Kidney Transplant Ureteroneocystostomy Techniques and ...

Kidney Transplant Ureteroneocystostomy Techniques and 

Complications: Review of the Literature 

L. Kayler, D. Kang, E. Molmenti, and R. Howard 

ABSTRACT 

Despite a variety of urinary tract reconstructive techniques, urinary complications are the 

most frequent technical adverse event following renal transplantation. These complications 

can be associated with substantial morbidity and generate excess cost. In this review 

we comprehensively discuss 4 techniques of ureteroneocystostomy, compare complications, 

and evaluate the strengths and weaknesses of each technique focusing on 4 specific 

urologic complications: urine leak, ureteric obstruction, hematuria, and symptomatic 

vesicoureteral reflux. 

DESPITE A VARIETY of urinary tract reconstructive 

techniques, urinary complications are the most frequent 

technical adverse event following renal transplantation. 

These complications can be associated with substantial 

morbidity and generate excess cost. The objective of this 

review is to describe 4 techniques of ureteroneocystostomy, 

compare complications, and evaluate the strengths and 

weaknesses of each technique. Following kidney transplantation, 

the overall incidence of urological complications in 

comparative studies ranges from 0% to 23% 1–13 ; however, 

definitions vary and the overall incidence depends on the 

type of urological complications ascertained in each report. 

In this review we focus on 4 specific urologic complications: 

urine leak, ureteric obstruction, hematuria, and symptomatic 

vesicoureteral reflux. We have evaluated studies for 

sites of urine leakage and ureteral obstruction to compare 

complications related to the actual technique of ureteroneocystostomy. 

HISTORY AND DESCRIPTION OF 

URETERONEOCYSTOSTOMY TECHNIQUES 

During the early years of experimental renal transplantation, 

kidneys were placed in the thigh with cutaneous 

ureterostomy drainage or in the renal fossa with drainage 

by ureteroureterostomy to the recipient native ureter. 9 In 

January 1951, Kuss and Teinturier placed a donor kidney 

into the iliopelvic region with a cutaneous ureterostomy. 14 

Soon thereafter other Parisian surgical teams established 

the concept that an allograft placed in the pelvic region 

could also accommodate a short ureteral segment for 

bladder drainage, 9 although these early attempts at kidney 

transplantation resulted in failure. Muray et al 15 in 1954 

performed the first successful renal transplant between 

identical twins using a Leadbetter-Politano (LP) technique 

to reimplant the transplanted ureter. This intravesicle technique 

utilizes one cystostomy to access the interior of the 

bladder and another cystostomy to recreate a new ureteric 

orifice in a normal anatomic position. The ureter is tunneled 

in the submucosal space to prevent reflux. Additionally, 

there was also no risk of injury to the pelvic ganglion, 

with subsequent persistent neurogenic bladder dysfunction, 

if the ureteral dissection was made within the layer of the 

meso-ureter, an important concept since this method was 

originally intended for the treatment of vesicoureteral 

reflux in children 16 (Figure 1). The LP technique was 

subsequently used by most transplant centers in North 

America during the 1960s; however, during that time it was 

recognized that the morbidity of this technique was increased 

by the performance of 2 cystostomies and the 

attendant risk of postoperative urine leakage. In the last 50 

years a number of other techniques utilizing an extravesical 

ureteral anastomosis and therefore requiring only 1 cystostomy 

have been employed, mainly to avoid the increased 

complications associated with the second cystostomy in the 

LP technique. 

The extravesical ureteroneocystostomy was first described 

by Witzel in 1896, 17 then again by Gregoir 18 at the 

German Congress of Surgery in April 1961, and soon 

From the Shands Hospital at the University of Florida (L.K., 

D.K., R.H.), Department of Surgery, Gainesville, Florida, and 

North Shore LIJ Health System (E.M.), Department of Surgery, 

Long Island, New York. 

Address reprint requests to L. Kayler, Department of Surgery, 

1600 SW Archer Road, Box 100118, Room 6142, Gainesville, 

Florida 32610. E-mail: liisekayler@yahoo.com 

© 2010 by Elsevier Inc. All rights reserved. 0041-1345/–see front matter 

360 Park Avenue South, New York, NY 10010-1710 doi:10.1016/j.transproceed.2010.04.016 

Transplantation Proceedings, 42, 1413–1420 (2010) 1413

1414 KAYLER, KANG, MOLMENTI ET AL 

Fig 1. Politano-Leadbetter intravesical technique. 13 An anterior 

cystostomy is performed to visualize the interior of the bladder. 

