Kidney Transplant Ureteroneocystostomy Techniques and ...

1418 KAYLER, KANG, MOLMENTI ET AL
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-