Reconstructive Urology Ureteropyelostomy Using the Native Ureter for the Management of Ureteric Obstruction or Symptomatic Reflux Following Renal Transplantation Kevinjit Sandhu, Jonathan Masters, and Yaron Ehrlich OBJECTIVE MATERIALS AND METHODS RESULTS CONCLUSION To evaluate the outcome of ureteropyelostomy using the native ureter for the management of ureteric obstruction or symptomatic reflux after renal transplantation. This is a single-center retrospective review of consecutive patients who underwent ureteropyelostomy after renal transplantation between the years 2000 and 2009. Ureteropyelostomy was performed using the ipsilateral native ureter. The native kidney was not removed. Patients’ baseline characteristics, preceding interventions, and postprocedural outcomes were analyzed. Ten patients underwent ureteropyelostomy after renal transplantation. All had initial Lich Gregoir ureterovesical anastomosis. Reasons for the reconstructive surgery were transplant ureteric stenosis in 8 patients or vesicoureteric reflux causing recurrent graft pyelonephritis in 2 patients. Median follow-up was 53 months (range 24-76). Postoperative complications included 3 patients who had transient anastomotic obstruction after removal of the double pigtail stent. They were managed with short-term ureteric restenting or nephrostomy tube insertion. In addition, 2 patients required delayed ipsilateral native nephrectomy because of infection. At last follow-up, all grafts remained unobstructed and free of infections. Ureteropyelostomy using the native ureter for the management of transplant ureteric obstruction or symptomatic reflux is safe and provides good long-term preservation of graft function in selected patients. UROLOGY 79: 929 –932, 2012. © 2012 Elsevier Inc. A uckland City Hospital is one of New Zealand’s national transplant centers that performs between 60 and 70 kidney transplants annually. Ureteric complications continue to be a significant cause of morbidity in transplant recipients. The most common complication is ureteric stricture with incidences ranging between 0.6% and 10.5%.1-6 The reported rate of vesicoureteric reflux leading to graft pyelonephritis is low and ranges between 0.1% and 1.1%.7,8 Management options for ureteric stricture include percutaneous decompression, ureteric stenting and endourological dilatation/incision. Success rates of such minimally invasive management have been reported between 45% and 62%.9,10 When these methods fail, surgical correction by reimplantation of the graft ureter or by using the native ureter is advocated. Less is known about the outcomes of recurrent transplant infections caused by reflux. Antimicrobial therapy is the mainstay. Surgical repair of the ureters is uncomFrom the Department of Urology, Auckland City Hospital, Auckland, New Zealand Reprint requests: Yaron Ehrlich, Department of Urology, Auckland City Hospital, Private Bag 92 024 Auckland Mail Centre, Auckland 1142, New Zealand. E-mail: yaronehrlich@gmail.com Submitted: September 29, 2011, accepted (with revisions): November 19, 2011 © 2012 Elsevier Inc. All Rights Reserved mon. There are only a handful of studies that report the efficacy of this method and the study populations are small.11,12 Within our center, ureteropyelostomy between the native ureter and the transplant renal pelvis is the surgical method of choice and is generally only performed after failure of other treatment modalities. Here we present our long-term results. MATERIAL AND METHODS Patients who underwent ureteropyelostomy after renal transplantation were identified and their information retrospectively obtained from the hospital database. Ethics approval was obtained from the New Zealand Health and Disability Ethics Committee. Patients’ baseline characteristics, preceding interventions, and postprocedural outcomes were analyzed. Postoperative complications were reported according to the Clavien classification. At the time of initial kidney transplantation, all patients underwent an extravesical tunneled ureterocystostomy and had a double pigtail sent for 4 weeks. Ureteropyelostomy was performed for the management