A retractor is used to flatten the trigone, and a circumferential 

incision is made around the ureteral orifice. A neohiatus is made, 

into which the transplanted ureter is inserted and a submucosal 

tunnel created. The distal ureter is sutured in place with absorbable 

sutures, and the bladder is closed in 2 layers. 

thereafter by Lich et al, 19 who published the technique in 

November 1961. The Lich-Gregoir (LG) technique was 

designed to avoid a second cystostomy, yet retain an 

antireflux mechanism. It consisted of anastomosis of the 

distal ureter to the bladder mucosa, which was then buried 

in a muscular tunnel intended to provide a valve effect 

(Figure 2). In addition to the avoidance of a separate 

cystostomy, other comparative advantages were less bladder 

dissection, a shorter ureteral length, and no interference 

with native ureteral function. Additionally, the LG was 

noted to be rapid and technically easier to perform than the 

LP technique. 9 Several variations of the LG implantation 

have been described, such as the use of running instead of 

interrupted sutures to create the ureteral mucosal anastomosis, 

9,13,20,21 performance of a tunnel by submucosal blunt 

dissection instead of muscular imbrication, 22 placement of a 

single horizontal Halsted stitch at the proximal apex of the 

bladder incision to the ureter to prevent tension at the acute 

angle of the anastomosis, 21 placement of an anchor stitch 

on the distal ureteral tip to the full thickness of the 

bladder, 23 folding back the tip of the ureter to make a 

terminal cuff, 24 and incorporation of the muscular layer 

with the mucosal layer of the bladder in the anastomosis. 

22,25 All of these so-called modified Lich ureteroneocystostomies 

include extravesicular access, the formation of an 

antireflux tunnel, and a urothelial anastomosis. 

Another extravesical approach to ureteroneocystostomy 

that also includes an antireflux tunnel but lacks a urothelial 

anastomosis, herein called the U-stitch technique, was 

described separately by Shanfield 26 and MacKinnon et al. 27 

The spatulated ureter is passed through the bladder opening 

and the sutures taken out through the anterior bladder 

Fig 2. Lich-Gregoir extravesical technique. 16 An incision is 

made in the bladder wall musculature at the dome for 2 to 3 cm 

to expose mucosa of the bladder wall. A small incision is made 

in the mucosa. The mucosa of the bladder is then sutured to the 

ureteral end with interrupted absorbable sutures. The detrusor 

muscle is then closed over the anastomosis to create a submucosal 

tunnel with an antireflux mechanism.

KIDNEY TRANSPLANT LITERATURE REVIEW 1415 

wall so that the ureteral end is ancored to the inner bladder 

wall (Figure 3). The tunneling procedure is performed in a 

similar manner to LG by imbricating the seromuscular layer 

Fig 3. U-stitch technique. 23,24 An incision is made in the bladder wall 

musculature at the dome for 2 to 3 cm to expose the mucosa of the 

bladder wall. An absorbable U-stitch is placed on the anterior aspect 

of the ureter so that each thread comes out into the ureteral lumen. An 

incision is made in the bladder mucosa. The ureteral end is then 

brought through the bladder mucosa after each thread is passed 

through and taken out through the bladder 2 cm distal to the caudal 

edge of the ureteral orifice. The U-stitch is then tied, anchoring the 

ureteral end against the inside of the bladder. The detrusor muscle is 

then closed over the anastomosis to create a submucosal tunnel with 

an antireflux mechanism. 

over the ureter. The technique described by Shanfield 26 

uses only 1 stitch for the bladder attachment placed at the 

distal aspect of the ureter, whereas that described by 

MacKinnon et al 27 uses 2 stitches at the distal aspect of the 

ureter. By elimination of the urothelial anastomosis, the 

U-stitch technique was demonstrated to shorten operative 

times even further than that of the LG technique. The average 

operative time was reduced from 29 minutes with the LG 

procedure to 14.2 minutes with the U-stitch technique (P 

.02) in one study (8) and from 24.6 minutes to 10.2 minutes, 

respectively, in another report. 11 

The last type of extravesicle ureteroneocystostomy technique 

utilized for kidney transplantation, and the least often 

described, is one that does not employ an antireflux mechanism 

based on the idea that antireflux procedures may be 

less important when dealing with normal ureters and bladders. 

