Ureteral Necrosis Research Articles

MP79-18 DOES ROUTINE URETERAL STENTING IN KIDNEY TRANSPLANTATION REALLY REDUCE URETERAL COMPLICATION RATES?

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery I1 Apr 2015MP79-18 DOES ROUTINE URETERAL STENTING IN KIDNEY TRANSPLANTATION REALLY REDUCE URETERAL COMPLICATION RATES? Samuel C. Haywood, Chad A. Reichard, and Daniel A. Shoskes Samuel C. HaywoodSamuel C. Haywood More articles by this author , Chad A. ReichardChad A. Reichard More articles by this author , and Daniel A. ShoskesDaniel A. Shoskes More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2875AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The use of routine ureteral stenting with ureteroneocystotomy in renal transplantation is debated, although meta-analyses and Cochrane reviews have demonstrated advantage for routine prophylactic stenting. We compared the rate of ureteral complications in stented versus un-stented patients in a large cohort of recipients. METHODS We retrospectively analyzed transplant recipients from 2004-2014. Standard practice for ureteral stenting differs among surgeons at our institution, thus patients were grouped into stent, no stent, and “stent for cause” (SFC). This unique group includes patients who received a stent based solely on intraoperative findings. This study represents a large, single center experience of kidney transplant recipients sharing common post-operative management pathways. RESULTS A total of 1745 recipients were included in the analysis. Ureteral stenting was employed in 1246/1745 cases (71%), which included 1155 patients routinely stented (66% of overall cohort) and 91 SFC recipients (5% of overall cohort). 499 patients (29%) who did not receive a ureteral stent. Mean age was similar among groups – 49.4±12.5 yrs no stent, 48.5±14.5 stent, 49.7±13.1 yrs SFC (p=0.3). There were 35 ureteral complications in this cohort (2.0%) within 1 yr post op. There were 5/499 ureteral complications in the no stent group (1.0%), 28/1155 in the routine stent group (2.4%), and 2/91 in the SFC group (2.1%) (p=0.16). Complications were ureteral stricture in 21/35 (60%), anastomosis leak in 7 (20%), ureteral necrosis in 5 (14%), and other in 3 (6%). All cases involving urine leak (anastamotic leak, ureteral necrosis) in the no stent group required re-operation for revision of ureteroneocystotomy (3/3, 100%). In the groups with ureteral stent in place (stent, SFC), there were 9 total cases involving urine leak or ureteral necrosis. 4/9 (44%) were managed with initial reoperation. The remaining 5 received initial conservative management (indwelling urethral catheter, prolonged stent), of which 2 required eventual re-operation. As such, 3/9 (33%) complications with ureteral stents in place were able to be managed successfully without surgery compared to none in the non stent group; however, this did not reach statistical significance (p=0.24) CONCLUSIONS The overall ureteral complication rate in this cohort is low. Ureteral stenting in renal transplant recipients is not associated with differing rates of ureteral complications, however the presence of ureteral stent may allow for non-surgical management of urine leaks. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1017 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Samuel C. Haywood More articles by this author Chad A. Reichard More articles by this author Daniel A. Shoskes More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Use of Appendix for Renal Transplant Urinary Diversion After Complete Transplant Ureteral Necrosis: A 12-Year Follow-up

A 15-year-old African American male patient with a history of posterior urethral valves ablated as a newborn and who also had formation of an appendicopyelostomy at 3 years of age due to transplant ureteral necrosis subsequently underwent cadaveric renal transplant. At the time, this was a novel method for salvaging urinary diversion for the renal allograft previously reported in 2003. He most recently presented to Arkansas Children's Hospital for transplant rejection secondary to nonadherence with medications. We present an interval case report of a novel technique allowing a complicated cadaveric renal transplant to survive for 12 years.

