Urological Complications after Renal Transplantation - Therapeutical Management

Abstract

Aims: Urological complications can affect the outcome of kidney transplantations by increasing the morbidity and mortality, including the lost of the graft. The aim of this study is to determine the incidence of urological complications, occurring after renal transplantation, in our centre. Methods: A series of 796 consecutive renal transplantations were performed between 1st of January 2004 and 31st of December 2011 in our Institute with a male to female ratio of 1.77/1. The mean age of the recipients was 35.16 years old. Renal grafts were obtained in 594 cases (74.62%) from living-related and in 202 cases (25.38%) from cadaveric donors. In 494 cases (62.1%) we performed a modified Leadbetter-Politano technique and, in another 302 cases (37.9%) a Lich-Gregoire ureterocystoneostomy. The follow-up of these patients ranged from 1 to 78 months, with none lost to follow-up. In 683 (85.8%) cases transplantation was carried out into the right iliac fossa, and only 113 (14.2%) cases in left iliac fossa. A double J ureteral stent was occasionally placed. Indwelling Foley catheters were removed seven to nine days post transplant and ureteral stents at four weeks post transplantation. Results: The overall incidence of urological complications was 7.78% (62 cases). Ureteral leakage and ureteral stenosis, located at the site of the ureterovesical anastomosis were the most common. We recorded 25 ureteral stenosis (3.14%), 16 ureteral fistulas (2.01%), 13 lymphoceles (1.63%), three hematoma with ureteral obstruction (0.37%),two cases of renal lithiasis(0.25%) and three cases of obstruction due to clot formation (0.37%). For the patients with ureteral stenosis (25 cases) the most common method of surgical treatment was vesicoureteral re-anastomosis 17 cases (2.13%). In the other eight cases (1.01%), with short and distal stenosis were treated effectively by anterograde (via NST) or retrograde endourological approach, with double pigtail stenting. Ureteral leakage was the second major urological complication (16 cases). Ureteral stenting was performed in eight cases (1.01%) (patients with vesicoureteral anastomosis leakage, marginal ureteral necrosis), seven vesicoureteral re-anastomosis (0.87%) (vesicoureteral anastomosis leakage, ureteral necrosis) and one ureteropyelostomy (0.13%) using the ipsilateral native ureter (inadequate length of ureter). Peri-graft collection with extramural obstruction of the ureter was diagnosed by ultrasonography in 13 cases. Percutaneous drainage was successful in six cases (0.75%) and open surgical peritoneal fenestration was performed in the other seven cases (0.88%). Two patients (0.25%) developed renal lithiasis. The treatment was retrograde double pigtail ureteral stent insertion followed by ESWL. Three patients (0.37%) developed hematoma with secondary ureteral obstruction, solved by percutaneous drainage in one case (0.12%) and open surgical evacuation and drainage in other two cases (0.25%). For the cases of ureteral clot obstruction (3 cases, 0.37%), a double pigtail ureteral stent insertion after endourological clot removal was successful. Conclusions: Urological complications related to leakage or stenosis can be treated minimally invasive by ureteral stent insertion or by surgical vesicoureteral reimplantation. Early diagnosis and treatment will help maintain renal graft function. In our study, graft survival after successful treatment has been similar for all the patients.