of transplant ureteric complications after failure of conservative treatment measures. None of 0090-4295/12/$36.00 doi:10.1016/j.urology.2011.11.028 929 Table 1. Characteristics and outcome of patients who underwent ureteropyelostomy Patients Time from Transplant to Ureteropyelostomy (months) Age Indication 1 2 44 60 Stenosis Stenosis 9 3 3 76 Stenosis 3 4 5 6 7 20 70 66 65 Stenosis Stenosis Stenosis Stenosis 5 5 252 5 8 9 10 53 28 34 Stenosis Reflux Reflux 5 36 144 Preceding Procedures Nephrostomy, ureteric stent Nephrostomy, balloon dilatation, ureteric stent Nephrostomy, balloon dilatation, ureteric stent Nephrostomy, ureteric stent Nephrostomy, ureteric stent Ureteric stent Nephrostomy, balloon dilatation, ureteric stent Nephrostomy, ureteric stent Antibiotic treatment Antibiotic treatment Follow-up (months) Serum creatinine ␮mol/L* 1 2 3 52 35 161 191 104 130 129 99 20 240 142 430† 76 62 59 17 290 190 430 200 150 170 180 108 150 79 349† 186 24 71 54 168 356 227 125 157 172 187 108 191 * (1) Serum creatinine before ureteropyelostomy, (2) at 12 months after ureteropyelostomy, and (3) at last follow-up. These 2 patients died of chronic allograft nephropathy. Ultrasound showed no hydronephrosis. † the patients referred to us underwent prior excision of the transplant stricture and primary re-implant. Patients with reflux as the original cause of renal failure were not considered for ureteropyelostomy. Retrograde pyelograms of the native kidney were performed in all patients before the reconstructive surgery. The surgery was performed through the previous Gibson scar. The graft ureter was ligated and transected at the former Lich– Gregoir ureterocystostomy. The native ipsilateral ureter was identified, taking care not injure its pelvic blood supply. It was then divided and its proximal end tied without performing a nephrectomy. A spatulated stented anastomosis to the transplant renal pelvis was performed. The double-J stent was removed after 2 weeks. RESULTS Between the years 2004 and 2009, 10 patients underwent reconstructive ureteropyelostomy because of ureteric complication after renal transplantation. Seven of the transplant kidneys were from deceased donors and 3 were from live donors. There were 6 male and 4 female patients. Reasons for requiring the initial kidney transplant were glomerular nephritis in 3 patients, diabetes mellitus in 3 patients, and 1 each for systemic lupus erythematosus, Alport’s syndrome, obstructive uropathy, and single kidney renal artery stenosis. Eight patients underwent ureteropyelostomy to correct ureteric obstruction despite conservative management (Table 1). One patient developed late ureteric obstruction after radiotherapy for vaginal cancer 20 years after renal transplantation. The remaining 7 patients had evidence of ureteric obstruction early after renal transplantation (median 3 months, range 2-5). Two patients had recurrent pyelonephritis of the transplant kidney associated with reflux. This occurred despite prophylactic antibiotic treatment and was diagnosed based on their symptoms, positive urine cultures, and micturating cystourethrograms. 930 The length of hospital stay after ureteropyelostomy ranged between 3 and 60 days, with a median stay of 8 days. There were no intraoperative complications. Grade I postoperative complication was encountered in one patient who had an anastomotic leak diagnosed on a routine check nephrostogram; it resolved with observation. Grade III postoperative complications were observed in 5 patients. Two patients required repositioning of their double-J stents because of stent migration. An additional 3 patients had a postoperative anastomotic obstruction after removal of the double-pigtail stent. They were managed with short-term ureteric restenting or nephrostomy tube insertion. Two patients required a laparoscopic nephrectomy of the native kidney because of pyelonephritis associated with obstruction within 6 months of undergoing ureteropyelostomy. Both patients were anuric before the initial transplantation. Median follow-up from the time of reconstructive surgery was 53 months (range 24-76). Two patients