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RESEARCH ARTICLE
Year : 2004  |  Volume : 20  |  Issue : 2  |  Page : 11-14
 

Ureteric complications in live related donor renal transplantation - impact on graft and patient survival


SGPGIMS, Lucknow, India

Correspondence Address:
A Srivastava
Department of Urology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Objective : The study was performed with an aim to determine the incidence of ureteric complications in live related donor renal transplantation, and to study the effect of ureteric complications on long term graft and patient survival.
Patients And Methods: Records of 1200 consecutive live related renal transplants done from 1989-2002 were reviewed. Twenty-six ureteric complications were noted to occur and treatment modalities employed were documented. In the non complication group sufficient data for evaluation was available in 867 patients. Survival analysis were performed using Kaplan-Meier techniques.
Results: The overall incidence of urological complications is 2.9%. Complications occurred at a mean interval of 31.9 days after renal transplantation. Ureteric complications occurred in 2% patients with stented and 7.7% patients with non stented anastomosis (p=0.001). Mean follow up following renal transplantation was 37.4 months. Survival analysis showed that ureteric complications did not increase the risk of graft fai lu re or patient death.
Conclusions: Ureteric complications in live related donor renal transplantation occurred in 2.9 % patients and did not impair graft and patient survival.


Keywords: Renal transplantation, ureteric obstruction, ureteric leak, vesico-ureteric reflux.


How to cite this article:
Srivastava A, Chaudhary H, Sehgal A, Dubey D, Kapoor R, Kumar A. Ureteric complications in live related donor renal transplantation - impact on graft and patient survival. Indian J Urol 2004;20:11-4

How to cite this URL:
Srivastava A, Chaudhary H, Sehgal A, Dubey D, Kapoor R, Kumar A. Ureteric complications in live related donor renal transplantation - impact on graft and patient survival. Indian J Urol [serial online] 2004 [cited 2019 Oct 21];20:11-4. Available from: http://www.indianjurol.com/text.asp?2004/20/2/11/37160



   Introduction Top


Ureteric complications have been reported primarily from centres with predominantly cadaver donor program [1],[2],[3] . Thus data on urological complications of renal transplantation in live donor setting is limited. It is also unclear whether ureteric complications have any impact on the patient and graft survival.

The aim of the study was to identify overall incidence of ureteric complications in live donor renal transplantation and to assess the effect of these complications on long term graft and patient outcome.


   Patients and Methods Top


One thousand two hundred consecutive live related renal transplants were done at SGPGIMS, Lucknow, India, from January 1989 to December 2002. Retrospective review of inpatient and follow up records of the transplant unit was done. All episodes of ureteric complications were recorded. Other non urological complications and episodes of acute or chronic rejection were noted. Patients were divided into 2 groups. Group 1 comprised of patients who suffered from ureteral complications. Group 2 included patients who did not have any ureteral complications. Variables noted were demographic profile of patients, warm ischemia time, and immunosuppressive regimens, mean serum creatinine at various post-operative intervals, post-operative surgical complications and combined patient and allograft survival. Failure of allograft was defined as need for another form of renal replacement therapy. Death with a functioning graft was considered as failure.

All donors underwent a standard preoperative workup. Preferably, the kidney was implanted in the right iliacfossa. Ureterovesical anastomosis was created by the anterior extra-vesical technique, as described by Lich R et al [4]. Polyurethane double pig tail stent (6Fr diameter and 16 cm in length) was used to splint the uretero-vesical anastomosis, in 714 cases. The stents were preferentially removed after 2 weeks. Suction drains were routinely used in all patients and removed once the 24 hour drainage was less than 50 ml.

Patients were monitored routinely with serum creatinine, blood urea nitrogen, leukocyte counts & chemical analysis of drainage fluid. Ultrasonography was done at 3 and 7 days postoperatively and repeated 3 monthly in the first year. When a urological complication was suspected grafts were evaluated using ultrasound, renography or antegrade pyelography when appropriate. Voiding Cysto- urethrography was done when vesico­ureteric reflux was suspected.

Continuous variables were reported as Mean Standard Error and compared using 'Student's t test'. Categorical variables were reported as number of patients (%of group studied) and were compared using Chi- square test and Fischer Exact Test. Odds Ratio(OR) was calculated with 95% confidence interval. Survival analyses were performed using Kaplan-Meier techniques & compared with log-rank tests. SPSS version 11 and NCSS version 6 program was used for statistical analysis. Values of p<0.005 were statistically significant.


   Results Top


Complete records and follow up of at least 1 year duration for analysis were available in 26 patients with ureteral complications (Group 1) and 867 patients in the non complication group (Group 2). The overall incidence of ureteric complications was 2.9%. Demographic profile was comparable in the 2 groups [Table - 1].