Management of Urologic Complications in Renal Transplantation: A Single-Center Experience

IntroductionUreterovesical complications subsequent to renal transplantation are associated with a high morbidity leading to graft loss or even death. In the present study, the management of these complications by using interventional and surgical procedures (native pyeloureterostomy [NPUS]/ureteroureterostomy [NUU] vs ureteroneocystostomy [UNC]) was evaluated retrospectively. Patients and MethodsBetween 1994 and 2012, a total of 780 kidney transplantations (690 deceased and 90 living donors) were performed at our institution. Demographic, clinical, and laboratory data from patients with urologic complications were analyzed and compared. ResultsFifty patients (6.4%) exhibited ureterovesical complications, and 18 patients (36%) were operated on immediately. In 32 (64%) of 50 patients, an interventional procedure was initially performed, with 21 patients (66%) undergoing operation due to therapy failure. NPUS/NUU and UNC were performed in 26 (66.6%) and 13 (33.3%) patients, respectively. Indications for an operation were ureteral stenosis in 12 patients (30.8%), ureteral necrosis and urine leakage in 19 patients (48.7%), and symptomatic vesicoureteral reflux in 8 patients (20.5%). Long-term results were comparable between all groups. ConclusionsSurgical revision of ureteral complications should be the standard therapy. NPUS/NUU, UNC, and the successful interventional procedures did not differ significantly in terms of long-term results.

Ureteral complications after renal transplant in children: Timing of presentation, and their open and endoscopic management

We retrospectively reviewed the records of 24 consecutive patients undergoing treatment for ureteral complications after RTx in the period 2001-2012 to determine the timing of presentation of the complications, and their open or endoscopic management. Three patients (12%) had a necrosis of the transplanted ureter soon after RTx. All required open urinary diversion in a native ureter. Ten cases (42%) developed ureteral obstruction. Time of presentation was variable mainly in relation to the underlying cause. Endoscopic treatment was successful in two cases with urinary stones and open surgery in two with mid-ureteral obstruction. Six patients had VUJ stenosis, three underwent open reimplantation, whereas temporary double-J stent placement was successfully performed in the remainder. Eleven patients (46%) had VUR. It seldom presented in the first year after RTx. Endoscopic treatment was attempted in all and was successful in all the six cases without vs. only one of the five with lower urinary tract pathology (p = 0.01). Endoscopic treatment is an option in patients with VUR in the absence of lower urinary tract pathology. It is an option also for the treatment of stones and can be attempted in case of VUJ stenosis. Ureteral necrosis always requires open treatment.

Sometimes the communications are of special value

In everyday practice, emphasis should be put on a well–evidenced series of procedures over individual cases, even when these are accomplished successfully and spectacularly. Nevertheless, sometimes communication regarding “rare birds” is of special value, particularly in surgery, because with time they may become the swallow which makes the summer. In this issue of CEJU [1], authors from a highly laparoscopically–experienced center report a case of reimplantation of a strictured ureter in a transplanted kidney. It is a pity that data regarding only one case, followed–up for 3 years, is presented; however, the authors do acknowledge that up to now they have performed five procedures of this kind. Although complications after kidney transplantation associated with the anastomosis of the donor ureter to the recipient bladder rarely cause graft loss, they are usually complicated and difficult to treat. Depending on the definition used, the incidence of ureteral complications may vary from 2.4 up to 12.5% [2, 3]. The incidence depends on several conditions, including the quality of the organ retrieved for transplantation, the length and vascularity of the ureter, personal surgical technique (extravesical or intravesical anastomosis), the center's volume, and the option of ureteric stents to provide better outflow from the transplanted kidney to the bladder. The differential diagnosis between an early ureterocystoneostomy leak or distal ureteral necrosis and acute renal insufficiency may be difficult sometimes, and even life–threatening [4]. In most cases, open reimplantation is considered a second–line treatment after failed endoscopic attempts. It usually consists of antegrade double J stent placement and balloon dilatation, with a success rate of 44–62% [5]. Other endourologic methods of treatment, including–antegrade or retrograde endoureterotomy using electrocautery, laser or cold knife, offer greater success rates [6, 7]. As laparoscopy, with all its well–known benefits, successfully replaces the classical open approach, it was only a matter of time before being implemented in the treatment of ureteral strictures [7]. Based on personal experience, I fully agree with the authors that the most difficult step of the aforementioned procedure is to identify the ureter without compromising its vascularity. They used an intraoperative pyelography for the identification of the ureter. It is both a clever and elegant trick. However, one must remember that in cases of long ureteral strictures (>5–6 cm), a Boari flap or psoach hitch procedure may be necessary, possibly requiring more laparoscopic experience. It would be interesting to know what the authors usually consider a first–line treatment. My experience with an endoscopic approach is limited. All transurethral devices are designed for straight–forward working direction and do not allow for an attempt at ureterocystoneostomy located on the anterior wall. At times, this makes the localization or insertion of any guide–wire difficult or even impossible. The authors of this paper raised an interesting question regarding the best method of treatment of ureteral strictures following kidney transplantation and, with the presented case, they demonstrate a possible solution and approach for the future.

