Major Urological Complications Research Articles

Routine Ureteral Stenting in Kidney Transplant Reduces Postoperative Hydronephrosis and Percutaneous Ureteral Interventions: A Single-Center Experience.

The effect of routine ureteral stenting on postoperative hydronephrosis and percutaneous ureteral intervention in kidney transplant remains unknown. This study aimed to evaluate the effects of routine ureteral stenting on hydronephrosis and percutaneous ureteral intervention and the cost benefit of ureteral stenting in kidney transplant. We retrospectively analyzed patients who underwent kidney transplant at a tertiary institution between 2005 and 2021. We adopted a ureteral stentingprotocol in2017, anda comparisonwas performed with previous patients without stents. In total, 539 patients underwent kidney transplant(271 with stents [51.3%], 268 without stents [49.7%]). Hydronephrosis was detected in 16 cases (5.9%) and 30 cases (11.2%) of groups with and without stents,respectively (P = .041). Among patients with hydronephrosis, the number of patients who underwent percutaneous ureteral intervention was significantly lower in the stent group than in the nostent group (1 [6.25%] vs 10 [33.33%]; P= .014).Twenty patients (3.71%) experienced major urologic complications (19 [7.1%] in the no-stent group, and 1 [0.4%] in the stent group; P = .001). No significant differences between the groups were shown in the incidence of urinary tract infections within 3 months of transplant (24 [8.9%] vs 22 [8.2%]; P = .846). No differences were shown between the groups in ureterovesical anastomosis time (24.4 vs 24.03 min; P = .699) or 1-year graft survival (97% vs 97.8%; P = .803). The healthcare cost was significantly lower in the stent group than in the no-stent group by $1702.05 ($15000.89 vs $16702.95; P < .001). Routine ureteral stenting in kidney transplant significantly decreased the incidence of postoperative hydronephrosis and percutaneous ureteral intervention. Stenting did notlead to increased urinary tract infections and was cost-effective.

#5542 THE ITALIAN REGISTRY OF POLYCYSTIC KIDNEY DISEASE (RIRP): DESIGN, PATIENT CHARACTERISTICS AND INITIAL RESULTS

Abstract Background and Aims ADPKD is the most common form of inherited renal disease worldwide. ADPKD care has advanced over the past decade by the identification of several clinical/genetic risk factors of progression and approval of first disease-modifying drug. Further clinical outcomes research is needed to improve patient-centered clinical care; in addition new disease-modifying therapies are in pipeline, requiring a growing need for patient enrolment in clinical trials. To advance these goals, the Italian Society of Nephrology, supported by the Italian PKD Foundation (AIRP) established in 2020 the creation of a National web-based ADPKD Registry. Here we present the design of this Registry and the preliminary results. Method Adult patients with clinical or genetically confirmed diagnosis of ADPKD have been enrolled in the Registry, hosted by a secure online platform including both a clinical and genetic database. Databases have modular design collecting clinical features, including demographic data, type of diagnosis, e-GFR at onset and at time of first and last nephrological referral, age at onset of hypertension (HTN) and major urological complications (UC), Total Kidney Volume (hTKV) and Mayo Imaging Classification of ADPKD, age at ESRD, use of aspecific renal-protective and disease-modifying drugs, additional risk factors for CKD progression (smoke, diabetes, NSAID), extra-renal manifestations. Genetic data collected include type of PKD1/2 variant with ACMG classification and pathogenic prediction tools, testing method, results of segregation analysis. Statistics included estimation of eGFR slope using linear-mixed modelling. Results By January 2023, the Registry had recruited 985 ADPKD patients across 21 Italian Nephrology Unit; 513 (52,1%) were females; 967 (98,2%) Caucasians. Familiar history of ADPKD was reported in 738 patients (79%). All CKD stages were represented and 105 (14,1%) patients reached ESRD (median age 57y ± 11,5). hTKV was available for 353 (35,9%) patients, with a median value of 1100 ± 996 ml/m; a Mayo class of 1C or higher was found in 221 (70,4%). PROPKD score was evaluated in 162 patients, and in 50% of them it was associated with low risk of progression. A total of 191 (21,6%) were receiving Tolvaptan. Demographic and clinical characteristics are summarized in Table 1. Genetic testing was performed in 288 patients; 111 (38,5%) had PKD1 truncating (T) variants; 67 (23,3%) PKD1 non truncating variants; 69 (24%) PKD2 variants. In 41 patients (14,2%) no pathogenic variants were detected. In our cohort deterioration of renal function over time, estimated using eGFR slope was significantly associated with Mayo Imaging classes, high-medium PROPKD score, PKD1-T variant, HTN onset before 35 yo (Figure) and early UC (−2,3 vs. −1,9 ml/min/1.73m2/y, p = 0.014). Conclusion The Italian ADPKD National Registry is an important research tool collecting clinical and genetic information. Our preliminary data confirm that in the Italian population genotype, early onset HTN or UC, Mayo Imaging classification and PROPKD score are able to predict deterioration of GFR in ADPKD. The future empowerment of the Registry will provide a comprehensive description of clinical features and genetic variants related to ADPKD in a large cohort of Italian patients, enabling us to better understand genotype-phenotype correlation. Furthermore, the Registry could be an opportunity to identify patients suitable for future clinical trials or observational studies concerning specific aspects of the disease.

