There were 116 renal transplants performed on 108 patients over a five-year period at Henry Ford Hospital with three major urological complications. The rate of 2.6% compares favorably with that reported in other series. Careful preoperative urological evaluation together with technically precise ureteroneocystostomy are factors that minimize the incidence of urological complications

Cerny, Joseph C.

Farah, Riad N.

Klugo, Richard

Mertz, Thomas

Henry Ford Health System Scholarly Commons

Henry Ford Hospital Medical Journal Manuscript 2015 Urological Complications in Renal Transplantation Riad N. Farah Richard Klugo Thomas Mertz Joseph C. Cerny Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal  Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Henry Ford Hosp Med Journal Vol 26, No 3, 1978 Urological Complications in Renal Transplantation Riad N. Farah, MD,* Richard Klugo, MD,* Thomas Mertz, MD,* and Joseph C. Cerny, M D ' There were 116 renal transplants performed on 108 patients over a five-year period at Henry Ford Hospital with three major urological complications. The rate of 2.6% compares favorably with that reported in other series. Careful pre-operative urological evaluation together with technically precise ureteroneocystostomy are factors that minimize the incidence of urological complications. RAFT survival after renal transplantation depends upon the vascular and urinary anastomosis as well as control of graft rejection. Numerous factors contribute to good results in transplantation, among which are immediate function of the homograft, high degree of histocompatibility, the avoid-ance of excessive immunosuppression, and minimal wound and urological complications. There have been several reportsof urological complications following renal transplantation (See Table). Complication rates as high as 25 .7%' have been reported wi th ureteropyelostomy, while the rates for ureteroneocystos-tomy range from 15%^ to less than 1 % . ' In our review of 116 renal transplants we found three urological complications (2.6%). This rate compares favorably wfth that reported in earlier series and underscores the importance of the urolo-gist in the work-up and management of the transplant recipient. *This paper has received the First Annual HFH In-Training Manuscript Award. Submitted for publication: September 11,1978 Accepted for publication: September 20,1978 * Departmentof LJrology, Henry Ford Hospital Address reprint requests to Dr. Cerny, Department of LJrology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, Ml 48202 Materials and Methods From 1972 to 1977, 116 renal transplant operations were performed on 108 patients at Henry Ford Hospital. Six patients received two kidneys, and one patient received three. There were 102 cadaver and 14 living-related donor transplants. Ninety-six of the 108 patients inthis series had a preoperative urological evaluation. Each had a careful urological history, physical examinat ion, cystoscopy, cystometry, delayed cystography, bi lateral retrograde pyelography, and if indicated, vo id ing or retrograde urethrograms. In all cases ureteroneocystostomy was used for the primary urinary anastomosis following the modified Leadbetter-Politanos technique (Figure 1). In males, the ureter is brought deep to the spermatic cord, and in all patients redundant ureter is excised. A 2-3 cm submucosal tunnel is created, and patency of the anastomosis is insured by retrograde passage of an 8 FR catheter. The cystostomy is closed in a three-layer, watertight fashion (Figure 2). 35 Farah, Klugo, Mertz, and Cerny Fig.1 Ureteroneocystostomy using modified Leadbetter-Pol-itanos Technique. A. Establishing entrance site of trans-planted ureter. B. and C. Developing submucosal tunnel and placing traction suture to pull ureter from outside bladder through tunnel in one motion. D. Ureter is then spatulated and anchored in place wi th 4-0 absorbable suture. E. Puncture wound at top of the tunnel is closed. 