No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Holmium:Yttrium-Aluminum-Garnet Laser Endoureterotomy for the Treatment of Transplant Kidney Ureteral Strictures
Abstract
The management of ureteral strictures in transplanted kidney is challenging. Open surgical treatment is effective but entails significant convalescence. Holmium:yttrium-aluminum-garnet (Ho:YAG) laser endoureterotomy is useful for other types of ureteral obstruction, and we aimed to assess its long-term success for strictures of transplant kidney ureters.
We reviewed the course of 12 kidney transplant patients managed with Ho:YAG laser endoureterotomy and/or percutaneous ureteroscopic balloon dilatation for ureterovesical anastomotic strictures or ureteropelvic junction obstruction. Success was defined as stable serum creatinine and no hydronephrosis on follow-up.
Of the patients, nine had ureterovesical anastomotic strictures. Of the six treated with balloon dilatation and Ho:YAG laser endoureterotomy, the success rate was 67% (58 months mean follow-up). Both strictures with failure were longer than 10 mm. Of the three patients treated with balloon dilatation only, there was success in only one (14 months follow-up) and both strictures with failure were shorter than 10 mm. There were three patients treated for ureteropelvic junction obstruction, one with balloon dilatation and two with balloon dilatation plus Ho:YAG laser endoureterotomy, all successfully (57 months mean follow-up). Overall, of the eight strictures 10 mm or shorter, there was success rate in six (75%), with 52 months mean follow-up, including five of five (100%) treated with laser endoureterotomy and one of three (33%) treated with only balloon dilation.
Our results suggest that Ho:YAG laser endoureterotomy should be a first line treatment for ureteral strictures of length 10 mm or shorter in kidney transplant patients.
... Hoy día, la endoureterectomía con visión directa representa la técnica preferida de la mayoría de los médicos. 18,20 El objetivo de este estudio es reportar la experiencia en el tratamiento de la estenosis de la unión ureterovesical en pacientes con trasplante renal. ...
... con láser Ho-YAG tuvo curación completa a 20 meses de seguimiento, que igualmente coincide con diversas investigaciones, que reportan éxito de 79% (63-100%). 18,20,21 CONCLUSIONES Las distintas modalidades de tratamiento endourológico son efectivas y seguras en pacientes con estenosis de la anastomosis ureterovesical a corto y mediano plazos; no obstante, es importante individualizar cada caso, porque hasta el momento no existe un consenso que establezca cuál es la mejor técnica quirúrgica endoscópica en este tipo de complicación. ...
OBJETIVO: Reportar la experiencia en el tratamiento de la estenosis de la unión ureterovesical en pacientes con trasplante renal. MATERIALES Y MÉTODOS: Estudio ambispectivo y descriptivo, efectuado en pacientes con estenosis de la unión ureterovesical que recibieron trasplante renal, atendidos en los servicios de Urología y de Trasplantes del Hospital General de México Dr. Eduardo Liceaga, entre los años 2013 a 2018. Se analizaron variables como: edad, tiempo transcurrido a partir del trasplante, permanencia de la nefrostomía, tiempo de permanencia de la estenosis hasta la curación; determinación de creatinina pre y posquirúrgica, permanencia del cateter doble J, seguimiento y tipo de tratamiento establecido. Para el análisis de los datos se utilizó estadística descriptiva (media, mediana, desviación estándar y rangos) con el programa SPSS 17. RESULTADOS: Se registraron 4 casos con estenosis de la unión ureterovesical: 2 se trataron con dilatación endoscópica con balón y 2 mediante ureterotomía con corte frio y láser. A tres pacientes se les practicó nefrostomía con la finalidad de preservar la función renal y el catéter se retiró, en promedio, 3 meses después de su colocación. Hasta el momento todos los pacientes se encuentran sin evidencia de reestenosis, a 36 meses de seguimiento. CONCLUSIONES: Las distintas modalidades de tratamiento endoscópico son efectivas y seguras en pacientes con estenosis de la anastomosis ureterovesical a corto y mediano plazos; no obstante, debe individualizarse cada caso, porque hasta el momento no existe un consenso que establezca cuál es la mejor técnica en este tipo de complicación.
... Hoy día, la endoureterectomía con visión directa representa la técnica preferida de la mayoría de los médicos. 18,20 El objetivo de este estudio es reportar la experiencia en el tratamiento de la estenosis de la unión ureterovesical en pacientes con trasplante renal. ...
... con láser Ho-YAG tuvo curación completa a 20 meses de seguimiento, que igualmente coincide con diversas investigaciones, que reportan éxito de 79% (63-100%). 18,20,21 CONCLUSIONES Las distintas modalidades de tratamiento endourológico son efectivas y seguras en pacientes con estenosis de la anastomosis ureterovesical a corto y mediano plazos; no obstante, es importante individualizar cada caso, porque hasta el momento no existe un consenso que establezca cuál es la mejor técnica quirúrgica endoscópica en este tipo de complicación. ...
OBJETIVO:
Reportar la experiencia en el tratamiento de la estenosis de la unión ureterovesical en pacientes con trasplante renal.
MATERIALES Y MÉTODOS:
Estudio ambispectivo y descriptivo, efectuado en pacientes con estenosis de la unión ureterovesical que recibieron trasplante renal, atendidos en los servicios de Urología y de Trasplantes del Hospital General de México Dr. Eduardo Liceaga, entre los años 2013 a 2018. Se analizaron variables como: edad, tiempo transcurrido a partir del trasplante, permanencia de la nefrostomía, tiempo de permanencia de la estenosis hasta la curación; determinación de creatinina pre y posquirúrgica, permanencia del cateter doble J, seguimiento y tipo de tratamiento establecido. Para el análisis de los datos se utilizó estadística descriptiva (media, mediana, desviación estándar y rangos) con el programa SPSS 17.
RESULTADOS:
Se registraron 4 casos con estenosis de la unión ureterovesical: 2 se trataron con dilatación endoscópica con balón y 2 mediante ureterotomía con corte frio y láser. A tres pacientes se les practicó nefrostomía con la finalidad de preservar la función renal y el catéter se retiró, en promedio, 3 meses después de su colocación. Hasta el momento todos los pacientes se encuentran sin evidencia de reestenosis, a 36 meses de seguimiento.
CONCLUSIONES:
Las distintas modalidades de tratamiento endoscópico son efectivas y seguras en pacientes con estenosis de la anastomosis ureterovesical a corto y mediano plazos; no obstante, debe individualizarse cada caso, porque hasta el momento no existe un consenso que establezca cuál es la mejor técnica en este tipo de complicación.
... Hoy día, la endoureterectomía con visión directa representa la técnica preferida de la mayoría de los médicos. 18,20 El objetivo de este estudio es reportar la experiencia en el tratamiento de la estenosis de la unión ureterovesical en pacientes con trasplante renal. ...
... con láser Ho-YAG tuvo curación completa a 20 meses de seguimiento, que igualmente coincide con diversas investigaciones, que reportan éxito de 79% (63-100%). 18,20,21 CONCLUSIONES Las distintas modalidades de tratamiento endourológico son efectivas y seguras en pacientes con estenosis de la anastomosis ureterovesical a corto y mediano plazos; no obstante, es importante individualizar cada caso, porque hasta el momento no existe un consenso que establezca cuál es la mejor técnica quirúrgica endoscópica en este tipo de complicación. ...
OBJETIVO: Reportar la experiencia en el tratamiento de la estenosis de la unión ureterovesical en pacientes con trasplante renal. MATERIALES Y MÉTODOS: Estudio ambispectivo y descriptivo, efectuado en pacientes con estenosis de la unión ureterovesical que recibieron trasplante renal, atendidos en los servicios de Urología y de Trasplantes del Hospital General de México Dr. Eduardo Liceaga, entre los años 2013 a 2018. Se analizaron variables como: edad, tiempo transcurrido a partir del trasplante, permanencia de la nefrostomía, tiempo de permanencia de la estenosis hasta la curación; determinación de creatinina pre y posquirúrgica, permanencia del cateter doble J, seguimiento y tipo de tratamiento establecido. Para el análisis de los datos se utilizó estadística descriptiva (media, mediana, desviación estándar y rangos) con el programa SPSS 17. RESULTADOS: Se registraron 4 casos con estenosis de la unión ureterovesical: 2 se trataron con dilatación endoscópica con balón y 2 mediante ureterotomía con corte frio y láser. A tres pacientes se les practicó nefrostomía con la finalidad de preservar la función renal y el catéter se retiró, en promedio, 3 meses después de su colocación. Hasta el momento todos los pacientes se encuentran sin evidencia de reestenosis, a 36 meses de seguimiento. CONCLUSIONES: Las distintas modalidades de tratamiento endoscópico son efectivas y seguras en pacientes con estenosis de la anastomosis ureterovesical a corto y mediano plazos; no obstante, debe individualizarse cada caso, porque hasta el momento no existe un consenso que establezca cuál es la mejor técnica en este tipo de complicación.
... In two series combining holmium YAG laser with balloon dilatation, the success rate was 100% and 67%, respectively. [19,20] Balloon dilatation has successfully been combined with cold knife and bugbee endoureterotomy. [21] The success rate of balloon dilatation is about 50%, its failures can be salvaged by endoureterotomy and the success rate is about 83%. ...
... [17] Laser endoureterotomy has a high success rate; it can be done retrograde using a semi-rigid ureteroscope and antegrade using a flexible ureteroscope in which it may be easier to approach the stricture from the dilated proximal segment. [3,19,20] Acucise ® balloon endoureterotomy using a 75W cut, placed anteriorly away from vessels and bowel may have a success rate of about 67%. [22,23] It is a blind procedure and has a risk of thermal injury to adjacent organs and therefore it did not become popular. ...
Introduction:
In the past, urological complications after renal transplantation were associated with significant morbidity. With the development and application of endourological procedures, it is now possible to manage these cases with minimally invasive techniques.
Materials and Methods:
A MEDLINE search for articles published in English using key words for the management of urological complications after renal transplantation was undertaken. Forty articles were selected and reviewed.
