World J. Surg. 1,231-235, 1977
Wor Journa
of
ry
9 1977 by the Soci6t~ Internationale de Chirurgie
Ureterocystostomy in Renal Transplantation: Comparison of Endo- and Extravesical Anastomoses L.
HOOGHE, M.D., P. KINNAERT, M.D., C. C. SCHULMAN, M.D., J. VAN GEERTRUYDEN, M.D., a n d P. VEREERSTRAETEN, M . D .
C.
TOUSSAINT,
M.D.,
Departments of Surgery, Medicine, and Urology, Brugmann Hospital, Universitb Libre de Bruxelles, Brussels, Belgium the two serious urologic complications, fistula and stenosis of the ureter.
Among 241 renal transplants with implantation of the ureter into the urinary bladder, the endovesical technique of Politano and Leadbetter (PL) was used in 108 cases and the extravesical technique of Gr6goir and Lich (GrL) was used in 133. Urinary fistulas occurred in 10 patients (9.3%) with the PL technique and in only 1 patient (0.8%) with the GrL technique. The difference was highly significant (p < 0.01). Stenosis of the ureter developed in 3 patients (2.8%) following the PL technique and in 9 patients (6.8%) after the GrL technique, an insignificant difference (p > 0.10). None of the complications resulted in death or failure of transplantation. It is concluded that the extravesical technique of Gr6goir and Lich is the best method of avoiding urinary leakage, which is the most dangerous urologic complication of kidney transplantation.
Materials and Methods
Between March, 1965 and December, 1975, the same surgical team performed 241 renal transplantations. Except for the reconstruction of the urinary tract, the operative procedure was the same in all cases. The ureterovesical implantatio n was accomplished in 108 cases using the Politano and Leadbetter technique (PL), as described by Starzl et al. [2] in 1964. In 133 cases the Gr6goir and Lich technique (GrL) was used for implantation of the ureter (Figure
1). The Gr6goir and Lich technique involves a vertical incision along the lateral margin of the bladder, 5 cm in length. The serosal and muscular layer s ar e opened completely but the mucosa is not entered. At the end of the dissection an outward herniation of the mucosa must be observed. At the inferior extremity of the incision, an opening of 5 mm in diameter is made into the mucosa. The ureter, cut to appropriate length, is then cradled into the incision, protruding about 0.5 to 1 cm into the bladder lumen. The ureter is secured by a U-form transfixing suture through the bladder wall. The muscular and serosal layers are then sutured over the ureter in two layers with 3-0 chromic catgut suture, thereby creating the antireflux mechanism. Treatment before, during, and after the transplantation operation, including immunosuppression therapy (azathioprine, steroids, ALG), was the same for both groups of patients. The Foley catheter was removed 24 hours after transplantation. Table 1 compares the two groups of Patients with regard to age,
Some of the urologic complications of the surgical procedure of renal transplantation are life threatening. Fistulas and stenosis of the ureter often lead to loss of the graft or even to death of the patient. T o avoid fistulas, most surgical teams now recommend the ureterovesical anastomosis, in which a submucosal tunnel is created in the bladder as described by Po!itano and Leadbetter [1], or one of the variants [2-4]. However, even with this technique the frequency of fistulas ranges from 1 to 25% [5-13]. In the most recent literature, several authors have advocated use of the Gr6goir and Lich procedure [14, 15], which avoids the complications of a cystotomy and at the same time provides an antireflux mechanism by a submucosal tunnel. We have compared the results of these two techniques with regard to the frequency of
Reprint requests: Professor Jean Van Geertruyden, Department of Surgery, H6pital Brugmann, 4, place van Gehuchten, B-1020 Brussels, Belgium. 231
232
World J. Surg. Vol. 1, No. 2, March, 1977
Fistula No. of
9
cases
The 11 fistulas (Table 3) occurred between the 1st and the 56th day after transplantation. Ten followed the PL technique and 1 followed the G r L technique. Of the l0 leaks resulting from the PL technique, 4 were at the cystotomy suture line, 1 was at the point of penetration of the ureter into the bladder, 1 was in the body of the ureter, 2 were in the renal pelvis, and the location of 2 was not determined because they were treated by simple drainage or indwelling bladder catheterization. The fistula from the body of the ureter resulted from necrosis of the terminal portion of the ureter with a 3-ram perforation 2 cm above the vesical implantation. The fistulas from the renal pelvis resulted from necroses and rupture due to adhesions around the ureter at the ureteropelvic junction in 1 case and perhaps in the other. The single fistula resulting from the G r L technique was due to malpositioning of the ureter within the submucosal tunnel; the end of the ureter had not been drawn far enough into the vesical lumen. Thus, 7 (6.5%) of the fistulas were due to the PL technique and 1 (0.8%) to the G r L procedure. The other causes of urinary leakage cannot be attributed with certainty to either one or the other implantation technique. O f the 11 patients with fistulas, 9 were operated on or treated within 24 hours following the first symptoms. One patient showed unobtrusive signs of fistula, consisting only of edema of the vulva, which caused a 3-day postponement in diagnosis and operation. In 1 other patient, a 2-day delay in reoperation was caused by a primary diagnosis of rejection. The treatment used in each case is shown in Table 3. In all cases, the treatment was successful without loss of transplant function.
