Urinary reconstruction after kidney transplantation: Pyeloureterostomy versus ureteroneocystostomy

Abstract

A best evidence topic in transplant surgery was written according to a structured protocol. The question addressed was: In adults undergoing renal transplantation, does pyeloureterostomy, as compared to ureteroneocystostomy, improve clinical outcomes? A total of 235 articles were identified using the search protocol described, of which six represented the best evidence available to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. These included one prospective cohort study, three retrospective cohort studies and two case series. The largest of the five cohort studies demonstrated significantly reduced levels of complications with pyeloureterostomy as compared to ureteroneocystostomy. The consensus from the remaining trials was that pyeloureterostomy is a safe but underused technique. However, the majority of the evidence pertaining to pyeloureterostomy and ureteroneocystostomy was archaic, with four of the six dating from pre-1990. Furthermore, the most recent articles (reported in 2010 and 2013) provide only level three and four evidence respectively, and contain important flaws with regard to patient-cohort allocation inherent to the study design. For these reasons we are cautious in recommending pyeloureterostomy over ureteroneocystostomy with the current evidence base, but would like to emphasise that pyeloureterostomy remains a safe surgical option which should form part of the modern transplant surgeon's reconstructive repertoire, particularly when managing patients in which multiple complications are anticipated, or when there is fear of ureteral vascular compromise, such as with cadaveric kidneys. We call for larger scale prospective trials to aid clarification of the roles of pyeloureterostomy and ureteroneocystostomy in renal transplant surgery and to enrich this prescient field with much needed 21st century evidence.

Imaging of Renal Transplant Complications throughout the Life of the Allograft: Comprehensive Multimodality Review

“…The transplant kidney ureter can be anastomosed to the recipient urinary bladder, often at the dome (ureteroneocystostomy), or alternatively to the recipient's native ureter after removal of the diseased native kidney using an end-toside anastomosis (ureteroureterostomy), in cases where the length of the transplant ureter is insufficient or the recipient bladder anatomy precludes ureteroneocystostomy (29). Pyeloureterostomy is an additional technique that involves recipient nephrectomy with preservation of the recipient ureter, which is anastomosed to the donor renal pelvis (22,30).…”

Urological Complications Associated With Pyeloureterostomy Without Ipsilateral Nephrectomy in Renal Transplant Recipients

“…Pyeloureterostomy is a well-known option for urinary tract reconstruction during kidney transplantation (3,4,8,24,26) as well as for the treatment of ureteroneocystostomy complications (10)(11)(12)(13). At least two surgical techniques, end-to-end and end-toside anastomosis, have been performed.…”

“…Classical techniques for urinary tract reconstruction during a kidney transplant surgery include reimplantation of the kidney donor ureter with the recipient´s bladder (ureteroneocystostomy) or with the recipient's native ureter (pyeloureterostomy or ureteroureterostomy). While both techniques show similar urological complication rates, most transplant centers initially opt for a ureteroneocystostomy using the Lich-Gregoir technique (1)(2)(3), deferring the use of ureteroureterostomy, usually without ipsilateral nephrectomy, as a secondary option in case of complications in the ureteroneocystostomy anastomosis, such as urinary leak and ureteral stenosis (3)(4)(5)(6)(7)(8)(9)(10). Although some reports have shown that the native ureter ligation without nephrectomy is safe (3)(4)(5)(6)(7)(8), this technique may cause hydronephrosis, primarily in patients with significant residual diuresis, and eventually discomfort or lumbar pain.…”

Eredményeink a teljes jogú Eurotransplant-tagság óta. A Debreceni Vesetranszplantációs Központ tapasztalatai

“…A pyeloureterostomia irodalma szintén kiterjedt. Norris és mtsai 235 közleményt áttekintve arra a követ-keztetésre jutottak, hogy ez a módszer kevéssé használt, és nincsenek prospektív vizsgálatok a témában, ugyanakkor ajánlják a cadavervese-átültetéseknél, ahol a donorureter vérellátása kérdéses lehet [23]. Kevés szó esik az alternatív technikának tekintett ureteroureterostomiák-ról, elsősorban a beszűkült neocystostomia utáni reoperációk vagy atrophiás húgyhólyag esetén ajánlják [24].…”

“…Ezt a saját anyagunk az eddigiek alapján alá-támasztani látszik. Az ureterrekonstrukciók sebészi lehetőségeinek bővítése mindenképpen előnyt jelent [23].…”