Results:
The incidence of urological complications postrenal transplantation was reported to be 2–13%. Ureteric leaks occurred in up to 8.6%, and 55% were managed endourologically. The incidence of lymphocele was as high as 20%, and less that 12% of the cases required treatment. Ureteric stricture was the most common complication, and endourological management was successful in 50–70%. The occurrence of complicated vesicoureteral reflux was 4.5%, and 90% of low-grade reflux cases were successfully treated with deflux injections. Stones and obstructive voiding dysfunction occurred in about 1% of kidney transplant recipients.
Conclusion:
Minimally invasive techniques have a critical role in the management of urological complications after renal transplantation. Urinary leakage should be managed with complete decompression. Percutaneous drainage should be the first line of treatment for lymphocele that is symptomatic or causing ureteric obstruction. Laparoscopic lymphocele deroofing is successful in aspiration-resistant cases. Deflux is highly successful for the management of complicated low-grade kidney transplant reflux. The principles of stone management in a native solitary kidney are applied to the transplanted kidney. Early identification and treatment of bladder outlet obstruction after renal transplantation can prevent urinary leakage and obstructive uropathy.
... Slightly more invasive are incisive approaches such as endoureterotomy which can be done with electrocautery, laser or the AcuciseÒ cutting balloon catheter (Applied Medical Resources Corp., Laguna Hills, CA, USA). All have been used successfully, but to date the evidence is not convincing as too few cases are reported [10][11][12][13][14]. ...
... Ureteric balloon dilatation [9,13] and the Acucise cutting balloon catheter [14] can be regarded as truly minimally invasive treatment options, but could not be used in the present case as an overgrown mesh stent was in place within the ureteric wall. The same is true for the slightly more invasive semi-rigid or flexible ureteroscopy for electro-or laserureterotomy [10,11]. In general, these procedures can become very challenging through the extra-anatomical access to and the passage through the transplanted ureter. ...
The incidence of ureteric obstruction after kidney transplantation is 3–12.4%, and the most common cause is ureteric stenosis. The standard treatment remains open surgical revision, but this is associated with significant morbidity and potential complications. By contrast, endourological approaches such as balloon dilatation of the ureter, ureterotomy or long-term ureteric stenting are minimally invasive treatment alternatives. Here we discuss the available minimally invasive treatment options to treat transplant ureteric strictures, with an emphasis on long-term stenting. Using an example patient, we describe the use of a long-term new-generation ureteric metal stent to treat a transplant ureter where a mesh wire stent had been placed 5 years previously. The mesh wire stent was heavily encrusted throughout, overgrown by urothelium and impossible to remove. Because the patient had several previous surgeries, we first considered endourological solutions. After re-canalising the ureter and mesh wire stent by a minimally invasive procedure, we inserted a Memokath® (PNN Medical, Kvistgaard, Denmark) through the embedded mesh wire stent. This illustrates a novel method for resolving the currently rare but existing problem of ureteric mesh wire stents becoming dysfunctional over time, and for treating complex transplant ureteric strictures.
... Ureteral strictures, especially at the ureterovesical junction, are the most common urological complication after renal transplantation [32]. With advancements in surgical techniques, the use of ureteral stent placement during renal transplantation has been shown to significantly decrease early urological mechanical complications [33]. However, prolonged stent placement has also been shown to increase complications after 30 days, with UTI and stent migration being common [34]. ...
Transitional cell carcinoma (TCC) of the urinary tract appears more commonly among the transplant population. The increased incidence of TCC has been primarily associated with the male gender, BK virus (BKV), and smoking. We report a case series and comprehensive review of the literature. The comprehensive literature review was conducted via Pubmed using the keywords “transitional cell carcinoma” and “renal allograft.” At our institution, all of our cases presented with hematuria, and hydronephrosis was present in 50% (two) of our cases. BKV was detected in 75% (three) of our cases. The average time from BKV detection to TCC diagnosis was 5.6 years. The average time from transplant to TCC diagnosis was 11.25 years. Upon review of the literature, a total of 20 cases were reported of TCC arising within the renal allograft. Of those patients, 55% (11) presented with hematuria, 30% (six) had BKV, and 35% (seven) were found to have hydronephrosis. The average time from BKV detection to TCC diagnosis was 3.4 years and the average time from transplant to TCC diagnosis was 9.5 years. Given the relatively increased incidence of neoplasm among solid organ transplant recipients, painless hematuria in a renal transplant recipient should raise concern for malignancy, especially in those with prior oncogenic viral infections, history of smoking, other environmental exposures, or in those with high cumulative doses of immunosuppressive medications.
... All patients experienced resolution of obstruction during the median follow-up time of 3.2 years [59]. In KT patients, Gdor et al. described a success rate of 67% in 6 KT patients with UVJO treated with holmium laser incision and balloon dilation at the same time, with the success rate being 100% in strictures with a maximum expansion of 1 cm in a mean follow up of 52 months [60]. ...
Kidney transplantation represents the gold standard treatment option for patients with end-stage renal disease. Improvements in surgical technique and pharmacologic treatment have continuously prolonged allograft survival in recent years. However, urological complications are frequently observed, leading to both postoperative morbidity and putative deterioration of allograft function. While open redo surgery in these patients is often accompanied by elevated surgical risk, endoscopic management of urological complications is an alternative, minimal-invasive option. In the present article, we reviewed the literature on relevant urological postoperative complications after kidney transplantation and describe preventive approaches during the pre-transplantation assessment and their management using minimal-invasive approaches.
... Short strictures (<3 cm) maybe endoscopically managed with ante-or retrograde balloon dilatation or flexible URS with holmium laser incision. For strictures <1 cm endoscopic laser incision was superior to balloon dilatation (50% success) [44]. Recurrence after endoscopy or strictures >3 cm require surgical reconstruction (ureteroneocystostomy, pyelovesicostomy, or ureteroureterostomy using native ureter) [42]. ...
Objective: To present the first Egyptian clinical practice guideline for kidney transplantation (KT).
Methods: A panel of multidisciplinary subspecialties related to KT prepared this document. The sources of information included updates of six international guidelines, and review of several relevant international and Egyptian publications. All statements were graded according to the strength of clinical practice recommendation and the level of evidence. All recommendations were discussed by the panel members who represented most of the licensed Egyptian centres practicing KT.
Results: Recommendations were given on preparation, surgical techniques and surgical complications of both donors and recipients. A special emphasis was made on the recipient’s journey with immunosuppression. It starts with setting the scene by covering the donor and recipient evaluations, medicolegal requirements, recipient’s protective vaccines, and risk assessment. It spans desensitisation and induction strategies to surgical approach and potential complications, options of maintenance immunosuppression, updated treatment of acute rejection and chemoprophylactic protocols. It ends with monitoring for potential complications of the recipient’s suppressed immunity and the short- and long-term complications of immunosuppressive drugs. It highlights the importance of individualisation of immunosuppression strategies consistent with pre-KT risk assessment. It emphasises the all-important role of anti-human leucocyte antigen antibodies, particularly the donor-specific antibodies (DSAs), in acute and chronic rejection, and eventual graft and patient survival. It addresses the place of DSAs across the recipient’s journey with his/her gift of life.
Conclusion: This guideline introduces the first proposed standard of good clinical practice in the field of KT in Egypt.
Abbreviations: Ab: antibody; ABMR: Ab-mediated rejection; ABO: ABO blood groups; BKV: BK polyomavirus; BMI: body mass index; BTS: British Transplantation Society; CAN: chronic allograft nephropathy; CDC: complement-dependent cytotoxicity; CKD: chronic kidney disease; CMV: cytomegalovirus; CNI: calcineurin inhibitor; (dn)DSA: (de novo) donor-specific antibodies; ECG: electrocardiogram; ESWL: extracorporeal shockwave lithotripsy; FCM: flow cytometry; GBM: glomerular basement membrane; GN: glomerulonephritis; HIV: human immunodeficiency virus; HLA: human leucocyte antigen; HPV: human papilloma virus; IL2-RA: interleukin-2 receptor antagonist; IVIg: intravenous immunoglobulin; KT(C)(R): kidney transplantation/transplant (candidate) (recipient); (L)(O)LDN: (laparoscopic) (open) live-donor nephrectomy; MBD: metabolic bone disease; MCS: Mean channel shift (in FCM-XM); MFI: mean fluorescence intensity; MMF: mycophenolate mofetil; mTOR(i): mammalian target of rapamycin (inhibitor); NG: ‘not graded’; PAP: Papanicolaou smear; PCN: percutaneous nephrostomy; PCNL: percutaneous nephrolithotomy; PKTU: post-KT urolithiasis; PLEX: plasma exchange; PRA: panel reactive antibodies; PSI: proliferation signal inhibitor; PTA: percutaneous transluminal angioplasty; RAS: renal artery stenosis; RAT: renal artery thrombosis;:rATG: rabbit anti-thymocyte globulin; RCT: randomised controlled trial; RIS: Relative MFI Score; RVT: renal vein thrombosis; TB: tuberculosis; TCMR: T-cell-mediated rejection; URS: ureterorenoscopy; (CD)US: (colour Doppler) ultrasonography; VCUG: voiding cystourethrogram; XM: cross match; ZN: Ziehl–Neelsen stain
... Dopo il suo sviluppo, il sistema Acucise ® ha presentato risultati favorevoli (tassi di successo primari tra l'83% e il 100% [39] ) ma, a causa delle cifre troppo esigue e di un follow-up troppo breve, non viene più utilizzato nella pratica clinica. Le incisioni a lama fredda o con laser presentano risultati equivalenti (tassi di successo primari dal 63% al 100% [40][41][42][43] ). Tuttavia, le cifre esigue e il riscontro molto scarso di queste serie limitano l'interpretazione di questi risultati. ...
