Int Urol Nephrol (2014) 46:2143–2145 DOI 10.1007/s11255-014-0798-7
UROLOGY - ORIGINAL PAPER
The management of urethral stricture after kidney transplantation Libo Xie • Tao Lin • Romel Wazir Kunjie Wang • Yiping Lu
•
Received: 13 May 2014 / Accepted: 21 July 2014 / Published online: 7 August 2014 Ó Springer Science+Business Media Dordrecht 2014
Abstract Objective To investigate the incidence and causes of urethral stricture after kidney transplantation, as well as analyze its diagnosis, treatment and prevention. Methods Clinical data of patients who developed urethral stricture after living-donor kidney transplantation in our center between January 2007 and June 2012 were retrospectively analyzed. Results Urethral stricture occurred in 8 of the 677 eligible kidney recipients (1.18 %) during the study period; the complication occurred at a mean of 4.4 months (range 2–7 months) after transplantation. Cystoscope-related iatrogenic injury and urinary tract infection seemed to be the most likely causes. In addition to frequency and dysuria, three patients had hydronephrosis and four had elevated serum creatinine levels. Urethrography showed that the urethral stricture was anterior in two patients and posterior in the remaining six. Two patients were treated by urethral
L. Xie T. Lin R. Wazir K. Wang Y. Lu (&) Department of Urology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu 610041, Sichuan, China e-mail: [email protected] L. Xie e-mail: [email protected] T. Lin e-mail: [email protected] R. Wazir e-mail: [email protected] K. Wang e-mail: [email protected]
dilation, four by internal urethrotomy and two by urethra reconstruction surgery. All patients urinated readily after treatment and four patients with impaired renal function recovered. Conclusion Urethral strictures after kidney transplantation are rare, and they can be safely and effectively treated by urethral dilation, internal urethrotomy or urethra reconstruction. Avoiding iatrogenic injury and shortening catheterization time may help reduce the risk of this complication. Keywords Living-donor kidney transplantation Urethral stricture Diagnosis and treatment
Introduction Kidney transplantation is widely considered the best treatment for patients with end-stage renal disease; it can improve their survival and quality of life, and it can be more economical than dialysis [1–3]. Improvements in surgical technology have substantially reduced the frequency of short-term surgical complications, such as hemorrhage and urinary fistula. However, later surgical complications, such as urethral or artery stricture, still occur in some patients. Urethral stricture is one of the most severe later-term complications; it can lead to dysuria or frequency, as well as cause hydronephrosis or even influence the function of the renal graft. Few studies have examined in detail the incidence and treatment of this complication or the prognosis for these patients. Therefore, we analyzed the clinical data of eight patients who developed urethral stricture after living-donor kidney transplantation at our large transplant center.
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Int Urol Nephrol (2014) 46:2143–2145
Materials and methods Transplantation surgery Between January 2007 and June 2012, 702 consecutive living-donor kidney transplantations were performed at our center. Recipients with incomplete or missing follow-up data (n = 25) were excluded, leaving 677 patients for analysis. None of these recipients complained of dysuria before developing uremia. Prior to the transplantation, a 16Fr silicone catheter was inserted in all recipients. The graft vein was revascularized with the external iliac vein, while the renal artery was anastomosed end-to-end with the internal iliac artery or end-to-side with the external iliac artery. Extravesical ureter anastomosis was carried out using the LichGregoir technique. During the transplantation procedure, a 4.7Fr double-J stent was inserted in all recipients between the anastomosis of the graft ureter and bladder. Catheters were removed from all recipients within 1 week of the transplantation, while the stent was removed 3–4 weeks after the procedure through the cystoscope. Patients received triple immunosuppressant therapy involving CsA (NeoralÒ, Novartis Pharma AG), MMF (CellceptÒ, Roche Pharma) and steroids; or involving Tac (PrografÒ, Astellas Pharma), MMF and steroids. Clinical data on urination of all recipients were collected for at least 1 year after transplantation. Treatment of urethral stricture Our choice of treatment for urethral stricture was guided by the degree, length and location of stenosis [4]. We
chose urethra dilation when the length of anterior urethral stricture was \l cm. Some urethral strictures were slightly longer with a small caliber and they contained scar tissue, which might cause local injury during the dilation procedure. In these cases, we performed transurethral internal urethrotomy alone or in combination with dilation once a week for 1–3 months [5]. We treated recurrent strictures after urethrotomy using urethra reconstruction [6], which can efficiently resect the segment with stenosis.
