British Journal of Urology (1979). 51. 184-187
Urological Complications in 1 19 Consecutive Renal Transplants S. N. MEHTA, J. A. KENNEDY, W. G. G. LOUGHRIDGE, J. F. DOUGLAS, R . A. DONALDSON and MARY G. McGEOWN Department of Nephrology, Belfast City Hospital, Belfast
Summary-One hundred and nine patients undergoing 1 1 9 transplants have been followed up from 8 months to 9 years. Urological complications occurred in 1 6 transplants, an incidence of 13.4%.
Ureteroneocystostomy w a s performed primarily in all cases; in 98 by the conventional Politano-Leadbetter technique with 9 ( 9 . 2 % ) urological complications and in 32 by an extravesical technique with 7 (21 - 8 % )urological complications. One patient died a s a result of ureteric obstruction, without operation. In 3 patients with lower ureteric obstruction, transurethral ureteric meatotomy w a s successful in 2 cases and resulted in no change in renal function in the third. Two patients with urinary fistulae were managed successfully by continuous drainage with indwelling urethral catheters. The remaining 1 0 patients required 1 2 open surgical procedures for relief of ureteric obstruction, with improvement in function in 7 patients.
Urological complications following renal transplantation are all potentially serious as the patients are on immunosuppressive therapy. This paper presents our experience with urological complicationsin I 19consecutive transplants from November 1968 to December 1977.
tion was restored to the graft a ureteroneocystostomy was performed. In earlier cases (87 transplants) the technique of ureteroneocystostomy was similar to that described by Politano and Leadbetter (1958) without the use of a ureteric splint. Later in the series (32 transplants) an extravesical method of ureteroneocystostomy Patients and Methods (MacKinnon et al., 1968) was found to be simpler and less time-consuming than the former method One hundred and nine patients received 119 transand was carried out as follows. plants. Four grafts came from living related The ureter was trimmed to the length required donors and 115 from cadavers. There were 8 to reach the lateral wall of the bladder without second transplants and 2 third transplants. The initial warm ischaemia time for cadaver grafts undue laxity or tension and ensuring that the varied from 2 to 80 min and the total ischaemia blood supply to the ureter was adequate, as time from 159 to I152 min. Bilateral nephrectomy judged by fresh bleeding from its distal end. A was carried out on 77 of the recipients before vertical myotomy, 3 to 4 cm long, was made on transplantation. Azathioprine and steroids were the lateral wall of the bladder and the submucosal used for immunosuppression and our regime has space opened over a distance of I cm on each been fully described elsewhere (McGeown et a/., side of the myotomy. A small incision in the mucosa at the distal end of the myotomy was 1977). Prior to commencing the operation the bladder made and the ureter anastomosed, after spatulawas washed out with a 1% solution of neomycin tion, to the bladder with 4 to 6 interrupted through a Foley’catheter. One hundred and fifty stitches of 4/0 chromic catgut through all layers ml of I % neomycin solution were left in the of the ureter and the bladder mucosa. The end bladder and the catheter spigoted. After circula- of the ureter was invaginated into the submucosal space and the edges of the myotomy approximated over the lower end of the ureter with interrupted Received 22 June 1978. 210 chromic catgut stitches. Acccpted for publication 24 October 1978 184
UROLOGICAL COMPLICATIONS IN I19 CONSECUTIVE RENAL TRANSPLANTS
A Foley catheter was left in the bladder for 4 days if there was no urine excretion or for 7 to 10 days if there was early graft function. When a small urinary leak occurred, the fluid was identified as urine by comparison with the blood and urinary urea levels, but usually the rapid increase in volume from the fistula made the diagnosis clear. The diagnosis of obstruction was usually suspected when a previously successful graft declined in function, especially if the patient remained clinically without symptoms. The absence of hypertension, lack of increase in protein excretion (although 2 patients with urinary obstruction also developed heavy proteinuria due to recurrence of mesangioproliferative glomerulonephritis of “dense deposit type”) and urinary N-acetyl-beta-D-glucosamidase were helpful. Renography, high dose pyelography and, in those patients where the orifice of the new ureter proved accessible, ascending pyelography were used. As well as the appearance of the ureter at operation in the most recent 3 cases, transureteric pressure measurements were used as confirmatory evidence of obstruction. A kidney biopsy was carried out in all cases and the results of these will be the subject of a separate communication. Results
