Accepted Article

Received Date : 06-Jul-2014 Revised Date : 17-Sep-2014 Accepted Date : 10-Oct-2014 Article type : Original Article

Surgical Management of Early and Late Ureteral Complications after Renal Transplantation: Techniques and Outcomes. Jens U Berli1, John R Montgomery2, Dorry L Segev3, Lloyd E Ratner4, Warren R Maley5, Matthew Cooper6, Joseph K Melancon7, James Burdick8, Niraj M Desai9, Nabil N Dagher10, Bonnie E Lonze11, Susanna M Nazarian12, Robert A Montgomery13 1-3,8-13

Johns Hopkins Hospital, Department of Surgery, Baltimore, U.S.A.

4

NewYork-Presbytarian Hospital/Columbia, New York City, U.S.A.

5

Jefferson University Hospital, Philadelphia, U.S.A.

6

MedStar Georgetown University Hospital, Washington D.C., U.S.A.

7

George Washington University Hospital, Washington D.C., U.S.A.

Key words: ureteral complications, renal transplantation, ureteral stenosis, ureteral leak, ureteral revision

Address all correspondence to: Robert A. Montgomery, MD, DPhil, Department of Surgery, The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287 email: [email protected] Telephone: 410-614-8297 Fax: 410-614-7649 FOOTNOTES:

Authors contributions: JUB1,2,4,5 JRM1,2,5 DLS1,5 LER3,5 WRM3,5 MC3,5 JB3,5 JKM3,5 NMD3,5 NND3,5 BEL3,5 SMN3,5 RAM1,2,3,4,5 1

Participated in design

2

Participated in writing of paper

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/ctr.12478 This article is protected by copyright. All rights reserved.

Accepted Article

3

Participated in performance

4

Contributed to discussion

5

Participated in paper review

Authors current affiliation and email address: 1

The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287, [email protected]

2

The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287, [email protected]

3 4

The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287, [email protected] NewYork-Presbytarian Hospital/Columbia, PH Room 14-408, 622 West 168th St New York, NY 10032,

[email protected] 5

Thomas Jefferson University Hospital, 1100 Walnut Street, Philadelphia, PA 19107,

[email protected] 6

MedStar Georgetown University Hospital, 3800 Reservoir Rd., Washington DC 20007,

[email protected] 7

The George Washington University Hospital, Department of Surgery, 900 23rd Street, NW Washington DC

20037 8

The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287, [email protected]

9

The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287, [email protected]

10

The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287, [email protected]

11

The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287, [email protected]

12

The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287, [email protected]

13

Corresponding author see page 1.

Authors disclosure / conflict of interest: None of the authors have any conflict of interest to report.

ABBREVIATIONS (alphabetic):

BMI:

Body mass index

DGF:

Delayed graft function

E-E:

End to end

eGFR:

Estimated glomerular filtration rate calculated

E-S:

End to side

PI:

Pyeloileostomy

PRA:

Panel reactive antibody

RRT:

Renal replacement therapy

PU:

Pyeloureteral

This article is protected by copyright. All rights reserved.

Accepted Article

team, a ureteric complication does not significantly impact graft survival or function as compared to a matched control group. BACKGROUND Widespread use of routine ureteral stenting during renal allograft transplantation [1,2], improved procurement methods, and lower perioperative steroid regimens [3] have decreased but not eliminated the overall incidence of ureteral complications. There are many large retrospective consecutive series (n=789 – 2000) that have looked at the incidence of ureteral complications in the setting of renal allotransplantation [1,4-16]. The overall reported incidence ranges from 4.8 to 9.2% in these select studies; the stenosis rate ranges from 2.4 to 6.5%, and the urine leak rate from 1.8 to 5.4%. Other complications such as urolithiasis (0.2% [8]), reflux (0.1 to 1.1%), infection or external obstruction were more rare and less consistently reported.

Some studies [5,6,17] looked at risk factors that were statistically associated with stricture and urine leaks. Most of them found donor age, multiple donor renal arteries and delayed graft function (DGF) to be associated with a higher rate of ureteral complications. The complication rate between living versus deceased donor transplants do not appear to be significant [6]. The main hypothesis to explain stricture formation remains ischemia induced fibrosis and/or necrosis of the donor ureter due to compromised arterial blood supply. The overwhelming majority of ureteral stenosis occurs during the first year after transplantation and later complications are most often due to rejection, recurrent infections or BK virus [1,6,18].