Polit ano - L e a d b e t t e r
ror~goir- Lich 66
60.
54
40_ 20.
1965
68
67
6g
70 71
C3
l'~
72 73
74 75
Fig. 1. Frequency of use, by year, of the two surgical techniques of ureterovesical anastomosis in 241 renal transplantations.
sex, renal disease, source of the kidney graft, and duration of graft survival. The follow-up period ranged from 14 months to 8 years for the PL technique, and from 5 months to 6 years for the G r L technique.
Results A total of 11 urinary fistulas (4.6%) and 12 ureteral stenoses (5.0%) occurred after the 241 renal transplantations (Table 2). N o n e of these complications resulted in death or failure of transplantation. In 1 case, a patient who received a pair of baby kidneys, a renal pelvis rupture required ablation of one of the two kidneys.
Table 1. Age, sex, renal disease, source of the kidney graft, and graft survival
Total cases Age--mean and range (years)
Politano-Leadbetter
Grdgoir-Lich
Cases
%
Cases
%
108 32 (6-53)
100
133 36 (12-64)
100
Sex
Male Female Renal disease* CGN CIN Others Source of kidney Cadaver Living donor Graft survival _> 30 days
68 40
63 37
82 51
62 38
65 35 8
60 32 8
78 26 29
59 19 22
86 22 95
80 20 88
128 5 114
96 4 86
* CGN, chronic glomerulonephritis; CIN, chronic interstitial nephritis; others, polycystic kidneys, nephroangiosclerosis, renal hypoplasia, Alport syndrome, oxalosis, cortical necrosis, Kimmelstiel-Wilson syndrome.
L. Hooghe et al.: Ureteroeystostomy in Renal Transplantation
233
Table 2. Frequency of urinary fistula and stenosis of ureter
PolitanoLeadbetter
Gr6goirLich
Cases
%
Cases
%
100
133
100
Total cases 108 Urinary fistula Total 10 Due to the implantation technique 7 Stenosis of ureter Total 3 Due to the implantation technique 1
p
9.3 6.5
1 1
0.8 0.8
0.10 >0.10
Stenosis
The 12 cases of stenosis of the ureter (Table 4) arose between the 15th day and the 48th month after transplantation. Nine occurred after the 4th month. Three were observed after the PL technique and 9 after the GrL reconstruction. Following the PL procedure 1 obstruction was located at the site of the anastomosis and 2 resulted from adhesions or periureteral fibrous reactions. In the GrL group, 2 stenoses were caused by a granuloma at the extremity of the ureter, 3 were at the site of the anastomosis, 3 were due to adhesions and periurteral fibrosis, and in 1 case, the ureter had been passed behind the spermatic cord which compressed it. Thus, the G r L technique was responsible for 5 (3.8%) cases of stenosis, and the PL type of reconstruction caused 1 (0.9%) case. Strictures due to adhesions or fibrous reactions were most probably the consequence of hematomas or low-grade infections, and the obstruction by the spermatic cord was not specifically related to one or the other technique.
The treatment used in each case is shown in Table 4. In 10 patients, after reoperation all radiologic signs of hydronephrosis disappeared and there was no alteration of renal function. In 1 patient, periureteritis recurred and a second ureterolysis was performed 11 months later. This patient regained fair renal function with a serum creatinine level of 1.7 mg% 20 months after the second reoperation. In 1 patien t radiologic signs of moderate hydronephrosis have persisted, without signs of worsening during the last 28 months, and renal function remains good with a serum creatinine level of 1.4 mg%. Discussion
The 2 groups of patients are not comparable because of the overlapping nature of the study. However, the same team performed all renal transplantations and the same treatment was used. Only the ureterovesical anastomosis techniques were different. Age and sex distribution and graft survival were similar in both groups. There were a few differences in primary renal disease and in graft donors, but these factors are not believed to influence the rate
Table 3. Patients with urinary fistulas
Patient sex/age
Anastomosis technique
Time after operation of firstsymptoms (days)
M 23 M 39 F 22 M 14 M 44 M 31 M 31 M 32 F 32 F 38 M 30
PL PL PL PL PL PL PL Pk PL PL GrL
9 2 20 1.2 13 11 15 56 11 3 1
Site/etiology* Treatment UVI C C NU ~ C RP RP C ~ UVI
Drainage Suture Suture Reimplantation Drainage Suture Ureteroureterostomy Excision 1 of 2 kidneys Drainage Foley catheter Reimplantation
* UVI, ureterovesical implantation: C, cystotomy; NU, necrosis of terminal portion of ureter; RP, rupture of renal pelvis; ?, site unknown.