In I 19 transplants, urological complications occurred in 16 patients (Table), an incidence of 13.4%. One (E.S.) of these 16 patients died from a chest infection with failing graft function at 1 year, a mortality of 6.7% for urological complications. Urinary Fistula Six patients developed a urinary fistula. In 2 patients the fistula followed soon after operation and closed spontaneously after a period of ucethral catheter drainage. In 1 patient the fistula occurred 19 days after transplantation and was due to necrosis of the ureter. The necrotic ureter was excised and using the patient’s own ipsilateral ureter, a ureteroureterostomy was performed. In Table ~
Ureferoneocystosfomy Politano-Leadbetter Extravesical technique
~
Number of cases 87 32
~
~
Ureteric pro biems 9 7
%
9.2 21.8
185
3 patients the fistula followed reimplantation of the ureter for treatment of late stenosis. One was re-explored within 24 h and the anastomosis was reconstructed with an excellent result. In a second patient the fistula closed spontaneously after continuous bladder drainage for 3 weeks. In the third patient urine began to leak from the drainage tube on the fifth day and at operation on the seventh day the lower end of the ureter was found to be narrowed and non-viable. Viable ureter was reimplanted and a ureteric splint was left in situ for 14 days. The kidney function has improved considerably. Antibiotics were not used prophylactically. Two patients with urinary fistulae developed urinary infections and were treated with appropriate antibacterial therapy. Immunosuppressive therapy was continued uninterrupted in these patients. Ureteric Obstruction Thirteen patients were found to have ureteric obstruction between 3 months and 6 months after transplantation. In 1 patient a tight stenosis was discovered at post mortem. The graft had functioned well at first but function gradually declined and the patient died from a chest infection 12 months after transplantation. In 1 patient the lower 5 cm of the ureter were stenosed and the remaining upper ureter grossly dilated but too short for reimplantation with an antireflux procedure. The ureter was anastomosed directly to the dome of the bladder with a successful result. In 3 patients the obstruction was due to stenosis of a short segment of the lower end of the ureter and transurethral ureteric meatotomy was sufficient for relief of the obstruction. Graft function improved in 2 patients but did not change in the third. In 4 patients the obstruction was due to kinks in the ureter with periureteric fibrosis. In 1 patient the ureter was straightened by freeing it from the fibrous tissue, with a successful result. In the other 3 patients the kinked ureter was freed and then reimplanted, with successful results in 2; in the other patient the kidney was lost soon afterwards from irreversible rejection 6 months after transplantation. In another patient the ureter was twisted at the lower end and was reimplanted, developed a urinary leak, but reimplantation a second time was successful.
186
In 1 patient the obstruction was due to dense periureteric fibrosis and had been present for many months before operation. The ureter was freed by dissection but graft function has slowly declined over the following 9 months, although it continues to support life. Two other patients developed stenosis of the lower end of the ureter. In one this was complicated by acute rejection 11 months after transplantation. The ureter was reimplanted and antirejection treatment given with some success, but graft function is declining 6 months later. The remaining graft had 2 ureters which had been joined and anastomosed to the bladder as a singled ureter by the extravesical technique, where stenosis occurred. Both anastomoses were repeated, with a successful result.
