Extravesical ureteral implantation in kidney transplantation

Eighty-eight cases of kidney transplantation and extravesical ureteral implantation are reviewed with long-term evaluation. The total complication rate was 18.14 per cent, and in only 3.4 per cent have these complications been responsible for the death of the patients. The technique has been shown to be safe and useful for reestablishing the urinary transit in kidney transplantation.     

Late ureteral obstruction after kidney transplantation

Today, the incidence of urological complications following renal transplantation is 2%–10%. Most of these complications occur within the 1st year and affect the distal ureter. We report on two patients who developed very late ureteral obstruction, 14 and 18 years after transplantation. Both patients had rejection episodes 1 and 10 months prior to the ureteral stenosis. Histological examination of one resected ureter revealed findings strongly suggestive of a rejection process. Open surgery with antirefluxive reimplantation into the bladder was successful in both patients, with a postoperative observation time of 20 and 8 months, respectively. We conclude that a percutaneous nephrostomy may be required in patients with rising creatinine and incipient hydronephrosis even long after transplantation has been performed.     

Late ureteral obstruction after kidney transplantation

Abstract Today, the incidence of urological complications following renal transplantation is 2 %-10 %. Most of these complications occur within the 1st year and affect the distal ureter. We report on two patients who developed very late ureteral obstruction, 14 and 18 years after transplantation. Both patients had rejection episodes 1 and 10 months prior to the ureteral stenosis. Histological examination of one resected ureter revealed findings strongly suggestive of a rejection process. Open surgery with antirefluxive reimplantation into the bladder was successful in both patients, with a postoperative observation time of 20 and 8 months, respectively. We conclude that a percutaneous nephrostomy may be required in patients with rising creatinine and incipient hydronephrosis even long after transplantation has been performed.     

Surgical treatment of ureteral stenosis after kidney transplantation

Ureteral stenosis is the most frequent complication after kidney transplantation. The diagnosis is based on an elevated creatinine level and a dilatation of the urinary cavity. The first step of the management is a urinary diversion with endo-ureteral prosthesis or a nephrostomy placement. The surgical gold standard is the pyelo-ureterostomy. This is a safe and efficient technique in the treatment of this complication. We describe the different surgical alternatives and the endo-urologic management of the stenosis.     

Mesh plug and ureteral necrosis after kidney transplantation

CASE REPORT: We present a 59-year-old male who underwent living related kidney transplantation. During the procedure a previously placed mesh plug was found to be adherent to structures in the vicinity of the area of implantation. After revascularization, neocystouretostomy was performed with the ureter over the spermatic cord in order to avoid excessive dissection through this adherent mass. Shortly thereafter the patient was diagnosed with a ureteral leak and returned to the operating room. The intraoperative findings included adhesion of the ureter to the mesh plug with necrosis of its distal portion. A redo neocystouretostomy was performed. The patient recovered uneventfully. CONCLUSION: This case report illustrates a unique cause of a urinary fistula related to mesh plug open inguinal hernia repair and demonstrates the importance of ensuring a safe distance between vital structures and any prosthetic device.     

Self-expanding metallic ureteral stents for treatment of ureteral stenosis after kidney transplantation

The incidence of post-renal transplantation ureteral stenosis ranges from 2%-12%. Because the role of self-expanding ureteral metallic stents for its treatment has been scarcely reported, the aim of this study was to evaluate the efficacy of Nitinol stents. Eleven ureteral stenoses in patients with chronic graft dysfunction (8 cases) or high surgical risk (3 cases) were treated by antegrade percutaneous implantation of Nitinol stents through a nephrostomy tract. The mean follow-up period was 48 +/- 7 months (range, 3-85 months). The patency rate at the moment of return to dialysis, death, or last check-up was 73% (8/11). Three patients (27%) developed stent occlusion. Two patients were treated using a trans-stent double-J catheter and 1 patient using stent removal and pyeloureterostomy using the native ureter. The mean percentage decrease in serum creatinine (Cr) level after stent implantation was 41% (range, 14%-63%). Nitinol ureteral stent implantation is an effective alternative for the treatment of ureteral stenosis in patients with chronic graft dysfunction or high surgical risk.     

Antegrade percutaneous dilation of ureteral strictures after kidney transplantation

Ureteral obstruction after renal transplantation is due mostly to retroperitoneal fibrosis in the area of surgical dissection, and pyeloureterostomy is the treatment of choice for such an obstruction. For confined strictures, especially at the site of the ureteroneocystostomy, endoscopic dilation may be a good alternative. Antegrade percutaneous dilation was used to treat six patients with ureteral stricture after kidney transplantation. Four patients had stricture at the ureterovesical junction, one a confined midureteral stricture, and one a secondary stricture at the site of pyeloureterostomy. Percutaneous antegrade dilation of the stricture to 14 Fr with semirigid fascial dilators and external ureteral stenting with a 12-Fr silicon splint for 6 weeks was successful in the four patients with ureterovesical junction obstruction but not in the two other patients. Results were judged on the basis of serum creatinine concentration, renal ultrasonography, and intravenous urography (IVU). The follow-up period was 12–20 months (mean 15 months). None of the six patients died and perioperative morbidity was minimal.     