234
World J. Surg. Vol. 1, No. 2, March, 1977
Table 4. Patients with stenosis of ureter
Patient sex/age M 20 M 31 M 31 F 14 F 21 F 27 M 25 M 25 F 29 M 28 F 25 M 12
Anastomosis technique PL PL PL GrL GrL GrL GrL GrL GrL GrL GrL GrL
Time after operation of first symptoms (days) 277 1475 15 115 18 404 209 688 289 184 144 19
Site/etiology* Treatment IM PA PA IM G IM PA PA IM PA G SpC
Reimplantation Ureterolysis Pyeloureterostomy Reimplantation Endoscopic resection Reimplantation Ureterolysis Ureterolysis Ureterovesicoplasty Ureterolysis Endoscopic resection Section spermatic cord
* IM, intramural stenosis; PA, periureteral adhesions, bands, or fibrosis; G, endovesical granuloma; SpC, compression by spermatic cord. of urologic complications [13, 16]. We used the G r L technique for the first time in 1970. During the following 18 months we had no urinary fistulas, whereupon we decided not to continue further the comparison of the GrL and PL procedures. After January, 1972, the PL technique was used in only 4 instances: 3 cases in which the bladder mucosa was accidentally opened during the muscular incision of the GrL procedure, and 1 patient who received a pair of baby kidneys. This last reason, however, is not an absolute indication for the PL technique, since 4 other transplantations have been performed with paired infant kidneys and GrL implantations without any operative difficulty or postoperative complications. The G r L procedure avoids the most frequent and most dangerous urologic complication of kidney transplantation, namely, urinary leakage. Urinary fistula occurred in 0.8% of the cases in our G r L group. In other series, the incidence of urinary fistula has ranged from 0 to 8% with the GrL technique [9, 13. 16. 17], and from 1 to 25% after the P L t y p e of reconstruction. Ureteral obstruction resulting from the GrL technique was more frequent, but the difference compared to the PL technique was not significant. Only 3 stenoses were located at the site of the anastomosis, and another 2 resulted from granuloma formation We have observed 3 other cases of such granulomas, I during investigations for hematuria (cured by transureteral coagulation) and 2 others in asymptomatic patients during routine pyelography. Some authors who perform the GrL technique do not pull the ureter into the bladder but suture its end to the vesical mucosa. We are not certain whether the transverse U-shaped suture used to anchor the ureter or the excessive endovesical ureteral length is responsible for the granuloma formation. However. since September.
1974 the anchorage has been performed by passing the suture longitudinally through the end of the ureter only one time, and the intraluminal portion of the ureter does not exceed 5 mm in length. In the last 42 transplantations performed with this modified technique, we have observed no case of granuloma formation. In our experience the technique described by Gr6goir and Lich is the best method to avoid urinary leakage, the most dangerous urologic complication of kidney transplantation. It creates as good an antireflux mechanism as the PL procedure. It is easy to perform. It requires no large paravesical dissection or cystotomy, and thereby reduces the danger of infection in immunodepressed patients. R6sum6
Sur 241 transplantations r6nales avec reconstruction de l'arbre urinaire par implantation ur6t6ro-v~sicale, 108 ont 6t6 faites scion la technique endov6sicale de Politano-Leadbetter (P.L.), 133 selon la technique extrav6sicale de Gr6goir-Lich (Gr.L). Les complications observ6es ont 6t6: 11 fistules urinaires, 10 (9.3%) apr6s P.L., 1 (0.8%) apr~s Gr.L. (P < 0.01) 12 st~noses, 3 (2.8%) apr6s P.L., 9 (6.8%) apr6s Gr. L. (P > 0.10). Aucune de ces complications urologiques n'a entraln~ de d6c6s ni d'6chec de la transplantation. La technique de Gr6goir-Lich 6vite donc la complication urologique la plus grave de la transplantation r6nale, !a fistule urinaire. References
1. Politano, V.A., Leadbetter, W.F.: An operative technique for the correction of vesicoureteral reflux. J Urol. 79:932, 1958
L. Hooghe et al.: Ureterocystostomy in Renal Transplantation