Post-circumcision urethrocutaneous fistulae: presentations, repairs and outcomes in a tertiary centre.

Circumcision is regarded as the most common surgical procedure world over. It is also perceived to be a simple and safe procedure; however, it could be fraught with major urological complications such as urethrocutaneous fistula (UCF). Repair of these fistulae poses a great reconstructive challenge to the paediatric surgeon/urologist with varied outcomes. We seek to review the presentations, repair and outcome of post-circumcision UCFs managed in a tertiary centre. This is a retrospective review of all the consecutive cases of repaired post-circumcision UCFs in Nnamdi Azikiwe University Teaching Hospital, Nnewi, South-East Nigeria, over a period of 9 years (January 2012-December 2020). Data on demography, size of fistula, type of repair and outcome were retrieved from the Records Department and patients' case notes and were analysed using SPSS (version 22, Chicago, Illinois). A total of 22 boys had post-circumcision UCF repair within the period, and they were aged between 2 weeks and 108 months with a median age of 4 months at presentation and aged between 8 months and 144 months with a median age of 24 months at the time of surgery. Circumcisions were by freehand technique in 21 (95.5%). Nurses performed most of the circumcisions in 19 (86.4%), and most of the circumcisions were performed in private hospitals 7 (31.8%), maternity homes 3 (13.6%) and general hospitals in 10 (45.5%) each, respectively. Most 17 (77.3%) fistulae were coronal, and the size of defect ranged from 1 mm to 10 mm. The most commonly employed technique of repair was simple closure in 16 (72.2%). Meatal stenosis and re-fistulation occurred in 2 (9.1%) and 4 (18.2%), respectively. Only two (12.5%) required reoperation. There was no relationship between the size of defect and re-fistulation, P = 0.377. Majority of the Post-circumcision urethrocutaneous fistulae were from free hand technique of circumcisions . These were performed mostly by nurses in general, private hospitals and maternity homes. Hence, there is a need to ramp up training of providers of neonatal circumcision in our environment. Most UCF in children could be repaired with simple closure technique reinforced with dartos flap.

236.12: Selective Ureteric Stenting Is Non-inferior to Routine Stenting for Major Urological Complications Following Renal Transplant in Low-Risk Patients

Introduction: Major urological complications (MUC) are a significant source of morbidity following a renal transplant occurring in up to 4% of cases. At our institution it has been standard practice to routinely place a J-J ureteric stent across the ureteroneocystostomy at the time of transplant. Meta-analysis has shown reduced incidence of MUC in randomised-controlled trials of stenting with a number needed to treat of 14 to prevent 1 MUC. Despite the potential benefits of routine stenting, evidence suggests there may be no statistical difference between routine vs. selective stenting for low-risk patients in terms of complications such as urinary leak and ureteric obstruction suggesting equipoise for this sub-group. Also, stenting itself is associated with several complications and increased costs such as urinary tract infection (UTI), BK virus and the need to retrieve the stent through flexible cystoscopy. We hypothesised that in select low-risk patients not stenting would be non-inferior to routine stenting in the remainder of our patients. Study design: After local ethics approval, our prospective observational cohort study was run between June 2017 and June 2021. In this period 380 consecutive renal transplants were performed at our centre. 30 patients were excluded who had dual kidney (including paediatric en bloc) transplant, early graft loss not related to a MUC, duplex ureter in the donor or an intra-peritoneal implantation. Following this, 350 transplants were included for analysis, 240 were stented and 110 were not. Primary outcomes were MUC and UTI and secondary outcome was the incidence of BK viraemia. All transplants used the same technique for ureteroneocystostomy, the Lich-Gregoir anti-refluxing anastomosis. The same 3 surgeons performed or directly supervised each transplant. The decision of whether to stent was at the discretion of each surgeon based on suggested criteria. Stenting was suggested for multiple donor renal arteries, technically difficult surgery, high risk (e.g. obese) patients or surgeon concerns regarding the ureteric anastomosis. A 5Fr Cook UniversaTM ureteric stent was used when stenting was performed. Patients were followed from transplant for a minimum of 6-months. Results: MUC occurred in 6.25% of stented vs. 7.2% of the not stented groups. These included early (<10 days) and late urinary leak, haematuria requiring washout, hydronephrosis requiring nephrostomy and stent encrustation. Observed rates of urinary tract infection (28.7% vs. 26.3%) and BK viraemia (8.7% vs. 8.1%) were similar between groups. Conclusions: In our cohort of 350 renal transplants, selectively stenting low-risk patients did not result in a higher rate of MUC. Rates of UTI or BK viraemia were not significantly different. Finally, not needing to remove a stent in our selective group was associated with savings of an estimated $165,000 AUD over 3 years with no statistically significant difference in complications.