36 Urological Complications in Renal Transplantation Postoperative management requires bladder drainage through a 22 FR urethral foley catheter for 3-5 days after transplantation. Strict attention is paid to catheter care and patency. Results In 96 patients, 25 urinary tract abnormalfties were dis-covered prior to transplantation. These were neurogenic bladder (10), obstructive prostatic hyperplasia (4), urethral stricture (3), polycystic renal disease (3), branch renal calculi (2), renal hypertension (2), and a renal mass found to be a benign cyst(l). Pretransplant treatment inthis group of patients consisted of transurethral prostatectomies in four patients, urethral stricture dilatation to 24 FR in three patients, and bilateral nephrectomy in those with polycystic rena l d isease, b ranched renal c a l c u l i , and renal hypertension. Major urological complications occurred in three cases (2.6%) after renal transplantation, all related to renal pelvic and ureteral dilatation and deteriorating renal function. Two of three patients had had a normal pretransplant urological evaluation. At surgical exploration in each case the collect-ing systems were drained by ureteral catheters or internal stents, but renal function did not improve. All three cases eventually had transplant nephrectomy. No deaths were related to these urological complications. Fig. 2 Three-layer bladder closure using 4-0 absorbable suture for the mucosa (A) followed byan inverting layer(B) and (C). Reinforcing sutures(D) of 0 or 2-0 suture approximate perivesical tissue in order to bury deeper layers. POSTOPERATIVE COMPLICATIONS OF URETERONEOCYSTOSTOMY AS THE PRIMARY URINARY ANASTOMOSIS IN RENAL TRANS PLANTATION REFERENCE STARZLetal BELZER et a l ® MALEK et a l ® BEWICK et a l ® COLFRY et a I ® GREENBERG et al' LEARY et a l ® PRESENT SERIES ® 178 220 93 196 125 47 221 116 COMPLICATIONS (%) NO. PTS. LEAK or FISTULA OBSTRUCTION TOTAL* 1.7 1.8 4.3 7.1 8.8 6.4 0.45 0.8 5.1 L4 5.1 3.2 6.4 0.45 2.6 9.0 5.0 6.5 13.3 12.0 15.0 0.9 2.6 SEQUELAE OF COMPLICATIONS (%) GRAFT LOSS MORTALITY t L7 •INCLUDES EXTRAVASATION, FISTULA, OBSTRUCTION, URETERAL SLOUGH. tXCURRlNG AS A DIRECT RESULT RELATED TO UROLOGIC COMPLICATIONS. 0.9 2.1 LO 4.0 3.2 0.8 37 Farah, Klugo, Mertz, and Cerny Fig. 3. Case 1 IVP (left) demonstrates pyelocaliectasis with poor visualization of the ureter. Retrograde pyelogram (right) outlines ureter and renal pelvis. Case Reports Case 1 A 37-year-old man received a cadaver kidney in November, 1974 and was treated for several rejection episodes until March, 1977, when he became azotemic and had a pyelogram consistent with ureteral dilatation. A retrograde pyelogram (Figure 3) demonstrated no ureteral obst ruct ion, but the kidney was explored, and ureterolysis, ureteroneocystostomy, and renal biopsy were per-formed. The biopsy indicated chronic rejection. The ureter was stented, but postoperatively renal function continued to deterior-ate. The ureteral stent was removed on the Mth postoperative day, and the patient developed a urinary fistula. Nephrectomy was performed, and the specimen demonstrated chronic rejection and ureteral necrosis. Case 2 A 27-year-old woman received a cadaver kidney in January, 1976 and did well until July, 1977 when her serum creatinine levels rose from 1,4 to 3,3 mg/d l . Ultrasound of the renal graft (Figure 4) was consistent with dilatation of the renal pelvis and calyceal system. Attempts at retrograde pyelography were unsuccessful due to stenosis at the ureteral vesical junction, A transvesical ureteral meatotomy was performed, andthe ureterwas left intubated. There was no intraoperative evidence of hydronephrosis, and renal function did not improve with the ureteral stent in place. The stent was removed two weeks later, A pericutaneous renal biopsy later demonstrated chronic rejection. The kidney was subsequently removed. 38 Urological Complications in Renal Transplantation 1 J Fig. 4. Case 2 Ultrasonic imaging in the saggital (left) and transverse (right) views shows separation of renal hilar structures consistent with hydronephrosis. Case 3 A 25-year-old man received a cadaver renal allograft in July, 1972. The pretransplant evaluation demonstrated a sensory paralytic bladder. The graft functioned, and over a one-year period the patient was treated for three rejection episodes until August, 1973 when his serum creatinine reached 7.4mg%, and IVP demon-strated hydronephrosis (Figure 5). Exploration of the kidney was performed. Through a pyelotomy incision an 8 FR ureteral catheter passed easily through the ureter into the urinary bladder and was left as an internal stent. Renal biopsy performed at exploration indicated chronic rejection. Postoperatively renal function did not improve with creatinine levels steady between 7 and 8 mg/d l . The ureteral stent was removed on the 15th postoperative day. The patient resumed hemodialysis 27 months later and had a nephrec-tomy and a second