Riassunto
Il trapianto renale è oggi considerato il trattamento di scelta per l’insufficienza renale allo stadio terminale, nonostante le sue complicanze mediche e chirurgiche. Le principali complicanze chirurgiche sono urinarie. Sono la conseguenza di una scarsa qualità dell’uretere trapiantato e di un difetto di realizzazione dell’anastomosi urinaria. Sebbene abbiano scarso impatto sulla sopravvivenza a lungo termine del trapianto renale, sono responsabili di una pesante morbilità e di un costo aggiuntivo significativo. La loro incidenza è diminuita nel tempo a causa dei progressi nella conoscenza dei loro meccanismi e grazie al miglioramento delle tecniche chirurgiche. Quindi, l’incidenza attuale sembra stabilizzarsi nonostante il crescente ricorso a trapianti provenienti da donatori che rispondono a criteri cosiddetti estesi. Le complicanze urinarie possono verificarsi nel primo mese postoperatorio (fistole urinarie e ostruzioni ureterali da compressione estrinseca), ma anche a distanza dal trapianto (stenosi ureterale o reflusso vescicoureterale). La gestione di queste complicanze deve essere effettuata in centri “esperti”, al fine di preservare la funzionalità del trapianto. Questo articolo discute le complicanze urinarie del trapianto renale. Le fistole ureterali a esordio precoce, a nostro avviso, richiedono un trattamento chirurgico tempestivo, per evitare ulteriori complicanze tardive. Malgrado lo sviluppo dell’endourologia e della laparoscopia, le stenosi ureterali richiedono soluzioni chirurgiche convenzionali ancora in un certo numero di casi.
... The most common minimally invasive techniques include antegrade or retrograde balloon dilatation, electrocautery ureterotomy, and holmium:yttriumaluminum-garnet (YAG) laser ureterotomy (17,23,24). In a study comparing balloon dilation to holmium:YAG laser ureterotomy, strictures with a length of 10 mm or less had better long-term patency rates and the laser approach was superior to balloon dilation (27). There are proponents of combined balloon dilation with holmium:YAG laser who report success rates of 75% (15). ...
Urologic complications of renal transplant occur commonly and can have significant impact on graft function, survival, and patient morbidity. This review examines the prevalence of urologic complications, risk factors, diagnosis and options for management of the most common urologic complications.
... For ureteric strictures besides surgical exploration endo-urological techniques has also been evolved and adopted with favorable outcomes. These include ureterotomy and balloon dilatation which has success rate of 70% [10][11][12][13][14][15] and 51% respectively [16][17][18][19]. ...
Kidney transplant has been proven treatment of choice for end stage renal disease population due to its benefit of being cost effective and conferring a natural way of way of life despite that fact, that transplantation journey is not devoid of some risks both surgical and medical. Amongst the surgical issues urological problems needs special attention, close surveillance for timely detection and intervention in order to safe guard renal allograft. These complications include lymphocele, seroma, ureteric obstruction and urinary leak. A very simple approach has been suggested to adopt which include concentrating on symptoms and signs, utilizing conventional diagnostic tools followed by appropriate intervention which include not only surgical but medical to curtail infection, adjusting immunosuppression, improving nutrition and mental and physical rehabilitation. This should be kept in mind that time is key to salvage the renal allograft by preserving nephrons. Time means nephrons and large number of nephron mass which has long term morbidity and mortality benefit. Multidisciplinary team based care strategy is mandatory to achieve success.
... For ureteric strictures besides surgical exploration endo-urological techniques has also been evolved and adopted with favorable outcomes. These include ureterotomy and balloon dilatation which has success rate of 70% [10][11][12][13][14][15] and 51% respectively [16][17][18][19]. ...
... Holmium:YAG laser endoureterotomy has not been investigated as much as stent placement or balloon dilation for management of USD in transplant patients. In a retrospective series of 12 kidney transplants that developed stricture, Gdor et al. investigated the success of laser endoureterotomy [50]. Amongst the six patients treated with balloon dilation and Ho:YAG laser endoureterotomy, the success rate was 67%, and both strictures that failed were greater than 1 cm; of the eight strictures that were 1 cm or less, there was an overall success rate of 75% with 52 months follow-up, which included 100% (5/5) success rate in the laser endoureterotomy group, and 33% (1/3) in the group that only received balloon dilation. ...
Purpose of review:
This review focuses on the role of endoscopic treatment of ureteral stricture disease (USD) in the era of minimally invasive surgery.
Recent findings:
There is a relative paucity of recent literature regarding the endoscopic treatment of USD. Laser endopyelotomy and balloon dilation are associated with good outcomes in treatment-naïve patients with short (< 2 cm), non-ischemic, benign ureteral strictures with a functional renal unit. If stricture recurs, repetitive dilation and laser endopyleotomy is not recommended, as success rates are low in this scenario. Patients with low-complexity ureteroenteric strictures and transplant strictures may benefit from endoscopic treatment options, although formal reconstruction offers higher rates of success. Formal ureteral reconstruction remains the gold-standard treatment for ureteral stricture disease as it is associated with higher rates of complete resolution. However, in carefully selected patients, endoscopic treatment modalities provide a low-cost, low-morbidity alternative.
... 148 Another treatment option is balloon-dilatation or laser endoureterotomy of the ureter. 149,150 A rare, but serious complication after peritoneal dialysis is encapsulating peritoneal sclerosis (EPS). This complication is not unique to peritoneal dialysis patients, and can occur in other clinical conditions as well (cirrhosis with ascites, generalized peritonitis, or even idiopathic). ...
Kidney transplantation is by far the best therapeutic option for most end-stage renal disease patients. However, there is an increased demand for donor organs worldwide, which cannot be met by the number of currently available organs. Live donation is the key to solving this problem, at least for kidneys. Besides the advantages of better patient and graft survival, short ischaemia times, and pre-emptive transplantation, live donor kidney transplantation offers many creative options to facilitate more transplants, such as paired kidney exchange programmes (or cross-over), unspecified and domino-paired donation. Due to new immunological possibilities, blood group AB0-incompatible transplantation and desensitization prior to transplantation are now a clinical reality. Over the years, the evolution of surgical techniques (from invasive towards minimally-invasive) for live donor nephrectomy has contributed tremendously to the success of the programme. This chapter gives a state-of-the-art overview of kidney donation and transplantation, with an emphasis on surgical aspects.
... Gdor et al. beschrijven een drietal patiënten bij wie pyelo-ureterale overgangsobstructie bij getransplanteerde nieren optrad, die allen werden behandeld met Ho:YAG-laser endopyelotomie. Zij schrijven de oorzaak van de obstructie toe aan knikken van de ureter en behalen met hun behandeling een succespercentage van 100 [11]. ...
Een obstructie van de proximale ureter is een zeldzame complicatie na niertransplantatie. Twee casus worden beschreven, waarin een functionele obstructie behandeld wordt met laser endopyelotomie. Dit is een veilige procedure en de behandeling is succesvol.
... Specific treatments correspond to different grades of strictures: temporary stent placement for G1 (increased creatinine and hydronephrosis without evidence of significant stricture), balloon dilation or endoscopic incision for G2 (stricture <1 cm), and immediate surgery for G3 (stricture >1 cm) (13). Ho:YAG laser endoureterotomy of the stenotic tract has a high success rate (>80%) in case of strictures less than 0.5-1 cm (14,15). Surgery provides the highest success rate (>75%) (12,16,17). ...
Renal transplant (RT) represents the treatment of choice for end-stage renal disease (ESRD) but harbours a wide range of possible complications and therapeutic challenges of urological competence. Dialysis years and clinical medical background of these patients are risk factors for sexual dysfunction and lower urinary tract symptoms (LUTS). On the contrary, RT itself may have a number of possible surgical complications such as ureteral stenosis and urinary leakage, while immunosuppressive treatment is a known risk factor for de-novo malignancies.
The present review describes the main urologic problems of RT patients and their up-to-date treatment options according to the most recently available literature evidences.
... A few studies have suggested that ureteral strictures in transplanted kidneys of one centimeter or less may be adequately treated with an antegrade ELU and balloon dilatation with similar success rates as non-transplanted ureters with success rates up to 75 versus 50 % in those treated with balloon dilatation only [43,44]. ...
Purpose:
Although minimally invasive approach is one of the first-line treatment choices for ureteral strictures, there are still controversies on the ideal method to treat this entity. The objective of this update was to define the level of evidence around endoscopic treatment of ureteropelvic junction (UPJ) and ureteral strictures.
Methods:
We reviewed the current available literature on the PubMed database from the last decade up to May 2014 on laser endoureterotomy and endopyelotomy.
Results:
The level of evidence for the endoscopic treatment of UPJ and ureteral strictures is low. Despite this, it appears that endoureterotomy and endopyelotomy performed mainly with Ho:YAG laser achieve good success rates with minimal perioperative morbidity.
Conclusions:
Laser endoureterotomy and endopyelotomy should be considered a reasonable treatment option in selected patients.
... In their study involving reimplanted ureters, Gdor and colleagues reported overall success rate in six out of eight strictures (75%) of up to 1 cm at 52 months mean follow up, five of which were treated with laser endoureterotomy and were all successful [Gdor et al. 2008]. Mano and colleagues had a success rate of 83% in nine ureterovesical anastomotic strictures of less than 1 cm treated with retrograde laser endoureterotomy; mean follow up was 44.4 months [Mano et al. 2012]. ...
Endourological techniques are used more often nowadays in the treatment of ureteric strictures of various etiologies. Advances in technology have provided new tools to the armamentarium of the endoscopic urological surgeon. Numerous studies exist that investigate the efficiency and safety of each of the therapeutic modalities available. In this review, we attempt to demonstrate the available and contemporary evidence supporting each minimally invasive modality in the management of ureteric strictures.
... Another minimally invasive method is endoscopic transplant ureterotomy, which has been reported for only 20 cases. The success rate was >50% [29,30] but there are too few cases to recommend this as a general approach. BD of the ureter is a minimally invasive approach for treating transplant ureteric stenosis, and an alternative to open reoperation with re-implantation of the transplant ureter, a new anastomosis of the native ureter with the renal transplant pelvis , performing a Boari flap/psoas hitch or replacement of the transplant ureter with ileum31323334. ...