2. Starzl, T. E., Marchioro, T.L., Dickinson, T.C., Rifkind, D., Stonington, O.G., Waddell, W.R.: Technique of renal homotransplantation. Experience with 42 cases. Arch. Surg. 89:87, 1964 3. Anderson, E.E., Glenn, J.F., Seigler, H.F., Stickel, D.L.: Ureteral implantation in renal transplantation. Surg. Gynecol. Obstet. 134:494, 1972 4. Kenefick, J.S., Fernando, O.N., Hopewell, J.P., Moorhead, J.F.: Ureteric implantation in renal transplantation. Br. J. Urol. 44:328, 1972 5. Anderson, E.E., Glenn, J.F., Seigler, H.F., Stickel, D.L.: Urologic complications in renal transplantation. J. Urol. 107:187, 1972 6. Belzer, F.O., Kountz, S.L., Najarian J.S., Tanagho, E.A., Hinman, F., Jr.: Prevention of urological complications after renal allotransplantations. Arch. Surg. 101:449, 1970 7. Dreikorn, K., R6hl, L.: Urological complications in renal transplantation. Eur. Urol. 1:170, 1975 8. Hricko, G.M., Birtch, A.G., Bennett, A.H., Wilson, R.E.: Factors responsible for urinary fistula in the renal transplant recipient. Ann. Surg. 178:609, 1973 9. Konnak, J.W., Herwig, K.R., Turcotte, J.G.: External ureteroneocystostomy in renal transplantation. J. Urol. 108:380, 1972 10. Leafy, F.J., Woods, J.E., De Weerd, J.H.: Urologic
INVITED COMMENTARY SAMUEL L. KOUNTZ, M.D.
State University of New York, Downstate Medical Center Brooklyn, New York, U.S.A.
It has been well established that urological complications may contribute greatly to the morbidity as well as the mortality of patients following kidney transplantation. The paper of Hooghe et al. describes experience in 241 renal transplants with implantation of the ureter into the bladder using two techniques, extravesical in 133 cases and endovesical in 108 cases. This experience extended over several years and the operations were done by the same operating team. The fact that no deaths or graft loss could be attributed to urological problems attests to the superior technical skill used in these operations. The investigators demonstrate that the extravesical tech-
235
problems
11. 12.
13.
14. 15. 16. 17.
in renal transplantation. Arch. Surg. 110:1124, 1975 Malek, G.H., Uehling, D.T., Daouk, A.A., Kisken, W.A.: Urological complications of renal transplantation. J. Urol. 109:173, 1973 Starzl, T.E., Groth, C.G., Putnam, C.W., Penn, I., Halgrimson, C.G., Flatmark, A., Gecelter, L., Bretschneider, L., Stonington, O.G.: Urological complications in 216 human recipients of renal transplants. Ann. Surg. 172:1, 1970 Van Geertruyden, J., Alexandre, G., Derom, F., DeRoose, J., Grosjean, O., Kinnaert, P., Lejeune, G., Maquinay, C., Otte, H., Otte, J.B., Ringoir, S., Toussaint, C., Troch, R., Van Ypersele, C., Vereerstraeten, P.: Les complications urologiques de la transplantation r6nale. Pr6vention. Traitement. Exp6rience de 306 cas. Minerva Chir. 28:866, 1973 Lich, R., Jr., Howerton, L. W., Davis, L.A.: Recurrent urosepsis in children. J. Urol. 86:554, 1961 Gr6goir, W.: Traitement chirurgical du reflux cong6nital et du m6gauret6re primaire. Urol. Int. 24:502, 1969 Campos Freire, G., Jr., Goes, G.M., Campos Freire, G. Extravesical ureteral implantation in kidney transplantation. Urology 3:304, 1974 McKinnon, K.J., Oliver, J.A., Morehouse, D.D., Taguchi, Y.: Cadaver renal transplantation: emphasis on urological aspects. J. Urol. 99:486, 1968
nique of Gr6goir and Lich was superior to the endovesical technique of Politano and Leadbetter. The simplicity of the extravesical technique suggests that this procedure is the best method for establishing urological drainage following kidney transplantation. It has the advantage of being much simpler to perform and it avoids the necessity of opening the bladder where a fistula could develop. Furthermore, the technique has another attraction in that only 50% of patients with cadaver transplantation have a successful transplant on the first try, so that many patients are now receiving retransplantation. This procedure is much easier to perfrom at retransplantation as it does not require repeated long incisions in the bladder. It requires less dissection around the bladder and can be performed by those who have minimum experience in urological techiques. Although for many years I had used the endovesical technique of Politano-Leadbetter, I have recently changed to the extravesical technique of Gr6goir and Lich and find it to be much simpler. It is my impression and belief that the technique of Gr6goir and Lich will become the procedure of choice in kidney transplantation.
