Transurethral incision of ureteroneocystostomy strictures in kidney transplant recipients

Authors


Dr R. Katz, Department of Urology, Hadassah Medical Center, Jerusalem, 91120, PO Box 12000, Israel.
e-mail: rank@cc.huji.ac.il

Abstract

OBJECTIVES

To report the treatment of patients who presented with vesico-ureteric stricture after kidney transplantation, using a minimally invasive endourological approach.

PATIENTS AND METHODS

Patients (10 men and four women, mean age 34 years, range 22–55) were assessed at presentation by serum creatinine level, ultrasonography and intravenous pyelography when the serum creatinine level was < 200 µmol/L. When there was hydronephrosis of the allograft a percutaneous antegrade pyelogram was taken, followed by inserting a nephrostomy. After decompression a stent nephrostomy was passed into the bladder and the strictures at the vesico-ureteric junction incised along the stent during cystoscopy.

RESULTS

All 14 patients were treated endourologically by an endoscopic incision through the bladder; 13 fared well and one died from sepsis and transplantation problems. The mean follow-up was 8 months.

CONCLUSIONS

Simple incision of the stricture via cystoscopy was safe and effective, and succeeded in most patients. The endourological management of ureteric lesions is feasible and is currently our first-line management of ureteric complications after kidney transplantation.

Abbreviation
VUA

vesico-ureteric anastomosis.

INTRODUCTION

Over the last 30 years kidney transplantation has been common worldwide. Urological complications are reported in 1.5–13% of patients in various series, including ureteric stricture and necrosis, urine leakage from a hole in the ureter or vesico-ureteric anastomosis (VUA), bladder perforation and compression of the renal unit by a lymphocele [1–3]. Patients may present with silent hydronephrosis and elevated serum creatinine levels, urine leakage (through the surgical drains, or urinoma formation), or pyonephrosis [4]. The diagnosis is supported by ultrasonography, IVU, renal isotopic scintigraphy and percutaneous antegrade pyelography [4,5].

These complications were often managed by re-operating, while percutaneous techniques were used as a temporary measure for drainage, improving renal function and treating infection. During the last two decades endourological intervention has become an accepted alternative for definitive treatment [5]. A common problem is stricture of the distal ureter at the VUA. The most common method for managing this problem is percutaneous antegrade stenting and balloon dilatation of the stricture [5]. We have used a different method, in which, after stenting, cystoscopy was used and the fibrotic area incised using electrocautery until a wide ureteric lumen was produced. We present our experience with patients referred to our service after renal transplantation. The goal of management in these patients was to use minimally invasive techniques, preserve renal function and avoid open surgery if possible.

PATIENTS AND METHODS

In all, 29 kidney transplant patients were treated in our department in the last 10 years for complications related to the ureter; 14 had a stricture at the VUA (10 men and four women, mean age 34 years, range 22–55). Eleven had a living unrelated allograft and three a cadaveric allograft. The patients’ records were reviewed for their transplantation type, course after transplantation and complications, clinical presentation, initial management, definite management and outcome.

The evaluation at the time of presentation included serum creatinine assay and ultrasonography; if the serum creatinine level was < 200 µmol/L IVU was used. A percutaneous nephrostomy was inserted and antegrade pyelogram taken. A cystogram was taken simultaneously to assess the length of the stricture and exclude bladder leakage. When a ureteric injury was diagnosed a stent nephrostomy was inserted through the stenotic area and into the bladder. Urine leakage was treated by 2–6 weeks of nephrostomy and/or catheter drainage. Ureteric strictures were incised through the bladder, using electrocautery to cut along the stent until a wide ureteric lumen was created. In one case the AcusizeTM device was used. A stent nephrostomy was left for 6 weeks, then changed again to a simple nephrostomy, and an antegrade pyelogram taken. After a satisfactory result the nephrostomy was closed for another 2–14 days after assessing the patient's urinary output and serum creatinine, and then removed. The follow-up assessment included serum creatinine levels and renal ultrasonography.

RESULTS

Four patients were transplanted at our institution using an unstented extravesical anastomotic technique. The exact anastomosis type created in other institutions was not available, but in three of the 10 patients stents had been used during the transplantation. Nine of the 14 patients had an unremarkable course immediately after transplantation; two had a febrile UTI, one urinary leakage and one acute rejection.

The clinical presentation varied; 12 patients presented with silent hydronephrosis and elevated serum creatinine levels, one with leakage and one with anuria. The median (range) time from transplantation to presentation was 1 (1–30) months. A percutaneous nephrostomy was placed in all patients at presentation and antegrade stenting used after the renal function improved, followed by an endoscopic incision of the strictured area. In 13 patients the treatment was successful and the VUA remained patent, with a mean (range) follow-up of 8 (1–30) months. One patient died in hospital from sepsis and transplantation problems.