Discussion The incidence of urological complications in recently reported series has ranged from 4 t o 30% and mortality rates attributed to these complications have ranged from 0 to 68% (Prout et al., 1967; Martin et al., 1969; Belzer et al., 1970; Starzl et al., 1970; Williams et al., 1970; Robson and Calne, 1971; Weil et al., 1971; O’Donoghue el al., 1973; Donaldson et al., 1977). In most of these series, the Politano-Leadbetter technique of ureteroneocystostomy was used. In 1 series of 35 transplants using the extravesical technique, only 1 urological complication was encountered (Woodruff et al., 1969) and in another series of 50 transplants, 5 significant urological complications occurred (Clunie el al., 1974). It is generally accepted that the successful management of ureteric complication requires early diagnosis and surgical correction. In our series, in the case of a urinary fistula the decision to undertake surgical exploration was dictated by the severity of the leakage. It was deemed necessary in 3 cases, when all urine excreted by the graft was passed through the fistula, indicating ureteric necrosis (H.D.) or complete disruption of a ureterovesical anastomosis (E.D. and K.McI.). In the case of a urinary fistula with a proportion of urine excreted by the graft still passing through the bladder, indicating incomplete disruption of a ureterovesical anastomosis, we found that conservative treatment was successful so long as strict attention was paid to the prevention of infection. On the other hand, we have found that better
BRITISH JOURNAL OF UROLOGY
results were obtained in those cases of ureteric obstruction where the diagnosis was quickly followed by surgical correction of the obstruction. In patients with gradually deteriorating graft function due to ureteric obstruction, delay in surgical relief was accompanied by a less satisfactory result. In 1 patient (A.R.) whose graft function deteriorated over several months and was treated with antirejection therapy on 3 occasions with doubtful response, there was little improvement in graft function after relief of ureteric obstruction. Renal biopsy at the time of operation showed no signs of acute rejection and she still has a life-supporting graft 9 months after her latest operation. In 2 patients (J.W. and D.B.) with already deteriorating renal function, the result of ureteric obstruction which had been left untreated for some time, acute rejection supervened and resulted in a more rapid decline in renal function. J.W. had a graft nephrectomy for acute irreversible rejection shortly after reimplantation of the obstructed ureter. D.B. made a good recovery after repeat ureteroneocystostomy and antirejection therapy, but her serum creatinine has gradually increased and graft function is poor 6 months later. In our experience, ureteric obstruction is more common than late rejection and must always be considered when renal function deteriorates. In addition t o clinical evaluation and standard tests of renal function, we made use of renography (Doherty et al., 1978), high dose pyelography, ascending ureterography, N-acetyl-beta-D-glucosamidase and urinary urinary protein excretion, and sometimes renal biopsy to distinguish between ureteric obstruction and rejection. As well as assisting in the diagnosis, radiological investigations helped to define the site and extent of ureteric obstruction so that corrective surgery could be planned. Transurethral meatotomy, a recommended procedure for the relief of ureteric obstruction, has been described previously (Donaldson et al., 1977) and was successful in 2 of our patients. If, on intravenous pyelography, the stenosis is seen t o be confined to the lower end of the ureter, cystoscopy should be performed and if this reveals stenosis confined to the tip of the ureter, .the remainder of the ureter within the submucosal tunnel will be seen to be normal or dilated, making transurethral meatotomy a simple and effective procedure. Emphasis should be placed upon prevention of urological complications with careful attention to
UROLOGICAL COMPLICATIONS IN 119 CONSECUTIVE RENAL TRANSPLANTS
187
