Upsala J Med Sci 90: 157-162, 1985 Urologic Complications in 159 Consecutive Renal Bansplantations J a n Wahlberg, Gunnar Tufveson and Lars Frodin Department of Urology, University Hospital, Uppsala, Sweden ABSTRACI The urologic complications were reviewed in 159 consecutive renal transplant- ations. There were 23 major complications ( 1 4 % ) in 22 patients. One patient died as a consequence of urologic complications and two other grafts were lost. I n the remaining cases the grafts could be saved by surgical revision o r con- servative treatment. The principles of diagnosis and treatment of these complic- ations are discussed, INTRODUCTION Although the diagnosis and treatment of graft rejection is the main problem in renal transplantation, surgical complications can create clinical difficult- ies. Survival o f patients and O F grafts has improved considerably in recent years ( 3 , 1 4 ) , predominantly due to better understanding of transplantation im- munology. The incidence of technical complications has not correspondingly de- creased. The complications associated with ureteral reconstruction still cause significant morbidity and also some mortality (9,10,11,13). The present study was initiated to review the incidence o f urologic complications in o u r renal transplant patients in the past 3 f years and to evaluate o u r diaqnostic and management procedures. MATERIAL AND METHODS Between January 1981 and July 1984, 159 renal transplantations were perform- ed on 144 patients. Ten o f the patients received kidneys from living relatives. The first 89 transplantations were made with azathioprine and prednisolone f o r immunosuppression, whereas in the later 70 cases cyclosporin A and prednisolone were used. Operative procedures F o r the primary urinary drainage, ureteroneocystostomy ( 1 , 1 5 ) was used in all cases. The bladder was filled with saline solution via a urethral catheter a?d an incision 3-4 cm long was made in the dome of the bladder down to the mucosa. At the distal end of the incision the mucosa was opened and the split end of the graft ureter was anastomosed to the opening in the mucosa, using a running 5-0 VicrylR suture. The muscle incision was closed with interrupted sutures, creating a subrnucosal tunnel to prevent reflux. F o r secondary,neocystostomy the same technique was used, provided that the length of the remaining ureter was sufficient for a tension-free ansstomosis, but in these cases a ureteral stent was left for 3-10 days. If the ureteral length was insufficient for neocystostomy, a ureteropelvostorny was made, utiliz- ing the graft recipient's own ureter for urinary drainage. In most of such cases the recipient's own kidney was left behind. Percutaneous nephropyelostomy was made under ultrasound guidance. Diagnostic procedures The patients were monitored with daily routine laboratory tests, includinq serum creatinine, urea, white blood count, haernoglobin and electrolytes. We have tried to perform ultrasound scanning as a once-weekly routine in the first three postoperative weeks, and additional scans were made if urologic conplic- ations were suspected. Renal scintigraphy was performed on the first postoper- ative day and once weekly for 3-4 weeks. Intravenous pyelography o r ultrasound- guided antegrade pyelography was added if further inforrnatioi was needed. RESULTS Among the 159 transplantations there were 23 major urologic complications in 22 patients, giving an overall rate of 14 L. Ureteral obstruction occurred on 11 occasiorls in 10 patients, and urinary leakage in 12. These 22 p3tients are individually presented in Table 1. One of the 144 patients died of sepsis following urinsry leakage, giving a mortality rate of 0.7 X. Three grafts were lost, two because of upper o r lower polar necrosis with urinary leakage, and the third was in the fatal case. The rate o f graft loss thus was 1 . 9 E. To treat the urologic complications, 23 ad- ditional procedures were performed (Fig. 1). 5econdary.ureteroneocystostomy was successful in seven of nine cases, giving adequate urinary outflow and/or healing of urinary fistula. In one patient a distal ureteral stenosis was corrected by neoimplantation, but ureteropelvost- omy was necessary 1 4 years later due to progressive fibrosis of the ureter. 