Nie et al. [7] and Faenza et al. [1] looked at differences in the incidence of urologic complications when the transplant ureter anastomosis was performed with either a Ureteroureterostomy (UU) or Uretercystostomy (UC) technique and they were similar. First line treatment for a complication usually consists of decompression and drainage via nephrostomy tube, retrograde double J stenting or balloon-dilation. All of these techniques have moderate short-term success rates of 39-86.7% [19-23] but are often not a durable solution due to recurrent infections associated with the hardware and high re-stenosis rates after dilatation. Late ureteral stenosis is even more recalcitrant to temporizing interventions (recurrence rates between 40-44%) [19,20]. We believe that early surgical intervention offers

This article is protected by copyright. All rights reserved.

Accepted Article

team, a ureteric complication does not significantly impact graft survival or function as compared to a matched control group. BACKGROUND Widespread use of routine ureteral stenting during renal allograft transplantation [1,2], improved procurement methods, and lower perioperative steroid regimens [3] have decreased but not eliminated the overall incidence of ureteral complications. There are many large retrospective consecutive series (n=789 – 2000) that have looked at the incidence of ureteral complications in the setting of renal allotransplantation [1,4-16]. The overall reported incidence ranges from 4.8 to 9.2% in these select studies; the stenosis rate ranges from 2.4 to 6.5%, and the urine leak rate from 1.8 to 5.4%. Other complications such as urolithiasis (0.2% [8]), reflux (0.1 to 1.1%), infection or external obstruction were more rare and less consistently reported.

Some studies [5,6,17] looked at risk factors that were statistically associated with stricture and urine leaks. Most of them found donor age, multiple donor renal arteries and delayed graft function (DGF) to be associated with a higher rate of ureteral complications. The complication rate between living versus deceased donor transplants do not appear to be significant [6]. The main hypothesis to explain stricture formation remains ischemia induced fibrosis and/or necrosis of the donor ureter due to compromised arterial blood supply. The overwhelming majority of ureteral stenosis occurs during the first year after transplantation and later complications are most often due to rejection, recurrent infections or BK virus [1,6,18].

Nie et al. [7] and Faenza et al. [1] looked at differences in the incidence of urologic complications when the transplant ureter anastomosis was performed with either a Ureteroureterostomy (UU) or Uretercystostomy (UC) technique and they were similar. First line treatment for a complication usually consists of decompression and drainage via nephrostomy tube, retrograde double J stenting or balloon-dilation. All of these techniques have moderate short-term success rates of 39-86.7% [19-23] but are often not a durable solution due to recurrent infections associated with the hardware and high re-stenosis rates after dilatation. Late ureteral stenosis is even more recalcitrant to temporizing interventions (recurrence rates between 40-44%) [19,20]. We believe that early surgical intervention offers

This article is protected by copyright. All rights reserved.

Accepted Article

a more consistent and durable solution and can potentially prevent renal allograft injury due to recurrent pyelonephritis and hydronephrosis.

Depending on the location, extent of periureteral fibrosis, indication and etiology of the problem various techniques have been described to reestablish urinary drainage of the allograft.. These procedures range from simple re-anastomosis of the UC via a LeadbetterPolitano or a Lich Gregoir technique to more complex procedures such as UU, UP, use of contralateral ureters, direct anastomosis of the renal pelvis, small bowel interposition and mobilization of the bladder (Boari Flap, Psoas hitch).

In poor operative risk or select candidates other techniques such as an extra-ureteric bypass [24], ante- or retrograde endoureteric surgery or the Nitinol stent have been described Burgos et al. [25] but results of these techniques are not proven. The gold standard, however, remains re-anastomosis of the graft to available recipient urologic structures.

The long term outcome after ureteral complications in terms of patient and graft survival with historic control groups has been looked at by Karam et al. [6] and van Roijen et al. [26] in 74/1713 and 42/695 patients respectively. They did not show any significant difference in terms of patient and graft survival; however, individual series, especially older ones, do report a higher rate of graft loss associated with ureteric complications.

In this study we present our experience with this challenging problem and report the outcomes compared to a matched control population generated from the Scientific Registry of Transplant Recipients. For this purpose we divided our population into early postoperative and late postoperative repair groups and we hypothesize that they are inherently different. Furthermore we present the various techniques used successfully in our cohort to reestablish urinary outflow.

METHODS: We retrospectively reviewed our database from 1997 up to June 2012 to identify patients that had revision ureteral surgery after kidney transplantation. We divided the patients into an early (defined

Surgical management of early and late ureteral complications after renal transplantation: techniques and outcomes.

In this study, we present our experience with ureteral complications requiring revision surgery after renal transplantation and compare our results to...
237KB Sizes 0 Downloads 8 Views