Although several different non-antireflux techniques 

have been described, in all reports the spatulated ureter is 

brought directly into the bladder without any attempt to 

tunnel it. 28–30 Lucas et al 29 and Woodruff et al 28 separately 

performed this method as an intravesicle technique utilizing 

parallel incisions and performance of the ureterovesical 

anastomosis of the ureter to the muscularis from inside the 

bladder. Starzl 30 took a more direct approach through a 

single cystostomy suturing the ureteral mucosa to the 

bladder mucosa. In this review, we depict a technique used 

at our center in which the ureter is directly anastomosed to 

the full thickness of the bladder (Figure 4). 

COMPLICATIONS 

Urine Leak 

In comparative analyses, the incidence of urine leak is 0% 

to 9.3% of cases (Table 1). In 6 retrospective analyses and 

2 prospective randomized trials, 2,6 there were no significant 

differences in the proportion of leaks between the LG and 

LP methods. 1,3–5 One report by Hoogh et al 7 found a 

significant difference in the proportion of leaks between the 

2 groups with 10/108 leaks in the LP group (9.3%) compared 

to 1/133 urine leaks in the LG group (0.8%). Of the 

10 leaks on the LP group, 4 were from the cystostomy, and 

it was the separate cystostomy that was credited for the 

difference. 

In 6 comparative studies, 1 of which was prospective and 

randomized, 11 urine leakage was proportionately similar in 

the LG and U-stitch groups. 3,8,10–13 One report noted 

significantly more leaks in the U-stitch compared to the LG 

group (5.7% vs. 2.2%, respectively, P .018). 9 The surgeons 

at this single center typically used the LG technique, 

but 2 surgeons had switched to the U-stitch technique for 

several months during the observation period, thus potentially 

introducing a selection bias in terms of surgical 

experience. There was also no analysis of early versus late 

complications or comments about the learning curve. The 

authors stated that 71% of the patients in the U-stitch and 

100% of those in the LG group who had leakage or stricture 

were nonstented. They suggested that since the use of stents 

was not controlled in their study, they could not determine


Fig 4. Full-thickness technique. A cystostomy is made through 

all layers of the bladder. The spatulated ureter is continuously 

sutured to the full thickness of the bladder (mucosa, musculature, 

and serosa) using absorbable suture. There is no additional 

closure of the bladder muscle layer over the anastomosis. 

whether the high rate of leakage in the U-stitch group could 

have been prevented. 

One retrospective study by Lucas et al 28 reported an 

absence of leaks in 112 kidney transplant recipients who 

underwent a antireflux technique versus 52 recipients transplanted 

with a non-antireflux technique (n 52). In both 

methods, parallel incisions were made for intravesicular 

access to the bladder and the urothelial anastomosis incorporated 

bladder muscularis. In the antireflux group, the 

tunnel was performed in the submucosal layer by blunt 

dissection with a tonsil clamp, and for the other group there 

was no attempt to tunnel the ureter. 