Risk Factors for Urologic Complications After Kidney Transplantation and Impact in Graft Survival.

Background and PurposeKidney transplantation (KT) is the best therapy for chronic kidney disease (CKD). Major urologic complications (MUCs) are the second etiology associated to morbidity and graft loss following KT, after rejection episodes. The objective of this study was to estimate the incidence, risk factors and impact on graft survival associated to urological complications in KT patients.Patients and MethodsA retrospective cohort based on electronic patient files of kidney transplant recipients from Colombiana de Trasplantes was created for the period August 2008 to September 2019. Initiation of follow-up was defined as the date of transplantation up to 3 years post-transplantation. Incidence of ureteral stenosis, ureteral obstruction, and ureteral leak was measured. A logistic regression multivariate model was adjusted to determine the associated factors to MUCs (yes/no). Patient and graft survival time were analyzed using a Kaplan-Meier method.ResultsA total of 1584 KT patients were included in the cohort. MUCs were present in 195 (12.6%) KT patients. We found that dialysis duration (OR: 1.004; p = 0.02) remained significant for the incidence of MUCs in KT patients of deceased donors. Probability of graft and patient survival at 3 years of follow-up was 90.5% and 85.5%, respectively. No significant difference was found on graft and patient survival in KT patients with or without MUCs.ConclusionMUCs are frequent complications for KT. We did not observe significant differences in graft or patient survival according to the presence of MUCs. The identification of MUCs and risk factors may guide transplant teams for future surgical and clinical decisions.

Outcome Analysis of Continuous Versus Interrupted Sutures for Adult Circumcision at a Tertiary Care Centre, Tamil Nadu, India

Introduction: Circumcision is the most common reconstructive urological procedure all over the world with minimal complications. It comprises of surgical removal of the prepuceal skin from the penis. Bleeding and infection are the major complications associated with traditional interrupted sutured circumcision. Hence continuous suturing techniques were explored to replace the traditional interrupted absorbable sutures. Aim: To compare the outcome of continuous and interrupted absorbable suturing techniques for adult circumcision. Materials and Methods: This retrospective study was conducted at PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India, in 250 adult patients undergoing circumcision between January 2018 and December 2020 in a Tertiary Care Hospital in Southern India. Among the 250 adult patients, 125 patients underwent circumcision with continuous absorbable suturing techniques (group I) and 125 patients with interrupted absorbable suturing technique (group II). Comparative outcome analysis of both the groups was done based upon the following parameters- bleeding, infection, surgical wound dehiscence, swelling in the phallus, Visual Analog Score (VAS) for pain assessment, readmission to the hospital, and cosmesis. The comparison of quantitative variables between the groups was done using chi-square test. Results: In total, 250 adult patients were included in this study. The age was 44.3±14.3 years in continuous suture and 43.4±13.6 years in interrupted suture group. Balanitis with phimosis was the commonest indication for adult circumcision. The mean time taken for circumcision in group I and II was 14 minutes and 45 minutes, respectively. The average healing period was six days in group I and 13 days in group II. No major urological complications were observed in both the groups which might have required re admission. But fewer postoperative complications were encountered in group I with respect to wound infection (p-value=0.0002) and suture granuloma (p-value=0.02). Conclusion: The present study demonstrated better postoperative outcomes, reduced surgical time, reduced suture material requirement, and better cosmesis in adult circumcision using continuous absorbable suturing technique compared to the traditional interrupted technique.

Early Removal of Ureteral Stent After Kidney Transplant Could Decrease Incidence of Urinary Tract Infection: A Systematic Review and Meta-Analysis.

