Salvage of Difficult Transplant Urinary Fistulae by Ileal Substitution of the Ureter

Abstract

We report our experience with 4 cases of ileal substitution of the ureter after live-donor kidney transplantation and review the literature. The indications were recurrent ureteric fistula and obstruction in 3 cases and extensive necrosis of the ureter and renal pelvis in one case. Nephrostomy tube drainage was a useful adjunct to diagnosis and treatment of the 4 cases. No mortalities or graft losses were encountered and satisfactory graft function was maintained 2-14 years after ileal substitution of the ureter. Moreover, no electrolyte or acid-base disturbances were observed. One patient developed recurrent vesical stones 2 and 4 years after ileoureteral replacement secondary to bladder neck obstruction. Ileal substitution of the ureter seems a feasible operation to salvage difficult and recurrent transplant urinary fistulae in exceptional situations when it is impossible to restore urinary continuity using urinary tract tissues.

Early urological complications after kidney transplantation: An overview

“…In this circumstance, an ipsilateral uretero-ureterostomy can be an alternative option if the cause of native kidney failure was not reflux disease. A pyelovesicostomy or an ileal ureter can be fashioned, the latter being preferred for larger gaps, in situations where no donor or recipient ureter can be salvaged[ 51 ]. Both these techniques are devoid of an anti-reflux mechanism.…”

Use of appendix for complete transplant ureteral necrosis

“…Over 20 yr ago, Mitrofanoff initially described the use of appendix as a continent vesicostomy (17). Similarly, others have successfully employed the use of small bowel for urinary drainage because of its mucosal surface and excellent perfusion (18–24). Martin and Mesrobian reported successful ureteral replacement using appendix (19, 25) and recently, Schlitt reported successful reconstruction of complete ureteropelvic necrosis using a vascularized jejunal patch in which a small‐vascularized patch of jejunum was fixed to the renal parenchyma allowing anastomosis of the native ureter to the reconstructed pelvis (26).…”

Early Urological Complications After Live Related Renal Transplantation: An Update

“…This conservative approach has been shown to be successful in a number of retrospective studies, with a success rate varying between 30% and 87%. 15,17,[37][38][39][40][41] We believe that outcome largely depends on the etiology, site and extent of urine leak and early intervention is the key to prevent graft loss and even morbidity and mortality. Surgical reconstruction is usually successful in the majority of cases.…”