Kidney Transplant Ureteroneocystostomy Techniques and ...

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