In this systematic review and meta-analysis, our aim was to explore the optimal timing of ureteric stent removal after kidney transplant. For our analyses, we searched the Cochrane Central Register of Controlled Trials, PubMed, and Embase databases for all randomized clinical trials that evaluated the timing of stent removal after kidney transplant. Patients with early versus late stent removal were compared. Seven eligible studies published from 2012 to 2018, which included 1277 patients, were found to be within the scope of our study. Significant differences were shown between early versus late stent removal groups with regard to development of urinary tract infections (relative risk of 0.42; 95% CI, 0.26-0.685; P < .001). In a further subgroup analysis of incidence of urinary tract infection with consideration of heterogeneity, early stent removal was also favored (relative risk at 2 and 3 weeks of 0.36 and 0.35, respectively; P < .001 for both). However, with regard to incidence of major urologic complications, there were no significant differences between early and late stent removal (odds ratio at 2 and 3 weeks of 2.79 and 1.97, respectively; P = .18 and P = .26, respectively). There were also no significant differences between groups in risk of development of urinary leakage (odds ratio at 2 weeks of 3.02, P = .18; and relative risk at 3 weeks of 2.00, P = .27). With regard to ureteral stenosis, only 3 cases were reported in the late stent removal group. Our study demonstrated that early ureteral stent removal (that is, not later than 3 weeks) could significantly decrease the incidence of urinary tract infections without affecting incidence of major urological complications. We suggest that the appropriate timing of stent removal should be within 14 to 21 days.

Predicting Strict Trifecta Outcomes after Robot-Assisted Partial Nephrectomy: Comparison of RENAL, PADUA, and C-Index Scores.

Nephrometry scores are designed to characterize tumors and stratify the surgical complexity. It remains unclear as to which nephrometry score can accurately predict the surgical outcomes. We aimed to assess the utility of radius, exophytic/endophytic, nearness, anterior/posterior, location (RENAL), preoperative aspects and dimensions used for anatomic classifications (PADUA), and centrality index (C-index) nephrometry scores for predicting the strict Trifecta achievement from a single institution series robotic-assisted partial nephrectomy (RAPN). We retrospectively identified the prospectively maintained robotic surgery database records of 91 patients who underwent RAPN between June 2015 and September 2020 in Antalya Training and Research Hospital. The main outcome of the study was the achievement of strict Trifecta (negative surgical margin, no major urologic complications, warm ischemia time ≤25 min, and ≥85% preservation of estimated glomerular filtration rate). A multivariable analysis was performed to identify the factors of strict Trifecta success. The mean patient age was 55.82 ± 13.37 years with a median clinical tumor size of 3.5 cm (IQR 2.5–4.9). The median RENAL, PADUA, and C-index score were 7(IQR 6–8), 8(IQR 7–10), and 2.01(IQR 1.64–2.72), respectively. A strict Trifecta could be achieved in 54 patients (59.3%). Clinical tumor size (P = 0.011), RENAL risk groups (low:reference; intermediate; P = 0.040; high; P = 0.009), PADUA risk groups (low:reference; intermediate; P = 0.044; high; P = 0.001) and C-index risk groups (low:reference; high; P = 0.015) were the independent predictors of strict Trifecta attainment in the multivariate analysis. None of the nephrometry scores were a superior predictor compared to other nephrometry scores in comparative analysis. RENAL, PADUA, and C-index scores were all independent predictors of a strict Trifecta achievement. Our comprehensive comparison of the three scores identified that none of the nephrometry scores proved to be inferior to others nephrometry scores.

Safety and efficacy of flexible and semi-rigid ureteroscopy with laser lithotripsy for the management of ureteral calculi in pregnancy

BackgroundSymptomatic ureteric stone during pregnancy can present a clinical challenge because of potential risks to both the mother and foetus. Ureteroscopy with laser and stone basket extraction represents an emerging strategy for definitive stone management in pregnancy, with minor complications. We aimed to evaluate the safety and efficacy of ureteroscopy with auxiliary procedures as a primary treatment for pregnant women with symptomatic ureteric stones who have failed conservative management.MethodsA prospective analysis was conducted in the Urology Department of Sulaymaniyah Teaching Hospital from June 2017 to November 2019 to evaluate pregnant patients who were treated with ureteroscopy and holmium laser lithotripsy for symptomatic ureteric stone.ResultsTwenty-six pregnant women aged between 18 and 34 years presented with renal colic (22 patients, 84.61%), severe hydronephrosis (3 patients, 11.53%), and progressive hydronephrosis (1 patient, 3.8%), suggesting ureteric stones. The diagnosis was established by abdominal ultrasonography. The mean stone size was 7.38 mm, ranging from 6–12 mm. The stones were located in the proximal ureter (n = 6, 23.1%), middle ureter (n = 0), and distal ureter (n = 20, 76.9%). Complete stone fragmentation was achieved in all patients. The overall procedure success rate was 87%, the stone-free rate was 23 out of 26 cases (88.46%), and no major obstetric or urologic complications were encountered.ConclusionsUreteric stone in pregnancy requires a high index of suspicion for a prompt and correct diagnosis. Ureteroscopy: flexible or semirigid endoscopy combined with holmium: YAG laser lithotripsy or with stone extraction are a preferred modality for the definitive treatment of symptomatic ureteric stone in pregnancy.

