Ureterostomy as an alternative to ileal conduits in pediatric kidney transplantation

Abstract

Introduction Urinary diversion in pediatric renal transplant candidates with bladders not amenable to primary reconstruction can be achieved by pre‐transplant ileal conduit creation. We performed cutaneous ureterostomies to limit pre‐transplant surgery, protect the peritoneum for dialysis, transplant patients sooner, and preserve ureter length for future surgical reconstruction. Methods We compared four pediatric transplant recipients with ureterostomies to four recipients with ileal conduits from 2009 to 2017. Results All patients with ileal conduits developed at least one urinary tract infection (UTI) within 1 year of transplant and three of four patients had recurrent UTIs within the first year. Two patients required ileal conduit revisions for redundant conduits and recurrent UTIs. Of the four ureterostomy patients, two patients had UTIs within one year of transplant. Two patients developed ureterostomy strictures requiring revision at the fascial level; one was associated with a UTI. Conclusion In our small case series, ureterostomy allowed for a single operative intervention with preservation of ureter length for later reconstruction. Ureterostomy is safe and recurrent UTI may be lower in the ureterostomy group. Long‐term evaluation of ureterostomy for urinary diversion in pediatric kidney transplant is warranted.

Long‐term outcome of transplant ureterostomy in children: A National Review

“…They reported comparable creatinine clearance and UTI occurrence at 1 year in four children with ureterostomy formation compared to those with ileal conduits concluding that ureterostomy formation is safe and may be associated with a lower incidence of recurrent UTI. 11 Original reports suggested that ureterostomy formation at renal transplantation was associated with frequent complications-particularly stomal stenosis. 14,15 As the technique progressed, outcomes improved, although stomal stenosis and need for dilatation remain a concern.…”

“…The formation of a cutaneous transplant ureterostomy is a relatively uncomplicated surgical procedure which has shown positive results, though to date most of the studies are in adults transplant recepients. 11,[14][15][16][17]21 This intervention can be performed as part of a single operative procedure at the time of transplantation in a select group of children with complex urological issues.…”

“…No definitive standards exist to guide the ideal timing or optimal surgical procedure for reconstruction or diversion of the urinary tract in this cohort. 11,12 Procedures such as Mitrofanoff stoma formation with or without bladder augmentation are commonly undertaken prior to transplantation. Bladder augmentation or de novo bladder formation prior to deceased donor transplantation is complicated in the context of oliguria/anuria-a good native urine output will help to clear mucous and ensure that the size of the construct remains stable; in the absence of an established urine output, an intensive program of bladder washout can allow such surgeries to be possible.…”

“…13 The use of cutaneous ureterostomy for urinary diversion at the time of renal transplantation was first described in adults by Kuss and colleagues in 1951 and has been reported in a number of small cohorts since. 11,[14][15][16][17][18][19][20][21] Although results were initially poor, this technique has been associated with better outcomes, predominantly in adult patients, in more recent times. [14][15][16][17][18][19][20] There is only a single study reporting the use of this technique in a pediatric cohort.…”

“…They suggested there may be a lower rate of recurrent UTI in the ureterostomy group. 11 We have cared for a number of children with ureterostomies performed to facilitate transplantation to proceed. We review the outcome, over a five-year follow-up period, for three groups of patients; those who had ureterostomies formed at transplantation; those who had alternative urinary diversion procedures prior to transplantation; and those with normal bladders.…”