Complications Following Unstented Parallel Incision Extra Vesical Ureteroneocystostomy in 1,000 Kidney Transplants

Abstract

Between May 10, 1982 and September 1, 1990, 1,000 kidney transplant recipients underwent parallel incision extravesical ureteroneocystostomy for urinary tract reconstruction. Complications attributed to this surgical technique that required reoperation occurred in 2.1% of the recipients. These complications included urinary extravasation in 9 patients, ureteral necrosis in 3, ureteral obstruction in 3, ureteral bleeding in 3, ureteral implantation into thickened folds of peritoneum in 2 on chronic ambulatory peritoneal dialysis and ureteral implantation into an ovarian cyst in 1. Vesicoureteral reflux occurred in 0.4% of the ureteroneocystostomies, none of which was revised. No allografts were lost as a result of these complications. The principles of the technique are sound. One should be careful if the patient has a small, defunctionalized or scarred bladder, has undergone multiple pelvic operations or has had pelvic inflammatory disease.

Extra-Anatomic Stent (EAS) as a Salvage Procedure for Transplant Ureteric Stricture

“…It has an incidence of around 2-5% and is most commonly due to ureteric ischemia (2,3). Three-fourths of all ureteric strictures occur either at the uretero-neocystostomy junction or in the distal ureteric segment, with the remaining involving longer segment or the entire length of the ureter (4). Ultrasound guided percutaneous nephrostomy is recommended to decompress and protect the transplanted kidney.…”

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“…11 Preservation of the distal ureter blood supply during donor nephrectomy, sparing of the periureteric fat during graft kidney harvesting, and the extravesical reconstruction technique may be responsible for these advancements in outcomes. [12][13][14][15][16] In this setting, a benefit of stenting has been reported. 6 The stent generally used to protect the urinary anastomosis is the DJS.…”

Surgical Complications of Renal Transplantation

“…In general, most urinary leaks are the results of ureteral problems, failure of ureterovesical anastomosis or ischemia and necrosis of the distal ureteral stump. Like the majority of surgeons now employ an extravesical ureteroneocystostomy technique for implantation of the ureter, there are shorter ureter and decreased likelihood of ischemia, and a limited cystostomy that rarely leads to leakage from the bladder (Gibbins WS, 1992;Thrasher JB, 1990).…”

“…This complication appears to be more common with the extravesical ureteroneocystostomies (Streen SB, 1994). Some authors have recommended use of a ureteral stent to lessen the likelihood of this complication (Gibbins WS, 1992). The second type of early ureteral leak, usually presents between 5 and 10 days, is associated with distal ureteral ischemia, which may be a consequence of injury during the donor nephectomy, technical causes such as tunnel hematoma or distal stripping of the blood supply (Rosenthal JT, 1994).…”