Results of kidney transplantation with simultaneous implantation of vascular graft

BACKGROUND: Arteriosclerosis and calcification of iliac arteries are common in patients on dialysis. This study sought to evaluate the outcome after kidney transplantation and simultaneous implantation of vascular grafts. PATIENTS AND METHODS: In a single center study we evaluated donor and recipient data among 443 kidney transplantations in adults performed between January 2002 and October 2006. In 11 recipients (2.5%) a vascular graft (Gore-Tex) was implanted due to severe arterioscleroses of the iliac vessels. RESULTS: Reconstruction of the lower limb blood supply was performed with an ileofemoral Gore-Tex-Bypass in 9 of 11 patients, with an aortofemoral bypass in 1 patient, and with a femoroiliac crossover bypass in 1 patient. Overall, 8 of 11 patients (73%) had an uneventful postoperative course. Six of 11 patients had primary graft function. CONCLUSIONS: This analysis demonstrated that vascular reconstruction during kidney transplantation has to be performed rarely but has a strong impact on further life and kidney function. In 8 of 11 patients, kidney function at 6 months was good. Severe arteriosclerosis is usually not a contraindication for kidney transplantation. However, training in vascular surgery seems to be important to achieve satisfying results. In this series, simultaneous implantation of vascular prosthetic grafts was safe since there were no infectious complications of the graft itself.     

Antibiotic prophylaxis for ureteral stent removal after kidney transplantation

There are no guidelines for antibiotic prophylaxis for ureteral stent removal after kidney transplantation. We reviewed the charts of 277 adult kidney transplant recipients with ureteral stents transplanted at our center between September 2014 and December 2015 and investigated whether antibiotic prophylaxis for stent removal was associated with reduced incidence of urinary tract infections (UTI). We defined UTI as a urine culture ≥10⁴ CFU/mL of bacterial isolates irrespective of symptoms. Primary outcome was the incidence of UTI within four weeks of stent removal. Among the 277 recipients, 199 (72%) were on sulfamethoxazole/trimethoprim (SMZ/TMP) as Pneumocystis jirovecii prophylaxis. At the time of ureteral stent removal, 56 recipients (20%) received additional antibiotic prophylaxis (ABX+) and 221 (80%) did not (ABX‐). The difference in the incidence of UTI in the ABX(+) group (16%) and ABX(?) group (19%) was not statistically significant (P = 0.85). Variables independently associated with the development of UTI were recipient age (odds ratio [OR] 1.04, [95% confidence interval 1.01‐1.07]) and UTI while stents were in situ (OR 3.9 [2.00‐7.62]). Use of SMZ/TMP was protective (OR 0.35 [0.18‐0.7]). Our study does not show a statistically significant benefit for additional antibiotic prophylaxis for ureteral stent removal. Antibiotic prophylaxis may be beneficial for recipients not on SMZ/TMP at the time of stent removal.     

The treatment of fistulae and ureteral stenosis after kidney transplantation

INTRODUCTION: The incidence of urological complications after kidney transplantation varies from 3% to 14%, with a probable loss of the graft in 10% to 15% of cases and a mortality rate of up to 15%, despite improvements in prevention, diagnosis, and treatment as well as the use of new immunosuppressive therapies. Urinous fistulae, which are considered early complications of transplantation, are due to ischemic damage or necrosis generally occurring in the distal third of the ureter. Preservation of accessory arteries to the lower portion of the kidney is important, as they may constitute the blood supply of this segment of the collecting system or ureter. Their ligation may lead to necrosis and urinary fistulae. Ureteral stenosis, as late complication, is related to a pathology of the ureter itself, to infections, to abscesses, to fibrosis, and to ischemia. An early endoscopic approach permits resolution in 70% of cases. The aim of this retrospective study was to determine incidence and treatment of these complications. MATERIALS AND METHODS: From 1991 to 2004 we performed 453 kidney transplantations both from cadaveric and living donors. In 199 patients we performed a transvesical ureteroneocystostomy (UNCS), and in 260, an extravesical UNCS. RESULTS: The nine patients who showed fistulae (1.9%) underwent surgical treatment. In eight we used a direct ureteral reimplantation, and in one, a Boari flap technique. Nephrectomy was necessary in four patients, including two who died of septic complications. In all 26 cases of ureteral stenosis (5.6%), we used an endourological approach (anterograde or retrograde), with surgical treatment afterward in 11 patients (42%) nine direct reimplants, one anastomosis to the native ureter (transplantation from a living donor), and in one case a Boari flap technique four patients who underwent surgical treatment showed progressive damage to graft function. CONCLUSIONS: In all patients who showed fistulae we suggest surgical review: for patients with ureteral stenosis, we suggest first an endourological approach and only when it is not successful do we consider surgical treatment.     