died of chronic graft nephropathy (both had an unobstructed graft determined by ultrasound) 20 and 59 months from the time of reconstructive surgery. One patient died of metastatic colon cancer 62 months after surgery. The remaining 7 patients were followed within the last 6 months of data acquisition. Follow-up consisted of postoperative ultrasound to exclude graft hydronephrosis and serial creatinine measurements. In case of renal function deterioration, an ultrasound study was repeated. All 8 patients who presented with ureteric stricture had no evidence of obstruction at the last follow-up. The 2 patients who underwent ureteropyelostomy for reflux have had no further episodes of transplant pyelonephritis. Serum creatinine pre-ureteropyelostomy ranged from 161-430 ␮mol/L. At 1 year after the procedure, all 10 patients had an improvement in their serum creatinine. Five patients had subsequent deterioration of renal function without evidence of recurrent obstruction (Table 1). UROLOGY 79 (4), 2012 COMMENT The most common urological complications after renal transplantation are those involving the ureter13,14; ureteric stricture is the leading complication. The etiology of its occurrence is thought to vary between those that present early and those that present late. Early causes of stricture are related to ischemia either at the time of harvesting the organ or at the creation of the ureteric anastamosis.9,15 Urine leak may also play a role. Late causes are likely a result of recurrent urinary tract infections, vascular insufficiency, or retroperitoneal fibrosis.4,9,16-18 Our series has a predominance of early onset ureteric strictures with 7 of the 8 patients presenting within 5 months of their renal transplant. Initial treatment options for ureteric strictures are percutaneous drainage of the kidney, stent insertion, and/or balloon dilatation. Failure of endourological management is more common in strictures that present late.19-21 Helfand et al have suggested that late-presentation ureteric strictures may benefit from surgery as the first-line management.22 All patients in our series had a failure of endourological interventions. Vesico-graft reflux has been identified in as many as 50% of kidney transplant recipients with recurrent urinary tract infections.11,23 Medical management is the first-line treatment. Failure to control recurrent infection is a cause of morbidity and may lead to graft loss. Endoscopic subureteral injection of various bulking agents for the prevention of reflux has been described in kidney transplant patients.21 Elimination of the reflux using the nonrefluxing native ureter is our preferred surgical approach. This method has been described by others.11 The most significant complication we encountered after ureteropyelostomy was pyelonephritis of the intentionally obstructed native kidney at the time of surgery, leading to delayed nephrectomy in 2 of 10 patients. Similarly, Lehmann et al reported that 2 of 35 patients required delayed nephrectomy because of symptomatic obstruction of the native kidney after ureteropyelostomy.12 Our experience may favor concomitant nephrectomy at the time of reconstruction. However, other series had better success with such an approach, reporting no complications relating to the remaining kidney.11,24 Other postoperative complications were transient anastomotic obstruction or leakage that may have been prevented with longer sent dwelling time. Long-term follow-up of our patients has shown an improved renal function and resolution of obstruction. This has been demonstrated by other studies as well.11,19 The 2 patients who had graft pyelonephritis associated with reflux had no further episodes of symptomatic urinary tract infections. Surgical repair of reflux in transplant patients is uncommon. There are only a handful of studies that report the efficacy of this method and the study populations are small. Lehmann et al reported 10 patients who had no further graft infections after native ureteropyelostomy.12 UROLOGY 79 (4), 2012 We have shown that ureteropyelostomy using the native ureter is safe and effective in selected patients who present with ureteric strictures or symptomatic reflux. Although we cannot advocate it being the first-line treatment, it is an appropriate definitive treatment. References 1. Breda A, Bui MH, Liao JC, et al. Incidence of ureteral strictures after laparoscopic donor nephrectomy. J Urol. 2006;176:1065-1068. 