Kidney Transplant Ureteroneocystostomy Techniques and ...

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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
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