Urine Leak Following Kidney Transplantation: An Evidence-based Management Plan

Abstract

Care of kidney transplant recipient remains complex and long-term graft survival is not seen in every transplant recipient. Due to reduced supply and increased demand of human organs, more transplants are carried out using marginal grafts on emergency lists. Transplant recipients have altered physiology due to known end-stage renal disease, recent surgery and the use of potent analgesic and immunosuppressive medications. Amongst the known surgical complications, urine leak remains the most common. It can result from poor graft preparation due to excessive peri ureteric or lower pole dissection or damage to lower polar artery resulting in ischemic necrosis. In addition, poor surgical technique, bladder outflow obstruction, iatrogenic injury to bladder or renal pelvis may contribute to urine leak. On-going urine leak may manifest itself as swelling, pain, high drain output, sepsis, ileus and eventual graft loss. Early identification, localisation and quantification of leak remain essential in management of these patients. In addition, sepsis should be identified and treated promptly as these patients are highly susceptible to infections. Early recognition of this complication can significantly reduce hospital stay, improve quality of life, reduce graft loss and mortality. In this article, we aim to develop an evidence-based management approach to a patient with urine leak using a clinical scenario.

Urological complications after renal transplantation.

“…установлено, что чрескожная нефростомия в 60% случаев может привести к успешному лечению несостоятельности уретероцистоанастомоза [20]. Если уриномы инфицируются или вызывают обструкцию мочеточника путем его сдавления извне, требуется срочное чрескожное пункционное дренирование затека [21]. При неэффективности консервативных методов лечения показано хирургическое реконструктивное вмешательство -повторная имплантация мочеточника трансплантата [22].…”

Identifying Early Extraperitoneal High-Volume Urine Leak Post Kidney Transplantation

“…18,38 Evidence-based management plan in extraperitoneal urine leak Low-volume leak at the anastomotic site can be managed conservatively by performing maximum decompression. 39,40 Antegrade pyelogram to identify the site of the leak is helpful. Placing a Foley catheter and ureteral stent performing a nephrostomy are the techniques used for decompression.…”

“…Placing a Foley catheter and ureteral stent performing a nephrostomy are the techniques used for decompression. 39,41 Once the urine leak stops, the Foley catheter and nephrostomy tube can be removed; however, the ureteral stent is only removed after a period of 4-6 weeks. 41 After conservative management, the patient is carefully followed-up.…”

“…41 After conservative management, the patient is carefully followed-up. 39 If the fluid collections become infected, or cause ureteral obstruction and extrinsic compression on the ureter, then urgent percutaneous drainage is required. 39,41 Surgical re-exploration and reimplanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain.…”

“…39 If the fluid collections become infected, or cause ureteral obstruction and extrinsic compression on the ureter, then urgent percutaneous drainage is required. 39,41 Surgical re-exploration and reimplanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain. 8,[39][40][41][42][43] Preventive measures: importance of the golden triangle Urine leak usually occurs because of technical errors in the ureteroneocystostomy technique, the method of graft ureter implantation in the recipient's urinary bladder, or because of the transplanted ureter's compromised vascularity, which is caused by vessel damage during the harvest of the donor kidney.…”