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Prof. M.A. Ghoneim, Urology & Nephrology Center, Mansoura, Egypt.
Objective To determine the incidence and management of urological complications after 1200 consecutive live-donor renal transplantations, all of which were carried out in one centre; the possible risk factors and the effect on patient and graft survival were also assessed.
Patients and methods Data were retrieved from an electronic database; the incidence of urological complications was determined, and correlated with relevant risk factors by univariate and multivariate analysis. The effect on patient and graft survival was assessed using Kaplan–Meier statistics.
Results There were 100 complications in 96 patients (8%); urinary leaks occurred in 37, ureteric strictures in 23 and lymphoceles causing ureteric obstruction in 17. Percutaneous needle biopsy was complicated by haematuria and clot anuria in six patients. Late complications included 11 cases of stones, four of bladder malignancy and two of haemorrhagic cystitis. There was evidence that the age of the recipients (< 10 years), method of establishing urinary continuity (uretero-ureteric anastomosis) and a high dose of steroids had an independent positive effect on the incidence of urological complications. However, their development did not influence graft or patient survival.
Conclusion When there is meticulous attention to the technical details, renal transplantation should incur few urological complications. Early intervention with percutaneous drainage reduces morbidity and the likelihood loss of graft function. Proper and prompt management should not affect the graft and/or the patient's survival.
The urological complications after renal transplantation have been addressed in many reports. With current improvements in graft survival concomitant with better immunosuppression, it would be unacceptable to lose a patient or graft as a result of technical issues. This is particularly important when dealing with living donors. In this contribution, the urological complications encountered after 1200 consecutive live-donor renal transplantations are described, with an analysis of the possible predictors and the different methods adopted in their management.
Patients and methods
Between 1976 and 1999, 1200 consecutive living-donor renal transplants were carried out for 892 male and 308 female patients (mean age 29.8 years sd 10.2, range 5–62; donors 34.9 years, sd 9.9, range 17–69). There were 1152 first, 46 second and two third transplants.
The graft was revascularized in a standard way; the renal vein was anastomosed to the side of the external iliac vein in most cases and the common iliac vein or inferior vena cava were used in children. For the renal artery, an end-to-end anastomosis with the internal iliac artery, or an end-to-side with the external or common iliac arteries were used.
The methods used for establishing urinary continuity were ureteroneocystostomy (Lich-Gregoire method in 999 and Politano-Leadbetter in 170), uretero-ureteric anastomosis in 25, pelvi-ureteric in three and an ileal conduit in three; ureteric stents were not used routinely. Their placement was indicated in cases with a difficult anastomosis and/or unhealthy bladder wall, usually seen in defunctionalized bladders. A Foley catheter was left in the bladder for 4–6 days. Suction drains were used routinely and removed within 72 h.
Several immunosuppressive regimens were used throughout the period of the study; initially they were azathioprine-based regimens (300 patients) and subsequently cyclosporin-based protocols (172 patients) but currently a triple-therapy approach is given (728 patients).
After surgery patients were monitored clinically, biochemically and radiologically. Different modalities were used to diagnose a urological complication; conventional ultrasonography, 99mTc-DTPA dynamic renal scintigraphy and aspiration of peri-graft collections, with determination of its creatinine content. Percutaneous nephrostomy with antegrade urography was carried out if indicated. Recently, newer imaging modalities (CT and MR urography) were also used. Further diagnostic and therapeutic procedures were dependent on the findings and the clinical course.
The data were stored in an electronic database. To determine the statistical significance of differences, the Pearson and chi-square tests were used. The survival of the graft and patients was computed using the Kaplan-Meier technique , with differences in survival calculated by the log-rank test , with P < 0.05 considered to indicate significance. Stepwise logistic regression was used for the multivariate analysis .
Overall, there were 100 complications in 96 patients, an incidence of 8% (Table 1); 60 intrinsic urological complications were recorded, presumably caused by the reimplantation procedures. There was extramural compression by a lymphocele in 17 patients and clot anuria after needle biopsy in six. Late complications (> 6 months after surgery) occurred in 17 patients, 11 from stone formation, four from the development of a bladder malignancy and two patients with haemorrhagic cystitis.