Objective
Despite many efforts to prevent ureteric stenosis in a transplanted kidney, this complication occurs in 3–5% of renal transplant recipients. Balloon dilatation (BD) is a possible minimally invasive approach for treatment, but reports to date refer only to the antegrade approach; we analysed our experience with retrograde BD (RBD) and reviewed previous reports.Patients and methodsFrom October 2008 to February 2011, eight patients after renal transplantation (RTX) underwent RBD for transplant ureteric stenosis at our hospital. We retrospectively analysed the outcome and reviewed previous reports.ResultsThe eight recipients (five men and three women; median age 55 years, range 38–69) were treated with one or two RBDs for transplant ureteric stenosis. There were no complications. The median (range) time after RTX was 4.5 (2.5–11) months. Long-term success was only achieved in one recipient, while five patients were re-operated on (three with a new implant, two by replacement of transplanted ureter with ileum) after a median (range) of 2.8 (0.7–7.0) months after unsuccessful RBD(s). For two recipients the success remained unclear (one graft loss due to other reasons, one result pending). When the first RBD was unsuccessful there was no improvement with a second.ConclusionRBD is technically feasible, but our findings and the review of previous reports on antegrade ureteric dilatation suggest that the success rate is low when the ureter is dilated at ⩾10 weeks after RTX. From our results we cannot recommend RBD for transplant ureteric stenosis at ⩾10 weeks after RTX, while previous reports show favourable results of antegrade BD in the initial 3 months after RTX.
... The endoureterotomy may be made with a cold knife, electrocautery , or Holmium laser. The overall success rate from five series was 79% (range 63% to 100%) at a mean follow-up of 29 months [6,14151617. However, these were small, heterogeneous studies that included all three techniques performed from both antegrade and retrograde approaches. ...
Introduction. Complications following renal transplantation include ureteral obstruction, urinary leak and fistula, urinary retention, urolithiasis, and vesicoureteral reflux. These complications have traditionally been managed with open surgical correction, but minimally invasive techniques are being utilized frequently. Materials and Methods. A literature review was performed on the use of endourologic techniques for the management of urologic transplant complications. Results. Ureterovesical anastomotic stricture is the most common long-term urologic complication following renal transplantation. Direct vision endoureterotomy is successful in up to 79% of cases. Urinary leak is the most frequent renal transplant complication early in the postoperative period. Up to 62% of patients have been successfully treated with maximal decompression (nephrostomy tube, ureteral stent, and Foley catheter). Excellent outcomes have been reported following transurethral resection of the prostate shortly after transplantation for patients with urinary retention. Vesicoureteral reflux after renal transplant is common.
Deflux injection has been shown to resolve reflux in up to 90% of patients with low-grade disease in the absence of high pressure voiding. Donor-gifted and de novo transplant calculi may be managed with shock wave, ureteroscopic, or percutaneous lithotripsy. Conclusions. Recent advances in equipment and technique have allowed many transplant patients with complications to be effectively managed endoscopically.
Purpose: To analyze the utility and outcomes of available endourologic options to treat ureteral stricture after kidney transplantation (KT). Methods: A systematic review was carried out for all English language articles from 2000 to 2023 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standards using EMBASE, MEDLINE, SCOPUS, Google scholar, and Cochrane library. The search term combination for the string was follows: [(Ureteral stricture) OR (ureter stenosis) OR (ureteral stenosis) OR (Stricture ureter) OR (Narrowing ureter) OR (Ureter restriction) OR (ureteral restriction) OR (ureteral narrowing) OR (ureteral obstruction) OR (ureter obstruction) OR (obstructing ureter) OR (obstructive ureter) OR (narrow ureter) OR (ureteral narrow)] AND [(kidney transplant) OR (transplanted kidney) OR (transplant) OR (transplantation)] AND [(management) OR (Robotic) OR (laser) OR (stent) OR (dilatation) OR (dilation) OR (endoscopic) OR (endourological) OR (Urologic) OR (laparoscopic) OR (surgery) OR (treatment)]. Case reports, review articles, animal and laboratory studies were excluded. Risk of bias assessment was conducted using the RoB 2 and ROBINS-I tools. Results: A total of 1102 relevant articles published from 2000 to 2023 were found. After screening of titles and abstracts, a total of 19 articles were included in our systematic review. Ureteral stent/nephrostomy placement, balloon dilatation (ureteroplasty) with or without laser was used as initial approaches whereas follow-up and success rate were analyzed among other parameters. Conclusions: The management of ureteral strictures after KT is challenging and selecting the most appropriate treatment is crucial for successful outcomes. Our review suggests that, an endourologic management is a safe option with good long-term outcomes, especially in short and early strictures.
The most common complications following kidney transplantation are presented in this chapter, such as; bleeding, indications for emergency surgery and for intensive monitoring of a patient with suspected bleeding into the transplanted kidney area or into the abdomen. Surgical treatment in the case of subcapsular bleeding after kidney transplantation, kidney’s rupture, renal artery, renal vein thrombosis and surgical treatment of urine fistula/urinary leakage will also be raised. Further we can read unusual description of two cases with urinary leak from which much can be learned, kidney ureter stenosis or ureteral obstruction of the transplanted kidney. The chapter will discuss the definition of lymphocele its incidence, risk factors, prevention, symptoms, diagnosis which is often made on ultrasound imaging, and treatment. Wound infection after kidney transplantation with signs symptoms, diagnose and treatment will also be touched upon. Infection or recurrent infection of the urinary tract after kidney transplantation due to urethra-bladder anastomosis decompression with a JJ catheter. Complications such a wound dehiscence after kidney transplantation with symptoms of dehisced surgical wound, the risk factors and finally treatment of dehisced surgical wound. Conclusion: Only an impeccable surgical technique can ensure maximum safety for the patient on the operating table and after the operation. Surgical complications after kidney transplantation can be divided into early and late. All complications require highly trained specialists very good equipment to diagnose and treat them early.KeywordsComplication after kidney transplantationSubcapsular bleedingRenal artery thrombosisRenal vein thrombosisRenal artery stenosisThrombolytic therapyUrine fistulaUreteral obstructionsLymphocele-incidenceRisk factorsSymptomsPreventionLaparoscopic fenestrationDrainageTenckhoff catheterInfectionDecompression with JJ catheterWoundDehisced surgical woundThrombolytic therapy
Biliary anastomotic stricture (BAS) is a frequent complication of liver transplantation and is associated with reduced graft survival and patient morbidity. Existing treatments for BAS involve dilation of the stricture though placement of 1 or more catheters for 6 to 24 months yielding limited effectiveness in transplant patients. In this case series, we present preliminary safety and efficacy of a novel percutaneous laser stricturotomy treatment in a cohort of 5 posttransplant patients with BAS refractory to long-term large bore catheterization. In all patients, holmium or thulium laser was used to excise the stricture and promote biliary re-epithelization. There were no periprocedural complications. Technical success was 100% and at mean follow-up time of 22 months, there have been no recurrences. In conclusion, percutaneous laser stricturotomy demonstrates preliminary safety and efficacy in treatment of refractory BAS following liver transplantation.
In this work, we report a comparative study on upconversion and downshifting properties of Ho³⁺-Yb³⁺ co-doped ATiO3 (A = Ca, Ba & Sr) perovskite phosphors for the first time. The phosphor samples are prepared via solid state reaction method in a programmable furnace at 1523 K. The phosphor samples are structurally characterized by X-ray diffraction (XRD) and scanning electron microscopy (SEM) techniques. The EDS analyses show the presence of the desired elements used in the synthesis. The vibrational structures of the phosphor samples are studied by Fourier transform infrared (FTIR) technique. The diffuse reflectance spectra show a number of bands in the UV–vis–NIR regions due to Ho³⁺ and Yb³⁺ ions. The optical band gap (Eg) is calculated using Wood and Tauc relation and its values are found to be 3.61, 3.20 and 3.32 eV for the Ho³⁺-Yb³⁺ co-doped ATiO3 (A = Ca, Ba & Sr) perovskite phosphor samples, respectively. The upconversion emission spectra are monitored by exciting these phosphor samples at 980 nm. The phosphor samples give intense green emission in all the cases. However, the UC emission intensity is higher for the Ho³⁺-Yb³⁺ co-doped CaTiO3 perovskite phosphor. These phosphor samples also give intense green downshifting emission upon 419 and 452 nm excitations. The Ho³⁺-Yb³⁺ co-doped BaTiO3 perovskite produces relatively larger emission intensity among these phosphors. The lifetime of green emitting level (⁵F4) of Ho³⁺ ion shows temporal behavior of these perovskite phosphors. Furthermore, the temperature versus UC emission intensities of the green thermally coupled levels of Ho³⁺-Yb³⁺ co-doped BaTiO3 phosphor gives the fluorescence intensity ratio (FIR) and FIR-based relative (SR) and absolute (SA) temperature sensor sensitivities are obtained as 0.0034 K⁻¹ and 0.0050 K⁻¹, respectively at 305 K. Thus, the Ho³⁺-Yb³⁺ co-doped ATiO3 (A = Ca, Ba & Sr) perovskite phosphors may be found suitable in display devices, solid state lighting, upconversion based devices and temperature sensing devices.
