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Year : 2010  |  Volume : 26  |  Issue : 3  |  Page : 450-453

Transplant ureter should be stented routinely

Departments of Urology and Kidney Transplant, Fortis Hospital, Vasant Kunj, New Delhi-110 070, India

Date of Web Publication1-Oct-2010

Correspondence Address:
Anant Kumar
Departments of Urology and Kidney Transplant, Fortis Hospital, Vasant Kunj, New Delhi-110 070
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-1591.70594

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Vesicoureteric complications present early after transplantation and contribute to patient morbidity, graft loss and mortality. Ureteral stenting provides a decrease in ureteroneocystostomy anastomotic complications following renal transplantation. There should be prophylactic stent insertion with endoscopic removal at a designated time post transplantation. With the addition of antibiotic prophylaxis post transplantation, ureteric stenting does not increase the rate of urinary tact infections. There is no significant increase in cost for stenting during transplantation in comparison to management of major ureteric complications. Routine stenting causes significant cost-saving per year and prevents anastomotic complications. It is wise to stent the transplant ureter routinely.

Keywords: Stent, transplant ureter

How to cite this article:
Mongha R, Kumar A. Transplant ureter should be stented routinely. Indian J Urol 2010;26:450-3

How to cite this URL:
Mongha R, Kumar A. Transplant ureter should be stented routinely. Indian J Urol [serial online] 2010 [cited 2021 Dec 7];26:450-3. Available from:

   Introduction Top

Kidney transplantation is the treatment of choice for end-stage kidney disease. Ureteroneocystostomy anastomotic leakage and/or strictures complicate 3-9% of all renal transplants. [1],[2],[3] These urinary complications remain the most common technical complication associated with contemporary renal transplantation. [2],[3],[4] Numerous studies have addressed the issue of routine anastomotic stenting in renal transplantation in an attempt to decrease the rate of urinary complications but the debate continues. [5],[6],[7],[8],[9],[10],[11],[12],[13] Many selectively stent only difficult anastomosis or in circumstances where the vesicoureteric viability may be additionally compromised. Vesicoureteric complications present early after transplantation and contribute to patient morbidity, graft loss and mortality. It has been our policy to use stents routinely in all cases.

We would like to address the following three categories:

   Prevention of Major Ureteric Complications-Prevention is Better than Cure! Top

Initially, ureterovesical anastomosis was done using a transvesical Leadbetter-Politano approach which is presently superceded by the extravesical ureteroneocystostomy (Lich-Gregoir) approach. [14],[15],[16] Refinement in surgical techniques and the introduction of new immunosuppressive protocols resulted in a significantly decreased incidence of urological complications from around 20% in the 1970s to less then 5% in the 1990s.[17],[18],[19],[20] Vesicoureteric complications present either as urine leaks, ureteric stenosis or obstruction (major urological complications (MUC)). In the absence of technical complications, ureteric ischemia is thought to be chiefly responsible for the early ureteric complications post transplantation. [21] Minor ureteric leak and obstruction have been successfully treated with "double-J" stent insertion, prompting surgeons to contemplate its use as a prophylactic measure in transplantation and other urological procedures.[22] Major urological complications (MUCs) mostly originate from the vesicoureteric anastomosis, present early after transplantation (within three months), [23] and could contribute to patient morbidity, graft loss and mortality. [24] Patients with urinary anastomotic complications have significantly longer hospitalizations in the first year of transplantation. The readmissions suggest that patient-specific morbidity is directly related to the anastomotic complication and graft dysfunction. Fluid balance abnormalities may develop which manifest as fluid overload and increased acute cardiac events. Urinary tract (UT) and non-UT infectious complications are also significantly increased in this patient population. Acute renal failure is almost 2.5 times more likely to develop in patients with urinary anastomotic complications. The increased patient morbidity associated with urinary anastomotic complications translates into increased costs.