Table 1. Urological complications from 1200 renal transplantations
No. of complications
Clot anuria (after needle biopsy)
Late (> 6 months):
There were 37 cases of urinary leakage (Table 1); the conservative management of vesical leaks by prolonged catheter drainage was successful in six patients. Three patients (with ureters reimplanted by the Politano-Leadbetter technique) required open repair and closure in two layers. Several methods were used to manage ureteric leaks. For minor leaks at the VUJ, definitive treatment by percutaneous nephrostomy (PCN) drainage was attempted in 14 patients (Fig. 1). Two patients required subsequent reconstructive procedures. Open surgical revision was required in 16 patients. For distal pathologies, a uretero-vesical reimplantation was possible. Leaks resulting from more ischaemic damage of the ureter required either a uretero-ureteric anastomosis (five) (Fig. 2), a Boari flap ureteroneocystostomy (two) or an anastomosis between the renal pelvis of the donor's kidney and the ureter of the recipient (one patient). In one patient with total necrosis of the ureter, interposition of a segment of ileum between the renal pelvis and the bladder was necessary.
There were 23 cases of intrinsic ureteric obstruction; the site of obstruction was at the PUJ (two), middle ureter (three) and at the VUJ (18). Endourological management in the form of percutaneous drainage, antegrade dilatation and stenting was effective in three of seven patients for whom such an approach was used. However, for definitive management, open surgery was required in most (Table 2). A ureteroneocystostomy or a Boari flap was successful in six cases. Uretero-ureteric anastomosis was feasible in three patients. Resection anastomosis of the PUJ was used in two patients with PUJ obstruction (Fig. 3). Extensive strictures involving the whole ureter were treated by an ileal replacement in three patients (Fig. 4) or by a pyelovesical anastomosis in one.
Table 2. The management of intrinsic ureteric obstruction
No. of strictures
PCN ± stent
Boari flap ureteroneocystostomy
Replacement by an ileal ureter
Direct vesico-ureteric reimplantation
Resection/anastomosis of PUJ
There were six episodes of anuria after needle biopsy of the grafts; these were the result of haematuria and clot obstruction of the ureter. These were all treated successfully by temporary PCN drainage (Fig. 5).
Using conventional ultrasonography, a diagnosis of a peri-graft collection was established in 291 patients (24.3%). Of these, only 17 were large enough to cause extramural obstruction of the ureter. Initially aspiration with or without sclerotherapy using tetracycline was tried for all cases. Definitive treatment by marsupialization was required in 10 (Fig. 6).
There were 11 cases of stones; three were in the kidney, four in the ureter and four in the bladder. Notably all the vesical stones followed reimplantation by the Politano-Leadbetter procedure; of these, two were treated by endoscopic litholapaxy and two required cystolithotomy. Renal stones were treated by ESWL and one case required adjuvant antegrade ureteroscopy. Three patients passed their ureteric stones spontaneously and one required antegrade ureteroscopy (Fig. 7).
One patient developed carcinoma in situ of the bladder and was treated by intravesical chemotherapy. Three patients had infiltrating bladder tumours and required cystectomy and orthotopic bladder substitution (Fig. 8). Unfortunately, within 2 years of the cystectomy, they all died from distant metastasis.
Analysis of risk factors
The incidence of urological complications was correlated with several potential risk factors (Table 3). Three factors were significant; the patient's age, the method used to restore primary urinary continuity and the regimens of immunosuppression. The highest incidence of complications relative to age occurred among recipients who were < 10 years old. Uretero-ureteric anastomosis was associated with the highest incidence of urological complications, most of which were caused by urinary leakage (28%). Again, initial regimens of immunosuppression in which high doses of steroids were used were associated with the highest rate of complications (17.1%). These observations were confirmed by the multivariate analysis (Table 4). Recipients aged < 10 years, use of a uretero-ureteric anastomosis and the use of a high dose of steroids supported their significance as independent risk factors.
Table 3. The univariate analysis of possible risk factors for urological complications
Table 4. The multivariate analysis of possible risk factors for urological complications
Regression estimate (B)
Recipient's age (years)
Primary urinary continuity
In general, there was no effect of the variables assessed on graft or patient survival (Fig. 9). No graft loss was identified that resulted directly from a urological complication or from its management. However, long-term survival could not be achieved in the three patients who developed infiltrating bladder tumours.
The potential value of the present series is that it included many patients, all of whom received kidneys from living donors and underwent transplantation in one centre. The reported incidence of urological complications in large series is 2.6–15% [4–13]. This wide range probably reflects the method of reporting; some authors do not include lymphoceles as a urological complication [10–13], and others include UTI . Furthermore, the complication rate was slightly higher in patients who received kidneys from living donors than in those who received organs from cadavers [8,14]. This is presumably a result of more extensive hilar dissection required during harvesting from the living donor, with the attendant risks of injury to the blood supply of the ureter.