DISCUSSION

Urological complications after renal transplantation have a significant effect on patient morbidity; most of these complications are attributed to the distal ureter and the VUA. Patients may present with urine leakage from a side hole in the ureter or from the anastomosis. Stenosis may involve the whole ureter [4,5] or the distal ureter [4,5] as described in the present series.

The main reasons for these complications are technical errors in the anastomosis and ischaemia of the distal ureter [1,4–6]. After harvesting the kidney from the donor the ureteric blood supply relies on branches from the renal artery. Extensive dissection around the distal ureter may denude the adventitia with its blood vessels and lead to ischaemia, which might result in sloughing and perforation of the ureter, or strictures [4,6,7].

There is controversy whether the technique of anastomosis affects the rate of complications. Most early series of kidney transplantation used the Leadbetter-Politano anti-refluxing technique, and later changed to the modified Lich-Gregoir extravesical technique, which is faster. However, this anastomosis is more prone to early leakage caused by technical errors [6]. Nane et al.[7] presented their experience with the unstented extravesical technique in 241 renal transplant recipients and noted five cases of leakage (attributed to technical error) and no strictures.

Butterworth et al.[3] compared the outcome of 140 kidney transplant recipients using the unstented Leadbetter-Politano technique in 108 consecutive patients in whom the stented Lich-Gregoir technique was used, and found that in the former group there was a higher rate of ureteric strictures and no difference in ureteric leakage or necrosis.

In our institution the extravesical approach is used routinely but in most patients, referred after transplantation abroad, these data were unavailable. Stenting of the transplanted ureter is also debated [6]. Pleass et al.[8] found no difference between the extravesical and the Leadbetter-Politano technique when both were unstented, as did Brantley et al.[9].

Domingez et al.[10], in a prospective randomized study, found no difference in the outcome of 280 transplant patients using the extravesical technique with or with no stent, yet Benoit et al.[11], also in a randomized prospective study, found that routine stenting of the extravesical anastomosis reduced the incidence of ureteric strictures and leaks. An important comment by Nicol et al.[12] indicated that in stented patients, ureteric perforation can be treated conservatively just by inserting a urethral catheter, avoiding percutaneous drainage or an open procedure. In the present series 11 of 14 patients had no stent; however, they were not a consecutive series of patients, but a selected group of referred failed cases.

Twelve of the present patients had silent deterioration of renal function and hydronephrosis. Transplant patients should be followed closely by measuring serum creatinine and by renal ultrasonography. There is no way to predict which patient will develop such a complication; nevertheless, patients who had an acute complication immediately after transplantation, e.g. leakage or infection, especially if they were re-operated, should be monitored carefully.

Eleven of the 14 patients received their allograft from a living donor. Cimic et al.[13] summarized their experience with 534 consecutive patients and reported a significant increase in leakage, but not strictures, in transplants from living donors, which they attributed to ischaemia of the distal ureter. The median time to presentation after transplantation in the present series was 1 month, in accordance with previous series showing that most complications appear during the first months after transplantation [4].

The initial management of these patients at presentation is drainage and decompression, usually by percutaneous nephrostomy [4–6]. Such management allows renal function to improve and controls infection, and further studies to locate the sight of injury (Fig. 1). Patients with leakage may be cured with drainage only.

Figure 1.

A nephrostogram of a transplanted kidney showing a kinked ureter and stricture at the VUA.

Retrograde stenting of the ureter is usually difficult, because of the location of the anastomosis and the presence of a stricture. Such management was recently described, with encouraging results, but required a long time in the operating room under anaesthesia [14].

Ureteric strictures, mainly in the distal ureter and VUA, may be managed endoscopically. Earlier series described percutaneous dilatation of the strictures with a success rate of 45–70% in a 12–24-month follow-up [15,16]. Endoureterotomy was used for benign ureteric strictures with a 62% success rate [17]. Our experience of the Acusize device in one case gave a good result but the procedure is difficult to control visually.

Incising the strictured area through the bladder under direct visual and fluoroscopic control is a simple and established method for managing strictures of the VUA in the native ureter, and may be adopted for the ureteroneocystostomy site, going up along the distal ureter. In the 13 patients who underwent this procedure the result was satisfactory (Fig. 2); the one death 4 weeks after the procedure was not related to it.

Figure 2.

The same patient as in Fig. 1 after stent-nephrostomy drainage and endoscopic incision of the stricture.

In conclusion, urological complications have a significant effect on the morbidity of transplant patients; most appear during the first months after transplantation and involve the distal ureter. Percutaneous nephrostomy and an antegrade pyelogram are essential for the diagnosis. Endourological management of the ureteric lesion is currently our first-line management of ureteroneocystostomy strictures after kidney transplantation.

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