The duration of drainage was 6.2 days and 3.0 days in Groups 1 & 2 respectively (p=0.001). Hospital stay was 23± 4.2 days in Group 1 and 13±1.6 days in Group 2 (p = 0.01).

Anastomosis was stented in 714 and non- stented in 182 patients. Demographic profiles were comparable in the 2 groups [Table - 2]. Ureteric complications occurred in 2% & 7.7% patients in Groups 1& 2 respectively (p=0.001). However there were few stent related problems. Documented urinary tract infections occurred in 217 patients with stented anastomosis and 32 cases with non stented anastomosis, the difference being statistically significant (p=0.001, OR= 2.05, 95% Cl 1.35- 3.1). 2 patients had forgotten stents, in whom stent removal was done after 36 and 11 months respectively. There were no cases of stent encrustation, breakage or migration.

The most common complication was leak from the ureteroneocystostomy site, which was observed in 15(1.67%) patients. The complication occurred at a mean interval of 4.6 ± 2 days after transplant. In patients who had leak, ureteroneocystostomy was stented in 5 cases and non - stented in 10 cases (p<0.001). All patients were initially treated with prolonged catheterization. Leakage ceased in 9 patients with catheterization alone in a mean duration of 7.2 ± 1.4 days. In 5 cases with stented anastomosis leaks subsided with prolonged catheterization alone. In the rest 6 patients percutaneous antegrade stenting was done. However in 2 patients the leak persisted after antegrade stenting and required re-exploration. In both these patients there was ischemic necrosis of the ureter Ureteroneocystostomy was ossible in one patient. Second patient required a pyeloureterostomy with native ureter.

Ureteric obstruction due to ureteric stricture occurred in 7 patients. These patients were detected to have gradually increasing serum creatinine at a mean interval of 106­33 days after transplant. Ureteroneocystostomy was non stented in 5 of these patients and stented in 2 patients. (p=0.015) Antegrade balloon dilatation with stenting was done in all the patients. Stents were kept for 6 weeks. None of the patient required further intervention after removal of the stent.

There were 6 patients with symptomatic vesico-ureteral reflux and recurrent Pyelonephritis. Voiding cystourethrogram revealed reflux to be the cause of recurrent pyelonephritis in all. All patients were managed with long term antibiotic prophylaxis (mean duration of prophylactic antibiotics 14.4 months).

Mean follow up after renal transplantation is 37.4±22.2 months. No renal grafts were lost due to a ureteric complication. Kaplan- Meier curves for complication and non complication groups illustrate a comparable overall graft and patient survivals in two groups [Figure - 1] and [Figure - 2].


   Discussion Top


Current literature indicates a frequency of ureteric complications between 4 to 11% [2],[3],[5]. A higher incidence of urological complications has been reported in live related donortransplantation as compared with cadaveric donor transplantation [5] . It was proposed that vascular injuries at time of graft procurement are more common in live donor nephrectomy and result in postoperative ureteric complication. However in our series overall ureteric complication rate was 2.9%. Overzealous dissection at the renal hilum and ureter has been identified to cause ureteral ischemia and subsequent complications. Thus it has been our policy to avoid dissection in the triangle between renal vessels, ureter and lower pole of kidney avoiding damage to the ureteral vasculature present in the area. Since ureter receives majority of the blood supply from the graft, we use minimum required length of ureter at the time of anastomosis. These maneuvers decrease the ischemic injury to the ureter, as reflected in the low incidence of ureteral complications in our study.

Otherfactor which might have resulted in a low complication rate in our series is routine use of an extravesical approach of ureteric reimplantation which has been shown to be associated with a lower incidence of complications [6] . The authors contended that intravesical technique has a higher incidence of obstruction due to the reimplanted ureter kinking in the submucosal tunnel, and/or ischemic stenosis due to the greater length of ureter involved.

Most of the urological complications occurred early after renal transplantation (mean interval 31.9 days). This corroborates with similarfindings in otherstudies [1],[3]

All complications occurred in the distal third of the ureter, most often involving the ureterovesical anastomosis. Urinary leakage most commonly occurred due to technical reasons; however ischemic necrosis of distal ureter was the cause in at least 2 cases. Ureteral obstruction encountered in 5 cases could be due to ischemia with subsequent fibrosis or technical reasons.

Six patients developed symptomatic vesico-ureteral reflux. True incidence of vesico- ureteral reflux is however unknown as only symptomatic patients were subjected to voiding cysto urethrography. All patients were managed on longterm antibiotic prophylaxis.