technique, Ureteric necrosis is due to damage to Doherty, C. C., Douglas, J. F. and McCeown, Mary G. (1978). Isotope renography and long-term follow-up of the ureteric blood vessels and may occur during renal transplant patients. British Journal of Radiology, removal and handling of the kidney but may be 51, 802-807. unavoidable if the ureter has an anomalous blood MacKinnon, K. J., Oliver, J. A., Morehouse, D. D. and Taguchi, Y. (1968). Cadaver renal transplaritation: emphasis supply mainly through arteries not arising from on urological aspects. Journal of Urology, 99, 486-490. the renal artery or its branches. Ureteric obstrucMary G., Kennedy, J. A., Loughridge, W. G. G., tion due to kinking of the ureter and periureteric McCeown, Douglas, J. F., Alexander, J. A., Clarke, S. D., McEvoy, fibrosis could probably be avoided by ensuring J., Hewitt, J. C. and Nelson, S . D. (1977). One hundred that the ureter is just long enough to reach the kidney transplants in the Belfast City Hospital. Lancet, 2, 648-65 1. bladder without undue tension. In our series of 119 transplants the overall Marlin, D. C., Mims, M. M., Kaufman, J. J. and Goodwin, W. E. (1969). The ureter in renal transplantation. Journal incidence of urological complications was 13.4%, Of Urology, 101, 680-687. with an incidence of 21.8% when the extravesical O'Donoghue, E. P. N., Chisholm, G . D. and Shackman, R. (1973). Urinary fistulae after renal transplantion. British technique was used compared with 9.2% when Journal of Urology, 45, 28-33. the Politano-Leadbetter technique was used. V. A. and Leadbetter, W. F. (1958). An operative Screening by renography has been carried out on Politano, technique for the correction of vesico-ureteral reflux. most of the surviving grafts done by the PolitanoJournal of Urology, 19, 932-941. Leadbetter technique (Doherty et al., 1978) and it Prout, G. R., Jr., Hume, D. M., Lee, H. M. and Williams, G. M. (1967). Some urological aspects of 93 consecutive seems unlikely that more cases of obstruction will renal homo-transplants in modified recipients. Journal of turn up in this group. Screening for signs of Urology, 91, 409-425. obstruction of the remaining grafts performed by Robson, A. J. and Calne, R. Y. (1971). Complications of the extravesical technique is planned. Renography urinary drainage following renal transplantation. British Journal of Urology, 43, 586-590. and intravenous pyelography suggest obstruction in 2 further cases of the 5 already screened. In Stanl, T. E., Groth, C. G., Putnam, C. W., Penn, I., Halgrimson, C. G., Flatmark, A., Grecelter, L., Bettour hands the extravesical technique leads to a schmeider, L. and Stonington. 0. C. (1970). Urological higher complication rate than the Politanocomplications in 216 human recipients of renal transplants. Leadbetter technique. We feel that the complicaAnnals of Surgery, 112, 1-22. tion rate of the extravesical technique is so high Weil, R., Simmons, R. L., Tallent, M. B., Lillehei. R. C., Kjellstrand, C. M. and Najarian, J. S. (1971). Prevention that it would be unjustifiable to continue with its of urological complications after transplantation. Annals use and we have decided .to return to the Politanoof Surgery, 174, 154-160. Leadbetter method of ureteroneocystostomy. Williams, G., Birtch, A. G., Wilson, R. E., Harrison, J. H.
Acknowledgement
and Murray, J. E. (1970). Urological complications of renal transplantation. British Journal of Urology, 42, 21-27.
We gratefully acknowledge support from the Northern Ireland Kidney Research Fund.
Woodruff, M. F. A., Robson, J. S., Nolan, B. and MacDonald, M. K. (1969). Renal transplantation in man. Lancet, 1, 6-12.
References
The Authors
Belzcr, F. 0..Kountz, S . L., Najarian, J . S., Tanagho, E. A. and Hinman, F., Jr. (1970). Prevention of urological com-
S. N. Mehta, MS, FRCS, Senior Registrar in Surgery. J. A. Kennedy, MCh, FRCS, Urologist. W. G. G. Loughridge, MA, MD, FRCS, Urologist. J. F. Douglas, MA, BCL, MB, BCh, MRCP, Nephrologist. R. A. Donaldson, BSc, MB, BCh, FRCS, Urologist and Transplant Surgeon. Mary G. McGeown, MD, PhD, FRCPE, FRCP, Nephrologist .
plications after renal allotransplantation. Archives of Surgery, 101, 449452. Clunie, G. J. A., Siddle, K. J., Hartley, L. C. J. and Hardie, 1. R. (1974). The ureter in renal transplantation-Results of a simple technique of uretero-vesical anastomosis. Australian Journal of Surgety, 131, 556-559. Donaldson. R. A., Jacobson, J. E. and Pontin, A. R. (1977). Ureteric obstruction in renal allograft recipients. South Grican Medical Journal, 52, 1077-1082.
Requests for reprints to: Mary G. McGeown, Renal Unit, Belfast City Hospital, Belfast BT9 7AB.