Urological Complications after Renal Transplantation - Therapeutical Management

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.

Impact à long terme des complications chirurgicales sur la survie du transplant rénal

To determine the incidence of surgical complications of renal transplantation at one institution, relate this to donor and recipient factors and to long-term graft survival. A consecutive series of 145 renal transplants were audited, and a database of donor and recipient characteristics created for risk-factor analysis. An unstented Barry-Sarramon anastomosis was the most used method of ureteric reimplantation. Lich-Gregoir anastomosis was used in 28.9% of cases. The mean follow-up time was 14.4 ± 6.23 years. There were 67 surgical complications including ten vascular, 39 urological and 18 parietal complications. Among urological complications, 13 were urinary leaks, four distal ureteric necrosis, 13 symptomatic ureteric reflux, six primary ureteric obstructions, and one ureteric stone at some time after transplantation. The overall incidence of urological complications was 26.2%. There was no association with recipient or donor age, cold ischaemic times before organ reimplantation, dialysis duration before transplantation, operating times, or ureteric stenting. Overall surgical complications had a significant pejorative impact on graft survival (Hazard Ratio [HR]=1.805; P=0.32), but as we studied them separately, we highlighted that in fact only vascular complications had an impact on long-term graft survival (HR=17.442, P<5E-10). There was no association between urological (P=0.566) or parietal (P=0.797) complications and long-term graft outcome. The onset of a urological or a parietal complication had no impact in this series on long-term graft survival. Vascular complications dramatically increase the rate of graft loss.

Urological complications after Kidney transplantation

Renal transplantation is a regular service at Tribhuvan University Teaching Hospital and complications have been known to occur after it. This study was conducted to assess complications after transplantation. To determine the incidence of urological complications after living related renal transplantation at Tribhuvan University Teaching Hospital. A clinical study was performed (from August 2008 to July 2010) which included 50 living-related renal transplantations at Tribhuvan University Teaching Hospital. All the donors and recipients were evaluated preoperatively with necessary investigations and followed up postoperatively with standard hospital transplant protocol. The incidence of urological complications were documented and analyzed. Fifty living-related, renal transplantations were carried out during the study period. Seven doors had minor post operative complications; three had post operative fever, two had chest infections and each one had superficial surgical site infections and severe pain at incision site. Ureteroneocystostomy was performed with double J stent in all recipients. Urological complications were noted in 12 (24%) recipients. Clinical significant hematuria occurred in four cases. One patient had ureteric necrosis and urinary leak which required re-exploration post operatively. Two patients developed delayed ureteric stricture which were managed by antegrade Double J stenting and ureteric reimplantation. Peri-graft abscess occurred in two cases, which were drained percutaneously. surgical site infections was seen in one case. Urological complications are inevitable in renal transplantation and our complications rate appears similar to that reported in literature.

Optimising expanded donor organs through dual kidney transplantation: a case-control study.

In order to take full advantage of ECD kidneys, which may not provide sufficient renal mass if used individually, it has been suggested that such organs be used in dual or bilateral kidney transplantation (DTx). We analysed the experience in a single hospital between May 2007 and March 2011 in a case-control study. Criteria for determining whether to perform single or dual Tx were defined in a protocol in which the biopsy score was important, but not the only factor. Donor's age, medical history, kidney size and creatinine clearance were also considered. During this time period, 80 kidneys from donors over age 65 were transplanted. Single transplants (STx) accounted for 40 of the organs, and another 40 were used in DTx. Mean donor age for STx was 68.7 ± 3.0 years; for DTx, it was 74.2 ± 4.3 years (P<.001), with more female donors for DTx (75%) than for STx (40%) (P<.001). There were no differences between groups with regard to glomerular filtration rate or proteinuria. Kidneys assigned to DTx received higher biopsy scores than those assigned to STx (2.95 ± 1.01 vs 1.8 ± 1.04; P<.001). DTx recipients were older than STx recipients. There were no differences between the groups regarding cold ischaemia time, delayed graft function, haemorrhagic complications or re-surgeries. However, DTx recipients achieved better creatinine clearance at 1, 3, 6 and 12 months, although the difference was only statistically significant at 6 months (53.4 ± 19.5ml/min vs 44.5 ± 15.6ml/min; P<.05). Renal artery thrombosis appeared in 2 STx patients and in both kidneys of 1 DTx patient. Another 2 patients in the DTx group each lost 1 kidney due to thrombosis and ureteral necrosis respectively, but were able to remain dialysis-free. Graft survival at 3 years was 90% for both groups. During the study period 3 patients died (2 in the STx group and 1 in the DTx group). Our preliminary experience indicates that DTx provides good results in terms of survival and renal function data, despite surgery being more complicated and the organs having characteristics that probably make them unsuitable for STx. The decision to perform DTx makes using ECD kidneys easier, and it should be based on a combination of pre-transplant histological criteria and the donor's clinical characteristics.