Wor Journa
of
ry
9 1977 by the Soci6t~ Internationale de Chirurgie
Ureterocystostomy in Renal Transplantation: Comparison of Endo- and Extravesical Anastomoses L.
HOOGHE, M.D., P. KINNAERT, M.D., C. C. SCHULMAN, M.D., J. VAN GEERTRUYDEN, M.D., a n d P. VEREERSTRAETEN, M . D .
C.
TOUSSAINT,
M.D.,
Departments of Surgery, Medicine, and Urology, Brugmann Hospital, Universitb Libre de Bruxelles, Brussels, Belgium the two serious urologic complications, fistula and stenosis of the ureter.
Among 241 renal transplants with implantation of the ureter into the urinary bladder, the endovesical technique of Politano and Leadbetter (PL) was used in 108 cases and the extravesical technique of Gr6goir and Lich (GrL) was used in 133. Urinary fistulas occurred in 10 patients (9.3%) with the PL technique and in only 1 patient (0.8%) with the GrL technique. The difference was highly significant (p < 0.01). Stenosis of the ureter developed in 3 patients (2.8%) following the PL technique and in 9 patients (6.8%) after the GrL technique, an insignificant difference (p > 0.10). None of the complications resulted in death or failure of transplantation. It is concluded that the extravesical technique of Gr6goir and Lich is the best method of avoiding urinary leakage, which is the most dangerous urologic complication of kidney transplantation.
Materials and Methods
Between March, 1965 and December, 1975, the same surgical team performed 241 renal transplantations. Except for the reconstruction of the urinary tract, the operative procedure was the same in all cases. The ureterovesical implantatio n was accomplished in 108 cases using the Politano and Leadbetter technique (PL), as described by Starzl et al. [2] in 1964. In 133 cases the Gr6goir and Lich technique (GrL) was used for implantation of the ureter (Figure
1). The Gr6goir and Lich technique involves a vertical incision along the lateral margin of the bladder, 5 cm in length. The serosal and muscular layer s ar e opened completely but the mucosa is not entered. At the end of the dissection an outward herniation of the mucosa must be observed. At the inferior extremity of the incision, an opening of 5 mm in diameter is made into the mucosa. The ureter, cut to appropriate length, is then cradled into the incision, protruding about 0.5 to 1 cm into the bladder lumen. The ureter is secured by a U-form transfixing suture through the bladder wall. The muscular and serosal layers are then sutured over the ureter in two layers with 3-0 chromic catgut suture, thereby creating the antireflux mechanism. Treatment before, during, and after the transplantation operation, including immunosuppression therapy (azathioprine, steroids, ALG), was the same for both groups of patients. The Foley catheter was removed 24 hours after transplantation. Table 1 compares the two groups of Patients with regard to age,
Some of the urologic complications of the surgical procedure of renal transplantation are life threatening. Fistulas and stenosis of the ureter often lead to loss of the graft or even to death of the patient. T o avoid fistulas, most surgical teams now recommend the ureterovesical anastomosis, in which a submucosal tunnel is created in the bladder as described by Po!itano and Leadbetter [1], or one of the variants [2-4]. However, even with this technique the frequency of fistulas ranges from 1 to 25% [5-13]. In the most recent literature, several authors have advocated use of the Gr6goir and Lich procedure [14, 15], which avoids the complications of a cystotomy and at the same time provides an antireflux mechanism by a submucosal tunnel. We have compared the results of these two techniques with regard to the frequency of
Reprint requests: Professor Jean Van Geertruyden, Department of Surgery, H6pital Brugmann, 4, place van Gehuchten, B-1020 Brussels, Belgium. 231
232
World J. Surg. Vol. 1, No. 2, March, 1977
Fistula No. of
9
cases
The 11 fistulas (Table 3) occurred between the 1st and the 56th day after transplantation. Ten followed the PL technique and 1 followed the G r L technique. Of the l0 leaks resulting from the PL technique, 4 were at the cystotomy suture line, 1 was at the point of penetration of the ureter into the bladder, 1 was in the body of the ureter, 2 were in the renal pelvis, and the location of 2 was not determined because they were treated by simple drainage or indwelling bladder catheterization. The fistula from the body of the ureter resulted from necrosis of the terminal portion of the ureter with a 3-ram perforation 2 cm above the vesical implantation. The fistulas from the renal pelvis resulted from necroses and rupture due to adhesions around the ureter at the ureteropelvic junction in 1 case and perhaps in the other. The single fistula resulting from the G r L technique was due to malpositioning of the ureter within the submucosal tunnel; the end of the ureter had not been drawn far enough into the vesical lumen. Thus, 7 (6.5%) of the fistulas were due to the PL technique and 1 (0.8%) to the G r L procedure. The other causes of urinary leakage cannot be attributed with certainty to either one or the other implantation technique. O f the 11 patients with fistulas, 9 were operated on or treated within 24 hours following the first symptoms. One patient showed unobtrusive signs of fistula, consisting only of edema of the vulva, which caused a 3-day postponement in diagnosis and operation. In 1 other patient, a 2-day delay in reoperation was caused by a primary diagnosis of rejection. The treatment used in each case is shown in Table 3. In all cases, the treatment was successful without loss of transplant function.