Results Among the 677 living-donor kidney transplantation recipients in our study, 8 (1.18 %) developed urethral strictures (Table 1). Of these eight patients, all of whom were men, seven underwent hemodialysis and one received peritoneal dialysis before transplantation. Mean dialysis time was 6.4 months (range 2–15 months). Two of these patients had a history of urinary tract infection. After transplantation, three patients showed obvious hematuria after cystoscopy, which was performed in order to remove the ureter stent. All eight patients gradually began to experience weak urine flow, high frequency, urinary hesitancy or dysuria starting an average of 4.4 months (range 2–7 months) after transplantation. The maximum flow rate (MFR) detected by uroflometry was 11.4 ml/s. Urethrography showed that the urethral stricture was anterior in two patients and posterior in the remaining six. Additional tests showed that three patients suffered
Table 1 Characteristic of patients with urethral stricture (US) after kidney transplantation Case
Age (years)
Time of US after KT (months)
Symptom
1
32
6
2
38
2
Dysuria, frequency Dysuria
3
42
4
4
47
5
5 6
29 19
7 5
7
35
4
8
52
2
Dysuria, frequency, hydronephrosis Frequent, hydronephrosis Frequency Dysuria hydronephrosis, Dysuria Dysuria, frequency
MFR max flow rate, Scr serum creatinine
123
Preoperative MFR (ml/s)
US site
Length of US (cm)
Treatment
Follow time (months)
Postoperative MFR (ml/s)
Scr (l mol/L)
Penile
0.5
Dilatation
69
26.3
143
16.7
Membranous
1.0
56
29.6
91
13.8
Membranous
1.3
Internal urethrotomy Internal urethrotomy
47
27.8
145
11.2
Membranous
2.5
28
25.4
103
9.6 8.4
Bulbar Membranous
0.8 1.6
23 21
31.1 27.3
125 94
13.7
Membranous
3.0
16
31.2
84
12.3
Membranous
1.2
Urethra reconstruction Dilatation Internal urethrotomy Urethra reconstruction Internal urethrotomy
14
23.5
101
5.3
Int Urol Nephrol (2014) 46:2143–2145
from hydronephrosis and that four had elevated serum creatinine (Scr). We treated the two patients with anterior urethral strictures using conventional urethral dilation. Four patients with posterior urethral strictures were treated using transurethral internal urethrotomy with a cold knife. This was followed by conventional urethral dilation once a week for 1–3 months in order to preserve the effects of the urethrotomy. Another two patients, who had posterior urethral strictures, suffered recurrent stenosis after one or three internal urethrotomies; these patients were ultimately treated using urethral reconstruction. All patients urinated freely after treatment (MFR, 27.8 ml/s), and ultrasonography of the patients with hydronephrosis showed no increase during a mean followup of 34.2 months (range 14–69 months). Four patients with impaired renal function recovered after the operation. Acute rejection occurred in one patient when diarrhea led to a low immunosuppressant concentration, unrelated to the urethral stricture. Two patients suffered urinary tract infection after their strictures had been cured. None of the patients suffered recurrence of the urethral stricture through the end of follow-up.
Discussion Improvements in surgical instrumentation and technology continue to reduce the risk of surgical complications of kidney transplantation, which include hemorrhage, venous thrombosis and urinary fistula. However, urethral stricture remains a serious complication after renal transplantation. The incidence of urethral stricture was only 1.18 % in our cohort, but this remains too high given the threat to allograft function. The obvious symptoms of urethral stricture after kidney transplantation make the complication easy to diagnose. Urethrography is necessary to identify the location and length of stenosis. However, during this procedure, given the manual reconstruction between the bladder and graft ureter, controlling the bladder pressure is important in order to avoid infection by reflux urine and contrast agent. The clinical characteristics of our patients lead us to suggest that urethral strictures can be caused by (1) iatrogenic injury, probably when the guide rod of the cystoscope scratches the urethral mucosa during ureter stent removal; and (2) urinary tract infection. Such infection may result from prolonged catheterization [7], use of immunosuppressive agents, inadequate catheter care and even the presence of parasites [8].