Urological Complications in 1 19 Consecutive Renal Transplants S. N. MEHTA, J. A. KENNEDY, W. G. G. LOUGHRIDGE, J. F. DOUGLAS, R . A. DONALDSON and MARY G. McGEOWN Department of Nephrology, Belfast City Hospital, Belfast
Summary-One hundred and nine patients undergoing 1 1 9 transplants have been followed up from 8 months to 9 years. Urological complications occurred in 1 6 transplants, an incidence of 13.4%.
Ureteroneocystostomy w a s performed primarily in all cases; in 98 by the conventional Politano-Leadbetter technique with 9 ( 9 . 2 % ) urological complications and in 32 by an extravesical technique with 7 (21 - 8 % )urological complications. One patient died a s a result of ureteric obstruction, without operation. In 3 patients with lower ureteric obstruction, transurethral ureteric meatotomy w a s successful in 2 cases and resulted in no change in renal function in the third. Two patients with urinary fistulae were managed successfully by continuous drainage with indwelling urethral catheters. The remaining 1 0 patients required 1 2 open surgical procedures for relief of ureteric obstruction, with improvement in function in 7 patients.
Urological complications following renal transplantation are all potentially serious as the patients are on immunosuppressive therapy. This paper presents our experience with urological complicationsin I 19consecutive transplants from November 1968 to December 1977.
tion was restored to the graft a ureteroneocystostomy was performed. In earlier cases (87 transplants) the technique of ureteroneocystostomy was similar to that described by Politano and Leadbetter (1958) without the use of a ureteric splint. Later in the series (32 transplants) an extravesical method of ureteroneocystostomy Patients and Methods (MacKinnon et al., 1968) was found to be simpler and less time-consuming than the former method One hundred and nine patients received 119 transand was carried out as follows. plants. Four grafts came from living related The ureter was trimmed to the length required donors and 115 from cadavers. There were 8 to reach the lateral wall of the bladder without second transplants and 2 third transplants. The initial warm ischaemia time for cadaver grafts undue laxity or tension and ensuring that the varied from 2 to 80 min and the total ischaemia blood supply to the ureter was adequate, as time from 159 to I152 min. Bilateral nephrectomy judged by fresh bleeding from its distal end. A was carried out on 77 of the recipients before vertical myotomy, 3 to 4 cm long, was made on transplantation. Azathioprine and steroids were the lateral wall of the bladder and the submucosal used for immunosuppression and our regime has space opened over a distance of I cm on each been fully described elsewhere (McGeown et a/., side of the myotomy. A small incision in the mucosa at the distal end of the myotomy was 1977). Prior to commencing the operation the bladder made and the ureter anastomosed, after spatulawas washed out with a 1% solution of neomycin tion, to the bladder with 4 to 6 interrupted through a Foley’catheter. One hundred and fifty stitches of 4/0 chromic catgut through all layers ml of I % neomycin solution were left in the of the ureter and the bladder mucosa. The end bladder and the catheter spigoted. After circula- of the ureter was invaginated into the submucosal space and the edges of the myotomy approximated over the lower end of the ureter with interrupted Received 22 June 1978. 210 chromic catgut stitches. Acccpted for publication 24 October 1978 184
UROLOGICAL COMPLICATIONS IN I19 CONSECUTIVE RENAL TRANSPLANTS
A Foley catheter was left in the bladder for 4 days if there was no urine excretion or for 7 to 10 days if there was early graft function. When a small urinary leak occurred, the fluid was identified as urine by comparison with the blood and urinary urea levels, but usually the rapid increase in volume from the fistula made the diagnosis clear. The diagnosis of obstruction was usually suspected when a previously successful graft declined in function, especially if the patient remained clinically without symptoms. The absence of hypertension, lack of increase in protein excretion (although 2 patients with urinary obstruction also developed heavy proteinuria due to recurrence of mesangioproliferative glomerulonephritis of “dense deposit type”) and urinary N-acetyl-beta-D-glucosamidase were helpful. Renography, high dose pyelography and, in those patients where the orifice of the new ureter proved accessible, ascending pyelography were used. As well as the appearance of the ureter at operation in the most recent 3 cases, transureteric pressure measurements were used as confirmatory evidence of obstruction. A kidney biopsy was carried out in all cases and the results of these will be the subject of a separate communication. Results