Acute renal failure due to bilateral ureteric necrosis following percutaneous chemical lumbar sympathectomy

We report a case of acute renal failure as a result of obstructive uropathy as a consequence of instillation of phenol used for chemical sympathectomy in Beurger's disease of the lower limbs. Extensive bilateral ureteral necrosis occurred as a result of phenol instillation that. Such practices are still common among the general surgeons and such a complication has not been described before.

Ureteral replacement with appendix in pediatric renal transplantation

Ureteral necrosis is an uncommon complication following RT which can adversely affect outcome. Even though authors agree that the native ureter ought to be preserved, there are cases in which graft function can only be salvaged by ureteral substitution. The scant references in the literature on the use of the appendix for left ureteral replacement in children prompted us to report the following two cases in whom the technique was employed and to assess the evolution of graft function in these patients.

Treatment of ureteral complications after kidney transplantation with native ureteropyelostomy reduces the risk of pyelonephritis

Urological complications contribute to morbidity and graft loss after kidney transplantation. Aim of this study was to assess the role of revisional surgery on patient outcome. From 1997 to 2007, 887 patients underwent kidney transplantation in our institution. Clinical data of patients with urological complications were analyzed. Ureteral complications were observed in 50 of 887 (5.6%) recipients, including ureteral necrosis (0.9%), stenosis (3.6%) and ureteral reflux with recurrent graft pyelonephritis (1.1%). Thirty-five patients underwent native ureteropyelostomy, and 14 patients had redo-ureterocystostomy. All patients treated for recurrent graft pyelonephritis had no further episodes. Overall, the rate of ureteral stenosis was significantly higher after secondary surgery, compared to the primary anastomosis (10% vs. 3.6%, p = 0.039). A significantly lower incidence of graft pyelonephritis was observed in patients after native ureteropyelostomy compared to patients treated with redo-ureterocystostomy (p = 0.019). In conclusion, reflux and recurrent graft pyelonephritis can be treated effectively by secondary surgery. The use of native ureteropyelostomy may offer protection from graft pyelonephritis after secondary surgery.

Surgical Complications in 2000 Renal Transplants

Introduction Renal transplantation is the best treatment for end-stage renal disease. In the last years, we have seen improvements in immunosuppressive treatment, which have allowed patients to experience a better quality of life and graft survival. Nevertheless, surgical complications remain important problems that increase morbidity, mortality, costs, and hospitalization. Our purpose was to evaluate surgical complications among a large series of 2000 renal transplantations. Patients and Methods We retrospectively analyzed all surgical complications among 2000 renal transplants performed between June 1980 and March 2010 in our department. Results Among 318 (15.9%) surgical complications, 4.8% of patients had urologic problems. Ureteral stenosis and fistula, stent obstruction, and ureteral necrosis occurred in 2.7%, 1.8%, 0.1%, and 0.2% of patients, respectively. Vascular complications reported in 2.7% of patients included arterial or venous thrombosis (1.0% or 0.4%), both arterial and venous thrombosis (0.1%), renal infarction (0.1%), renal artery aneurysm (0.1%) as well as arterial stenosis (0.5%), kinking (0.4%), or dissection (0.1%). Other complications, not specifically related with transplantation surgery, occurred in 4.4% of patients. Conclusion Renal transplantation is a safe surgery by experienced teams. Our rates of surgical complications were within those reported by other series. A meticulous surgical technique is mandatory to prevent them. Prompt diagnosis and management are required to prevent graft damage and patient morbidity.