158 T a b l e 1. U r o l o g i c c o m p l i c a t i o n s i n 159 r e n a l t r a n s p l a n t a t i o n s Immuno- Time sup- a f t e r Case Age p r e s s - t r a n s - no ( y r s ) i o n * p l a n t I 33 Az 2 1 days 2 52 Az 3 days 3 45 Az 1 mo 4 33 Az 23 mo 5 28 Az 1 mo 18 mo 6 53 Az 4 days 7 42 Az 4 days 8 38 Az 3 mo 9 38 Az 2 mo 1 0 39 CyA 2 days 11 62 CyA 2 rno 1 2 38 C ~ A 40 days 13""" 52 Az 4 days 1 4 6 1 CyA 6 mo 15 54 CyA 16 5 9 CyA 17 43 CyA 18 64 CyA 19 35 CyA 20 32 CyA 2 1 67 CyA 22""" 36 CyA 30 days 4 days 30 days 6 days 7 days 1 day 7 days 7 days D i a g n o s i s Management** f i s t u l a UPS o b s t r u c t i o n n e o i m p l a n t a t i o n f i s t u l a Tx o b s t r u c t i o n c l o t r e m o v a l o b s t r u c t i o n n e o i r n p l a n t a t i o n o b s t r u c t i o n UPS f i s t u l a n e o i m p l a n t a t i o n f i s t u l a n e o i r n p l a n t a t i o n + l o w e r p o l a r r e s e c t i o n o b s t r u c t i o n n e o i m p l a n t a t i o n o b s t r u c t i o n NPS f i s t u l a n e o i r n p l a n t a t i o n o b s t r u c t i o n p e l v o p l a s t y f i s t u l a UPS f i s t u l a n e o i m p l a n t a t i o n o b s t r u c t i o n NPS f i s t u l a Tx o b s t r u c t i o n UPS f i s t u l a UPS f i s t u l a n e o i m p l a n t a t i o n o b s t r u c t i o n NPS f i s t u l a UPS o b s t r u c t i o n UPS f i s t u l a n e o i m p l a n t a t i o n Ob- s e r v - a t i o n Outcome t i m e s a t i s f a c t o r y 6 rno s a t i s f a c t o r y 1 " g r a f t l o s s - - s a t i s f a c t o r y 9 rno o b s t r u c t i o n 17 'I r e c u r r e d s a t i s f a c t o r y 2 'I s a t i s f a c t o r y 30 g r a f t l o s s , 2 " p a t i e n t d i e d s a t i s f a c t o r y 26 I ' s a t i s f a c t o r y 1 5 " s a t i s f a c t o r y 17 s a t i s f a c t o r y 14 " s a t i s f a c t o r y 1 3 " s a t i s f a c t o r y 1 2 " u n s a t i s f a c t - 2 O r Y g r a f t l o s s - - s a t i s f a c t o r y 8 mo s a t i s f a c t o r y 6 'I s a t i s f a c t o r y 2 " s a t i s f a c t o r y 7 I ' s a t i s f a c t o r y 6 I ' s a t i s f a c t o r y 3 s a t i s f a c t o r y 4 I' * Az a z 3 t h i o p r i n e , CyA = c y c l o s p o r i n A ** NPS = p e r c u t a n e o u s nephropyelosotomy, Tx = t r a n s p l a n t e c t o r n y , UPS = u r e t e r o - pelvostornv *** = l i v i n g donor I n t h e n i n t h p a t i e n t t h e secondary u r e t e r o n e o c y s t o s t o m y was f o l l o w e d by r e c u r r - ence o f u r i n a r y leakage, s e p s i s and death. U r e t e r o p e l v o s t o r n y was s u c c e s s f u l i n a l l seven cases i n w h i c h i t was p e r f o r r n - ed. I n s i x o f them t h e r e c i p i e n t ' s own k i d n e y was l e f t b e h i n d , w i t h o u t c o m p l i c - a t i o n s . The outcome a f t e r c l o t r e m o v a l i n one case and u r e t e r o p e l v o p l a s t y i n a n o t h e r was l i k e w i s e s a t i s f a c t o r y . F o l l o w i n g c o n s e r v a t i v e t r e a t m e n t , with p e r c u t a n e o u s nephropyelostorny, t h e u r e t e r a l o b s t r u c t i o n s u b s i d e d s p o n t a n e o u s l y i n two o f t h e t h r e e cases and t h e c a t h e t e r c o u l d be removed. I n t h e t h i r d case t h i s c o n s e r v a t i v e t r e a t m e n t was c o n t i n u e d because t h e p a t i e n t r e f u s e d f u r t h e r s u r g e r y . 159 10 from living 138 no further operations \159 1 23 additional procedures transplants /donors patients 3 nephropyelostomy 149 cadaveric / 1 ureteropelvoplasty 159 144 transplants 1 clot removal from ureter 7 pelvoureteric anastomosis 9 repeat ureteroneocystosomy 2 transplantectomy (to own ureter) Fig. of renal transplantation -- 1. Additional procedures performed in treatment o f urologic complications - DISCUSSION In considering the urologic complications of renal transplantation, three figures are particularly important, viz. the rates of mortality and graft loss and the total morbidity. One patient in the present series died as a result of urologic complications. This figure IS lawer than in many earlier reports ( 1 0 , 1 1 , 1 3 ) , but is comparable with other authors’ results (2). The rate of graft loss was also fairly low, 3/159. In all three cases there was calyceal leakage due to upper o r lower polar necrosis in grafts with multiple arteries. The lesson learned from these disastrous complications is that early removal of such grafts should be considered. An attempt to save one kidney with lower polar necrosis by ureteral neoimplantation and lower polar resection resulted in re- currence of the urinary fistula and, ultimately, death of the patient. I r i contrast to mortality rate and graft loss, the overall complication rate was rather high compared with some other series (2,5,10,12), but was largely similar to figures in two reports ( 9 , l l ) . Analysis of the complications in our series revealed inadequate ureteral blood supply as the probable cause in 75 76 of the cases. This stresses the importance of careful handling of the