Anastomotic urine leaks can be ureteral or vesical in 

origin. 13 Extravesical techniques decrease the risk of leaks 

by obviating the need for a separate cystostomy. Technical 

issues may arise with the LG technique when the bladder 

mucosa is extremely thin, allowing for urine filtration 

through 1 or more suture orifices or when the thin mucosa 

tears away from the suture lines. 13 Urine leakage with the 

U-stitch technique has been attributed to the lack of a 

mucosal-to-mucosal anastomosis. 11 The incorporation of 

muscularis in the anastomosis in both groups in the study by 

Lucas et al 28 may have strengthened the anastomosis 

against leakage. Nontechnical risk factors for the development 

of urine leakage include: recipient age, number of 

renal arteries, site of arterial anastomosis, the occurrence of 

acute rejection episodes, bladder problems, and immunosuppressive 

regimen. 31 

Ureteral Obstruction 

In comparative studies, the incidence of ureteral obstruction 

ranges from 1% to 8.3% (Table 1). Four retrospective 

1,3,5,7 plus 1 prospective 2 analyses did not demonstrate 

any significant difference in the proportion of ureteral 

obstructions between the LG and LP techniques; however, 

2 studies 4,6 reported significant but conflicting findings 

comparing LP to LG. In a retrospective analysis, Thrasher 

et al 4 observed significantly higher proportions of ureteral 

obstruction overall in the LP (5.6%) compared to the LG 

(1.3%) group, specifically identifying obstruction at the 

ureterovesicle junction (UVJ) to be the main reason for the 

difference (1/160 LG vs. 6/160 LP, P .05). In this study, a 

single surgeon performed both types of implantation during 

2 different eras under identical immunosuppression. The 

groups were well matched in terms of recipient age, renal 

allograft source, and diabetic status, but significantly more 

men underwent LP implantation. Gender, however, is not 

known to be a risk factor for UVJ obstruction. The authors 

believed that the difference in UVJ obstruction related to 

technique, citing several disadvantages of the LP technique 

including: (1) UVJ obstruction due to kinking of the ureter 

within the new muscular hiatus in the bladder, (2) damage 

to the adventitial blood supply while handling the terminal 

ureter during placement in the submucosal tunnel with 

subsequent ischemia and stenosis, and (3) increased risk of 

the distal ureter to ischemic injury in the LP due to the 

greater ureteral length needed to perform the technique. 

An advantage of extravesical techniques for prevention of 

ureteral stenosis is the ability to use a shorter segment of 

the ureter and possibly decreased handling of the ureter. In 

contrast, another study by Waltke et al, 6 in which 131 

patients were prospectively randomized to 1 of 2 techniques, 

reported a 0% anastomotic obstruction rate with LP 

implantation performed by 1 of 2 surgeons who utilized 

stents in all cases compared to 6.3% with the LG technique 

performed by a third surgeon without stent usage (P .05). 

The groups were otherwise comparable in terms of age, sex,


etiology of end-stage renal disease, and immunosuppression. 

The authors did not provide a definitive cause of 

obstruction and hypothesized that it was related to anastomotic 

scarring or placement of the ureteroneocystostomy 

on the dome of the bladder. 6 They did not discuss the 

potential selection bias introduced by various surgeons 

performing different techniques or the disparities in stent 

usage. 

Most comparative analyses have shown no differences in 

ureteral obstruction rates between the LG and U-stitch 

methods. 3,8,10–13 However, in one report the U-stitch group 

showed a higher proportion of ureteral obstructions compared 

to the LG group (3.1% vs. 0.3%, respectively, P 

.003). 9 In this retrospective study, patients were well 

matched for demographic factors; however, differences may 

have been due to surgeon inexperience since it involved 

surgeons who typically performed the LG implantation, 

with 2 surgeons performing the U-stitch instead of the LG 

technique during 19 of the 27-month study period. Also, a 

Table 1. Urologic Complications in Comparative Studies 

Ref. Year F/U Type DD (%) Stent (%) Leak (%) Obstruction a (%) Hematuria b (%) Reflux c (%) 

1 2009 2 y LG NR 92 8/412 (1.9) 13/412 (3.2) NR NR 

LP NR 100 9/265 (3.4) 12/265 (4.5) NR NR 

2 1995 d NR LG 50 5/150 (3.3) 5/150 (3.3) 2/150 (1.3) e 

LP 50 8/150 (5.3) 8/150 (5.3) 22/150 (14.7) 

3 1994 4 m LG NR 0 4/295 (1.4) 3/295 (1.0) 1/295 (0.3) 

U NR 0 2/481 (0.004) 22/481 (4.6) 6/481 (1.3) 

LP NR 0 7/410 (1.7) 18/410 (4.0) 7/410 (1.7) 

4 1990 LG 76 NR 2/160 (1.3) 2/160 (1.3) e NR NR 

LP 88 NR 2/160 (1.3) 9/160 (5.6) NR NR 

5 1988 NR LG 0 NR 2/125 (1.6) 1/125 (0.8) NR NR 

LP 0 NR 5/125 (3.2) 0/125 (0) NR NR 

6 1982 d NR LG 100 100 2/72 (2.8) 6/72 (8.3) e NR NR 

LP 100 0 2/59 (3.4) 0/59 (0) NR NR 

7 1977 5 m LG NR NR 1/133 (0.8) e 5/133 (3.8) NR NR 

LP NR NR 10/108 (9.3) 1/108 (0.9) NR NR 

8 2007 f LG 73 14 6/238 (2.5) 5/238 (2.1) 3/238 (1.3) e 2/238 (0.8) 