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In order to prevent urethral strictures, we should maintain catheter patency, sterilize the catheter regularly and shorten catheterization time after renal transplantation. In addition, we should avoid scratching the urethral mucosa with the guide rod of the cystoscope; or alternatively, we can use the belt line bracket tube [9]. Patients with dysuria or weak urine flow should be analyzed by ultrasonography or urethrography in order to detect urethral stricture as early as possible and prevent deterioration of kidney function. In summary, urethral strictures after kidney transplantation are rare and may be associated with iatrogenic urethral injury and urinary tract infection. They can be safely and effectively treated by urethral dilation, internal urethrotomy or urethra reconstruction. Avoiding iatrogenic injury and shortening catheterization time may help reduce the risk of this complication. Kidney recipients with urinary dysfunction should receive special attention in order to diagnose and treat urethral strictures as soon as possible after kidney transplantation. Conflict of interest interests.
The authors declare no funding or conflict of
References 1. Evans RW, Manninen DL, Garrison LP et al (1985) The quality of life of patients with end-stage renal disease. N Engl J Med 312:553–559 2. Port FK, Wolfe RA, Mauger EA et al (1993) Comparison of survival probabilities for dialysis patients vs cadaveric renal transplant recipients. JAMA 270:1339–1343 3. Garcia GG, Harden P, Chapman J, World Kidney Day Steering Committee (2012) The global role of kidney transplantation. Lancet 2012(379):36–38 4. Tritschler S, Roosen A, Fullhase C et al (2013) Urethral stricture: etiology, investigation and treatments. Dtsch Arztebl Int 110(13):220–226 5. Bailey MJ, Shearer RJ (1979) The role of internal urethrotomy in the prevention of urethral stricture following transurethral resection of prostate. BJU Int 51:28–31 6. Dorfman B, Yussim A, Gillon G et al (1997) Conservative approach to lower urinary tract abnormalities in cadaveric renal transplantation. Transplant Proc 29:143–144 7. Hammarsten J, Indgvist K, Sunzel H (1989) Urethral strictures following transurethral resection of the prostate: the role of the catheter. BJU Int 63(4):397–400 8. Wang Y, Sebaratnam DF, Wong JCh et al (2012) Urethral stricture caused by schistosomiasis in a renal transplant recipient. Nephrology 17(2):197–198 9. Dong J, Lu J, Zu Q et al (2011) Routine short-term ureteral stent in living donor renal transplantation: introduction of a simple stent removal technique without using anesthesia and cystoscope. Transplant Proc 43:3747–3750
123
UROLOGY - ORIGINAL PAPER
The management of urethral stricture after kidney transplantation Libo Xie • Tao Lin • Romel Wazir Kunjie Wang • Yiping Lu
•
Received: 13 May 2014 / Accepted: 21 July 2014 / Published online: 7 August 2014 Ó Springer Science+Business Media Dordrecht 2014
Abstract Objective To investigate the incidence and causes of urethral stricture after kidney transplantation, as well as analyze its diagnosis, treatment and prevention. Methods Clinical data of patients who developed urethral stricture after living-donor kidney transplantation in our center between January 2007 and June 2012 were retrospectively analyzed. Results Urethral stricture occurred in 8 of the 677 eligible kidney recipients (1.18 %) during the study period; the complication occurred at a mean of 4.4 months (range 2–7 months) after transplantation. Cystoscope-related iatrogenic injury and urinary tract infection seemed to be the most likely causes. In addition to frequency and dysuria, three patients had hydronephrosis and four had elevated serum creatinine levels. Urethrography showed that the urethral stricture was anterior in two patients and posterior in the remaining six. Two patients were treated by urethral
L. Xie T. Lin R. Wazir K. Wang Y. Lu (&) Department of Urology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu 610041, Sichuan, China e-mail: [email protected] L. Xie e-mail: [email protected] T. Lin e-mail: [email protected] R. Wazir e-mail: [email protected] K. Wang e-mail: [email protected]
dilation, four by internal urethrotomy and two by urethra reconstruction surgery. All patients urinated readily after treatment and four patients with impaired renal function recovered. Conclusion Urethral strictures after kidney transplantation are rare, and they can be safely and effectively treated by urethral dilation, internal urethrotomy or urethra reconstruction. Avoiding iatrogenic injury and shortening catheterization time may help reduce the risk of this complication. Keywords Living-donor kidney transplantation Urethral stricture Diagnosis and treatment
Introduction Kidney transplantation is widely considered the best treatment for patients with end-stage renal disease; it can improve their survival and quality of life, and it can be more economical than dialysis [1–3]. Improvements in surgical technology have substantially reduced the frequency of short-term surgical complications, such as hemorrhage and urinary fistula. However, later surgical complications, such as urethral or artery stricture, still occur in some patients. Urethral stricture is one of the most severe later-term complications; it can lead to dysuria or frequency, as well as cause hydronephrosis or even influence the function of the renal graft. Few studies have examined in detail the incidence and treatment of this complication or the prognosis for these patients. Therefore, we analyzed the clinical data of eight patients who developed urethral stricture after living-donor kidney transplantation at our large transplant center.
