Re-Implantation and Boari Flap Reconstruction for the Management of Ureteric Stricture Following Renal Transplant: A Single Centre Experience.

Abstract

Purpose: This study aims to review the outcomes of patients with ureteric strictures and reconstruction following renal transplantation in a single centre. Methods: All patients who developed ureteric stricture and subsequently underwent ureteric reconstruction between December 2003 and November 2013 were included in this study. Results: 1560 renal transplants were performed during the study period. 42 ureteric reconstructions were performed in this period. Two reconstructions were performed at the time of transplant for high ureteric injury, the remaining 40 for ureteric stricture, giving an incidence of 2.5%. There were 25 male and 15 female recipients with a median age of 48 (range 14-78). Of these, 18 (45%) received a DBD, 12 (30%) received a DCD (including one dual transplant) and 10 (25%) received a living donor (LD) graft. 5 were re-transplant (2nd or 3rd). The median time to stricture was 78 days (range 41-1016 days) from transplant. The median cold and warm ischaemia times were 14:38hr (32m-24:30hr) and 33 minutes (20m-42m) respectively. 7 kidneys had multiple arteries, 3 with a lower polar artery that was anastomosed. The majority of patients underwent nephrostomy insertion and antegrade stenting prior to surgical repair. 19 patients were reconstructed by re-implantation to the bladder, 18 utilized a Boari flap, 2 used an ileal conduit and 1 an anastomosis to a native ureter. All ureteric anastomoses were stented. In one patient, reconstruction was deemed impossible and was subsequently managed with an extra-anatomic stent. Two patients (5%) required re-operation for re-stricture and kinking. Median serum creatinine at 12 months following surgery was 148 (84-508) μmol/l. There was no 90 day mortality and 11 grafts were lost with a median time of 323 days (27-3103 days) from reconstruction. Conclusions: The incidence of ureteric stricture following renal transplant in our centre is low. Most strictures occur early following transplant. Re-implantation of transplant ureter or short Boari flap reconstruction was successfully employed in most cases. Native ureter is useful in reconstruction of strictures in dual renal transplants. None of the strictures requiring reconstruction after 2006 were associated with positive BK virus serology.