Resumen
El trasplante renal se considera en la actualidad el tratamiento de elección de la insuficiencia renal terminal a pesar de sus complicaciones médicas y quirúrgicas. Las principales complicaciones quirúrgicas son urinarias. Se deben a una mala calidad del uréter del injerto y a un defecto técnico de la anastomosis urinaria. Aunque su impacto sobre la supervivencia a largo plazo del trasplante renal es escaso, provocan una morbilidad considerable y un sobrecoste importante. Su incidencia ha disminuido con el tiempo debido a los progresos en los conocimientos de sus mecanismos y gracias a la mejora de las técnicas quirúrgicas. Por tanto, en la actualidad la incidencia parece haberse estabilizado a pesar de la realización cada vez más frecuente de injertos procedentes de donantes con criterios ampliados. Las complicaciones urinarias pueden aparecer en el mes posterior a la intervención (fístulas urinarias y obstrucciones ureterales por compresión extrínseca), pero también a largo plazo tras el trasplante (estenosis ureteral o reflujo vesicoureteral). El tratamiento de estas complicaciones debe realizarse en centros «expertos» para preservar la función del injerto. En este artículo, se describen las complicaciones urinarias del trasplante renal. En opinión de los autores del artículo, las fístulas ureterales de aparición precoz requieren un tratamiento quirúrgico rápido para evitar otras complicaciones tardías. A pesar del desarrollo de la endourología y de la laparoscopia, las estenosis ureterales requieren todavía soluciones quirúrgicas convencionales en un cierto número de casos.
Urinary tract obstruction resulting from ureteropelvic junction obstruction or strictures within the ureter or urethra can be challenging conditions to manage effectively. With careful patient selection and proper technique, endoscopic incisions, including endopyelotomy, endoureterotomy, and visual urethrotomy, can be valuable treatment options. Endoscopic management offers the advantage of reduced operative morbidity and postoperative recovery with acceptable success rates. This chapter will cover the indications, equipment, and techniques of endopyelotomy, endoureterotomy, and visual urethrotomy.
Distal ureteral strictures are a common problem encountered in clinical practice. Critical in management is comprehensive knowledge of the anatomic relationships and etiology of the stricture. Management depends on the etiology, length, and patient comorbidities. The minimally invasive approach is reserved for shorter, non‐ischemic, or malignant strictures. The choice of a minimally invasive approach is limited by the lack of level 1 evidence and the heterogeneity of case series. Use of stenting is reserved for patients when a more invasive procedure is detrimental. Balloon dilation is reserved for short non‐ischemic strictures. Endoureterotomy with a cold knife is typically utilized for strictures less than 1.5 cm without extrinsic obstruction. Yet the ease and decreased morbidity make them a logical first choice. It is critical to involve the patient in the decision‐making, both to temper unrealistic expectations and for the opportunity to have a more invasive but effective procedure. In this chapter we initially define the anatomical, histological, vascular, and endoscopic anatomy of the ureter. This produces a virtual anatomy, helping and improving to avoid injuries during treatment of the ureteral stricture. Normal and altered anatomies and their impact on treatment will be discussed. A comprehensive descriptions of instruments, ancillary techniques, and tricks employed in treating difficult strictures will follow. Lastly there will be a review and critique of the literature.
Las estenosis del uréter son un problema frecuente en urología. La diversidad de los tipos de estenosis, únicas o múltiples, largas o cortas, intrínsecas o extrínsecas, refleja la variedad de las etiologías de estenosis ureterales (iatrogénicas, postirradiación, traumáticas, infecciosas, extrínsecas, etc.). El diagnóstico de una obstrucción es fácil en caso de estenosis completa, pero puede ser más difícil en caso de estenosis intermitente o parcial. En esta última situación, es preferible limitar el número de pruebas complementarias. El objetivo del tratamiento es evitar una pérdida de nefronas y la atrofia renal. A la diversidad de las etiologías y de los tipos de estenosis ureterales responde la pluralidad de las técnicas de tratamiento, desde la endoscopia hasta la cirugía abierta o laparoscópica. La elección de la técnica depende de la evaluación de las capacidades de recuperación del riñón, de las características de la estenosis, de la etiología de la estenosis, de la experiencia del cirujano y de la operabilidad del paciente. Así, a pesar de una tasa de éxito claramente inferior a la de la cirugía, la endoscopia permitiría tratar las estenosis ureterales cortas con una menor morbilidad. Para la cirugía abierta o laparoscópica hay diversas técnicas: reimplantación ureteral, reemplazo ileal, autotrasplante o nefrectomía. Es preciso conocer bien la anatomía del uréter y en particular su vascularización. El principio de la anastomosis sin tensión es prioritario para aumentar las posibilidades de éxito de esta cirugía.
Minimally invasive incisional techniques have become an established part of the endourologist’s armamentarium for the treatment of a variety of congenital and acquired conditions. Improvements in equipment and technique have allowed these procedures to become a first-line option in properly selected patients for the treatment of various causes of upper and lower urinary tract obstruction. Despite lesser success rates compared to open and laparoscopic reconstructive approaches, shorter postoperative convalescence makes these procedures especially attractive to patients. This chapter will review the indications, technical aspects, equipment needs, and outcomes for incisional procedures used for the management of ureteropelvic junction obstruction and ureteral and urethral strictures.
Résumé
Objectif
Rapporter la nature, l’incidence, les outils diagnostiques et les moyens thérapeutiques des complications chirurgicales de la transplantation rénale.
Matériels et méthodes
Une recherche bibliographique exhaustive à partir de Medline (http://www.ncbi.nlm.nih.gov/) et Embase (http://www.embase.com/) a été réalisée entre 1960 et 2016 en utilisant les mots clés suivants « complications chirurgicales ; fistule ; lymphocèle ; sténose ; thrombose » en combinaison avec le mot clef « transplantation rénale » dans le champ « Titre/Résumé ». Les articles obtenus ont ensuite été sélectionnés sur leur méthodologie. Ainsi 7618 articles ont été identifiés dont plus spécifiquement 981 pour les complications vasculaires, 1016 pour les complications urinaires et 239 pour les lymphocèles. Après élimination des doublons et sélection, 190 articles ont été revus et sélectionnés.
Résultats
L’incidence des complications chirurgicales de la transplantation rénale varie de 1 à 30 % selon les séries ; elles sont souvent rapportées de façon incomplète et leur prise en charge est rarement consensuelle. Les techniques d’angioplastie ont apporté une amélioration sensible du traitement des complications vasculaires du transplant à moyen et long terme. Les facteurs de risque de thromboses des vaisseaux du transplant sont le rein droit, la présence d’artères multiples du transplant, l’existence d’une artériopathie chez le donneur ou le receveur, les troubles hémodynamiques per-procédure, la présence d’une néphropathie diabétique ou un antécédent d’accident thromboembolique chez le receveur. Les complications urinaires et la lymphocèle, si elles ne mettent pas en jeu la survie du transplant, sont responsables d’une morbidité conséquente pour le receveur. L’anastomose pyélo-urétérale d’emblée ou de rattrapage fait partie des principales options thérapeutiques des sténoses et fistules urétérales.
Conclusion
La prévention des complications chirurgicales de la transplantation nécessite une préparation minutieuse du transplant, et un respect rigoureux des bonnes pratiques chirurgicales. Les comorbidités de plus en plus importantes des receveurs sélectionnés, et des donneurs marginaux, n’ont pas permis de diminuer significativement la morbidité globale de la transplantation rénale.
Our objective was to define optimal management of distal ureteric strictures following renal transplantation. A systematic review on PubMed identified 34 articles (385 patients). Primary endpoints were success rates and complications of specific primary and secondary treatments (following failure of primary treatment). Among primary treatments (n = 303), the open approach had 85.4% success (95% CI 72.5-93.1) and the endourological approach had 64.3% success (95% CI 58.3-69.9). Among secondary treatments (n = 82), the open approach had 93.1% success (95% CI 77.0-99.2) and the endourological approach had 75.5% success (95% CI 62.3-85.2). The most common primary open treatment was ureteric reimplantation (n = 33, 81.8% success, 95% CI 65.2-91.8). The most common primary endourological treatment was dilation (n = 133, 58.6% success, 95% CI 50.1-66.7). Fourteen complications, including death (4 weeks post-op) and graft loss (12 days post-op), followed endourological treatment. One complication followed open treatment. This is the first systematic review to examine the success rates and complications of specific treatments for distal ureteric strictures following renal transplantation. Our review indicates that open management has higher success rates and fewer complications than endourological management as a primary and secondary treatment for post-transplant distal ureteric strictures. We also outline a post-transplant ureteric stricture evaluation and treatment algorithm.
Holmium : YAG Laser is solid state, pulsed laser that emits light at 2100 nm. It combines the qualities of the carbon dioxide and Nd: YAG laser providing both tissue cutting and coagulation in a single device. Since Holmium wavelength can be transmitted down optical fibers, it is especially suited for endoscopic surgery Holmium :YAG Laser is a multipurpose, multi-specialty surgical laser. It is safe and effective for multiple soft tissue applications and stone fragmentation. Its utilization in urology is anticipated to increase with time because of its unique features.
BACKGROUND: Ureteric obstruction is the most common complication after renal transplantation. Traditionally, this complication has been managed with open surgery. Currently, minimally invasive endourological techniques may offer an appropriate alternative to open surgery with the development of endourological techniques and the accumulation of experience. OBJECTIVE: To sum up the clinical effect of endourological techniques on ureteric obstrucion in transplanted kidneys. METHODS: Between February 2001 and October 2010, 23 cases of uretertic obstruction in transplanted kidneys were treated by endoscopical technique. After the obstruction was dilated with balloon or completely cut, two double-J stents were placed in the ureter for 4-6 weeks. During follow-up, renal function tests, B ultrasound examination and wash-out renal scintigraphy were performed. RESULTS AND CONCLUSION: Balloon dilation was performed in four patients and endoscopic incision was performed in 19 patients. All procedures resulted in successful incision of the obstruction. No complication was recorded during or after the procedure. At the mean follow-up of 6-108 months, 14 patients have ureteral patency and stable renal function, nine patients presented with recurred obstructive uropathy. Among them, two patients required permanent change of ureteral cathers, one patient required permanent nephrostomy, six patients required open surgical correction (four cases successful and two cases failed). Endourological technique for the ureteric obstruction in transplanted kidney is safe and effective. However, if the first endourological procedure fails, the recurrence rate of repeated endoscopic insicion is high.