ureteral blood vessels during procurement and transplantation, and consequently these procedures should be entrusted only to surgeons familiar with the techniques. Since urologic complications produce significant morbidity, the emphasis should be on prevention. F o r this purpose, a method for preoperative o r intraoperative assessment o f the ureteral blood supply would be of great value. Successful visualization of the ureteral blood supply was obtained with sodium fluorescein in the perfusion solution ( 6 ) . We have tried this method in six kidneys, but so 1 6 0 f a r have been u n a b l e t o draw c l i n i c a l l y r e l e v a n t c o n c l u s i o n s f r o m o u r a t t e m p t s . O f t h e r e m a i n i n g cases w i t h a e t i o l o g y o t h e r t h a n u r e t e r a l i s c h a e m i a , two had u r i n a r y l e a k a g e due t o i n s u f f i c i e n c y o f u r e t e r o n e o c y s t o s t o m y and i n one case t h e u r e t e r was i n a d v e r t e n t l y anastomosed t o t h e p e r i t o n e u m . The p a t i e n t w i t h u r e t e r a l o b s t r u c t i o n from b l o o d c l o t s was o f s p e c i a l i n t e r e s t , s i n c e t h e h a e m a t u r i a was caused by an i n f e c t i o n w i t h a d e n o v i r u s t y p e 11 ( 4 ) . O u r s e r i e s c o n t a i n e d one case o f u r e t e r o p e l v i c j u n c t i o n o b s t r u c t i o n p r o b a b l y p r e e x i s t i n g i n t h e g r a f t b u t becoming s i g n i f i c a n t when t h e k i d n e y was i n a new p o s i t i o n . T h i s c o m p l i c a t i o n has been e a r l i e r r e p o r t e d (11). Our case was s u c c e s s f u l l y managed w i t h a von L i c h t e n b e r g u r e t e r o p e l v o p l a s t y ( 7 ) . Our r e s u l t s i n d i c a t e t h a t i t i s p o s s i b l e t o p e r f o r m a u r e t e r o p e l v o s t o m y and s i m p l y l i g a t e t h e p r o x i m a l end o f t h e p a t i e n t ' s own u r e t e r , l e a v i n g t h e n a t i v e k i d n e y b e h i n d . We have n o t o b s e r v e d i n f e c t i o n i n t h e r e m a i n i n g k i d n e y or o t h e r n e g a t i v e e f f e c t s from t h i s p r o c e d u r e . Nonperformance o f nephrectomy m i n i m i z e s t h e o p e r a t i v e trauma - a g r e a t advantage i n t h i s g r o u p o f p a t i e n t s . S i n c e u r e t e r a l o b s t r u c t i o n s u b s i d e d d u r i n g nephropyelostomy t r e a t m e n t i n t w o cases, a c o n s e r v a t i v e approach may b e w a r r a n t a b l e i n o b s t r u c t i v e d i s o r d e r s . P o s s i b l y t h i s approach may be t r i e d f o r a l o n g e r p e r i o d t h a n i n o u r s t u d y . S u c c e s s f u l t r e a t m e n t o f u r o l o g i c c o m p l i c a t i o n s u s i n g p e r c u t a n e o u s n e p h r o p y e l o - stomy and d i l a t i o n o f u r e t e r a l s t r i c t u r e s has been r e p o r t e d ( 8 ) . We t r i e d d i l - a t i o n o f t h e u r e t e r t h r o u g h a p e r c u t a n e o u s nephropyelostomy t u b e i n one p a t i e n t (Case 1 6 ) w i t h o u t success. P r o b a b l y , however, t h i s mode o f t r e a t m e n t m e r i t s t r i a l i n most p a t i e n t s w i t h s t e n o s i s o f t h e g r a f t u r e t e r . I n c o n c l u s i o n we, l i k e o t h e r t r a n s p l a n t surgeons, recommend t h a t u r o l o g i c c o m p l i c a t i o n s i n r e n a l t r a n s p l a n t a t i o n be t r e a t e d w i t h o u t d e l a y . I n c o m p l i c a t e d c o n d i t i o n s , such a s r e n a l p o l a r n e c r o s i s w i t h c a l y c e a l u r i n a r y l e a k a g e , t r a n s - p l a n t e c t o m y s h o u l d be c o n s i d e r e d a t an e a r l y s t a g e , t o a v o i d e n d a n g e r i n g t h e p a t i e n t ' s l i f e . I f u r e t e r a l o b s t r u c t i o n i s p r e s e n t , a t e m p o r a r y u r i n a r y d i - v e r s i o n t h r o u g h a p e r c u t a n e o u s nephropyelostomy i s a d v i s a b l e . The f i n a l c o r - r e c t i o n s h o u l d be done l a t e r , w i t h p a t i e n t and g r a f t i n o p t i m a l c o n d i t i o n . M i n o r u r i n a r y l e a k a g e w i t h o u t s i g n s o f i n f e c t i o n can p r o b a b l y h e a l d u r i n g p r o - l o n g e d u r i n a r y d i v e r s i o n . We have f o u n d u l t r a s o u n d s c a n n i n g e x t r e m e l y u s e f u l i n t h e management o f u r i n a r y c o m p l i c a t i o n s . 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L a n c e t I:6-12, 1969. Address f o r r e p r i n t s : Jan Wahlberg Department o f U r o l o g y U n i v e r s i t y H o s p i t a l S-781 85 Uppsala Sweden 162