral implantation technique provides excellent graft outcomes with low recipient morbidity. Renal artery multiplicity may increase the risk of ureteral complications.     

Ureteral reconstruction in renal transplantation

The complications associated with ureteral reconstruction in renal transplantation produce significant morbiditiy and mortality rates.We have evolved a combined intravesical-extravesical nonstented ureteroneocystostomy and have used it in 100 consecutive transplants, 50 of which were in high-risk diabetic recipients. No instances of urinary extravasation, fistula formation, disruption of the ureterovesical anastomosis, ureteral solughing, or ureterovesical obstruction have occurred in this series. The lack of urologic complications utilizing this technique offers reduced morbidity and mortality to transplant recipients.     

Living donor transplantation. Surgical complications

Although nephrectomy by open surgery is the most used technique for the extraction of kidney transplants in the living donor, nephrectomy under laparaoscopy is increasingly practiced. Laparoscopic nephrectomy is less invasive and performed under videoscopy control, after insufflation of the peritoneal cavity. Three to four incisions are done in order to enter the surgical instruments. The kidney is extracted through a horizontal sus-pubic incision. The exposition is either exclusively transperitoneal, retroperitoneal or hand assisted. The advantages of laparoscopy are esthetical, financial due to a shorter hospitalisation and a quicker recovery, as well a confort for the donor. The disadvantages are a longer warm ischemia time and possibly a higher risk of delayed graft function. Randomised studies having compared laparoscopy and open surgery in the living donor have not find any significant difference regarding the per- and perioperative in the complications.     

The ureter in renal transplantation

The outcome of kidney transplantation depends on several factors. The quality of the ureter of the transplanted kidney and the technique of its connection with the recipient's urinary tract seem to be two of the most important ones.In this paper the authors analyse the incidence of ureteral complications of the grafted kidney in 99 ureterocystoneostomies performed in conjunction with kidney transplantation.Urinary fistulas occurred in 7, stenosis of the ureter in 3 cases. The diagnostic possibilities and treatment of the complications are discussed.     

Ureteral triplication with contralateral ureter duplication.

A rare case of ureteral triplication with contralateral duplication is reported. The incidence, embryology, classification and symptomatology are commented. The most relevant literature is reviewed.     

Cadaveric renal transplantation with cyclosporine in patients more than 60 years of age

Advanced age has been a relative contraindication to kidney transplantation because of the likelihood of increased morbidity and mortality in the geriatric population. However, the introduction of cyclosporine has improved renal allograft survival rates dramatically, and higher-risk patients are now being successfully transplanted. With the introduction of cyclosporine in 1983, we have performed 36 cadaveric renal transplants in 34 recipients 60 years of age or older, including 34 primary and 2 retransplants. Most of the patients (88%) were on dialysis prior to transplantation and 29% had ASCVD. Three-year actuarial patient and allograft survival are 91% and 74%, respectively. Surgical complications were infrequent, and postoperative rejection episodes were less frequent than in younger patients but were more likely to lead to graft loss. Medical complications, especially infection, were common after transplantation but easily managed. Cadaveric renal transplantation with cyclosporine immunosuppression is a safe and effective therapeutic modality that is no longer contraindicated in elderly patients.     

Urologic complications in renal transplantation.

The current overall reported incidence of major urologic complications following renal transplantation is 5 per cent. The presence of such a complication increases the likelihood of patient mortality by a factor of three. Standard utilization of postoperative radionuclide scanning is very useful in early diagnosis. Vesical fistulas generally result from improper bladder closure. The incidence of bladder complications increases with secondary and tertiary grafts. Ureteral complications result when the blood supply of the ureter is impaired. These include fistula formation, necrosis, and obstruction. Immediate surgical correction is indicated in almost all serious urologic complications following transplantation; otherwise there is marked increase in morbidity and mortality. Complications appearing early in the postoperative period carry a poor prognosis for both graft and recipient survival. The presence of urinary tract infection early in the postoperative period also correlates negatively with graft survival. The presence of multiple renal arteries in the donor has been associated with an increased rate of urologic complications. Ureteral fistulas can be avoided by meticulous dissection of the donor at the time or organ harvesting. Great care must be taken to preserve the arterial and venous blood supply to the ureter by avoiding any dissection into the renal hilum. Aberrant renal arteries must be preserved or repaired if damaged. Ureteroneocystostomy is the preferred method for re-establishing urinary tract continuity following transplantation. The immediate surgical correction of urologic complications is mandatory, and the techniques involved are highly specialized and must be individualized with each patient.     

Ligation of the native ureter in renal transplantation.

PURPOSE: Native ureteral ligation may be required in renal transplantation when ureteroureterostomy is performed. Native nephrectomy has been done to avoid the complication of hydronephrosis after native ureteral ligation. We reviewed the records of renal transplant recipients who underwent native ureteral ligation to determine the incidence of post-ligation symptoms and need for native nephrectomy. MATERIALS AND METHODS: We retrospectively reviewed 1,275 renal transplants performed from January 1986 through September 1999, including 278 cases (22%) of native ureteral ligation. The majority of patients had anuria or oligouria before transplantation, although 3 were not dialysis dependent. Followup was 1 to 140 months. Charts were reviewed for flank pain, infection and the need for native nephrectomy. RESULTS: Six of 278 patients (2.2%) required native nephrectomy 7 to 82 months after transplantation with flank pain as the indication in all. The cause of renal failure was polycystic disease in 3 of the 6 cases, unknown in 2 and diabetes in 1. The patient with diabetes had papillary necrosis and bleeding in the nephrectomized kidney. None of the 278 patients had infection and early post-ligation flank pain developed in only 1 (0.4%). CONCLUSIONS: The native ureter may be safely ligated during renal transplantation. Late nephrectomy may be required in a small percent of cases, most commonly in those of polycystic disease. The need for nephrectomy is most often related to the original renal disease.     