Polit ano - L e a d b e t t e r
ror~goir- Lich 66
60.
54
40_ 20.
1965
68
67
6g
70 71
C3
l'~
72 73
74 75
Fig. 1. Frequency of use, by year, of the two surgical techniques of ureterovesical anastomosis in 241 renal transplantations.
sex, renal disease, source of the kidney graft, and duration of graft survival. The follow-up period ranged from 14 months to 8 years for the PL technique, and from 5 months to 6 years for the G r L technique.
Results A total of 11 urinary fistulas (4.6%) and 12 ureteral stenoses (5.0%) occurred after the 241 renal transplantations (Table 2). N o n e of these complications resulted in death or failure of transplantation. In 1 case, a patient who received a pair of baby kidneys, a renal pelvis rupture required ablation of one of the two kidneys.
Table 1. Age, sex, renal disease, source of the kidney graft, and graft survival
Total cases Age--mean and range (years)
Politano-Leadbetter
Grdgoir-Lich
Cases
%
Cases
%
108 32 (6-53)
100
133 36 (12-64)
100
Sex
Male Female Renal disease* CGN CIN Others Source of kidney Cadaver Living donor Graft survival _> 30 days
68 40
63 37
82 51
62 38
65 35 8
60 32 8
78 26 29
59 19 22
86 22 95
80 20 88
128 5 114
96 4 86
* CGN, chronic glomerulonephritis; CIN, chronic interstitial nephritis; others, polycystic kidneys, nephroangiosclerosis, renal hypoplasia, Alport syndrome, oxalosis, cortical necrosis, Kimmelstiel-Wilson syndrome.
L. Hooghe et al.: Ureteroeystostomy in Renal Transplantation
233
Table 2. Frequency of urinary fistula and stenosis of ureter
PolitanoLeadbetter
Gr6goirLich
Cases
%
Cases
%
100
133
100
Total cases 108 Urinary fistula Total 10 Due to the implantation technique 7 Stenosis of ureter Total 3 Due to the implantation technique 1
p
9.3 6.5
1 1
0.8 0.8
0.10 >0.10
Stenosis
The 12 cases of stenosis of the ureter (Table 4) arose between the 15th day and the 48th month after transplantation. Nine occurred after the 4th month. Three were observed after the PL technique and 9 after the GrL reconstruction. Following the PL procedure 1 obstruction was located at the site of the anastomosis and 2 resulted from adhesions or periureteral fibrous reactions. In the GrL group, 2 stenoses were caused by a granuloma at the extremity of the ureter, 3 were at the site of the anastomosis, 3 were due to adhesions and periurteral fibrosis, and in 1 case, the ureter had been passed behind the spermatic cord which compressed it. Thus, the G r L technique was responsible for 5 (3.8%) cases of stenosis, and the PL type of reconstruction caused 1 (0.9%) case. Strictures due to adhesions or fibrous reactions were most probably the consequence of hematomas or low-grade infections, and the obstruction by the spermatic cord was not specifically related to one or the other technique.
The treatment used in each case is shown in Table 4. In 10 patients, after reoperation all radiologic signs of hydronephrosis disappeared and there was no alteration of renal function. In 1 patient, periureteritis recurred and a second ureterolysis was performed 11 months later. This patient regained fair renal function with a serum creatinine level of 1.7 mg% 20 months after the second reoperation. In 1 patien t radiologic signs of moderate hydronephrosis have persisted, without signs of worsening during the last 28 months, and renal function remains good with a serum creatinine level of 1.4 mg%. Discussion
The 2 groups of patients are not comparable because of the overlapping nature of the study. However, the same team performed all renal transplantations and the same treatment was used. Only the ureterovesical anastomosis techniques were different. Age and sex distribution and graft survival were similar in both groups. There were a few differences in primary renal disease and in graft donors, but these factors are not believed to influence the rate
Table 3. Patients with urinary fistulas
Patient sex/age
Anastomosis technique
Time after operation of firstsymptoms (days)
M 23 M 39 F 22 M 14 M 44 M 31 M 31 M 32 F 32 F 38 M 30
PL PL PL PL PL PL PL Pk PL PL GrL
9 2 20 1.2 13 11 15 56 11 3 1
Site/etiology* Treatment UVI C C NU ~ C RP RP C ~ UVI
Drainage Suture Suture Reimplantation Drainage Suture Ureteroureterostomy Excision 1 of 2 kidneys Drainage Foley catheter Reimplantation
* UVI, ureterovesical implantation: C, cystotomy; NU, necrosis of terminal portion of ureter; RP, rupture of renal pelvis; ?, site unknown.