123
2144
Int Urol Nephrol (2014) 46:2143–2145
Materials and methods Transplantation surgery Between January 2007 and June 2012, 702 consecutive living-donor kidney transplantations were performed at our center. Recipients with incomplete or missing follow-up data (n = 25) were excluded, leaving 677 patients for analysis. None of these recipients complained of dysuria before developing uremia. Prior to the transplantation, a 16Fr silicone catheter was inserted in all recipients. The graft vein was revascularized with the external iliac vein, while the renal artery was anastomosed end-to-end with the internal iliac artery or end-to-side with the external iliac artery. Extravesical ureter anastomosis was carried out using the LichGregoir technique. During the transplantation procedure, a 4.7Fr double-J stent was inserted in all recipients between the anastomosis of the graft ureter and bladder. Catheters were removed from all recipients within 1 week of the transplantation, while the stent was removed 3–4 weeks after the procedure through the cystoscope. Patients received triple immunosuppressant therapy involving CsA (NeoralÒ, Novartis Pharma AG), MMF (CellceptÒ, Roche Pharma) and steroids; or involving Tac (PrografÒ, Astellas Pharma), MMF and steroids. Clinical data on urination of all recipients were collected for at least 1 year after transplantation. Treatment of urethral stricture Our choice of treatment for urethral stricture was guided by the degree, length and location of stenosis [4]. We
chose urethra dilation when the length of anterior urethral stricture was \l cm. Some urethral strictures were slightly longer with a small caliber and they contained scar tissue, which might cause local injury during the dilation procedure. In these cases, we performed transurethral internal urethrotomy alone or in combination with dilation once a week for 1–3 months [5]. We treated recurrent strictures after urethrotomy using urethra reconstruction [6], which can efficiently resect the segment with stenosis.
Results Among the 677 living-donor kidney transplantation recipients in our study, 8 (1.18 %) developed urethral strictures (Table 1). Of these eight patients, all of whom were men, seven underwent hemodialysis and one received peritoneal dialysis before transplantation. Mean dialysis time was 6.4 months (range 2–15 months). Two of these patients had a history of urinary tract infection. After transplantation, three patients showed obvious hematuria after cystoscopy, which was performed in order to remove the ureter stent. All eight patients gradually began to experience weak urine flow, high frequency, urinary hesitancy or dysuria starting an average of 4.4 months (range 2–7 months) after transplantation. The maximum flow rate (MFR) detected by uroflometry was 11.4 ml/s. Urethrography showed that the urethral stricture was anterior in two patients and posterior in the remaining six. Additional tests showed that three patients suffered
Table 1 Characteristic of patients with urethral stricture (US) after kidney transplantation Case
Age (years)
Time of US after KT (months)
Symptom
1
32
6
2
38
2
Dysuria, frequency Dysuria
3
42
4
4
47
5
5 6
29 19
7 5
7
35
4
8
52
2
Dysuria, frequency, hydronephrosis Frequent, hydronephrosis Frequency Dysuria hydronephrosis, Dysuria Dysuria, frequency
MFR max flow rate, Scr serum creatinine
123
Preoperative MFR (ml/s)
US site
Length of US (cm)
Treatment
Follow time (months)
Postoperative MFR (ml/s)
Scr (l mol/L)
Penile
0.5
Dilatation
69
26.3
143
16.7
Membranous
1.0
56
29.6
91
13.8
Membranous
1.3
Internal urethrotomy Internal urethrotomy
47
27.8
145
11.2
Membranous
2.5
28
25.4
103
9.6 8.4
Bulbar Membranous
0.8 1.6
23 21
31.1 27.3
125 94
13.7
Membranous
3.0
16
31.2
84
12.3
Membranous
1.2
Urethra reconstruction Dilatation Internal urethrotomy Urethra reconstruction Internal urethrotomy
14
23.5
101
5.3
Int Urol Nephrol (2014) 46:2143–2145
from hydronephrosis and that four had elevated serum creatinine (Scr). We treated the two patients with anterior urethral strictures using conventional urethral dilation. Four patients with posterior urethral strictures were treated using transurethral internal urethrotomy with a cold knife. This was followed by conventional urethral dilation once a week for 1–3 months in order to preserve the effects of the urethrotomy. Another two patients, who had posterior urethral strictures, suffered recurrent stenosis after one or three internal urethrotomies; these patients were ultimately treated using urethral reconstruction. All patients urinated freely after treatment (MFR, 27.8 ml/s), and ultrasonography of the patients with hydronephrosis showed no increase during a mean followup of 34.2 months (range 14–69 months). Four patients with impaired renal function recovered after the operation. Acute rejection occurred in one patient when diarrhea led to a low immunosuppressant concentration, unrelated to the urethral stricture. Two patients suffered urinary tract infection after their strictures had been cured. None of the patients suffered recurrence of the urethral stricture through the end of follow-up.