In I 19 transplants, urological complications occurred in 16 patients (Table), an incidence of 13.4%. One (E.S.) of these 16 patients died from a chest infection with failing graft function at 1 year, a mortality of 6.7% for urological complications. Urinary Fistula Six patients developed a urinary fistula. In 2 patients the fistula followed soon after operation and closed spontaneously after a period of ucethral catheter drainage. In 1 patient the fistula occurred 19 days after transplantation and was due to necrosis of the ureter. The necrotic ureter was excised and using the patient’s own ipsilateral ureter, a ureteroureterostomy was performed. In Table ~
Ureferoneocystosfomy Politano-Leadbetter Extravesical technique
~
Number of cases 87 32
~
~
Ureteric pro biems 9 7
%
9.2 21.8
185
3 patients the fistula followed reimplantation of the ureter for treatment of late stenosis. One was re-explored within 24 h and the anastomosis was reconstructed with an excellent result. In a second patient the fistula closed spontaneously after continuous bladder drainage for 3 weeks. In the third patient urine began to leak from the drainage tube on the fifth day and at operation on the seventh day the lower end of the ureter was found to be narrowed and non-viable. Viable ureter was reimplanted and a ureteric splint was left in situ for 14 days. The kidney function has improved considerably. Antibiotics were not used prophylactically. Two patients with urinary fistulae developed urinary infections and were treated with appropriate antibacterial therapy. Immunosuppressive therapy was continued uninterrupted in these patients. Ureteric Obstruction Thirteen patients were found to have ureteric obstruction between 3 months and 6 months after transplantation. In 1 patient a tight stenosis was discovered at post mortem. The graft had functioned well at first but function gradually declined and the patient died from a chest infection 12 months after transplantation. In 1 patient the lower 5 cm of the ureter were stenosed and the remaining upper ureter grossly dilated but too short for reimplantation with an antireflux procedure. The ureter was anastomosed directly to the dome of the bladder with a successful result. In 3 patients the obstruction was due to stenosis of a short segment of the lower end of the ureter and transurethral ureteric meatotomy was sufficient for relief of the obstruction. Graft function improved in 2 patients but did not change in the third. In 4 patients the obstruction was due to kinks in the ureter with periureteric fibrosis. In 1 patient the ureter was straightened by freeing it from the fibrous tissue, with a successful result. In the other 3 patients the kinked ureter was freed and then reimplanted, with successful results in 2; in the other patient the kidney was lost soon afterwards from irreversible rejection 6 months after transplantation. In another patient the ureter was twisted at the lower end and was reimplanted, developed a urinary leak, but reimplantation a second time was successful.
186
In 1 patient the obstruction was due to dense periureteric fibrosis and had been present for many months before operation. The ureter was freed by dissection but graft function has slowly declined over the following 9 months, although it continues to support life. Two other patients developed stenosis of the lower end of the ureter. In one this was complicated by acute rejection 11 months after transplantation. The ureter was reimplanted and antirejection treatment given with some success, but graft function is declining 6 months later. The remaining graft had 2 ureters which had been joined and anastomosed to the bladder as a singled ureter by the extravesical technique, where stenosis occurred. Both anastomoses were repeated, with a successful result.