Should Routine Pyeloureterostomy be Advocated in Adult Kidney Transplantation? A Prospective Study of 283 Recipients

Ureteroneocystostomy surgical techniques have been repeatedly debated in the medical literature, in contrast to pyeloureterostomy, which is merely considered a salvage procedure. We assessed urological complications and their management after routine pyeloureterostomy in adult kidney transplantation cases. We performed a 2-center, uncontrolled, prospective study from January to December 2007. We compared results in 151 consecutive kidney transplantations with routine pyeloureterostomy (group 1) and in 129 procedures with extravesical anti-reflux ureteroneocystostomy (group 2). Perioperative ureteral stenting was done on demand in each group. Major complications included complex leakage, stenosis and surgical revision. Transient leakage or obstruction less than 15 days in duration were considered minor complications. Recipients in group 1 were more likely to undergo ureteral stenting on demand than those in group 2 (68.9% vs 21.7%). The incidence of overall complications was similar in groups 1 and 2 (9.3% and 13.2%, respectively, p = 0.15), although the major complication rate was higher in group 2. Group 1 recipients had a tendency to require long-term ureteral stenting more often. The only recipient with ureteral necrosis in group 1 was treated with surgical resection and repeat end-to-end ureteroureterostomy. In each group no graft was lost due to urological complications or their management. Routine pyeloureterostomy is a safe technique that may be a valuable alternative to ureteroneocystostomy for adult renal transplantation. It does not preclude further open re-intervention. Its main advantages include a significant decrease in the risk of surgical re-intervention, the opportunity to perform further endourological procedures on the allograft urinary system and the avoidance of vesicoureteral reflux.

Successful urinary tract reconstruction following ureteral necrosis in kidney transplant patient

Abstract Ureteric complications following renal transplantation are well known to cause significant morbidity and compromised graft survival. The necrosis of a major part of the ureter could be a highly detrimental situation, and hardly solvable complication, that poses great challenges. Herein we are presenting a case report to introduce a possible surgical solution following repeated ineffective radiological interventions, in a patient with ureteric necrosis that appeared 3 months after cadaveric kidney transplantation. We transplanted the right kidney to the right iliac fossa performing end-to-side vascular anastomoses and end-to-side uretero-ureterostomy. His clinical course was uneventful during 3 months, when he presented a mild borderline acute cellular rejection together with dilatation of the pyelon. Percutaneous nephrostomy was performed by interventional radiologist. During further radiologic interventions the stenosis was not permeable. We finally made up our minds for surgical solution. We found a totally necrotized graftureter. During a second operation we performed a right nephrectomy, transsecting the pyelon. After mobilization of the transplanted kidney approaching and identifying the pyelon, a large pyelopyelar anastomosis was performed with stenting. The postoperative follow-up showed excellent urine flow from the kidney to the bladder, then the TRD was removed. Surgery had to be considered only if minimally invasive procedures are infeasible or ineffective. A regimen of reconstructive methods are well-known, but all cases have to be evaluated individually. If the native kidneys can be removed, their pyelons and entire ureters should be used for reconstruction.

Outcome of renal transplant in patients with abnormal urinary tract

To determine whether surgical procedures of the lower urinary tract in patients with uropathies affect evolution of the graft in renal transplantation. 156 kidney transplantations were performed in 150 patients with end-stage renal failure due to urologic disorders. The patients were classified into three groups: A, patients who did not require surgery in the lower urinary tract; B, required surgery and preserved adequate bladder function, and C, required surgery due to vesical dysfunction. Graft survival rates at 1 year were 93.38% in group A, 95.45% in group B and 93% in group C. Rates at 5 years post-transplantation were 82.45, 79.85 and 86.58% for each group, respectively (not significant). Complications were vesicoureteral stenosis: 2 in group A, 3 in B and 1 in C; vesicoureteral reflux: 1 in group A, 1 in B and 10 in C; distal ureteral necrosis: 2 cases in group A, 2 in B and 1 in C; upper urinary tract infection: 12, 23.1 and 42.2% in each group, respectively. Children with reconstructed urinary tract may be good candidates for kidney transplantation despite the higher frequency of urinary infections. Thus, careful and strict post-surgical urologic follow-up is mandatory.