Background:Urological complications after kidney transplantation are related to the ways of urinary reconstruction. It still remains to be determined whether ureteroureterostomy can become the first choice for urinary reconstruction instead of ureteroneocystostomy. Objective: To retrospectively analyze the occurrence and management of urological complications after ureteroureterostomy in kidney transplantation, and to investigate the feasibility that ureteroureterostomy become the first choice for urinary reconstruction after kidney transplantation. Design, Time and Setting: A retrospective case analysis was performed at Department of Urology, Research Institute of Field Surgery, Daping Hospital, the Third Military Medical University from December 1993 to April 2007. Participants: A total of 275 renal allograft recipients in whom ureteroureterostomy was adopted for urinary reconstruction were selected in the experiment. Msthods: The proximal end of ureter in recipient was ligated, and distal end exploration was used by ducts. The anastomosed ends of the patency of ureters in recipient and donor were trimed into a cuff shape. A 6Fr double J tube was located in the ureter in donor from renal pelvis to bladder. Urinary catheter was routinely used in the transplantation. The urinary catheter was removed at 7th day after transplantation, and double J tube was removed at 8th day. The second generation cephalosporin was used as antibiotic, and 5 days were assigned as one course. Main Outcome Measure: The occurrence and management of urological complications such as urine leakage, ureteral obstruction and vesicoureteral reflux (VUR) were summarized. Results: Overall, urological complications were encountered in 17 (6.2%) cases. Urine leakages were occurred in 4 (1.5%) patients. Of them, conservative treatment was successful in 3 patients, and 1 patient needed a second ureteroureterostomy due to distal ureteral necrosis. Ureteral obstructions were occureed in 13 (4.7%) patients. Of them, 4 patients were early obstruction, including hematoma in iliac fossa in 2 patients, ureteral blood clot in 1 patient and calculi in 1 patient. They were successfully management with surgical drainage, replacing the ureteral stent or ESWL. 9 patients were late obstruction, including a stenosis of nastomotic stoma in 6 patients and calculi in 3 patients. They were successfully treated with endourology. All recipients regained normal urine volume and graft function. Urological complications were no recurrence over six months followed up. Conclusion: Ureteroureterostomy is a safe way of urinary reconstruction. It can be regarded as the first option in anuric uremia recipients with a greater possibility of resolving a ureteral obstruction with endourology and no risk of reflux.
Renal transplantation is the best method for end-stage renal diseases in clinic. With the development of immunosuppressive agents, renal transplantation has been quite successful. Various complications after renal transplantation still threaten the function of graft and the life of patients. Some medical complications are difficult to prevent, but surgical complications are effective to prevent. The article comprehensively analyzes the etiology, diagnosis, treatment and prevention of some common urological complications such as urinary fistula, ureteral obstruction and ureteric reflux. The urological complications as the common complication are correlated to surgical skill. It has been an important link in improvement of transplantation quality to reduce incidence of urological complications and to diagnose and manage.
When compared with maintenance dialysis, renal transplantation affords patients with end-stage renal disease better long-term survival and a better quality of life. Approximately 9% of patients will develop a major urologic complication following kidney transplantation. Ureteral complications are most common and include obstruction (intrinsic and extrinsic), urine leak and vesicoureteral reflux. Ureterovesical anastomotic strictures result from technical error or ureteral ischemia. Balloon dilation or endoureterotomy may be considered for short, low-grade strictures, but open reconstruction is associated with higher success rates. Urine leak usually occurs in the early postoperative period. Nearly 60% of patients can be successfully managed with a pelvic drain and urinary decompression (nephrostomy tube, ureteral stent, and indwelling bladder catheter). Proximal, large-volume, or leaks that persist despite urinary diversion, require open repair. Vesicoureteral reflux is common following transplantation. Patients with recurrent pyelonephritis despite antimicrobial prophylaxis require surgical treatment. Deflux injection may be considered in recipients with low-grade disease. Grade IV and V reflux are best managed with open reconstruction.
Ureteral stricture disease management has changed with the introduction of minimally invasive treatment options such as ureteroscopy, laparoscopy, and robotics over the last 10–20 years. The advantages of decreased morbidity, pain, and convalescence time with minimally invasive surgery tempered with good results in the appropriate clinical scenario have led to a shift in treating this disease process ureteroscopically depending on the etiology. This chapter will focus on the ureteroscopic management (both retrograde and antegrade) of ureteral strictures, including ureteroenteric anastomotic and kidney transplant-related ureteral strictures. The techniques of surgery and the process of determining which patients are the right candidates for this treatment option will be discussed via an evidence-based approach. This will allow urologists to appropriately select candidates for ureteroscopy, provide them with the tools and technique for success, and allow counseling of patients regarding the risks, benefits, and alternatives taking into account success rates.
Objectives: To discuss various endourological techniques used for treatment of urological complications after renal transplantation. Comparison between different endourological options, optimization of patient selection, and criteria of success of these minimally invasive procedures are also provided. Materials and Methods: Database of PubMed and the Cochrane Database were searched through May 2011 without time limit. The following keywords were used: renal transplant, urological complications, urinary leakage, stricture, reflux, urolithiasis, and endoscopy. A total of 500 publications were retrieved. Relevant studies were analyzed. Results: Major urological complications following renal transplantation are ureteral leakage and stricture resulting mainly from technical errors. Initial management of obstructed ureters by percutaneous nephrostomy tube (PCN) fixation may improve graft survival and provide better access for diagnosis and intervention. Regardless of the technique of management of ureteral stricture, postoperative ureteral stenting for 6–8 weeks is mandatory. Minimal urinary leakage is an encouraging factor for applying conservative treatment by prolonged urethral catheterization in case of vesical leakage or PCN ± ureteral stent for ureteral leakage, otherwise, early open surgical reconstruction is recommended. Endoscopic intraureteral or subureteral injection of bulking agents seems to be a plausible alternative treatment to correct posttransplant vesicoureteral reflux. Meticulous and careful trials of stone disintegration and extraction by flexible ureteroscopy should be attempted before proceeding to percutaneous nephrolithotomy. Conclusions: A vast majority of, but not all, urological complications after renal transplantation are amenable for endourological intervention. Early diagnosis and careful patient selection for specific endourological techniques are the mainstays of a successful outcome.
Distal ureteral strictures can be defined as an abnormal narrowing involving the lower third of the ureter. Luminal obstruction can be partial or complete, with varying resultant effect. Most strictures pose clinical significance when they impair the ureter's principal function of expeditious forward transport of urine. Such an effect can result in pain, infection, calculus formation, or renal dysfunction. Strictures have historically been managed with open repair. However, advances in ureteroscope design, technique, and experience have reduced the morbidity and mortality associated with endoscopic repair. This chapter reviews the causes, diagnosis, and endoscopic management of distal ureteral strictures.
BACKGROUND: To determine histomorphological changes of ureter and kidney
following experimental ureteral anastomosis. OBJECTIVES: The aim of this study was to
evaluate more details about complications arising from ureteral anastomosis in dogs.
METHODS: Five healthy mongrel dogs weighing between 15-30 kg were used. Anesthesia
was induced by acepromazine and thiopenthal sodium and maintained by halothane in
oxygen in a closed circuit. After midline celiotomy, left ureter near trigon area was incised
and immediately end to end anastomosis was performed in simple interrupted pattern by using
polydiaxanon 6/0. All animals were euthanized at day 90 after operation and the ureters and
their related kidneys were evaluated both macroscopically and microscopically. RESULTS:
The gross observations of the ureters showed obstruction (one case) and mild hydroureter
(three cases). Microscopically, hyperplasia (in epithelial and muscularis layers), fibrosis
(lamina properia-submucosa and serosal layers) and different phases of inflammation and
repair (in lamina properia-submucosa, muscularis and serosal layers) were observed in the
ureters. Histological sections in the related kidneys revealed hydronephrosis in one case.
CONCLUSIONS: Although ureteral anastomosis is technically difficult in small animals and
has a high rate of postoperative obstruction, in case of transected or damaged ureter, ureteral
reanastomosis is one of the options for veterinary surgeons. In the present study, in spite of
some complications, the anastomosis has been performed successfully in 80 percent of
animals and certainly meticulous surgery is mandatory to prevent ureteral obstruction.
A ureteral stricture is a rather rare urological event, defined as a narrowing of the ureter causing a functional obstruction and renal failure, if left untreated. Aim of this review paper is to summarize and discuss current knowledge on the incidence, pathogenesis, management and follow-up of proximal, mid and distal ureteral strictures.
To evaluate the long-term outcomes and complications of retrograde endoureterotomy for persistent ureterovesical anastomotic strictures in renal transplant patients after percutaneous balloon dilation failure.
From January 2000 to May 2010, 26 (2.6%) of 1004 renal transplant patients developed ureterovesical anastomotic stricture after surgery. Seven of these patients and five additional referred patients with similar characteristics were treated with retrograde endoureterotomy after ≥1 previous unsuccessful attempt at percutaneous balloon dilation. All strictures treated were <1 cm in length. The clinical characteristics and outcomes were analyzed. Success was defined as the absence of symptoms and the resolution of obstruction on imaging after the procedure.
The median interval from initial treatment to endoureterotomy was 2.9 months (range 1.3-62.1). Before endoscopic treatment, 8 patients (67%) were treated with a single trial of balloon dilation and 4 (33%) with multiple trials. Endoureterotomy was performed using cold knife, holmium:yttrium-aluminum-garnet laser, and Bugbee electrode in 9, 2, and 1 patients, respectively. The median follow-up period was 44.4 months (range 2.4-68.6). Recurrent stricture developed in 2 patients during a mean follow-up of 4.7 months. Thus, the overall success rate was 83%. Postoperative complications appeared in 3 patients (25%) with culture-positive urinary tract infection. One graft failure occurred but was not related to a recurrent stricture.
After failure of antegrade percutaneous balloon dilation, retrograde endoureterotomy is an effective salvage procedure for well-selected cases of renal transplant patients with a short ureterovesical anastomotic stricture.