Discussion The incidence of urological complications in recently reported series has ranged from 4 t o 30% and mortality rates attributed to these complications have ranged from 0 to 68% (Prout et al., 1967; Martin et al., 1969; Belzer et al., 1970; Starzl et al., 1970; Williams et al., 1970; Robson and Calne, 1971; Weil et al., 1971; O’Donoghue el al., 1973; Donaldson et al., 1977). In most of these series, the Politano-Leadbetter technique of ureteroneocystostomy was used. In 1 series of 35 transplants using the extravesical technique, only 1 urological complication was encountered (Woodruff et al., 1969) and in another series of 50 transplants, 5 significant urological complications occurred (Clunie el al., 1974). It is generally accepted that the successful management of ureteric complication requires early diagnosis and surgical correction. In our series, in the case of a urinary fistula the decision to undertake surgical exploration was dictated by the severity of the leakage. It was deemed necessary in 3 cases, when all urine excreted by the graft was passed through the fistula, indicating ureteric necrosis (H.D.) or complete disruption of a ureterovesical anastomosis (E.D. and K.McI.). In the case of a urinary fistula with a proportion of urine excreted by the graft still passing through the bladder, indicating incomplete disruption of a ureterovesical anastomosis, we found that conservative treatment was successful so long as strict attention was paid to the prevention of infection. On the other hand, we have found that better
BRITISH JOURNAL OF UROLOGY
results were obtained in those cases of ureteric obstruction where the diagnosis was quickly followed by surgical correction of the obstruction. In patients with gradually deteriorating graft function due to ureteric obstruction, delay in surgical relief was accompanied by a less satisfactory result. In 1 patient (A.R.) whose graft function deteriorated over several months and was treated with antirejection therapy on 3 occasions with doubtful response, there was little improvement in graft function after relief of ureteric obstruction. Renal biopsy at the time of operation showed no signs of acute rejection and she still has a life-supporting graft 9 months after her latest operation. In 2 patients (J.W. and D.B.) with already deteriorating renal function, the result of ureteric obstruction which had been left untreated for some time, acute rejection supervened and resulted in a more rapid decline in renal function. J.W. had a graft nephrectomy for acute irreversible rejection shortly after reimplantation of the obstructed ureter. D.B. made a good recovery after repeat ureteroneocystostomy and antirejection therapy, but her serum creatinine has gradually increased and graft function is poor 6 months later. In our experience, ureteric obstruction is more common than late rejection and must always be considered when renal function deteriorates. In addition t o clinical evaluation and standard tests of renal function, we made use of renography (Doherty et al., 1978), high dose pyelography, ascending ureterography, N-acetyl-beta-D-glucosamidase and urinary urinary protein excretion, and sometimes renal biopsy to distinguish between ureteric obstruction and rejection. As well as assisting in the diagnosis, radiological investigations helped to define the site and extent of ureteric obstruction so that corrective surgery could be planned. Transurethral meatotomy, a recommended procedure for the relief of ureteric obstruction, has been described previously (Donaldson et al., 1977) and was successful in 2 of our patients. If, on intravenous pyelography, the stenosis is seen t o be confined to the lower end of the ureter, cystoscopy should be performed and if this reveals stenosis confined to the tip of the ureter, .the remainder of the ureter within the submucosal tunnel will be seen to be normal or dilated, making transurethral meatotomy a simple and effective procedure. Emphasis should be placed upon prevention of urological complications with careful attention to
UROLOGICAL COMPLICATIONS IN 119 CONSECUTIVE RENAL TRANSPLANTS
187