Ureteral implantation in peritoneum. Exceptional complication in renal transplantation

Because of the extraperitoneal location, generally used for renal grafting, intraperitoneal urine leaks are a rare complication after transplantation. We report a patient on peritoneal dialysis who developed ascites, abdominal pain, anuria and shock suddenly after renal transplantation. The patient was immediately taken back to the operating room. An abnormal implantation of ureter into the peritoneum overlying the bladder when carrying out an unstented parallel incision extravesical ureterone-ocystostomy was identified. After correcting ureter implantation the patient had immediate diuresis, renal function rapidly improved, with no further complications. Contributing causes were poor exposure, thickened peritoneum secondary to recurrent peritonitis, and the presence of residual peritoneal dialysis fluid.     

Urological complications in pediatric renal transplantation.

OBJECTIVE: In this study, we evaluated the urological complications and their consequences after renal transplantation in children. MATERIALS AND METHODS: A retrospective study was performed concerning urological complications after kidney transplantation in children at the University Medical Center St Radboud Nijmegen from August 1977 until July 1999. The mean age of the cadaver kidney donors was 23.2 (range 1-74.3) years. RESULTS: In this period 146 children received 183 renal allografts. Twenty-four urological complications (13.1%) were noted in 23 patients. Urinary leakage was seen in 8 cases (4.4%) and a ureteral stenosis was present in 7 cases (3.8%), 5 patients developed stones (2.7%) and 4 severe lymph leakage needing surgical treatment (2.2%). In 3 patients the urological complication induced graft loss. In cadaver kidneys from donors younger than 5 years there was no significantly increased complication rate in comparison to older cadaver kidneys [2/32 (6.3%) versus 16/125 (12.2%)]. In a subgroup of 24 patients treated for severe posterior urethral valves the complication rate was not significantly increased in comparison to the others (8.3% in the group with posterior urethral valves against 13.7% in the group without). CONCLUSIONS: Urological complications are a small threat for graft function and the results are comparable with earlier studies. Routine ultrasound can be important for early detection of problems in the postoperative period. A close observation in the postoperative care and good collaboration between pediatric nephrologist and urologist is mandatory. Sometimes, early intervention can be undertaken with the possibility of saving graft function and reducing morbidity.     

Vascular complications in human renal transplantation.

There were 13 arterial complications in 202 transplants done in 162 patients, an incidence of 6.5 percent. Renal arterial stenosis was demonstrated by angiogram in six kidneys; four were reconstructed successfully. Four renal arterial occlusions were found in delayed rejected kidneys. Of three arterial dehiscences secondary to infection, all led to graftectomy. One of these patients died 56 days later due to infectious hepatitis, and one underwent a successful retransplant. One patient had an occluded iliac artery which was repaired successfully. A single venous complication occurred in one patient.     

Patient survival after renal transplantation; more than 25 years follow-up

Background: The determinators of patient survival after renal transplantation are incompletely known, and conflicting results hae been reported. This may have been influenced by time-related changes in patients selection, post-transplantation management and immunosuppressive regimens. This study was performed to evaluate in recipients of a first renal transplant the effect of patient characteristics, transplantation era, and the immunosuppressive regimen on patient survival. Method: We studied data from the Leiden Renal Transplant Database of all first renal transplantations performed between 1966 and 1994 in Leiden, the Netherlands. The effect of the following parameters on mortality was investigated: era of transplantation, sex, age at transplantation, cause of renal failure, immunosuppressive regimen, type and duration of pretransplantation dialysis, hypertension, diabetes mellitus, and smoking. In addition we analysed the causes of death. Results were expressed as crude mortality rates, relative risks of mortality, and standardized mortality ratios as compared with death rates in the Dutch population. Results: The analysis comprised 86 living donor transplant recipients and 916 cadaver transplant recipients. After adjustment for age and sex, the relative risk of morality for living donor transplant recipients compared with cadaver transplant recipients was 0.5 (95% CI 0.2 to 10.3, P=0.06). In the first cadaver kidney transplant recipients the risk of first-year mortality improved significantly with time, which coincided with the introduction of cyclosporin. The risk of mortality after the first year was higher in patients aged over 40 years at transplantation, men, smokers, and in the presence of hypertension or diabetes, but the effect of individual factors on mortality was small. We found no effect of the type of pretransplantation dialysis or the duration of pretransplantation haemodialysis on post-transplantation mortality. The standardized mortality ratio for recipients of first renal transplants was 14 times the population average in the first year after transplantation and was still four times in the remaining years. Conclusion: In the present study, time-related changes in patient management were responsible for improved patient survival in the first year after transplantation during the study period. Many individual factors contributed moderately to the risk of mortality after the first year. Compared to the general population the mortality rate of renal transplant recipients was significantly higher during the whole follow-up period.