Conventional native ureteric repairs over stents are widely accepted to have a better outcome. [25] In addition they have been successfully used in pyeloplasty, ureterovesical reconstruction and in the management of stone disease.[26],[27] There are many theoretical benefits of prophylactic stenting. A stent has been reported to make the anastomosis technically easier to perform and the final luminal diameter may be larger. [8] A stent probably avoids ureteral bending, kinking or external compression from perigraft fluid collections. Stenting may eliminate compression from a tight submucosal tunnel and equalize ureteral and bladder pressure, facilitating urine drainage during the high diuresis experienced in the early post-transplantation period. Finally, the stent physically traverses the anastomosis, preventing urinary extravasations though potential gaps in the suture line or small areas of necrosis and effectively decreasing the risk of urinary complications. Moreover, prophylactic stenting can treat minor leaks and obstruction at the anastomotic site. Routine stenting was clinically demonstrated to improve renal function in the early postoperative period in a prospective, randomized study. [6] Perigraft fluid collections were also shown to be significantly decreased with stenting; [8] similarly the drain output is significantly less when intraoperative drains are routinely placed around the transplant graft. [5]

In all randomized and quasi-randomized controlled trials looking at the use of double-J stents to prevent urological complications, the incidence of MUCs ranged between 0 and 5% in stented patients (median 1.0%) and between 0 and 17.3% (median 7.0 %) in the non-stented patients [Table 1]. [5],[6],[7],[8],[9],[10],[11] A three-phase longitudinal study done in the year 2000 included 670 consecutive living related renal transplants. In Phase 1, a stent was introduced as and when required. Only 15 of 170 patients were stented. In Phase 2, 57 and 43 cases were randomized to stenting and no stenting, respectively. The stent was removed after four weeks. In Phase 3, all patients received a stent, which was removed 10 to 14 days just before discharge. In Phase 1 the major ureteral complication rate was 8.8%, which decreased to 3% in Phase 2 when half of the cases were stented. In Phase 3 there was only one ureteral complication (0.04%) in 400 patients, of whom all received a stent. The overall ureteral complication rate in non-stented and stented cases was 8.5% (18 of 213) and 0.22% (1 of 457) respectively. [23]
Table 1 :Major urological complications

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   Complications of Stenting Top

The most significant theoretical complication in the use of a stent is an increase in the number and severity of urinary tract infections (UTIs). Other possible complications include persistent hematuria, bladder discomfort, stent migration, breakage, encrustation and complications during removal. Most centers have adopted a policy of prophylactic stent insertion with endoscopic removal at a designated time post transplantation in an effort to reduce the rate of MUCs. [28] UTIs, in general, were more common in stented patients unless the patients were prescribed cotrimoxazole in which case the incidence was equivalent. Stents appear to be generally well tolerated, although studies using longer stents (20 cm) for longer periods (> six weeks) had more problems with encrustation and migration. 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, it was found that stenting for two weeks avoids complications of prolonged use of stents without compromising the benefits. [29] In a similar study it was suggested that the routine use of a double-J stent for ureterovesical anastomosis neither significantly increased UTI rates, nor decreased the incidence of urinary leaks, but may decrease the gravity of the latter as evidenced by the need for surgical intervention. [30]

The maximum reported non-infectious complications were irritative symptoms 5.6%, [9] breakage 2.0%, [6] migration/malposition/expulsion 7.4%, [9] encrustation/urolithiasis 5.7% [5] and "forgotten" stents 7% [8] [Table 2]. Earlier removal of stent at two weeks does not increase morbidity (rate of urological complica­tions) in transplant recipients and prevents stent-related complications associated with prolonged use of stent. It obviates the risk of forgotten stents as well as curtails the cost of second admission for stent removal. [29] There is no evidence that the presence of a stent predisposes to recurrent or severe hematuria.
Table 2 :Non-infectious complications

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In another study it has been suggested that ureteral stasis may cause tubuloepithelial injury and slow down the decrease in creatinine levels. They concluded that Double J Stent (DJS) did not increase UTIs but provided a smooth decline in creatinine levels, which may reduce the question of acute rejection. [31]

   Inpatient Hospital Cost of Major Urological Complications vs Routine Stenting Top

The incremental inpatient hospital costs associated with a urinary complication during the first 12 months following renal transplantation were 145% of the cost of renal transplantation without this complication. Notably, this value does not include inpatient hospital indirect costs, any expenses generated on an outpatient basis or elsewhere, or any inpatient or outpatient professional costs. Thus, the actual incremental cost associated with a urinary anastomotic complication following renal transplantation is significantly higher than this value. [32] There is no significant increase in cost for stenting during transplantation except the cost of stent which costs a few hundred rupees and can be electively removed at the time of discharge avoiding second admission. This causes significant cost saving per year and prevents anastomotic complications and avoids the morbidity of prolonged stenting.