The most commonly reported urological complications are urinary leakage and/or ureteric obstruction; the reported incidence of the former is 1.2% [6,7] to 8.9% . In the present series, the incidence was 3.1%. Leakage from the urinary bladder was usually easily treated by prolonged catheter drainage. Almost half of the ureteric leaks were managed by percutaneous techniques. This is currently used as the initial management in all cases; open surgical revision can be used subsequently if this fails. The choice of the reconstructive procedure depends on the operative findings. Distal pathologies can be corrected by uretero-vesical reimplantation or a uretero-ureteric re-anastomosis. For more proximal lesions a pelvi-ureteric or a Boari tube can be used. In the present experience, the highest incidence of urinary leaks followed primary uretero-ureteric anastomosis, probably because the suture line could not withstand the stresses resulting from the significant diuresis encountered in some cases. This observation was also reported by others ; the recipient's ureter should be reserved for secondary procedures only.
The reported incidence of obstruction by intrinsic lesions of the ureter is 1.3%  to 10.2% ; in the present series, the incidence was 1.9%. Most of the obstructions involved the distal ureter or the VUJ. Various causes are possible in the pathogenesis of this complication. Ischaemia of the ureter , urinary leaks with peri-ureteric fibrosis , technical problems [6,12]and ureteritis resulting from acute rejection episodes [16,17] were all implicated. Percutaneous drainage with antegrade dilatation and stenting can be attempted initially but for failures, open surgical revision is necessary. Imaging techniques usually underestimate the extent of the pathology. Open surgical repair should involve the use of a healthy well-vascularized proximal segment. The choice of re-establishing the urinary continuity depends on the operative findings. Uretero-ureteric, pelvi-ureteric and pyelovesical anastomosis can all be used. The replacement of the ureter by an isolated ileal segment was successfully used in three patients in whom there was extensive ischaemic damage of the ureter.
The development of peri-graft lymphatic collections is not uncommon; Khauli et al. reported an incidence of 36%, most of which were small and resolved spontaneously. The source of lymph production is either the perivascular lymphatics of the recipient or the renal hilar lymphatics of the donor. These lymphatic channels must be avoided or meticulously controlled to minimize the possibility of developing such a complication. Active management of lymphoceles is only indicated if they are large enough to become symptomatic or cause an obstruction of the ureter. Percutaneous drainage with sclerotherapy can be tried initially, but if these measures are not sufficient, marsupialization by an open or laparoscopic procedure is then necessary.
Several studies have compared the incidence of complications relative to the technique of ureteroneocystostomy. In a retrospective study, Hakim et al. found no advantage with any specific technique. Other retrospective studies suggested an advantage for the Lich-Gregoire over the Politano-Leadbetter procedure [20–22]. In prospective randomized studies, Waltke et al. reported a higher incidence of ureteric obstruction with the end-to-side technique than with the Politano-Leadbetter method. Analysis of the data from Pleass et al. suggests that there is no difference in the incidence of major complications between the extravesical (Lich-Gregoire) and Politano-Leadbetter techniques. In the present experience, the rate of urological complications after the Politano-Leadbetter was 15.3% and was 6.6% after the Lich-Gregoire technique. Nevertheless, the difference was not significant in the multivariate analysis. It was observed that an important number of complications following Politano–Leadbetter method was due to vesical leaks. The highest rate of complications occurred following uretero-ureteric anastomosis. The volume of urine produced soon after surgery is unpredictable; if these are large the fresh suture line cannot withstand such a diuretic load and this can result in urine leakage. If this method is chosen, a stent or nephrostomy drainage must be placed. The patient's ureter should not be used during primary surgery but be saved for a secondary procedure if required.
Several authors advocate the routine use of ureteric stents and maintain that this would result in a lower incidence of urological complications, particularly urinary leaks and early postoperative obstruction [25–27]. This was confirmed in a randomized study by Benoit et al. but the use of stents is not without potential hazards. Degradation of the polyurethane stents, encrustation, migration and increased incidence of UTI are reported . A meticulously performed Lich-Gregoire anastomosis does not require stenting; stents were used sparingly and were inserted only if a difficult vesico-ureteric reimplantation was encountered. This usually occurs when ureters are reimplanted into a bladder which was defunctionalized for a long time. We also advocate the use of routine stenting if a uretero-ureteric or a pelvi-ureteric anastomosis is used as a primary procedure, to decrease the incidence of urinary leaks.
There is a correlation between the rate of urological complications and the steroid dose of immunosuppression . Furthermore, the rate of these complications was reduced when recent protocols with low-dose steroids were introduced . The present study confirmed these observations. Evidence was provided that the use of high doses of steroids can act as an independent factor in the pathogenesis of urological complications.