Treatment of ureteral obstruction and urinary fistulas after kidney transplantation]

In 285 renal transplantations, performed during the years 1967-1978, 6 ureteral obstructions (2,1%) and 15 urinary fistulas (5,3%) were observed. Ureteral obstructions occurred in the late phase after transplantation and were caused by strictures at the uretero-vesical anastomosis (two patients), compression of the ureter by enlarged kidney during rejection (one patient) resp. lymphocele (one patient) and strictures at the pyelo-ureteral junction (two patients). Satisfactory results were achieved by surgical treatment in all patients. Urinary fistulas occurred in the early postoperative phase. Two vesical, 12 vesico-ureteral and one calyceal fistula were observed. 7 fistulas (1 vesical, 6 vesico-ureteral) closed spontaneously after temporary drainage of the bladder. 8 fistulas were repaired surgically. While satisfactory results were obtained in 13 patients, two patients died due to infection and sepsis after reoccurrence of fistulas.     

Anterograde ureteral dilatation in kidney transplantation

Ten antegrade endoprostheses were inserted in renal transplant patients. Eight dilatations and 2 intubations were performed. Six stenoses had recurred after 6 months.     

肾移植后继发移植肾淀粉样变一例

淀粉样变病是一种以淀粉样蛋白物质沉积于组织器官的细胞间引起的少见疾病.我院自1977年7月至今共施行同种异体肾移植2400余例,其中并发移植肾淀粉样变1例,发生率为0.04%.现结合文献报告如下.     

Ureteral obstruction after kidney transplantation secondary to bone metaplasia

We report a case of ureteral obstruction after kidney transplantation caused by localized bone metaplasia in the donor ureter. Surgical treatment consisted of removal of the involved ureteral segment, which was located 3 cm above the bladder and creation of a spatulated end-to-end anastomosis. Although bone metaplasia has been observed in the ureteral wall of some animal species secondary to experimental ischemia and microtrauma, it is exceedingly rare in humans and has never before been documented after kidney transplantation.     

A simple technique for the treatment of ureteral stenosis after kidney transplantation

An intraperitoneal approach has been used successfully in 3 patients for surgical correction of ureteral stenosis after kidney transplantation. Although the procedure cannot be used if the kidney has been transplanted in the homolateral iliac fossa, in the majority of cases it avoids the difficult dissection of the renal hilum. Thus, blood loss is minimal and the duration of the surgical procedure is shortened.Supported by the Fonds de la Recherche Scientifique Medicale (grant No 3.4526.78) and the Fondation Universitaire David and Alice van Buren.     

肾移植术后长段输尿管狭窄的诊断与开放性手术治疗

目的 总结肾移植术后发生长段输尿管狭窄的诊断方法与手术治疗经验.方法 分析11例肾移植术后发生长段输尿管狭窄患者的临床资料.患者发生长段输尿管狭窄的时间为肾移植术后2～6个月,临床表现为血肌酐升高、体重增加、尿量减少和移植肾区肿胀.所有患者均经B型超声、64层螺旋CT尿路造影(CTU)或磁共振尿路水成像(MRU)确诊,输尿管狭窄长度为3～7 cm.11例患者的治疗方法为:5例行膀胱壁瓣输尿管成形术;2例行供肾肾盂-自体输尿管吻合术;4例行供肾输尿管-自体输尿管吻合术.结果 11例长段输尿管狭窄的患者经开放性手术治疗后,均取得成功,恢复了尿路的通畅.手术时间为2.5～4 h,无明显手术并发症.术后尿量显著增加,血肌酐下降至75～156μmol/L,B型超声示移植肾积水明显减轻或消失.术后随访8～62个月,患者肾功能稳定,无再发狭窄.结论 对肾移植术后出现血肌酐升高等临床特点的患者,应考虑到输尿管狭窄的可能,及时采用B型超声进行常规的检查,采用CTU或MRU明确狭窄的长度及部位;明确诊断后应及时进行开放性手术治疗.肾移植术后的长段输尿管狭窄经早期诊断和及时治疗成功率较高.     

Rare cause of ureteral stenosis more than 10 years after kidney transplantation

Late renal graft failure is in most cases due to a chronic allograft nephropathy. In this report, we present a case in which a surgical complication led to ureteral stenosis more than 10 years after transplantation. The patient developed slowly deteriorating renal function and ultimately progressive hydronephrosis. At surgical exploration, the ureter was found to perforate the wall of the small bowel before entering the bladder. We successfully performed ureter reimplantation to restore the outflow of the kidney.