Endoscopic management was the treatment of choice in patients with leak and obstruction. A trial of conservative management (prolonged catheterization) was given in all patients with low output urinary fistulas. This strategy was successful in 9 patients, including all 5 patients with stented anastomosis. In 6 patients percutaneous antegrade stenting was done, which was successful in 4 patients. An open surgical reconstruction was required in only 2 patients with urinary leaks. In patients with ureteric obstruction, percutaneous antegrade dilatation of the strictured segment was sufficient in all cases.

Role of routine ureteric stenting is debatable in the literature. Early on in our experience routine stents were not used. We evaluated the effect of ureteric stenting in a prospective randomized study and concluded that routine placement of stents was cost effective and almost eliminated urological complications [7] . Sincethen it has been our policy to use stents routinely in all cases. The use of stents though beneficial in reducing the incidence of ureteri complications, is fraught with possibility of complications like infection, encrustation/stone formation, migration or breakage of stents. These possible complications can be avoided by using the stents for the minimal possible duration. The optimal duration of stenting in renal transplantation is not yet established. In a case controlled study done at our centre we found that stenting for 2 weeks avoids complications of prolonged use of stents without compromising the benefits [8] .

At present the deleterious effect of ureteral obstruction on long term outcome of allograft is unknown. In rat model, unilateral ureteral ligation has been shown to increase expression of adhesion molecules, chemo attractants, TGF-a, increased tissue inhibitor of meta I loprotei nases, increased types I and IV collagenases and fibronectin [9] . These changes lead to extracellular matrix accumulation, a fore-runner for interstitial fibrosis. This cascade once established requires a lengthy time for normalization. Since events culminating in interstitial fibrosis are common in both experimental hydronephrosis and renal allograft rejection, it remains to be determined whether renal allograft hydronephrosis contributes to the process of chronic rejection [10] . We did not find a compromise in the overall graft survival in subjects who had ureteric complications as compared to the control group. This corroborates with similar findings in other studies [3],[5]


   Conclusions Top


Overall incidence of ureteric complication in our series is 2.9%. Ureteric complications though add to the morbidity of the recipient, do not influence the long term function of the graft and patient survival if promptly recognized and duly attended.

 
   References Top

1.Shoskes DA, Hanbury D, Cranston D, Morris PJ: Urological complications in 1,000 consecutive renal transplant recipients. J Urol, 153: 18-21, 1995.  Back to cited text no. 1    
2.Whang M, Geffner S, Baimeedi S, Bonomini L, Mulgaonkar S: Urologic complications in over 1000 kidney transplants performed at the Saint Barnabas healthcare system. Transpl Proc, 35:1375-7, 2003.  Back to cited text no. 2    
3.van Roijen JH, Kirkels WJ, Zietse R, RoodnatJl, Weimar W, ljzermans JN: Long-term graft survival after urological complications of 695 kidney transplantations. J Urol, 165: 1884-7, 2001.  Back to cited text no. 3    
4.Lich R Jr, Howerton LW and Davis LA: Recurrent urosepsis in children. J Urol, 86: 554, 1961.  Back to cited text no. 4    
5.Cimic J, Meulemar EJ, Costerhof JO et al: Urological Complications in renal transplantation : a comparison between living related and cadaver grafts. Eur Urol, 31: 433-5,1997,  Back to cited text no. 5    
6.Butterworth PC, Horsburgh T, Veitch PS, Bell PR, Nicholson ML: Urological complications in renal transplantation: impact of a change of technique. Br J Urol, 79: 499-502, 1997.  Back to cited text no. 6    
7.Kumar A, Kumar R, Bhandari M: Significance of routine JJ Stenting in living related renal transplantation: a prospective randomized study. Transplant Proc, 30: 2995-7,1998.  Back to cited text no. 7    
8.Verma BS, Bhandari M, Srivastava A, Kapoor R, Kumar A: Optimum duration of JJ Stenting in Live Related Renal Transplantation. IJU, 19: 54-7, 2002.  Back to cited text no. 8    
9.Diamond JR: Macrophages and progressive renal disease in experimental hydronephrosis. Am J Kidney Dis, 26:133-40,1995.  Back to cited text no. 9    
10.Diamond JR, Tilney NL, Frye J, Ding G, McElroy J, Pesek-Diamond I, Yang H: Progressive albuminuria and glomerulosclerosis in a rat model of chronic renal allograft rejection. Transplantation, 54: 710-6, 1992.  Back to cited text no. 10    


    Figures

  [Figure - 1], [Figure - 2]
 
 
    Tables

  [Table - 1], [Table - 2]



 

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    Abstract
    Introduction
    Patients and Methods
    Results
    Discussion
    Conclusions
    References
    Article Figures
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