PICTORIAL

Persistent Grade 5 Reflux into a Transplanted Kidney in a Spinal Patient Despite Sphincterotomy

Michael S Floyd Jr, Vasileios Sakalis, Melissa C Davies

Keywords: reflux; spinal injury; sphincterotomy; transplantation; videourodynamics.

A 43 year-old spinal injury patient was found to have asymptomatic hydronephrosis of his transplant during annual surveillance (Figure 1). Prior to presentation, he had developed urinary tract infection and serum 
creatinine was measured at 159μmol/l. His past history was remarkable for type 1 diabetes since the age of 5, 
spinal artery thrombosis aged 19 culminating in a C6 incomplete tetraplegia and diabetic nephropathy for which 
he received a live donor transplant at the age of 37. Bladder management involved convene drainage and he had 
undergone two previous sphincterotomies. Videourodynamics revealed a stable bladder during filling but high 
pressure sustained contractions during voiding resulting in grade V reflux into the transplanted kidney (Figures 2a 
& b). The bladder emptied completely with no evidence of dyssynergia. The patient was counselled regarding his 
treatment options and was listed for repeat videourodynamics in 6 months.
There is limited data on renal transplant outcome in spinal injury patients. It is acknowledged that transplant 
reduces urolithiasis and has similar outcomes to non-spinal patients.(1) Endoscopic management is recognised as 
first line treatment for transplant related reflux.(2) Where concomitant graft reflux and acute retention occur due to 
prostatic hyperplasia hybrid techniques involving holmium enucleation and simultaneous nephrostomy have been 
described.(3)

Departments of Urology & Duke of Cornwall Spinal Injury Unit, Salisbury NHS Foundation Trust, Wiltshire, 
SP2 8BJ, United Kingdom. 
*Correspondence: Departments of Urology & Duke of Cornwall Spinal Injury Unit, Salisbury NHS Foundation 
Trust, Salisbury, Wiltshire, SP2 8BJ, United Kingdom.
Email: nilbury@gmail.com.
Received January 2016 & Accepted December 2016

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Figure 1. Ultrasound revealing Hydronephrosis of the transplanted 
kidney.

Figure 2. a: Videourodynamic trace demonstrating reflux into the transplanted kidney with clubbing of the 
calyces; b: Videourodynamic trace demonstrating grade 5 reflux into the transplanted kidney and neoureter  
with clubbing of the calyces.



Reflux grade V into transplnated kidney-Floyd et al.

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Moghddam SM, Parvaneh MJ, Azadvari M. 
Renal transplant in patients with spinal cord 
injuries. Exp Clin Transplant. 2009; 7 :28-32.

 2.  Akiki A, Boissier R, Delaporte V, Maurin 
C, Gaillet S, Karsenty G. et al. Endoscopic 
treatment of symptomatic vesicoureteral 
reflux after renal transplantation. J Urol. 2015; 
193: 225-9.

 3.  Nohara T, Matsuyama S, Shima T, Kawaguchi 
S, Seto C. Holmium Laser Enucleation of the 
Prostate With Percutaneous Nephrostomy 
Into the Transplanted Kidney in Patient With 
Severe Benign Prostatic Hyperplasia With 
Vesicoureteral Reflux - A Case Report. Urol 
Case Rep. 2015; 4: 33-5.

Vol 14 No 01  January-February 2017  2990