Discussion Improvements in surgical instrumentation and technology continue to reduce the risk of surgical complications of kidney transplantation, which include hemorrhage, venous thrombosis and urinary fistula. However, urethral stricture remains a serious complication after renal transplantation. The incidence of urethral stricture was only 1.18 % in our cohort, but this remains too high given the threat to allograft function. The obvious symptoms of urethral stricture after kidney transplantation make the complication easy to diagnose. Urethrography is necessary to identify the location and length of stenosis. However, during this procedure, given the manual reconstruction between the bladder and graft ureter, controlling the bladder pressure is important in order to avoid infection by reflux urine and contrast agent. The clinical characteristics of our patients lead us to suggest that urethral strictures can be caused by (1) iatrogenic injury, probably when the guide rod of the cystoscope scratches the urethral mucosa during ureter stent removal; and (2) urinary tract infection. Such infection may result from prolonged catheterization [7], use of immunosuppressive agents, inadequate catheter care and even the presence of parasites [8].
2145
In order to prevent urethral strictures, we should maintain catheter patency, sterilize the catheter regularly and shorten catheterization time after renal transplantation. In addition, we should avoid scratching the urethral mucosa with the guide rod of the cystoscope; or alternatively, we can use the belt line bracket tube [9]. Patients with dysuria or weak urine flow should be analyzed by ultrasonography or urethrography in order to detect urethral stricture as early as possible and prevent deterioration of kidney function. In summary, urethral strictures after kidney transplantation are rare and may be associated with iatrogenic urethral injury and urinary tract infection. They can be safely and effectively treated by urethral dilation, internal urethrotomy or urethra reconstruction. Avoiding iatrogenic injury and shortening catheterization time may help reduce the risk of this complication. Kidney recipients with urinary dysfunction should receive special attention in order to diagnose and treat urethral strictures as soon as possible after kidney transplantation. Conflict of interest interests.
The authors declare no funding or conflict of
References 1. Evans RW, Manninen DL, Garrison LP et al (1985) The quality of life of patients with end-stage renal disease. N Engl J Med 312:553–559 2. Port FK, Wolfe RA, Mauger EA et al (1993) Comparison of survival probabilities for dialysis patients vs cadaveric renal transplant recipients. JAMA 270:1339–1343 3. Garcia GG, Harden P, Chapman J, World Kidney Day Steering Committee (2012) The global role of kidney transplantation. Lancet 2012(379):36–38 4. Tritschler S, Roosen A, Fullhase C et al (2013) Urethral stricture: etiology, investigation and treatments. Dtsch Arztebl Int 110(13):220–226 5. Bailey MJ, Shearer RJ (1979) The role of internal urethrotomy in the prevention of urethral stricture following transurethral resection of prostate. BJU Int 51:28–31 6. Dorfman B, Yussim A, Gillon G et al (1997) Conservative approach to lower urinary tract abnormalities in cadaveric renal transplantation. Transplant Proc 29:143–144 7. Hammarsten J, Indgvist K, Sunzel H (1989) Urethral strictures following transurethral resection of the prostate: the role of the catheter. BJU Int 63(4):397–400 8. Wang Y, Sebaratnam DF, Wong JCh et al (2012) Urethral stricture caused by schistosomiasis in a renal transplant recipient. Nephrology 17(2):197–198 9. Dong J, Lu J, Zu Q et al (2011) Routine short-term ureteral stent in living donor renal transplantation: introduction of a simple stent removal technique without using anesthesia and cystoscope. Transplant Proc 43:3747–3750
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