Kidney Transplant Ureteroneocystostomy Techniques and ...

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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-
KIDNEY TRANSPLANT LITERATURE REVIEW 1419 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. REFERENCES 1. Tillou X, Raynal G, Demailly M, et al: Endoscopic management of urologic complications following renal transplantation: impact of ureteral anastomosis. Transplant Proc 41:3317, 2009 2. Pleass HC, Clark KR, Rigg KM, et al: Urologic complications after renal transplantation: a prospective randomized trial comparing different techniques of ureteric anastomosis and the use of prophylactic ureteric stents. Transplant Proc 27:1091, 1995 3. Hakim NS, Benedette E, Pirenne, et al: Complications of ureterovesical anastomosis in kidney transplant patients: the Minnesota experience. Clin Transplant 8:504, 1994 4. Thrasher JB, Temple DR, Spees K: Extravesical versus Leadbetter-Politano ureteroneocystostomy: a comparison of urological complications in 320 renal transplants. J Urol 144:1105, 1990 5. Shah S, Nath V, Gopalkrishnan G, et al: Evaluation of extravesical and Leadbetter-Politano ureteroneocystostomy in renal transplantation. Br J Urol 62:412, 1998 6. Waltke EA, Adams MB, Kauffman HM Jr, et al: Prospective randomized comparison of urologic complications in end-to-side versus Politano-Leadbetter ureteroneocystostomy in 131 human cadaver renal transplants. J Urol 128:1170, 1982 7. Hooghe L: Ureterocystostomy in renal transplantation: comparison of endo- and extravesical anastomosis. World J Surg 1:231, 1977 8. Lee RS, Bakthavatsalam CL, Marsh CL, et al: Ureteral complications in renal transplantation: a comparison of the Lich- Gregoir versus the Taguchi technique. Transplant Proc 39:1461, 2007 9. Veale JL, Yew J, Gjertson DW, et al: Long-term comparative outcomes between 2 common ureteroneocystostomy techniques for renal transplantation. J Urol 177:632, 2007 10. Moreira P, Parada B, Figueiredo A, et al: Comparative study between two techniques of ureteroneocystostomy: Taguchi and Lich-Gregoir. Transplant Proc 39:2480, 2007 11. Zargar MA, Shahrokh MR, Fallah M, et al: Comparing Taguchi and anterior Lich-Gregoir ureterovesical reimplantation techniques for kidney transplantation. Transplant Proc 37:3077, 2005 12. Tzimas GN, Hayati H, Tchervenkov JI, et al: Ureteral implantation technique and urologic complications in adult kidney transplantation. Transplant Proc 35:2420, 2003 13. Secin FP, Rovegno AR, Marrugat RE, et al: Comparing Taguchi and Lich-Gregoir ureterovesical reimplantation techniques for kidney transplants. J Urol 168:926, 2002 14. Kuss R: Human renal transplantation memories 1951 to 1981. In Terasaki P: History of Transplantation: Thirty-Five Recollections. Los Angeles, Calif: UCLA Tissue Typing Laboratory, Regents of the University of California; 1991, pp 3–4 and 39–40. 15. Murray JE, Merrill JP, Harrison JH: Renal homotransplantations in identical twins. 1955. J Am Soc Nephrol 12:201, 2001 16. Politano VA, Leadbetter WF: An operative technique for the correction of vesicoureteral reflux. J Urol 79:932, 1958 17. Witzel O: Extraperitoneale ureterocystostomie mit Schragkanalbildung. Zentralbl Gynakol 11:289, 1986
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