Results of a previously unreported extravesical ureteroneocystostomy technique without ureteral stenting in 500 consecutive kidney transplant recipients.

Gaetano Ciancio,Paolo Vincenzi,Jeffrey J. Gaynor,Javier Gonzalez,Ahmed Farag,Justyna Gołębiewska

doi:10.1371/journal.pone.0244248

Abstract

Urologic complications can still occur following kidney transplantation, sometimes requiring multiple radiological and/or surgical procedures to fully correct the problem. Previously proposed extravesical ureteral reimplantation techniques still carry non-negligible risks of the patient developing urologic complications. About 10 years ago, a new set of modifications to the Lich-Gregoir technique was developed at our center, with the goal of further minimizing the occurrence of urologic complications, and without the need for initial ureteral stent placement. It was believed that an improvement in the surgical technique to minimize the risk of developing urologic complications was possible without the need for stent placement at the time of transplant. In this report, we describe the advantages of this technique (i.e., mobilized bladder, longer spatulation of the ureter, inclusion of bladder mucosa with detrusor muscle layer in the ureteral anastomosis, and use of a right angle clamp in the ureteral orifice to ensure that it does not become stenosed). We also retrospectively report our experience in using this technique among 500 consecutive (prospectively followed) kidney transplant recipients transplanted at our center since 2014. During the first 12mo post-transplant, only 1.4%(7/500) of patients developed a urologic complication; additionally, only 1.0%(5/500) required surgical repair of their original ureteroneocystostomy. Five patients(1.0%) developed a urinary leak, with 3/5 having distal ureteral necrosis, and 1/5 subsequently developing a ureteral stricture. Two other patients developed ureteral stenosis, one due to stricture and one due to ureteral stones. These overall results are excellent when compared with other reports in the literature, especially those in which routine stenting was performed. In summary, we believe that the advantages in using this modified extravesical ureteroneocystostomy technique clearly help in lowering the early post-transplant risk of developing urologic complications. Importantly, these results were achieved without the need for ureteral stent placement at the time of transplant.

Highlights

Despite advances in surgical techniques in the field of kidney transplantation, urologic complications, i.e., ureterovesical junction (UVJ) stenosis or stricture, ureteral necrosis, and urinary leak, may still occur in the early post-transplant period and are associated with a myriad of potentially unfavorable outcomes, including recurring morbidity, repeat hospitalizations, graft failure, and even death [1, 2] Some urologic complications may require multiple radiological and/or surgical procedures to fully correct the problem
It was believed that if the surgical technique could be sufficiently improved so as to avoid/minimize urologic complication risk post-transplant, there would be no need for routine or even selective stent placement at the time of transplant. We describe this technique and retrospectively report our experience using it among 500 consecutive kidney transplant recipients transplanted at our center since 2014
We provide a descriptive comparison of our results with those reported in the literature using the extravesical Lich-Gregoir or modified Lich-Gregoir technique with and without routine stent placement

Summary

Introduction

Despite advances in surgical techniques in the field of kidney transplantation, urologic complications, i.e., ureterovesical junction (UVJ) stenosis or stricture, ureteral necrosis, and urinary leak, may still occur in the early post-transplant period and are associated with a myriad of potentially unfavorable outcomes, including recurring morbidity, repeat hospitalizations, graft failure, and even death [1, 2] Some urologic complications may require multiple radiological and/or surgical procedures to fully correct the problem. The transplanted ureter continues to be the major culprit behind the development of most of these urologic complications. Multiple techniques for performing the ureteral anastomosis have been introduced over the years with a major goal of further reducing the patient’s risk of developing a urologic complication post-transplant. The older Politano-Leadbetter technique requires a second cystotomy and longer donor ureter, and its use is known to be associated with some hematuria [6]. Advantages in performing the extravesical ureteral anastomosis are well known and include avoidance of a separate cystostomy (thereby decreasing operative time), a lowered risk of developing hematuria, an enhanced performance capability with a shorter donor ureter, and a reduced time required for Foley catheter drainage [6]

Methods

Results

Conclusion