Transplant ureteral strictures occur in about 5% of cases. If treated in an accurate and timely manner, harm to the renal transplant can be avoided. This review article presents options to avoid ureteral stenosis and elucidates various interventional strategies and their success rates, from minimally invasive to open surgical approaches. Knowledge of risk factors and interventional strategies may help to improve long-term transplant outcomes.
To investigate the clinical value and safety of holmium: YAG laser endoureterotomy in the treatment of ureteral obstruction.
Holmium: YAG laser endoureterotomy, with the laser optic fiber 550 microm in diameter and the output power of 3.5 Watt, via ureteroscopy, was performed on 18 patients ureteral obstruction, 8 males and 10 females, aged 52.1 (34-67), 11 with the stricture in the upper segment (complete obstruction in 4 cases), 5 in the middle segment, and 2 in lower segment; and 6 cases complicated with ureteral calculus. Postoperatively, an orthopedic ureteral stent (a 6-Fr double-J ureteral stent with a movable 5 cm length 9-Fr orthopedic cannula) was remained indwelling for 3-6 months. Follow-up was conducted for 10.7 (2-14) months.
The operative duration was 32 (25-70) minutes. One patient underwent failed endoureterotomy and was turned to percutaneous nephroscopy. Success was achieved in 16 patients. The glomerular filtration rate (GFR) of these affected kidneys increased from 16.4+/-6.9 ml/min ante-operatively to 24.9+/-8.2 ml/min (P<0.01) postoperatively. One kidney was resected because of non-function, with GFR of 2 ml/min and intractable pyelitis. No recurrence of ureteral stricture was observed.
Holmium: YAG laser endoureterotomy with insertion of orthopedic ureteral stent is an efficient and safe treatment for ureteral strictures with minimal invasion, less complications and easy recovery. This operation should be performed with a thorough preparation and severely restricted indication.
Since the Ruby laser was first developed in 1960 as the first successful optical laser, laser energy has continued to be developed and used in industry and medicine alike. Laser use in urology has been limited, however, largely until the last decade. The unique properties of laser energy have now led to its widespread use within urology, particularly in the treatment of benign prostatic hyperplasia, urolithiasis, stricture disease, and novel laparoscopic applications. This article details laser developments in each of these areas.
Since the holmium:yttrium-aluminum-garnet (Ho:YAG) laser is the flexible lithotrite of choice for ureteral stones, its application to ureteral strictures associated with ureteral calculi is convenient. The results of Ho:YAG laser endoureterotomy in this specific setting have not been defined. We report our experience with Ho:YAG laser endoureterotomy of ureteral strictures associated with ureteral stone treatment, with or without a history of stone impaction.
We reviewed the medical records of 13 patients with ureteral stricture related to stone treatment, with (n = 9) or without (n = 4) a history of impacted ureteral stones, who were managed with Ho:YAG laser endoureterotomy. Follow-up was obtained with radiographic imaging and renal scans.
The overall success rate was 62%, with a mean follow-up of 21 months in successful cases and a mean recurrence time of 1.6 months in failures. Outcome was not associated with length or location of the stricture. Among the nine strictures associated with impacted stones, treatment was successful in only 5 (56%). Of the four strictures that occurred after stone removal but without history of impaction, the success rate was 75%. Success was also greater for strictures managed with post-procedure stents >or=8 Fr (75%), compared to stents <or=7 Fr. (56%).
Our results suggest that laser endoureterotomy of ureteral strictures due to ureteral stone treatment without a history of impaction is associated with a reasonable success rate (75%), but that laser endoureterotomy for strictures related to impacted stones is associated with a success rate of only 56%. Larger caliber stents might be preferred in this setting.
We report a patient who was diagnosed with end-stage renal disease and who received renal transplantation in her right iliac fossa in 2003. After transplantation, right hydronephrosis was noted on abdominal ultrasonography and right lower ureteral stricture was diagnosed by antegrade pyelography. She received ureter internal stent insertion three times, but hydronephrosis and urinary tract infection recurred after the stent was removed. Therefore, Acucise endoureterotomy was used to treat the recurrent ureteral stricture. The patient was discharged on the second postoperative day and abdominal ultrasonography revealed no hydronephrosis during regular follow-up.
The tissue effects of a holmium:YAG (Ho:YAG) laser operating at a wavelength of 2.1 mu with a maximum power of 15 watts (W) and 10 different energy-pulse settings was systematically evaluated on kidney, bladder, prostate, ureteral, and vasal tissue in the dog. In addition, various urologic surgical procedures (partial nephrectomy, transurethral laser incision of the prostate, and laser-assisted vasovasostomy) were performed in the dog, and a laparoscopic pelvic lymph node dissection was carried out in a pig. Although the Ho:YAG laser has a strong affinity for water, precise tissue ablation was achieved in both the contact and non-contact mode when used endoscopically in a fluid medium to ablate prostatic and vesical tissue. Using the usual parameters for tissue destruction (blanching without charring), the depth of thermal injury in the bladder and ureter was kept superficial. In performing partial nephrectomies, a 2-fold reduction in the zone of coagulative necrosis was demonstrated compared to the use of the continuous wave Neodymium:YAG laser (Nd:YAG). When used through the laparoscope, the Ho:YAG laser provided precise cutting and, combined with electrocautery, allowed the dissection to proceed quickly and smoothly. Hemostatic control was adequate in all surgical procedures. Although the results of these investigations are preliminary, our initial experience with the Ho:YAG laser has been favorable and warrants further investigations.
The urological complications in the first consecutive 1,000 renal transplants at our transplant center are reported with a minimum followup of 12 months. The kidney was implanted in the iliac fossa in all cases and in all but 3 the ureter was inserted into the bladder with a Politano-Leadbetter technique. Overall, there were 71 primary complications in 68 patients (7.1%), which included 36 ureteral obstructions, 25 ureteral or bladder leaks (including ureteral necrosis), 7 bladder outflow obstructions, 2 ureteral stones and 1 case of symptomatic vesicoureteral reflux. The use of high dose steroids in the early years was associated with a 10% urological complication rate, which decreased to 4% in patients receiving low dose steroids thereafter combined with azathioprine or cyclosporine. The urological complication was corrected after 1 procedure in 65 cases and after 2 procedures in 4. No grafts were lost due to urological complications. Two patients died, 1 of sepsis following transurethral resection of the prostate and subsequent ureteral necrosis, and 1 of hemorrhage following nephrostomy tube insertion. Most ureteral complications were treated by an open operation, although in recent years endoscopic techniques have become more common. Meticulous retrieval technique, low dose steroid protocols and rapid diagnosis are the crucial factors associated with a minimal incidence of urological complications after renal transplantation.
Treatment of ureteral stenosis has been attempted in many patients with transplanted kidneys. Treatment with the Acucise catheter system is a new approach for such patients. Published results of the approach in eight patients promise safety, effectiveness, and low perioperative morbidity. We report two cases of transplant ureteral stenosis treated with Acucise. One patient with stenosis of the pyeloureteral junction was treated successfully and has been free of recurrence for 9 months. The other patient had long-distance stenosis of the lower portion of the transplant ureter. Acucise incision was successful, but the patient had to undergo uretero-neocystostomy because of a ureteroperitoneal fistula. We use these cases to illustrate the disadvantages of endourological ureteral surgery as a standard therapeutic approach after renal transplantation. We suggest that Acucise is reliable when used in patients with uncomplicated short-distance ureteral stenosis; however, patients with long-distance stenosis or stenosis caused by heavily scarred periureteral tissue will not profit from it because of a higher complication rate.
The safety and efficacy of treating renal transplant ureteral stenosis with the Acucise endoureterotomy catheter are described.
We treated 4 women and 3 men 31 to 63 years old (mean age 45) with Acucise endoureterotomy for distal (6) and proximal (1) ureteral stenosis. Diagnosis was based on increasing serum creatinine and hydronephrosis on ultrasound, and confirmed by antegrade nephrostogram. One patient had recurrence and, therefore, 8 procedures were performed. Mean followup was 13 months (range 7 to 21).
Technical success was 100%. One patient had a recurrent stricture and was successfully re-treated. Of the patients 3 had chronic rejection and renal failure, and 4 had stable renal function. All ureters remain patent to date.
Treatment of short ureteral stenosis with Acucise endoureterotomy in a renal transplant is safe and effective. Furthermore, it can be performed in an ambulatory setting with minimal morbidity. This procedure should be considered as the initial approach for distal ureteral stenosis in the transplanted kidney.
The management of ureterointestinal stricture in patients who have undergone urinary diversion can be challenging. Endourological techniques have been increasingly used in recent years for ureteral stricture. While long-term results may not be as reliable or durable as those of traditional open reconstructive surgical techniques, associated morbidity is much less. The holmium (Ho):YAG laser, which has cutting and coagulating properties, has been demonstrated to have many applications in urology. We report our experience with and long-term results of Ho:YAG laser endoureterotomy for ureterointestinal strictures.
We reviewed the charts and followup history of 23 patients in whom the Ho:YAG laser was used to treat ureterointestinal anastomotic stricture. Strictures were treated percutaneously via the antegrade approach with flexible endoscopes and the holmium laser. A reversed 12/6Fr endopyelotomy stent was left indwelling for 6 weeks postoperatively. Success was defined as symptomatic improvement and radiographic resolution of obstruction.
Between 1993 and 2000, 23 patients with a mean age of 61 years underwent endo-ureterotomy using the Ho:YAG laser for 24 ureterointestinal stricture. An overall success rate of 71% (17 of 24 cases) was achieved at a mean followup of 22 months. The success rate of holmium laser endoureterotomy for ureterointestinal stricture at 1, 2 and 3 years was 85%, 72% and 56%, respectively. Seven patients had recurrent strictures of which 4 developed 16 months or more postoperatively. No complications were noted.
Ho:YAG laser endoureterotomy for ureterointestinal stricture disease is a minimally invasive endourological procedure that may provide more durable results than other modalities used for endoureterotomy. The Ho:YAG laser with its ability to cut tissue precisely and provide hemostasis combined with its versatility and compatibility with flexible endoscopes is an ideal instrument for safely performing endoureterotomy.
