Diagnosis and management of ureteral complications following renal transplantation

Abstract

When compared with maintenance dialysis, renal transplantation affords patients with end-stage renal disease better long-term survival and a better quality of life. Approximately 9% of patients will develop a major urologic complication following kidney transplantation. Ureteral complications are most common and include obstruction (intrinsic and extrinsic), urine leak and vesicoureteral reflux. Ureterovesical anastomotic strictures result from technical error or ureteral ischemia. Balloon dilation or endoureterotomy may be considered for short, low-grade strictures, but open reconstruction is associated with higher success rates. Urine leak usually occurs in the early postoperative period. Nearly 60% of patients can be successfully managed with a pelvic drain and urinary decompression (nephrostomy tube, ureteral stent, and indwelling bladder catheter). Proximal, large-volume, or leaks that persist despite urinary diversion, require open repair. Vesicoureteral reflux is common following transplantation. Patients with recurrent pyelonephritis despite antimicrobial prophylaxis require surgical treatment. Deflux injection may be considered in recipients with low-grade disease. Grade IV and V reflux are best managed with open reconstruction.

Ureteral Stenosis of Transplanted Kidney

“…In select cases, endourologic techniques have been utilized in the effort to spare patients the potential morbidity of open reconstruction (4,15). In our group, the majority of ureteral stenoses were treated by surgery -retroureteroneocystostomy or pelveureteroanastomosis.…”

“…hematoma, lymphocele, abscess), kinking of a redundant ureter, collecting system hematoma, a stone transplanted with the kidney, and anastomotic edema can because of ostenosis during the early postoperative (<3 months) period. Late stenosis (>3 months) usually results from ureteral ischemia, but vasculitis secondary to acute rejection, lymphocele, fibrosis from immunosuppressive medications, and ureterolithiasis may also occur (4). The risk factors for development of ureteral stenosis may be divided to surgical factors, factors on side of the donor, and factors on side of the recipient -table 1 (5,6,7).…”

Post‐renal transplant ureterocutaneous fistula: Management of complications and literature review

“…Conservative management includes the placement of a double‐J stent or percutaneous nephrostomy. However, if urine extravasation persists, the placement of percutaneous nephrostomy or open surgical repair will be required . From July 2010 to June 2018, our centre managed three cases of post‐renal transplant ureterocutaneous fistula requiring surgical repair.…”

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“…A larger urine collection may need to be drained to reduce risk of infection if there is a delay in operative intervention. [16][17][18][19] It is possible to manage urine leak associated with hydronephrosis by maximal decompression with external drainage (percutaneous nephrostomy) and double J stent placement. However, sufficient hydronephrosis is required to perform nephrostomy.…”

“…If there is a small urine leak, the patient should be treated with maximal decompression (conservative procedure). 16,17 If the urine leak is associated with hydronephrosis, an anterograde stent placement can be performed. 5 Alcaraz and associates 20 assessed that percutaneous nephrostomy can result in successful treatment for 60% of recipients who develop urine leak 3 days after kidney transplant.…”