234
World J. Surg. Vol. 1, No. 2, March, 1977
Table 4. Patients with stenosis of ureter
Patient sex/age M 20 M 31 M 31 F 14 F 21 F 27 M 25 M 25 F 29 M 28 F 25 M 12
Anastomosis technique PL PL PL GrL GrL GrL GrL GrL GrL GrL GrL GrL
Time after operation of first symptoms (days) 277 1475 15 115 18 404 209 688 289 184 144 19
Site/etiology* Treatment IM PA PA IM G IM PA PA IM PA G SpC
Reimplantation Ureterolysis Pyeloureterostomy Reimplantation Endoscopic resection Reimplantation Ureterolysis Ureterolysis Ureterovesicoplasty Ureterolysis Endoscopic resection Section spermatic cord
* IM, intramural stenosis; PA, periureteral adhesions, bands, or fibrosis; G, endovesical granuloma; SpC, compression by spermatic cord. of urologic complications [13, 16]. We used the G r L technique for the first time in 1970. During the following 18 months we had no urinary fistulas, whereupon we decided not to continue further the comparison of the GrL and PL procedures. After January, 1972, the PL technique was used in only 4 instances: 3 cases in which the bladder mucosa was accidentally opened during the muscular incision of the GrL procedure, and 1 patient who received a pair of baby kidneys. This last reason, however, is not an absolute indication for the PL technique, since 4 other transplantations have been performed with paired infant kidneys and GrL implantations without any operative difficulty or postoperative complications. The G r L procedure avoids the most frequent and most dangerous urologic complication of kidney transplantation, namely, urinary leakage. Urinary fistula occurred in 0.8% of the cases in our G r L group. In other series, the incidence of urinary fistula has ranged from 0 to 8% with the GrL technique [9, 13. 16. 17], and from 1 to 25% after the P L t y p e of reconstruction. Ureteral obstruction resulting from the GrL technique was more frequent, but the difference compared to the PL technique was not significant. Only 3 stenoses were located at the site of the anastomosis, and another 2 resulted from granuloma formation We have observed 3 other cases of such granulomas, I during investigations for hematuria (cured by transureteral coagulation) and 2 others in asymptomatic patients during routine pyelography. Some authors who perform the GrL technique do not pull the ureter into the bladder but suture its end to the vesical mucosa. We are not certain whether the transverse U-shaped suture used to anchor the ureter or the excessive endovesical ureteral length is responsible for the granuloma formation. However. since September.
1974 the anchorage has been performed by passing the suture longitudinally through the end of the ureter only one time, and the intraluminal portion of the ureter does not exceed 5 mm in length. In the last 42 transplantations performed with this modified technique, we have observed no case of granuloma formation. In our experience the technique described by Gr6goir and Lich is the best method to avoid urinary leakage, the most dangerous urologic complication of kidney transplantation. It creates as good an antireflux mechanism as the PL procedure. It is easy to perform. It requires no large paravesical dissection or cystotomy, and thereby reduces the danger of infection in immunodepressed patients. R6sum6
Sur 241 transplantations r6nales avec reconstruction de l'arbre urinaire par implantation ur6t6ro-v~sicale, 108 ont 6t6 faites scion la technique endov6sicale de Politano-Leadbetter (P.L.), 133 selon la technique extrav6sicale de Gr6goir-Lich (Gr.L). Les complications observ6es ont 6t6: 11 fistules urinaires, 10 (9.3%) apr6s P.L., 1 (0.8%) apr~s Gr.L. (P < 0.01) 12 st~noses, 3 (2.8%) apr6s P.L., 9 (6.8%) apr6s Gr. L. (P > 0.10). Aucune de ces complications urologiques n'a entraln~ de d6c6s ni d'6chec de la transplantation. La technique de Gr6goir-Lich 6vite donc la complication urologique la plus grave de la transplantation r6nale, !a fistule urinaire. References
1. Politano, V.A., Leadbetter, W.F.: An operative technique for the correction of vesicoureteral reflux. J Urol. 79:932, 1958
L. Hooghe et al.: Ureterocystostomy in Renal Transplantation