Do you really want to deactivate your sacral neuromodulation device during pregnancy? A single center case series

Introduction and hypothesisThe main objective of the study is to assess the efficacy and safety of sacral neuromodulation (SNM) during pregnancy.MethodsWe retrospectively enrolled patients who underwent SNM implantation in our center and subsequently became pregnant. The indication for SNM, timing of device de-activation (if performed), course of pregnancy and urological complications, duration of labor, childbirth term, delivery mode, congenital abnormalities and SNM dysfunctions after delivery were recorded.ResultsFourteen pregnancies were recorded among 11 women undergoing SNM. Indications for device implantation were urinary retention (7 cases) and dysfunctional voiding (4 cases). Two patients carried on two and three pregnancies, respectively, with the device turned off since the first trimester. They both had to return to self-catheterization and developed recurring urinary tract infections. No major urological complications were recorded among the remaining nine women that kept the device on during pregnancy. A cesarean section was performed in four cases for obstetric reasons, and in seven cases it was planned by the urologist and gynecologist to avoid lead damage/displacement. Three pregnancies resulted in a vaginal delivery, and no association with term of delivery or duration of labor was observed. No congenital abnormalities related to SNM or lead displacement are reported, and only one patient required device removal because of significant loss of efficacy after childbirth.ConclusionsThe use of SNM during pregnancy appears to be safe, without morbidity for the fetus. Moreover, risks associated with switching the device off may be greater than benefits and justify maintaining the electrical stimulation throughout pregnancy.

Is peritoneal dialysis prior to kidney transplantation a risk factor for ureteral stenosis after adult to adult live kidney transplantation.

Major urinary complications such as urinary leaks, stenosis or urinary tract infections after kidney transplantation can lead to graft or patient loss. The effect of peritoneal dialysis on post-kidney transplantation complications have been discussed but its effect on ureteral stenosis is unknown. In this study, it was aimed to analyze factors effecting major ureteral complications after living donor kidney transplantation and impact of peritoneal dialysis and double J-stents (JJ stents). This study included 116 adult to adult living donor kidney transplant patients. Factors effecting major urologic complications after living donor kidney transplantation were analyzed. The donors were primary relatives of the recipients. Major urologic complications after living donor kidney transplantation was 8/116 (6.9%). Urinary leak was present in 2 (1.7%) patients. Ureteral stenosis was encountered in 6 (5.2%) patients. Double J stents were used in 84 (72.4%) of the cases. The effect of JJ ureteral stent was not statistically significant for urinary leak, ureteral stenosis (p= 0.074, p= 0.470, respectively). A total of 29 (25%) patients had peritoneal dialysis before kidney transplantation. Preoperative peritoneal dialyses and bacteriuria after kidney transplantation were independent risk factors for ureteral stenosis in multivariate analysis (p= 0.013, and p= 0.010 respectively). In the guidance of the results of the present study, peritoneal dialysis prior to kidney transplantation and bacteriuria are independent risk factors for ureteral stenosis after living donor kidney transplantation. JJ stents have no effect on urologic complications after living donor kidney transplantation.

Comparison of Removing Double-J Stent With and Without Cystoscopy in Kidney Transplant Patients: A Randomized Clinical Trial.

The ureteric stent can be attached to the Foley catheter in kidney transplantation to exclude cystoscopy for its removal. It is rarely practiced in renal transplantation. There has been no randomized trial to evaluate the outcome of this procedure on major urologic complications. One hundred sixty-three kidney transplant patients were randomized into an intervention group in which the stent was attached to the Foley catheter and removed together and a control group in which stent was removed by cystoscopy. In both groups, stents were removed around the 8th post-operative day. From March 2016 to June 2017, out of 234 kidney transplants performed in our center, one hundred Sixty-three (69.6%) patients met the study inclusion criteria. 91patients (55.8%) were allocated to the intervention group. Mean days before JJ removal for intervention and control groups ("per-protocol" group) were 8.08 ± 1.52 and 8.57 ± 1.58, respectively (P = .09). There was no difference between groups regarding major urologic complications (P = .679). Visual analog scale pain scores were significantly higher in the control group (p = .001). The procedure reduced 63-120 USD from the cost of operation in the intervention group. In selected kidney transplant patients, attaching stent to the Foley catheter and removing both of them early may be a safe maneuver regarding major urological complications, reduces pain, and eliminates the cost of cystoscopy.