Reply

The indication to apply nephrocutaneous bypass should primarily cover patients with malignant ureteral obstruction, a life expectancy of <12 months, and reduced general conditions. In particular clinical circumstances, this method may be a useful alternative also for long-term urinary diversion in patients with a less reduced life expectancy, including etiologically nonmalignant ureteric obstruction or lost/severely impaired ureteric functionality. Several reports cover this benign subgroup of thoroughly selected patients, and the respective indications include aortic aneurysm, retroperitoneal fibrosis, and ureteral necrosis after kidney transplantation.

Renal transplantation in children: Critical analysis of age related surgical complications

To determine age-related risk factors of urological and vascular complications. We performed a retrospective analysis of the data of 202 renal transplantations in 193 children between 1989 and 2007 at a single institution. Out of 193 grafts (combined renal and liver grafts were excluded), we observed urological complications in 42 cases (21.7%) leading to graft loss in one case and vascular complications in 27 cases (13.9%) leading to graft loss in seven. The urological complications were VUR (n=25, 12.4%), ureteral stricture (n=10, 5%), anastomotic leak (n=4, 2%), ureteral necrosis (n=2, 1%), and incrustative pyelitis (n=1, 0.5%). Vascular complications were arterial stricture (n=14, 7.2%), arterial thrombosis (n=4, 2%), venous thrombosis (n=2, 1%), and others (n=7). Donors aged less than six yr were a risk factor of vascular complications leading to graft loss (p=0.0001), whereas patients with PUV had more urological complications (p=0.001). Overall patient and graft survival is 93.1% and 84% at five yr, respectively. Surgical complications remain a major cause of graft loss (12%) and morbidity in children's kidney transplantation (38.9%). Young age of donors is the major risk factor of early graft loss as a result of vascular complication. However, donor selection based on age is limited by the shortage of organs.

Comparison of urological complications with primary ureteroureterostomy versus conventional ureteroneocystostomy

Urological complications after kidney transplantation may be serious and carry a high risk of graft loss. The purpose of this study was to compare urological complications with primary ureteroureterostomy versus conventional ureteroneocystostomy retrospectively. Between December 1993 and April 2008, 1287 kidney transplants were performed at our institution. Urological complications such as urine leakage, ureteral obstruction and vesicoureteral reflux (VUR) were summarized according to the different ways of urinary tract reconstruction, ureteroureterostomy (U-U) and ureteroneocystostomy (U-C). Overall, urological complications were encountered in 94 (7.3%) cases, including urine leakage (n = 44, 3.4%), ureteral obstruction (n = 36, 2.8%), VUR (n = 14, 1.1%). Seventy-six cases (7.8%) were in the U-C group and 18 cases (5.8%) were in the U-U group. Ninety-three recipients were successfully treated, and one lost the graft because of pelvis and ureteral necrosis. There was no recipient loss secondary to these complications. In conclusion, U-U does not change the overall incidence of urological complications comparing to U-C, but it can decrease the incidence of urine leakage. It is a good first option with a greater possibility of resolving a ureteral stenosis with endourology and no risk of reflux.

Transplantation rénale à partir de donneurs vivants prélevés sous laparoscopie assistée par robot. À propos d’une série de 35 cas

Renal transplantation with living donor is actually the best technique for renal replacement therapy, particularly with the problem of shortage of organs. Laparoscopic nephrectomy is actually developed because of low surgical mortality and morbidity. Our medical centre uses an original removal method: robot-assisted laparoscopic donor nephrectomy. We report our 35 first robot-assisted kidney removals at our centre. After a precise preoperative evaluation, all donors choosed robotic-assisted laparoscopic surgery. The mean hospitalitalization duration was 5,5 days. The serum creatinine level reached respectively 107, 104, 91, 71micromol/l within a period of 1, 2, 3 and 4 years after the operation. None of the recipients required post-transplant dialysis. No vascular complication was listed. The urological complications observed were: six lymphoceles, one ureteral stenosis and one ureteral necrosis. Ten patients (29% of the recipients) showed 16 biopsy-proven episodes of acute rejection. All donors and recipients were alive after a mean graft survival of 3,8+/-1 years. Thirty-four grafts fared well with an average serum creatinine level respectively of 107, 124, 125micromol/l at 1, 2, 3 and 4 years after transplantation. Considering the very low morbidity rate and the positive long term results for donors as well as for recipients, robot-assisted donor laparoscopy seems to be a safe and efficient surgical technique. By offering optimal operative conditions to the urological surgeon, it would serve as a favourable alternative to the present kidney graft shortage.