2. Starzl, T. E., Marchioro, T.L., Dickinson, T.C., Rifkind, D., Stonington, O.G., Waddell, W.R.: Technique of renal homotransplantation. Experience with 42 cases. Arch. Surg. 89:87, 1964 3. Anderson, E.E., Glenn, J.F., Seigler, H.F., Stickel, D.L.: Ureteral implantation in renal transplantation. Surg. Gynecol. Obstet. 134:494, 1972 4. Kenefick, J.S., Fernando, O.N., Hopewell, J.P., Moorhead, J.F.: Ureteric implantation in renal transplantation. Br. J. Urol. 44:328, 1972 5. Anderson, E.E., Glenn, J.F., Seigler, H.F., Stickel, D.L.: Urologic complications in renal transplantation. J. Urol. 107:187, 1972 6. Belzer, F.O., Kountz, S.L., Najarian J.S., Tanagho, E.A., Hinman, F., Jr.: Prevention of urological complications after renal allotransplantations. Arch. Surg. 101:449, 1970 7. Dreikorn, K., R6hl, L.: Urological complications in renal transplantation. Eur. Urol. 1:170, 1975 8. Hricko, G.M., Birtch, A.G., Bennett, A.H., Wilson, R.E.: Factors responsible for urinary fistula in the renal transplant recipient. Ann. Surg. 178:609, 1973 9. Konnak, J.W., Herwig, K.R., Turcotte, J.G.: External ureteroneocystostomy in renal transplantation. J. Urol. 108:380, 1972 10. Leafy, F.J., Woods, J.E., De Weerd, J.H.: Urologic
INVITED COMMENTARY SAMUEL L. KOUNTZ, M.D.
State University of New York, Downstate Medical Center Brooklyn, New York, U.S.A.
It has been well established that urological complications may contribute greatly to the morbidity as well as the mortality of patients following kidney transplantation. The paper of Hooghe et al. describes experience in 241 renal transplants with implantation of the ureter into the bladder using two techniques, extravesical in 133 cases and endovesical in 108 cases. This experience extended over several years and the operations were done by the same operating team. The fact that no deaths or graft loss could be attributed to urological problems attests to the superior technical skill used in these operations. The investigators demonstrate that the extravesical tech-
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problems
11. 12.
13.
14. 15. 16. 17.
in renal transplantation. Arch. Surg. 110:1124, 1975 Malek, G.H., Uehling, D.T., Daouk, A.A., Kisken, W.A.: Urological complications of renal transplantation. J. Urol. 109:173, 1973 Starzl, T.E., Groth, C.G., Putnam, C.W., Penn, I., Halgrimson, C.G., Flatmark, A., Gecelter, L., Bretschneider, L., Stonington, O.G.: Urological complications in 216 human recipients of renal transplants. Ann. Surg. 172:1, 1970 Van Geertruyden, J., Alexandre, G., Derom, F., DeRoose, J., Grosjean, O., Kinnaert, P., Lejeune, G., Maquinay, C., Otte, H., Otte, J.B., Ringoir, S., Toussaint, C., Troch, R., Van Ypersele, C., Vereerstraeten, P.: Les complications urologiques de la transplantation r6nale. Pr6vention. Traitement. Exp6rience de 306 cas. Minerva Chir. 28:866, 1973 Lich, R., Jr., Howerton, L. W., Davis, L.A.: Recurrent urosepsis in children. J. Urol. 86:554, 1961 Gr6goir, W.: Traitement chirurgical du reflux cong6nital et du m6gauret6re primaire. Urol. Int. 24:502, 1969 Campos Freire, G., Jr., Goes, G.M., Campos Freire, G. Extravesical ureteral implantation in kidney transplantation. Urology 3:304, 1974 McKinnon, K.J., Oliver, J.A., Morehouse, D.D., Taguchi, Y.: Cadaver renal transplantation: emphasis on urological aspects. J. Urol. 99:486, 1968
nique of Gr6goir and Lich was superior to the endovesical technique of Politano and Leadbetter. The simplicity of the extravesical technique suggests that this procedure is the best method for establishing urological drainage following kidney transplantation. It has the advantage of being much simpler to perform and it avoids the necessity of opening the bladder where a fistula could develop. Furthermore, the technique has another attraction in that only 50% of patients with cadaver transplantation have a successful transplant on the first try, so that many patients are now receiving retransplantation. This procedure is much easier to perfrom at retransplantation as it does not require repeated long incisions in the bladder. It requires less dissection around the bladder and can be performed by those who have minimum experience in urological techiques. Although for many years I had used the endovesical technique of Politano-Leadbetter, I have recently changed to the extravesical technique of Gr6goir and Lich and find it to be much simpler. It is my impression and belief that the technique of Gr6goir and Lich will become the procedure of choice in kidney transplantation.