Association of robotic partial nephrectomy for clinical T2a renal mass with improved trifecta outcome compared to open partial nephrectomy: A single surgeon comparative analysis.

653 Background: We compared surgical quality and functional outcomes of robotic partial nephrectomy (RPN) and open PN (OPN) for cT2a renal masses (cT2aRM). Methods: Retrospective analysis of 150 consecutive patients [RPN 59/OPN 91] from 6/2008 to 6/2016. Main outcome was achievement of Trifecta [negative surgical margin, no major urologic complications, and ≥90% preservation of estimated glomerular filtration rate (eGFR)]. Multivariable analysis was performed to identify factors of Trifecta attainment. Results: Mean tumor size (RPN 7.9 vs. OPN 8.4 cm, p=0.139) and median RENAL score (p=0.361) were similar. No difference was noted for positive margins (RPN 3.4% vs. OPN 1.1%, p=0.561), DeGFR (RPN -6.2 vs. OPN -7.8, p=0.543), and ≥90% eGFR recovery (RPN 54.1% vs. OPN 47.2%, p=0.504). RPN had lower blood loss (p=0.015), hospital stay (p=0.013), and Clavien ≥3 complications (RPN 5.1% vs. OPN 16.5%, p=0.041). Trifecta rate was significantly higher in RPN (47.5% vs. 34.0%, p=0.041). Multivariable analysis demonstrated decreasing RENAL score (OR 1.11, p&lt;0.001), RPN (OR 1.2, p=0.013), and decreasing EBL (OR 1.02, p=0.016) to be associated with Trifecta attainment. Conclusions: RPN provided similar functional and oncologic precision to OPN, while being associated with improvements in major complications, the latter of which was reflected in a higher rate of Trifecta achievement for RPN. RPN may be considered to be a first-line option for select patients with cT2aRM when feasible and safe.

An Update on Early Urological Complications in Kidney Transplantation: A National Cohort Study.

BackgroundThis study aimed to provide an update on the occurrence of early urological complications in living-donor and deceased-donor kidney transplantation (KTX).Material/MethodsData on all kidney transplant recipients in the Netherlands between January 2005 and December 2015 were retrieved from the prospectively collected Dutch National Organ Transplant Registry Database (NOTR). We assessed the incidence of major urological complications (MUCs) within 3 months after KTX, defined as urinary leakage and ureteral obstruction. Outcomes of living donor and deceased donor kidney transplants were compared. We performed regression analysis to identify predictive factors of urological complications and studied the influence of early urological complications on graft and patient survival. We performed an additional sub-study to explore the influence of preservation of the peri-ureteric connective tissue in living-donor KTX on the occurrence of urological complications.ResultsAmong 3329 kidney transplant recipients, urological complications occurred in 208 patients (6.2%) within 3 months after surgery. There were no significant differences in complication rates between recipients from living donors and deceased donors. Multiple regression analysis showed that older donor age and previous cardiac events of the recipient were predictors for the development of urological complications. Graft and patient survival were not affected by early MUCs. The additional sub-study showed that preservation of peri-ureteric tissue within living-donor KTX was not independently associated with urological complications.ConclusionsMany living- and deceased-donor KTX recipients have early urological complications. MUCs did not affect long-term graft or patient survival.

Meta-analysis of Early Versus Late Ureteric Stent Removal After Kidney Transplantation

BackgroundUreteral stents have been widely used in kidney transplantation to prevent postoperative ureter-related complications such as ureteral stricture, ureteral obstruction, and ureteral leakage; however, a longer indwelling ureteral stent time corresponds to a greater risk of complications such as urinary tract infections. Currently, transplantation centers have not yet reached an agreement on the time to remove ureteral stents. Several randomized controlled trials (RCTs) have evaluated the optimal removal time for ureteral stents. ObjectiveThis meta-analysis was designed to evaluate and discuss the optimal removal time for ureteral stents after kidney transplantation. MethodWe used key words to search PubMed, Embase, and Cochrane Library and retrieve published articles. A total of 568 kidney transplantation patients from 5 RCTs were included in this meta-analysis. We collected information regarding postoperative complications related to indwelling stents, such as ureteral stricture, ureteral obstruction, ureteral leakage, and urinary tract infection, and evaluated whether early removal of ureteral stents (≤7 days) was superior to late removal (≥14 days). ResultsA significant difference was observed in the incidence of urinary tract infection between the early removal group and the late removal group (risk ratio [RR] = 0.43, 95% confidence interval [CI] [0.32, 0.59], P < .01). No significant between-group difference was observed in the incidence of major urological complications (MUCs) (RR = 1.87, 95% CI [0.45, 7.70], P > .05). ConclusionEarly removal of ureteral stents of transplanted kidneys after kidney transplantation (≤7 days) did not significantly increase the incidence of postoperative MUCs (ureteral stricture, ureteral obstruction, and ureteral leakage) relative to late removal (≥14 days). Early removal may significantly reduce the incidence of postoperative urinary tract infection relative to late removal.