U 93 17 6/73 (8.2) 3/73 (4.1) 6/73 (8.2) 1/73 (1.4) 

9 2007 3 y LG NR 20 8/360 (2.2) e 1/360 (0.3) e 5/360 (1.4) e 

U NR 24 20/353 (5.7) 11/353 (3.1) 21/353 (5.9) 

10 2007 NR LG NR NR 6/217 (2.8) 3/217 (1.4) NR NR 0/217 (0) 

U NR NR 2/60 (3.3) 1/60 (1.7) NR NR 0/60 (0) 

11 2005 d f LG 100 100 1/100 (1.0) 2/100 (2.0) 1/100 (1.0) 

U 100 100 0/44 (0.0) 1/44 (2.2) 3/44 (6.8) 

12 2003 1 y LG 73 NR 5/148 (3.4) 11/148 (7.4) 5/148 (3.4) e 

U 83 NR 0/64 (0) 2/64 (3.1) 22/64 (34.0) 

13 2002 f LG 36 0 22/416 (5.3) 23/416 (5.5) 6/416 (1.4) e 8/416 (1.9) 

U 72 e 0 11/159 (6.9) 7/159 (4.4) 5/159 (3.1) 0/159 (0) 

DD, deceased-donor; F/U, follow-up minimum; NR, not reported; LG, Lich-Gregoir; LP, Leadbetter-Politano; U, U-stitch; Ref, reference. 

a 

Includes ureteropelvic and ureterovesical obstruction. When data were available, we excluded cases of obstruction that were not related to technique, including 

stone, lymphocele, spermatic cord compression, hematoma, tumor, etc. Exclusion of cases did not change the significance of any of the findings, but reflects the 

incidence of complications that may be more attributable to technique for the purposes of this review. 

b 

Hematuria was defined as requirement for continuous bladder irrigation and bedside clot evacuation, cystoscopy for clot evacuation or fulguration, or reoperation 

for bleeding or complications of hematuria for reference 9. For references 11 and 3, hematuria was defined as the requirement of cystoscopy or surgery only. 

Definitions were not provided in the remaining studies. 

c 

Symptomatic reflux only. VCUG not routinely performed. 

d 

Prospective randomized trial. 

e 

Significant difference between the 2 groups of the same study (P .05). 

f 

Ref. 8, mean follow-up between the 2 groups was similar, 33.4 months for LG and 37 months for U-stitch. Ref. 11, mean follow-up was 12 and 8 months for LG 

and U-stitch. Ref 13, median follow-up was significantly longer in the LG group (76.6 months) than the U-stitch group (23.8 months). However, 90% of cases in the 

U-stitch group were followed up for more than 1 year. 

more meaningful comparison of various operative techniques 

is made when the incidence of ureterovesical junction 

obstruction is used; unfortunately, the sites of the 

ureteral obstructions were not provided in this study. 

Only 1 comparative study evaluated ureteral obstruction 

between antireflux and non- antireflux techniques, observing 

favorable experiences of zero leaks in both groups. 28 

Although some causes of ureteral obstruction include 

fluid collections, adhesions, tumor, stones, blod clots, or 

compression by the round ligament or the spermatic cord, 

the majority are due to strictures, 4 which are believed to be 

related to ischemia or to rejection events. 32 The sole 

arterial supply of the transplant ureter is the descending 

branch of the main artery or of its lower polar branch. 

Damage to these vessels can easily be sustained during 

organ recovery, particularly if the hilum is dissected too 

enthusiastically or if there is skeletonizing or inadvertent 

stretching of the ureter. 33,34 Any trivial mishandling of the 

ureter may jeopardize the tiny periureteral arterial branches,


threatening the anastomosis. Unfortunately it is not always 

possible to discern intraoperatively whether a ureter will 

develop ischemic necrosis or stricture. Potential causes of 

obstruction related to technique of ureteroneocystostomy are 

kinking within the submucosal tunnel 4,35 or delayed necrosis 

of ureteral tips from an excessively tight closure at the 

seromuscular layer of the bladder. 20 

Hematuria 

In comparative analyses, the incidence of hematuria ranges 

from 1.0% to 34.0% (Table 1). Only 2 studies compared the 

incidence of hematuria between the LG and LP techniques. 