2. Emiroğlu R, Karakayall H, Sevmiş S, et al. Urologic complications in 1275 consecutive renal transplantations. Transplant Proc. 2001; 33:2016-2017. 3. Fuller TF, Deger S, Büchler A, et al. Ureteral complications in the renal transplant recipient after laparoscopic living donor nephrectomy. Eur Urol. 2006;50:535-541. 4. Davari HR, Yarmohammadi H, Malekhosseini SA, et al. Urological complications in 980 consecutive patients with renal transplantation. Int J Urol. 2006;13:1271-1275. 5. Rigg KM, Proud G, Taylor RM. Urological complications following renal transplantation. A study of 1016 consecutive transplants from a single centre. Transpl Int. 1994;7:120-126. 6. Shrestha BM, Darby CR, Moore RH. Ureteric complications following renal transplantation: An eight years experience. Kathmandu Univ Med J (KUMJ). 2006;4:409-414. 7. Nie ZL, Zhang KQ, Li QS, et al. Urological complications in 1,223 kidney transplantations. Urol Int. 2009;83:337-341. 8. Faenza A, Nardo B, Fuga G, et al. Urological complications in kidney transplantation: Ureterocystostomy versus uretero-ureterostomy. Transplant Proc. 2005;37:2518-2520. 9. Bachar GN, Mor E, Bartal G, et al. Percutaneous balloon dilatation for the treatment of early and late ureteral strictures after renal transplantation: Long-term followup. Cardiovasc Interv Radiol. 2004;27:335-338. 10. Juaneda B, Alcaraz A, Bujons A, et al. Endourological management is better in early-onset ureteral stenosis in kidney transplantation. Transplant Proc. 2005;37:3825-3827. 11. Salomon L, Saporta F, Amsellem D, et al. Results of pyeloureterostomy after ureterovesical anastomosis complications in renal transplantation. Urology. 1999;53:908-912. 12. Lehmann K, Müller MK, Schiesser M, et al. Treatment of ureteral complications after kidney transplantation with native ureteropyelostomy reduces the risk of pyelonephritis. Clin Transpl. 2011;25: 201-206. 13. Mundy AR, Podesta ML, Bewick M, et al. The urological complications of 1000 renal transplants. Br J Urol. 1981;53:397-402. 14. Jaskowski A, Jones RM, Murie JA, et al. Urological complications in 600 consecutive renal transplants. Br J Surg. 1987;74:922-925. 15. Shoskes DA, Hanbury D, Cranston D, et al. Urological complications in 1,000 consecutive renal transplant recipients. J Urol. 1995; 153:18-21. 16. Butterworth PC, Horsburgh T, Veitch PS, et al. Urological complications in renal transplantation: Impact of a change of technique. Br J Urol. 1997;79:499-502. 17. Karam G, Hétet JF, Maillet F, et al. Late ureteral stenosis following renal transplantation: Risk factors and impact on patient and graft survival. Am J Transplant. 2006;6:352-356. 18. Dinckan A, Tekin A, Turkyilmaz S, et al. Early and late urological complications corrected surgically following renal transplantation. Transpl Int. 2007;20:702-707. 19. Lojanapiwat B, Mital D, Fallon L, et al. Management of ureteral stenosis after renal transplantation. J Am Coll Surg. 1994;179: 21-24. 20. Latchamsetty KC, Mital D, Jensik S, et al. Use of collagen injections for vesicoureteral reflux in transplanted kidneys. Transplant Proc. 2003;35:1378-1380. 931 21. Song JC, Hwang HS, Yoon HE, et al. Endoscopic subureteral polydimethylsiloxane injection and prevention of recurrent acute graft pyelonephritis. Nephron Clin Pract. 2011;117:c385c389. 22. Helfand BT, Newman JP, Mongiu AK, et al. Reconstruction of late-onset transplant ureteral stricture disease. BJU Int. 2011;107: 982-987. 932 23. Dupont PJ, Psimenou E, Lord R, et al. Late recurrent urinary tract infections may produce renal allograft scarring even in the absence of symptoms or vesicoureteric reflux. Transplantation. 2007;84:351355. 24. Lord RH, Pepera T, Williams G. Ureteroureterostomy and pyeloureterostomy without native nephrectomy in renal transplantation. Br J Urol. 1991;67:349-351. UROLOGY 79 (4), 2012