Patterns of complications following urinary tract reconstruction after multivisceral surgery in colorectal and anal cancer

BackgroundMulti-visceral resection, including parts of the urinary tract, is sometimes warranted to achieve cancer clear resection margins and optimize survival in patients with locally advanced colorectal and anal cancer. The aim of this study was to assess morbidity after urinary tract reconstruction dictated by colorectal and anal malignancy and to identify potential predictors of urological complications. MethodsAll patients undergoing surgery for colorectal or anal malignancy, including urinary tract resection and synchronous reconstruction, performed at the Karolinska University Hospital during 2004–2015 were included in this retrospective cohort study. Data was collected from medical records with follow-up until at least one year after the index surgery. Complications were graded according to the Clavien-Dindo classification system of surgical complications. ResultsThe study included 189 patients; 121 underwent cystectomy and 68 partial ureter resection. The rate of high grade urological complications was 22%. The risk of major urological complications was significantly higher in patients subjected to ureter resection compared to after cystectomy (OR 2.60, 95% CI 1.23–5.49). Also, preoperative radiotherapy and intestinal anastomotic dehiscence significantly increased the risk of high grade urological complications. ConclusionTo achieve potentially curative resections with uninvolved margins in patients with locally advanced colorectal and anal cancer, multi-visceral resection including urinary tract reconstruction can be performed with reasonable morbidity.

Routine Stenting of Extravesical Ureteroneocystostomy in Kidney Transplantation: A Systematic Review and Meta-analysis

BackgroundAlthough rare, major urologic complications (MUC) in kidney transplantation can cause significant morbidity, increased cost, and may even lead to graft loss. Ureteric stents are routinely used to prevent MUC, although complications related to their use have been reported. Here, we systematically reviewed the role of routine stenting in preventing MUC in kidney transplantation with extravesical ureteric implantation and performed a meta-analysis of 6 randomized controlled trials. MethodsA PubMed search was performed for studies on MUC and stents in kidney transplant recipients. Randomized controlled trials were shortlisted for the review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RevMan 5 was used for statistical analysis, and outcome analysis was done with Cochran-Mantel-Haenszel test using random effect model. ResultsSix trials meeting the criteria were identified. Although stent use did not decrease the incidence of urinary leak (odds ratio [OR], 0.39; 95% CI, 0.14–1.11; P = .08) or obstruction (OR, 0.41; 95% CI, 0.13–1.24; P = .11), it was associated with a higher incidence of urinary tract infection (OR, 3.59; 95% CI, 1.33–9.75; P = .01). ConclusionIn the present era of extravesical ureterovesical anastomosis, routine stenting has a limited role in decreasing major urologic complications and may be associated with higher incidence of urinary tract infections.

Externalized Percutaneous Stent Versus Internal Double J Stent: Short- and Long-term Complications After Kidney Transplantation

BackgroundIn patients undergoing kidney transplantation, ureteral stents are an established technique to reduce major urologic complications such as leakage and stenosis of the ureter. However, the best technique for ureteral stenting remains unclear. The aim of this study was to compare the outcome of percutaneous ureteral stents (PS) with internal double J stents (JJS) after kidney transplantation. MethodsAll patients undergoing kidney transplantation between 2005 and 2014 were retrospectively analyzed. After excluding patients <18 years old, patients without stenting, and patients who underwent multiorgan transplantation, a total of 308 patients were included in the study. Two consecutive cohorts of patients were compared. In the cohort transplanted between 2005 and 2010, stenting was routinely performed using PS (216 patients), and in the second cohort, those transplanted after 2011, stenting was routinely performed using JJS (92 patients). For ureteric anastomosis, the Lich-Grégoir technique was used in all patients. ResultsThere was no statistical difference in postoperative urinary tract infections (P = .239) between the 2 cohorts. In patients with PS, the incidence of major urologic complications (11.6% vs 3.3%; P = .018), vesicoureteral reflux (14.3% vs 2.2%; P < .001), and urologic reinterventions (14.4% vs 5.4%; P = .031) was significantly higher when compared with JJS patients. Multivariable logistic regression revealed increased incidence of major urologic complications (odds ratio [OR] 3.66, 95% confidence interval [CI] 1.07–12.55, P = .039) and vesicoureteral reflux (OR 5.29, 95% CI 1.21–23.10, P = .027) in patients with PS compared with JJS. ConclusionStenting of ureterovesical anastomosis using JJS is associated with reduced complications compared with PS after kidney transplantation.