transplant in March, 1976. Discussion Urological compl icat ions far outnumber other surgical compl icat ions associated w f th renal transplantat ion." U p t o 12% of all transplanted kidneys do not perform adequately because of urological problems invo lv ing the transplanted kidney and ureter,^ Ureteral obstruct ion due to k ink ing, tors ion, ureteral necrosis or fibrosis, and stricture at the anastomosis are the most frequently seen compl icat ions. Obstruct ion due to adjacent abscess, lymphocele, and spermatic cord compression are less c o m m o n . Vascular insuff iciency and ureteral necrosis are the most c o m m o n causes of ureteral fistula. Bladder dehiscence and vesical fistulas can be prevented if care is taken dur ing surgery to avoid previous bladder incisions and perform a watert ight bladder closure. Other compl icat ions inc luded calyceal renal f istula, spontaneous renal rupture, scrotal hydrocele, testicular atrophy, ep id idymi t is , and scrotal edema. A v e r y important factor in reducing the incidence of bladder leaks and fistulas is the preoperat ive assessment of bladder funct ion . El iminat ion of bladder out let obstruct ion or the recognit ion and t reatmentof neurogenic bladders that cause high intravesical pressure w i l l help avoid these compl i ca -t ions. Likewise, sensory paralytic bladders that are prone to overdistent ion should be placed on t imed vo id ing schedules 39 Farah, Klugo, Mertz, and Cerny Fig. 5. Case 3 IVP demonstrates hydro-ureteronephrosis. to insure integrity of the ureteroneocystostomy and bladder closure. Catheter patency must be maintained in the imme-diate postoperative period to avoid undue stress on the cystostomy closure and to prevent bladder dehiscence."^ Problems with the transplanted ureter can be reduced by careful harvesting and technical precision at the urinary anastomosis. In ureteral harvesting it is essential that maxi-mal ureteral length and blood supply be preserved in order to avoid a "too short" ureter and the need to change to a less rel lable method of urinary anastomosis. An extensive review of ureteropyelostomy and ureteroneocystostomy by Barker et a/^ demonstrates a higher incidence of complications, graft loss, and patient death with ureteropyelostomy as the primary urinary anastomosis. The compi ications encountered in this series involved dete-riorating renal function and the urological finding of ureteral dilatation or hydronephrosis. In each case surgery to relieve obstruction did not result in improved renal function. Graft rejection was the primary cause of azotemia in these patients, which raises the question ofthe functional signifi-cance of the hydronephrosis. The delay in developmentof hydronephrosis suggests that it was caused by ureteral rejection and fibrosis as opposed to initial technical errors during transplantation. Histopathologically, the renal pelvis and ureters demonstrate both acute and chronic inflamma-tory changes consistent with and similar to rejecting renal cortical tissue. References 1. Donohue JP, Hosletter M, Glover J, and Madura J: Ureteroneocystos-tomy vs ureteropyelostomy; a comparison in the same renal allograft series, / Urot 114:202, 1975. 2. GreenburgSH, Wein AJ, Perloff LJ, and Barker CF: Ureteropyelostomy and ureteroneocystostomy in renal transplantation; post operative urological complications, / Urol 118:17, 1977. 3. Leary FJ, Woods JE, and DeWeerd JH: Urologic problems in renal transplantation. Arch Surg 110:1124, 1975. 4. Salaman JR, et a/: Surgical aspects of clinical renal transplantation. / 5urg 56:413, 1977. 5. ehrl ich RM and Smith RB: Surgical complicationsof renal transplanta-tion. Urology 10:43, 1977. 6. Belzer RO, Korentz SL, Najarian JS, et at: Prevention of urological compi ications after renal allotransplantation. Arch Surg 101:449,1970. 7. StarllTE, Groth CG, Putnam CW, eta/: Urological complications in 216 human recipients of renal transplants. Ann 5urg 172:1, 1970. 8. Malik GH, Uehlin DT, Daouk AA, and Kisken WA: Urologic complica-tions of renal transplantation. / Urot 109:173, 1973. 9. BewickJ, Collins RE, Saxton HM, eta/ : The Surgery and problemsof the ureter in human renal transplantation. 6r / t / Urot 45:493, 1974, 10. Colery AJ, Jr, Schleger JU, Lindsey ES, and McDonald JC: Urological complications in renal transplantation. / Urot 112:564, 1974. 40 

Urological Complications in Renal Transplantation

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