Eight patients with ureteral stricture after renal transplantation underwent minimally invasive treatment with Acucise incision or balloon dilation. Acucise endoureterotomy was used to treat four patients with strictures at the ureterovesical anastomosis, and balloon dilation was used to treat four patients with a ureteroureterostomy stricture. Success was defined as an acceptable serum creatinine concentration in the absence of hydronephrosis with at least 1 year of follow-up.
Acucise endoureterotomy for ureterovesical anastomosis stricture was successful in two of three patients (67%) with a mean follow-up of 20 months. One patient had an indeterminate outcome. Balloon dilation of strictured ureteroureterostomy was successful in three of four patients (75%) with a mean follow-up of 23.7 months. Three of the four patients with previously failed open revision were treated successfully with endourologic techniques. The two patients in whom treatment failed had strictures >/=1.5 cm and manifested comorbidities including diabetes mellitus.
As our results are comparable to those of other published series, endourologic management of transplant ureteral stenosis is a reasonable strategy.
To report our results after antegrade endoscopic treatment of ureteral stenosis with balloon dilation with or without holmium laser endoureterotomy. Ureteral stenosis is the most common long-term urologic complication of renal transplantation.
From July 2000 to October 2002, 9 renal transplant patients with ureteral obstruction diagnosed by an increase in serum creatinine and radiologic evidence presented for endoscopic treatment. All patients were treated with nephrostomy tube drainage followed by antegrade flexible nephroureteroscopy and balloon dilation of the stricture. Three patients required holmium laser endoureterotomy during the same procedure because of fluoroscopic and endoscopic evidence of persistent stricture. All patients were treated with ureteral stents and nephrostomy tubes postoperatively. The median follow-up was 24 months (range 6 to 32).
The site of stenosis was at the ureterovesical anastomosis in all patients, and the mean stricture length was 0.28 cm. Two patients had previously undergone ureteroneocystostomy for prior ureteral stenosis. Six patients (66%) required only balloon dilation, and 3 patients (33%) also required holmium laser endoureterotomy. The median ureteral stent and nephrostomy tube duration was 40 and 62 days, respectively. The mean serum creatinine level was 2.3 mg/dL at presentation and 1.7 mg/dL at the last follow-up visit. After a median follow-up of 24 months, the ureteral patency and graft function rates were both 100%. No perioperative complications occurred.
Balloon dilation with or without holmium laser endoureterotomy was successful and safe in this group of renal transplant patients with short ureterovesical anastomotic strictures.
Ureteric strictures, with a reported incidence ranging from 2% to 7.5%, are the most frequent urological complication of renal transplantation. This article reports the results of open surgery and percutaneous or endoscopic techniques used to treat these strictures, based on a single-centre retrospective series of renal transplantations.
From January 1990 to December 2002, in a series of 1787 consecutive renal transplantations performed in our centre, 74 were complicated by ureteric stricture (4.1% of cases). Strictures occurred at the ureterovesical implantation in 82.4% of cases and during the first year in 88% of cases. The mean time to management of the stricture after transplantation was 9 months (range: 6 days-120 months). Criteria of success were defined by regression or even resolution of ultrasound signs of dilatation associated with stabilization of serum creatinine obtained by the external urinary diversion. Surgical or percutaneous revisions (particularly repeated changes of double J stents) were considered to be treatment failures.
44 strictures (59.5% of cases) were treated by open surgery and 30 (40.5%) were treated by a first-line endoscopic or percutaneous technique. In our hands, open surgical techniques (ureteropelvic anastomosis: 80% of success (n=5), ureterovesical reimplantation: 82% of success (n=11), ureteroureteric anastomosis: 100% of success (n=4)) gave better results than endourological techniques (endoscopic electrical incision: 61.5% of success (n=13), double J stent: 61.5% of success (n=13), balloon catheter dilatation: no success (n=4)).
Classical open surgical revision remains the reference treatment for ureteric strictures in renal transplantation for our team.
Despite the popularity of hand assisted laparoscopic donor nephrectomy published experience is less than that with standard laparoscopic donor nephrectomy and few critical assessments of operative maneuvers have been described.
We describe the impact of changes in operative technique made by a single surgeon during 200 hand assisted laparoscopic donor nephrectomies.
With a mean operative time of 229 minutes and hospital stay of 1.9 days the rates of conversion to open surgery, intraoperative complications and major postoperative complications were 1%, 1.5% and 6%, respectively. Lasting changes in technique were dissection of a ureteral/gonadal packet, bipolar cautery use on gonadal/adrenal/lumbar veins and resting the kidney before removal. The incidence of ureteral complications decreased from 8% to 5.1% with dissection of the ureter in conjunction with the gonadal vein rather than isolating it. Warm ischemia time decreased from a mean of 186 to 143 seconds with bipolar electrocautery instead of clips to control gonadal/adrenal/lumbar veins. After starting to rest the kidney before removal the incidence of primary graft nonfunction and delayed function decreased from 6.7% to 0% and 30% to 11.8%, respectively, with a corresponding improvement in 2-year graft survival from 83% to 95%.
This large series of hand assisted donor laparoscopic nephrectomies with a mean followup approaching 3 years demonstrates that the procedure is safe for the donor and procures a good specimen. Decreases in ureteral complications, warm ischemia time and graft dysfunction might be attributable to specific changes in our operative technique.
This study compared the immediate and long-term results and complications of hot-wire balloon endopyelotomy and ureteroscopic holmium laser endopyelotomy.
Between March 1994 and January 2002, 64 patients with a primary (N = 52) or secondary (N = 12) ureteropelvic junction obstruction underwent retrograde endopyelotomy using either a fluoroscopically guided hot-wire balloon incision (N = 27) or a ureteroscopically guided, direct-vision holmium laser incision (N = 37). This study group included 46 women and 18 men aged 13 to 79 years (mean 38.9 years). The indications and contraindications to a retrograde approach were identical in each group and included documented functionally significant evidence of obstruction, no upper-tract stones, obstruction <2 cm, and no radiographic evidence of entanglement of crossing vessels at the ureteropelvic junction. Immediate and long-term outcomes were obtained from a prospective registry, with success defined as resolution of symptoms and radiographic relief of obstruction as determined by follow-up with intravenous urography, diuretic renography, or both. Follow-up ranged from 39 to 133 months (mean 75.6 months).
Length of hospital stay, indwelling stent duration, and long-term success rates (77.8% v 74.2% in the hot-wire balloon and holmium-laser group, respectively) were equivalent. However, two patients in the hot-wire balloon group developed bleeding necessitating transfusion and selective embolization of lower-pole vessels. No patient in the ureteroscopic group suffered a major complication.
These two alternatives for retrograde endopyelotomy provide comparable success rates for similarly selected patients. However, because significant hemorrhagic complications developed with greater frequency in those treated with the hot-wire balloon, our preference is for a ureteroscopic approach, as it allows direct visual control of the incision and thus, a lower risk of significant bleeding.
Ureteral obstruction necessitating intervention occurs in 2% to 7.5% of all renal allograft recipients. Conventional management includes open surgical repair, although more recently, percutaneous ureteral dilation has been performed.
The management and outcome of all seven allograft ureteral strictures treated with balloon dilation in our unit over a 4-year period were reviewed. Half (55%) of these strictures occurred in the proximal ureter.
Four strictures were dilated successfully with a requirement for five dilations in total. These patients have stable graft function with no evidence of obstruction. Five strictures persisted despite 11 dilations. There were no significant complications from balloon dilation.
Definitive surgical management should be considered if obstruction persists after one attempt at ureteral dilation, as multiple dilations have a low success rate (25%).
Our transplantation team has performed 1615 renal transplantations since 1975. After September 2003, we began a corner-saving technique for urinary tract continuity. In this study, we analyzed these 174 renal transplantations retrospectively. The mean recipient age was 31.6 years (range, 7 to 66). The mean donor age was 39.8 years (range, 6 to 67). For ureteral reimplantation, a running suture is started 3 mm ahead of the middle of the posterior wall and is finished 3 mm afterward. After the last stitch, both ends of the suture material are pulled, and the posterior wall of the ureter and bladder are approximated tightly. The anterior wall is sewn either with the same suture or another running suture. Since using this technique, we have not employed a double-J or any other stent to prevent ureteral complications at the anastomosis site. We have seen only 4 (2.2%) ureteral complications (2 ureteral stenosis and 2 anastomotic leaks) during a follow-up period of 18.9 months. In conclusion, due to the low complication rate, we believe that our new technique is the safest way to perform a ureteroneocystostomy.
We performed a randomized, prospective trial to compare the incidence of early urological complications and health care expenditures in renal transplant recipients with or without ureteral stenting.
Patients receiving a renal transplant at a single center were randomized preoperatively to undergo Double-J stent or no-stent ureterovesical anastomosis from November 1998 to October 2001. Early urological mechanical complications were recorded, including urinary leakage or obstruction, or urinary tract infections within 3 months of transplantation. Direct health care costs associated with stenting, urological complications and urinary tract infection management were also collected.
A total of 201 patients were randomized to a stent (112) and a no-stent (89) group. In the no-stent group 11 patients received a stent due to intraoperative findings and were excluded from study. At 3 months there were significantly more cases of urinary leakage (8.9% vs 0.9%, p <0.008) and ureteral obstruction (7.7 % vs 0%, p <0.004) in the no-stent than in the stent group. Mean time of stent removal was 74.3 days. A significant increase in urinary tract infections was observed when stent was left greater than 30 days after transplantation compared to the rate in the no-stent group (p <0.02). An additional cost of 151 UK pounds per patient was incurred in the no-stent group vs the stent group.
Using a ureteral stent at renal transplantation significantly decreases the early urinary complications of urine leakage and obstruction. However, there is a significant increase in urinary tract infections, primarily beyond 30 days after transplantation. Stent removal within 4 weeks of insertion appears advisable.
Treatment of transplant ureteral stenosis with Acucise endoureterotomy.
- Gross