Early versus late ureteric stent removal after kidney transplantation.

Kidney transplantation is the treatment of choice for patients with end-stage kidney disease. In a previous review we concluded that the routine use of ureteric stents in kidney transplantation reduces the incidence of major urological complications (MUC). Unfortunately, this reduction appears to lead to a concomitant rise in urinary tract infections (UTI). For kidney recipients UTI is now the commonest post-transplant complication. This represents a considerable risk to the immunosuppressed transplant recipient, particularly in the era of increased immunologically challenging transplants. There are a number of different approaches taken when considering ureteric stenting and these are associated with differing degrees of morbidity and hospital cost. This review aimed to look at the benefits and harms of early versus late removal of the ureteric stent in kidney transplant recipients. We searched the Cochrane Kidney and Transplant Specialised Register up to 27 March 2017 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register Search Portal and ClinicalTrials.gov. All RCTs and quasi-RCTs were included in our meta-analysis. We included recipients of kidney transplants regardless of demography (adults or children) or the type of stent used. Two authors reviewed the identified studies to ascertain if they met inclusion criteria. We designated removal of a ureteric stent before the third postoperative week (< day 15) or during the index transplant admission as "early" removal. The studies were assessed for quality using the risk of bias tool. The primary outcome of interest was the incidence of MUC. Further outcomes of interest were the incidence of UTI, idiosyncratic stent-related complications, hospital-related costs and adverse events. A subgroup analysis was performed examining the difference in complications reported depending on the type of ureteric stent used; bladder indwelling (BI) versus per-urethral (PU). Statistical analyses were performed using the random effects model and results expressed as relative risk (RR) with 95% confidence intervals (CI). Five studies (1127 patients) were included in our analysis. Generally the risk of bias of the included studies was judged low or unclear; they addressed the research question and utilised a prospective randomised design. It is uncertain whether early stent removal verus late stent removal improved the incidence of MUC (5 studies, 1127 participants: RR 1.87, 95% CI 0.61 to 5.71; I2 = 21%; low certainty evidence). The incidence of UTI may be reduced in the early stent removal group (5 studies, 1127 participants: RR 0.49 95% CI 0.30 to 0.81; I2 = 59%; moderate certainty evidence). This possible reduction in the UTI incidence was only apparent if a BI stent was used, (3 studies, 539 participants, RR 0.45 95% CI 0.29 to 0.70; I2 = 13%; moderate certainty evidence). However, if an externalised PU stent was used there was no discernible difference in UTI incidence between the early and late group (2 studies, 588 participants: RR 0.60 95% CI 0.17, 2.03; I2 = 83%; low certainty evidence). Data on health economics and quality of life outcomes were lacking. Early removal of ureteric stents following kidney transplantation may reduce the incidence of UTI while it uncertain if there is a higher risk of MUC. BI stents are the optimum method for achieving this benefit.

Early double J stent removal in renal transplant patients to prevent urinary tract infection - systematic review and meta-analysis of randomized controlled trials.

Ureteral stents are routinely used in renal transplant and are associated with reduced urological complications but increased urinary tract infections (UTIs). There is no agreement on the preferred time to removal of stents after transplantation. We performed a systematic review and meta-analysis of all randomized controlled trials (RCTs) comparing stent duration of <14days vs > =14days. Electronic databases were searched to identify RCTs that compared early vs late stent removal. Primary outcome was urinary tract infections. Secondary outcomes included various urological complications. No significant difference in UTI rates was demonstrated between short and long stent duration (relative risk (RR) 0.85, 95% confidence interval (CI) 0.44-1.64), with significant heterogeneity (I2 = 86%). Sensitivity analysis evaluating studies with low risk of bias for allocation concealment demonstrated statistically significant lower rates of UTI with short stent duration (RR 0.48, 95% CI 0.32-0.71) with no heterogeneity. No significant difference was demonstrated for the outcome of major urological complications (RR 0.72, 95% CI 0.50-1.05), without heterogeneity. Ureteral stenosis rates were significantly lower in the short duration arm (RR 0.42, 95% CI 0.18-0.98). Early removal of ureteral stents after renal transplant may be associated with reduced rates of UTI and ureteral stenosis. Additional RCTs are needed.