   Meta-Analysis Top

A recent meta-analysis evaluated five prospective, randomized, controlled clinical trials of routine stenting following renal transplantation and indicated that the collective urinary complication rate following routine stenting was 1.5% compared to 9% without stenting (OR 0.24, P <0.0001). [1] The OR for urinary complications with routine stenting varied among these five prospective studies at between 0.02 and 0.53 with three of the five demonstrating statistical significance independently. [5],[6],[7],[8],[9] Similarly, a Cochrane review evaluated these five series and included two additional prospective, randomized series. The study concluded that the collective urinary complication rate following routine stenting was 1.0% compared to 7.0% without stenting (OR 0.24, P = 0.02). [12]

   Conclusion Top

The review of the literature appears to tilt the balance heavily in favor of routine prophylactic stenting in renal transplant recipients. Transplant units currently using antibiotic regime as prophylaxis for pneumocystis carnii should not notice an excess of stent-related infections. The use of an appropriate size of stent and early removal at two weeks prevents morbidity and stent-related complications. It is wise and cost-effective to stent the ureteroneocystostomy after transplantation.

   References Top

1.Mangus RS, Haag BW. Stented versus nonstented extravesical ureteroneocystostomy in renal transplantation: a meta-analysis. Am J Transplant 2004;4:1889-96.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Englesbe MJ, Dubay DA, Gillespie BW, Moyer AS, Pelletier SJ, Sung RS, et al. Risk factors for urinary complications in renal transplantation. Am J Transplant 2007;7:1536-41.   Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.DuBay DA, Moyer AS, Englesbe MJ, Sung RS, Pelletier SJ, Magee JC, et al. Predictive factors for ureteral complications after renal transplantation. Am J Transplant 2005;5:201.  Back to cited text no. 3      
4.Konnak JW, Herwig KR, Finkbeiner A, Turcotte JG, Freier DT. Extravesical ureteroneocystostomy in 170 renal transplant patients. J Urol 1975;113:299-301.  Back to cited text no. 4  [PUBMED]    
5.Basseri A, Amiransari B, Yazdani M, Sesavar Y, Gol S. Renal transplantation using ureteral stents. Transplant Proc 1995;27:2593-4.  Back to cited text no. 5      
6.Benoit G, Blanchet P, Eschwege P, Alexandre L, Bensadoun H, Charpentier B. Insertion of a double pigtail ureteral stent for the prevention of urological complications in renal transplantation: A prospective, randomized study. J Urol 1996;156:881-4.  Back to cited text no. 6  [PUBMED]    
7.Dominguez J, Clase CM, Mahalai K, MacDonald AS, McAlister VC, Belitsky P, et al. Is routine ureteric stenting needed in kidney transplantation? (A randomized trial). Transplantation 2000;70:597-601.  Back to cited text no. 7      
8.Kumar A, Kumar R, Bhandari M. Significance of routine JJ stenting in living related renal transplantation: A prospective randomized study. Transplant Proc 1998;30:2995-7.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Guleria S, Agarwal S, Kumar R, Khazanchi RK, Agarwal SK,Tiwari SC. The double J stent: Its impact on the urological complications in live - related transplantation. Indian J Urol 1998;14:101-4.  Back to cited text no. 9      
10.Pleass HC, Clark KR, Rigg KM, Reddy KS, Forsythe JL, Proud G, et al. Urologic complications after renal transplantation: A prospective randomized trial comparing different techniques of ureteric anastomosis and the use of prophylactic ureteric stents. Transplant Proc 1995;27:1091-2.   Back to cited text no. 10  [PUBMED]    
11.Osman Y, Ali-el-Dein B, Shokeir AA, Kamal M, El-Din AB. Routine insertion of ureteral stent in live-donor renal transplantation: Is it worthwhile?. Urology 2005;65:867-71.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]  
12.Wilson CH, Bhatti AA, Rix DA, Manas DM. Routine intraoperative ureteric stenting for kidney transplant recipients. Cochrane Database Syst Rev 2005;19:CD004925.   Back to cited text no. 12      