One retrospective analysis failed to detect significant differences, 

3 whereas a prospective randomized trial reported a 

14.7% incidence of bladder clot retention in the LP compared 

to 1.3% in the LG group, attributing the difference to 

the single, smaller cystostomy with LG. 2 

In 2 analyses, 1 retrospective 3 and 1 prospective, 11 there 

were no differences in the incidence of hematuria between 

the LG and U-stitch methods. In 4 retrospective analyses, 

significantly higher proportions of hematuria were reported 

in the U-stitch reimplantation groups relative to the LG 

groups. 8,9,12,13 

In the majority of cases, hematuria originates from the 

ureteral stump 8,13 and often requires continuous bladder 

irrigation for several days. Some cases require cystoscopy 

with evacuation of clots and/or fulguration of bleeding sites. 

Hakim et al 3 attributed their low rates of hematuria to a 

greater technical expertise associated with high volumes. In 

their report, the predominant technique was the U-stitch. 3 

Secin et al 13 similarly suggested that a potential cause for 

variations in the incidences of hematuria with the U-stitch 

technique may be due to the handling of the discrete 

longitudinal vessels at the distal margin of the ureter. They 

suggested that anastomotic site bleeding in the U-stitch 

group could be attributable to the learning curve; meticulous 

hemostasis proved to minimize this risk. In contrast, 

Veal et al reported that hematuria persisted despite careful 

ligation of ureteral stump vessels, arguing instead that 

intravesical exposure of the distal ureter to urine containing 

urokinase could theoretically dissolve a hemostatic fibrin 

clot. 

Vesicoureteral Reflux 

The incidence of vesicoureteral reflux (VUR) is not known 

from the studies reported herein, since voiding cystourethrograms 

(VCUG) were not routinely done. However, in 

the transplant studies where a VCUG was performed for 

indications such as recurrent pyelonephritis or urinary tract 

infections, symptomatic VUR was a rare complication 

occurring in 0 to 2% 8,10,13 of cases. Both extravesical and 

intravesical techniques have been shown to be excellent 

surgical procedures to correct native kidney VUR in prospective 

36 and retrospective analyses. 37,38 In kidney transplantation, 

the long submucosal tunnel utilized with these 

techniques similarly was intended to act as an antireflux 

mechanism. 39 However, in adult renal transplant recipients 

the data supporting a nonrefluxing anastomosis to prevent 

UTI and/or VUR are not particularly compelling. 40 When 

routinely checked in transplant patients, the frequency of 

VUR varies from 1% to 86%, 7,22,41 implying that asymptomatic 

VUR is common and occurs despite the tunneling 

procedure. Although fewer studies have been done, the 

incidence of VUR in kidney transplant recipients who did 

not undergo antireflux procedures is 7% to 21.3%. 42,43 

Comparative analyses have also failed to show significant 

differences in reflux in transplant recipients after antireflux 

compared with non-antireflux ureteroneocystostomies. 28,30 

Furthermore, the likelihood of VUR in renal transplant 

recipients increases with post-transplant time regardless of 

surgical technique. 44 Even when VUR is present, its importance 

in terms of overall graft survival for transplant 

patients is controversial. Early, it was argued that VUR 

might be a cause of late deterioration in function, mimicking 

chronic rejection. 45 More recently other workers have 

described groups of patients in whom reflux is quite common, 

but they have been unable to incriminate it as a cause 

of deteriorating function or of lesser problems such as 

urinary infection and hypertension. 26,46 

Graft Loss 

Notwithstanding the potential for graft loss, ureteral complications 

are usually amenable to surgical treatment in 

most cases. Most series have not demonstrated significant 

differences in graft survival between patients with and 

without ureteral complications. 47–50 

CASE SERIES 

A technically simple technique of ureteroneocystostomy 

utilizing a full-thickness ureter to bladder anastomosis (FT) 

without tunneling is employed by some surgeons at the 

University of Florida (Figure 4). It has been associated with 

a low incidence of complications during early follow-up. 

