Problems of the Distal Ureter in Renal transplantation

Abstract

The incidence and mortality rates of urologic complications in renal transplantation have decreased significantly during the last decade. This was achieved by improved techniques of donor nephrectomy with preservation of the ureteric blood supply and refined procedures for the reconstruction of the urinary tract. Intra- and extravesical ureteroneocystostomies have shown to be the most reliable and preferred techniques to restore the urinary tract continuity. Beside ureteral ischemia and technical failure ureteral rejection is increasingly accepted as an important contributory factor for the development of ureteric fistula and stenosis formation. Controversy still exists concerning the pathogenesis of reflux into the graft and its impact on long-term graft function. Percutaneous and endoscopic procedures have supplemented and partially replaced open surgical management of ureteric fistulas and stenoses. By adherence to the principles described the frequency of urologic complications and its associated mortality rates can be minimized.

Ureteral urine leak presenting as a pleural effusion in a renal transplant recipient

“…The incidence of both ureteral urine leak and ureteral stricture appears to have declined over the last decade, perhaps due to lower steroid doses in current immunosuppression protocols [1]. Others have noted a connection between transplant rejection and the occurrence of both ureteral perforations and strictures [9], indicating that improved immunosuppressive regimens could further decrease the incidence of these complications. The incidence of ureteral complications may also be decreased if post-operative ureteral stenting is routinely employed [10,11].…”

Surgical Complications of Renal Transplantation

“…Some patients can need a third procedure due to a new recurrence showing that the necrosis can extend after surgery and that extensive resection of the ureter is frequently necessary. Mortality directly related to the fistula or to its correction was high in the early transplantation era (Dreikom K, 1992) and nowadays is reported to range from 0 to 8% (Salomon L, 1999). These better results are due to an earlier and more aggressive approach, reduction in the amount of corticosteroids in the immunosuppressive regimen and to better antibiotics and clinical support.…”

The use of contralateral native pelvis and ureter for total transplant ureteric reconstruction

“…The treatments of choice are ureteroneocystostomy or an endourological procedure [1,2], but when the stricture is too long to reimplant, ipsilateral pyeloureterostomy or pyelopyelostomy, joining the distal portion of the ipsilateral native ureter or pelvis to the pelvis of the renal graft, constitutes the standard ureteric reconstruction [3]. Pyelopyelostomy was described first by Carpus et al in 1968 and then by Wagner and Dieckmann in 1994 [4].…”