13.Thomalla JV, Leapman SB, Filo RS. The use of internalised ureteric stents in renal transplant recipients. Br J Urol 1990;66:363-8.   Back to cited text no. 13  [PUBMED]    
14.Merrill, JP, Murray JE, Harrison JH, Guild WR. Successful homotransplantations of the human kidney between identical twins. JAMA 1984;251:2566-71.  Back to cited text no. 14  [PUBMED]    
15.Politano VA, Leadbetter WF. An operative technique for the correction of vesicoureteric reflux. J Urol 1958;79:932-41.  Back to cited text no. 15  [PUBMED]    
16.Konnak JW, Herwig KR, Turcotte JG. External ureteroneocystostomy in renal transplantation. J Urol 1972;108:380-1.  Back to cited text no. 16  [PUBMED]    
17.Mundy AR, Podesta ML, Bewick M, Rudge CJ, Ellis FG. The urological Complications of 1000 renal transplants. Br J Urol 1981;53:397-402.  Back to cited text no. 17  [PUBMED]    
18.Fjeldborg O, Kim CH. Ureteral complications in human renal transplantation. Urol Int 1972;27:417-31.  Back to cited text no. 18  [PUBMED]    
19.Gibbons WS, Barry JM, Hefty TR. Complications following unstented parallel incision extravesical ureteroneocystostomy in 1000 kidney transplants. J Urol 1992;148:38-40.  Back to cited text no. 19  [PUBMED]    
20.Shoskes DA, Hanbury D, Cranston D, Morris PJ. Urological complications in 1,000 consecutive renal transplant recipients. J Urol 1995;153:18-21.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]  
21.Karam G, Maillet F, Parant S, Soulillou JP, Giral-Classe M. Ureteral necrosis after kidney transplantation: risk factors and impact on graft and patient survival. Transplantation 2004;78:725-9.  Back to cited text no. 21  [PUBMED]  [FULLTEXT]  
22.Insall RL, Bell R, Hutchison BG, Haywood EF, House AK. A method for the treatment of ureteric complications following renal transplantation. Aust N Z J Surg 1995;65:654-7.  Back to cited text no. 22  [PUBMED]    
23.Kumar A, Verma BS, Srivastava A, Bhandari M, Gupta A, Sharma R. Evaluation of the urological complications of living related renal transplantation at a single centre during the last ten years: impact of the double J stent. J Urol 2000;164:657-60.   Back to cited text no. 23  [PUBMED]    
24.Rigg KM, Proud G, Taylor RM. Urological complications following renal transplantation. A study of 1016 consecutive transplants from a single centre. Transpl Int 1994;7:120-6.   Back to cited text no. 24  [PUBMED]    
25.Turner MD, Witherington R, Carswell JJ. Ureteral splints: results of a survey. J Urol 1982;127:654-6.  Back to cited text no. 25  [PUBMED]    
26.Baum NH, Brin E. Use of double J catheter in pyeloplasty. Urology 1982;20:634.  Back to cited text no. 26  [PUBMED]    
27.Finney RP. Experience with new double J ureteral catheter stent. J Urol 2002;167:1135-8.   Back to cited text no. 27  [PUBMED]    
28.Lin LC, Bewick M, Koffman CG. Primary use of a double J silicone ureteric stent in renal transplantation. Br J Urol 1993;72:697-701.  Back to cited text no. 28  [PUBMED]    
29.Verma BS, Bhandari M, Srivastava A, Kapoor R, Kumar A. Optimum duration of J.J. stenting in live related renal transplantation. Indian J Urol 2002;19:54-7.  Back to cited text no. 29      
30.Giakoustidis D, Diplaris K, Antoniadis N, Papagianis A, Ouzounidis N, Fouzas I, et al. Impact of double-j ureteric stent in kidney transplantation: single-center experience. Transplant Proc 2008;40:3173-5.  Back to cited text no. 30  [PUBMED]  [FULLTEXT]  
31.Moray G, Yagmurdur MC, Sevmis S, Ayvaz I, Haberal M. Effect of routine insertion of a double-J stent after living related renal transplantation. Transplant Proc 2005;37:1052-3.  Back to cited text no. 31  [PUBMED]  [FULLTEXT]  
32.DuBay DA, Lynch R, Cohn J, Ads Y, Punch JD, Pelletier SJ, et al. Is routine ureteral stenting cost-effective in renal transplantation? J Urol 2007;178:2509-13.  Back to cited text no. 32  [PUBMED]  [FULLTEXT]  


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