technique, Ureteric necrosis is due to damage to Doherty, C. C., Douglas, J. F. and McCeown, Mary G. (1978). Isotope renography and long-term follow-up of the ureteric blood vessels and may occur during renal transplant patients. British Journal of Radiology, removal and handling of the kidney but may be 51, 802-807. unavoidable if the ureter has an anomalous blood MacKinnon, K. J., Oliver, J. A., Morehouse, D. D. and Taguchi, Y. (1968). Cadaver renal transplaritation: emphasis supply mainly through arteries not arising from on urological aspects. Journal of Urology, 99, 486-490. the renal artery or its branches. Ureteric obstrucMary G., Kennedy, J. A., Loughridge, W. G. G., tion due to kinking of the ureter and periureteric McCeown, Douglas, J. F., Alexander, J. A., Clarke, S. D., McEvoy, fibrosis could probably be avoided by ensuring J., Hewitt, J. C. and Nelson, S . D. (1977). One hundred that the ureter is just long enough to reach the kidney transplants in the Belfast City Hospital. Lancet, 2, 648-65 1. bladder without undue tension. In our series of 119 transplants the overall Marlin, D. C., Mims, M. M., Kaufman, J. J. and Goodwin, W. E. (1969). The ureter in renal transplantation. Journal incidence of urological complications was 13.4%, Of Urology, 101, 680-687. with an incidence of 21.8% when the extravesical O'Donoghue, E. P. N., Chisholm, G . D. and Shackman, R. (1973). Urinary fistulae after renal transplantion. British technique was used compared with 9.2% when Journal of Urology, 45, 28-33. the Politano-Leadbetter technique was used. V. A. and Leadbetter, W. F. (1958). An operative Screening by renography has been carried out on Politano, technique for the correction of vesico-ureteral reflux. most of the surviving grafts done by the PolitanoJournal of Urology, 19, 932-941. Leadbetter technique (Doherty et al., 1978) and it Prout, G. R., Jr., Hume, D. M., Lee, H. M. and Williams, G. M. (1967). Some urological aspects of 93 consecutive seems unlikely that more cases of obstruction will renal homo-transplants in modified recipients. Journal of turn up in this group. Screening for signs of Urology, 91, 409-425. obstruction of the remaining grafts performed by Robson, A. J. and Calne, R. Y. (1971). Complications of the extravesical technique is planned. Renography urinary drainage following renal transplantation. British Journal of Urology, 43, 586-590. and intravenous pyelography suggest obstruction in 2 further cases of the 5 already screened. In Stanl, T. E., Groth, C. G., Putnam, C. W., Penn, I., Halgrimson, C. G., Flatmark, A., Grecelter, L., Bettour hands the extravesical technique leads to a schmeider, L. and Stonington. 0. C. (1970). Urological higher complication rate than the Politanocomplications in 216 human recipients of renal transplants. Leadbetter technique. We feel that the complicaAnnals of Surgery, 112, 1-22. tion rate of the extravesical technique is so high Weil, R., Simmons, R. L., Tallent, M. B., Lillehei. R. C., Kjellstrand, C. M. and Najarian, J. S. (1971). Prevention that it would be unjustifiable to continue with its of urological complications after transplantation. Annals use and we have decided .to return to the Politanoof Surgery, 174, 154-160. Leadbetter method of ureteroneocystostomy. Williams, G., Birtch, A. G., Wilson, R. E., Harrison, J. H.
Acknowledgement
and Murray, J. E. (1970). Urological complications of renal transplantation. British Journal of Urology, 42, 21-27.
We gratefully acknowledge support from the Northern Ireland Kidney Research Fund.
Woodruff, M. F. A., Robson, J. S., Nolan, B. and MacDonald, M. K. (1969). Renal transplantation in man. Lancet, 1, 6-12.
References
The Authors
Belzcr, F. 0..Kountz, S . L., Najarian, J . S., Tanagho, E. A. and Hinman, F., Jr. (1970). Prevention of urological com-
S. N. Mehta, MS, FRCS, Senior Registrar in Surgery. J. A. Kennedy, MCh, FRCS, Urologist. W. G. G. Loughridge, MA, MD, FRCS, Urologist. J. F. Douglas, MA, BCL, MB, BCh, MRCP, Nephrologist. R. A. Donaldson, BSc, MB, BCh, FRCS, Urologist and Transplant Surgeon. Mary G. McGeown, MD, PhD, FRCPE, FRCP, Nephrologist .
plications after renal allotransplantation. Archives of Surgery, 101, 449452. Clunie, G. J. A., Siddle, K. J., Hartley, L. C. J. and Hardie, 1. R. (1974). The ureter in renal transplantation-Results of a simple technique of uretero-vesical anastomosis. Australian Journal of Surgety, 131, 556-559. Donaldson. R. A., Jacobson, J. E. and Pontin, A. R. (1977). Ureteric obstruction in renal allograft recipients. South Grican Medical Journal, 52, 1077-1082.
Requests for reprints to: Mary G. McGeown, Renal Unit, Belfast City Hospital, Belfast BT9 7AB.
