The Current Role of Endourologic Management of Renal Transplantation Complications

Abstract

Introduction. Complications following renal transplantation include ureteral obstruction, urinary leak and fistula, urinary retention, urolithiasis, and vesicoureteral reflux. These complications have traditionally been managed with open surgical correction, but minimally invasive techniques are being utilized frequently. Materials and Methods. A literature review was performed on the use of endourologic techniques for the management of urologic transplant complications. Results. Ureterovesical anastomotic stricture is the most common long-term urologic complication following renal transplantation. Direct vision endoureterotomy is successful in up to 79% of cases. Urinary leak is the most frequent renal transplant complication early in the postoperative period. Up to 62% of patients have been successfully treated with maximal decompression (nephrostomy tube, ureteral stent, and Foley catheter). Excellent outcomes have been reported following transurethral resection of the prostate shortly after transplantation for patients with urinary retention. Vesicoureteral reflux after renal transplant is common. Deflux injection has been shown to resolve reflux in up to 90% of patients with low-grade disease in the absence of high pressure voiding. Donor-gifted and de novo transplant calculi may be managed with shock wave, ureteroscopic, or percutaneous lithotripsy. Conclusions. Recent advances in equipment and technique have allowed many transplant patients with complications to be effectively managed endoscopically.

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“…In addition, immunosuppression may increase the risk of developing urinary tract infection that may cause urolithiasis. [10][11][12][13] The most common clinical findings of urolithiasis in kidney transplant recipients include unexplained fever, increased creatinine level, decreased urine output, and hematuria. Renal colic usually is absent because the innervation of the kidney is impaired, but lower abdominal discomfort may occur from peritoneal irritation caused by a hydronephrotic collecting system.…”

“…When hydronephrosis is present, a noncontrast computed tomography scan may show the anatomy more clearly. 8,11 Treatment options for stones include observation, dietary and medical therapy, extracorporeal SWL, endourologic procedures including TUL and PCNL, and open procedures. Small stones (< 4-5 mm) with little or no deterioration in renal function can be monitored.…”

“…[14][15][16][17][18] However, no level 1 data are available for transplant patients that may help guide treatment decisions. 11 Nevertheless, SWL or TUL are reasonable options for stones < 1.5 cm, and PCNL is used for larger calculi. 16,17 The SWL may be used as an initial approach for nonobstructive stones (< 15 mm), but the pelvic location of the transplanted kidney can be problematic during SWL.…”

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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.…”