The potential impact of urinary bilharziasis has been addressed by several studies [29–33] with controversial conclusions. In the present series the rate of complications among patients with evidence of bilharziasis was 10%, while that among patients with no evidence was 7.4%; this difference was not statistically significant in the univariate analysis. All our transplant recipients are surveyed clinically and serologically for evidence of bilharziasis and if positive patients received one or more courses of praziquantel.
The incidence of urological complications in paediatric renal transplantation is relatively high . The high lumbar position of the transplanted kidney often dictates the use of a uretero-ureteric or a pelvi-ureteric anastomosis. These procedures are usually associated with a higher incidence of urinary leaks, as noted previously. In addition, the blood supply to the donor kidney, obtained from an adult, is relatively disproportionate. As a result, the blood supply to the ureter may be compromised. Furthermore, ureters are often reimplanted into neuropathic or pathological bladders with a history of PUV. Under such circumstances, bladder augmentation, if required, is carried out 8–12 weeks before the transplantation. The augmentation is constructed from a segment of ileum arranged in a ‘W’ configuration. The native ureter is implanted during the initial procedure using a serous-lined tunnel to provide the future antireflux mechanism . During transplantation the native kidney is removed and its ureter, which was already reimplanted, is anastomosed to the donor's ureter.
The present incidence of urinary calculi was 0.9%, which is within the range reported previously [36,37]. The incidence of urinary stone disease appears to be the same in transplant recipients as in the general population. Motayne et al. reported an incidence of 6.3%, but this could be explained by the use of stapled uretero-ureteric anastomosis; the staples act as a nidus for stone formation. There is an increased incidence of bladder calculi in pancreas/renal transplant recipients through the use of nonabsorbable suture in the pancreas-to-bladder anastomosis .
There were early suggestions that transplanting a kidney with multiple arteries is associated with an increased risk of urological complications such as calyceal or ureteric fistulae [39,40]; these reports were not confirmed in more recent studies . The present results confirmed that the incidence of urological complications has no relation with the number of renal arteries. Nevertheless, the use of a kidney with a single artery is generally preferred, with the condition that renal function is similar or nearly so on either side. If there is an important difference in clearance values, as determined by radioisotope renography, the kidney with the lower clearance is harvested irrespective of the anatomical findings .
The increased risk of neoplasia among renal transplant recipients has long been recognized . Penn reported that of all newly diagnosed tumours among organ allograft recipients, 2% will originate in the lower urinary tract . Gutièrrez et al. reported three cases of bladder tumour in 57 patients who developed neoplasia after transplantation. Buzzeo et al. reported six cases of bladder cancer; they calculated that renal transplant recipients have a relative risk of 3.3 of developing bladder cancer, compared with a similar cohort of the normal population. A higher incidence was also reported among the subpopulation of patients who had a kidney transplant as a result of analgesic nephropathy ; among 65 such kidney transplant patients, 10 (15%) had transitional papillary carcinoma of the renal pelvis, ureter and bladder. Four of the present patients (0.3%) developed bladder urothelial carcinoma; one had carcinoma in situ and three were infiltrating. The carcinoma in situ was treated by intravesical chemotherapy instillation and the remaining three by cystectomy and orthotopic bladder substitution using a urethral Kock pouch in one and an ileal-‘W’ neobladder with serous-lined extramural tunnel in two. In general, the results were unfavourable and none survived in the long term.
Although the incidence of haematuria after percutaneous needle biopsy of renal allografts is rare (through the use of atraumatic ultrasound-guided techniques) it may still occur. Rarely, the extent of bleeding will lead to the formation of blood clots which fill the renal pelvis and ureter, leading to obstructive anuria. To manage this situation PCN drainage of the kidney is the safest approach. The PCN tube is left until the clot is completely dissolved, as shown by the free passage of dye.
Haemorrhagic cystitis is a known complication of the long-term use of cyclophosphamide. In the early part of the present experience, cyclophosphamide was used in patients who developed hepatotoxicity as a result of azathioprine immunosuppression. These patient were converted later to a cyclosporin-based regimen and more recently to mycophenolate mofetil.
In conclusion, renal transplantation should incur few urological complications. If there is meticulous attention to the technical details during the bench preparation and/or the implantation procedure, with preservation of the ureteric vasculature, many important problems can be avoided. Stents can be used prophylactically in difficult procedures. Early intervention with percutaneous drainage of the kidney reduces morbidity, sepsis and the risk of losing graft function [48–50]. In general, proper and prompt management should not affect the graft and/or the patient's survival.