After University of Florida institutional review board approval, 

we evaluated records of 126 isolated deceaseddonor 

kidney transplant adult recipients between April 

2007 and September 2008 with 1-year follow-up. Ureteral 

stents were not employed. Foley catheters were generally 

removed on postoperative day 2. There were 3 (2.4%) cases 

with ureteral strictures, 1 (0.8%) of gross hematuria requiring 

bladder irrigation, and neither urinary leaks nor symptomatic 

vesicoureteral reflux requiring operative intervention. 

The strictures diagnosed at 2, 4, and 9 months 

post-transplantation were characterized as: (1) long segment 

ureteral stricture extending from the ureteropelvic 

junction to the bladder, (2) isolated narrowing of the 

mid-ureter, and (3) multiple strictures throughout the ureter. 

One-year graft and patient survivals were 94% and 98% 

(Table 2). In our series, there were no urine leaks with the 

FT technique. We attributed this finding to the strong seal 

that results from incorporating the full thickness of the 

bladder in the anastomosis. The location of ureteral ob-


Table 2. Characteristics of 126 Kidney Transplants Performed 

Using the Full-Thickness Ureteroneocystostomy Between April 

1, 2007, and September 15, 2008 

Characteristics N (%) 

Donor age 

0–6 24 (15.7) 

7–35 31 (19.0) 

36–50 35 (27.8) 

50 36 (28.6) 

Donor race, African-American 28 (22.2) 

Donor gender, female 42 (33.3) 

Donation after cardiac death 24 (19.0) 

Expanded criteria donor 27 (21.4) 

Recipient age, y 

7–35 13 (10.3) 

36–50 29 (23.0) 

50 84 (66.7) 

Recipient race, African-American 39 (31.0) 

Recipient gender, female 50 (39.7) 

Recipient, panel reactive antibodies 0 10 (7.9) 

Recipient induction therapy 

Simulect 116 (92.1) 

Thymoglobulin 10 (7.9) 

Double kidney transplant performed 5 (4.0) 

Delayed graft function 34 (27.0) 

Leak 0 (0) 

Stricture 3 (2.4) 

Reflux 0 (0) 

Hematuria 1 (0.01) 

1-year graft survival 118 (94) 

1-year patient survival 124 (98) 

Creatinine at 1 year 

1.5 43 (34.1) 

1.5–1.9 20 (15.9) 

2.0–3.0 8 (6.3) 

struction following the FT technique in our series was 

consistent with an ischemic etiology. There were no instances 

of anastomotic obstruction. The absence of a submucosal 

tunnel with the FT technique potentially minimizes 

this technical complication. Hematuria following the FT 

implantation was low in our series, and the incidence was 

commensurate with that reported using the LG technique, 

probably due to the fact that both techniques incorporate 

the longitudinal vessels in the anastomotic suture line. 

Although we did not identify any cases of symptomatic 

VUR among FT cases at 1-year follow-up, this diagnosis 

often requires a high index of suspicion; further studies are 

needed to further investigate this potential complication. 

Starzl et al 30 noted specific benefits with a nonantrireflux 

technique, including its usefulness for cases in which a 

conventional Lich operation or open bladder implantation 

is too difficult and or when grafts present difficulty because 

of small size or short ureters. 

In conclusion, most kidney transplant surgeons have 

moved away from the intravesical Politano- Leadbetter 

ureteral reanastomosis, which compared with the Lich- 

Gregoir and U-stitch techniques is technically more de- 

manding, requires longer operative times, and involves 

potential additional morbidity associated with a second 

cystostomy. Urological complications are similar with both 

extravesical techniques in most comparative analyses, except 

for a potentially higher rate of hematuria with the 

U-stitch method, which can be mimimized with meticulous 

hemostasis at the ureteral stump. Although data are limited, 

techniques that do not incorporate a refluxing tunnel 

are technically simple and associated with a low incidence 

of complications upon early follow-up. 

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ureterovesical anastomosis in kidney transplant patients: the Minnesota 

experience. Clin Transplant 8:504, 1994 

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ureteroneocystostomy: a comparison of urological 

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5. Shah S, Nath V, Gopalkrishnan G, et al: Evaluation of 

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transplantation. Br J Urol 62:412, 1998 

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