Use of appendix for complete transplant ureteral necrosis

Abstract

A 3-yr-old boy with posterior urethral valves underwent cadaveric renal transplant. On the ninth day after transplantation the patient developed a urinary leak, with complete ureteral necrosis. There was insufficient length of undamaged ureter to permit ureteroneocystostomy, unavailability of a native ureter to permit ureteroureterostomy, and an inability to mobilize the transplant kidney or bladder sufficiently to permit direct pyelovesicostomy. As the kidney was otherwise functioning perfectly, we decided to create an appendiceal conduit in the hope of salvaging the patient's renal allograft. At present, 7 months post-transplant, the child is clinically well with a serum creatinine of 0.7 mg/dL. Complete ureteral necrosis is an infrequent but devastating complication following renal transplantation. We report a novel method that allowed an otherwise normally functioning cadaveric graft to be salvaged.

Preperitoneal Surgical Approach to Treat Vesicoureteral Anastomotic Leakage, Distal Stenosis or Reflux After Kidney Transplantation

“…However, if the gap between the viable part of the transplanted ureter and the bladder is too large in relation to an extended stricture, some advocate creation of a Boari flap as a direct connection between the transplant ureter and bladder [15, 16]. When the native ureter is not usable, and the grafted ureter completely destroyed, interposition of the appendix [17], vesicocalycostomy between the lower pole of the renal transplant and recipient bladder [18], or replacement with ileum [19, 20] have all been reported to be successful in isolated cases. Subcutaneous pyelovesical bypass by a percutaneous approach has also been proposed for total ureteral replacement in case of ureteral necrosis after KT [21, 22], but there is a lack of large series and long‐term follow‐up.…”

Ureteral replacement with appendix in pediatric renal transplantation

“…Ureteric leakage or obstructions are the most common urological complications observed in 2–15% (12, 13) of patients who have undergone a RT. On the other hand, ureteric necrosis is an infrequent urological complication which may develop in up to 5% of transplanted patients (4). It usually occurs early; when complete, it can lead to renal shutdown and anuria.…”

“…However, Blaszac et al. (4) and then Sinha et al. (3) were the first to perform a right ureteral substitution in children who had previously undergone a RT.…”

“…Ureteral reconstruction is generally accomplished by direct anastomosis of the renal pelvis to either the native ureter or bladder. Nevertheless, whenever there is insufficient length of undamaged ureter to enable ureteroneocystostomy, lack of native ureter to perform ureteroureterostomy, or inability to mobilize the transplanted kidney or the bladder to perform a direct pyelovesicostomy (4), the small bowel or the appendix is occasionally used to replace the ureter either partially or completely (5, 6).…”

“…The scant references in the literature on the use of the appendix for left ureteral substitution in children (3–10) prompted us to report the following two cases that underwent this technique and to assess the evolution of the graft function in these patients.…”