Results of pyeloureterostomy after ureterovesical anastomosis complications in renal transplantation.

OBJECTIVES: The most frequent urologic complications after renal transplantation involve the ureterovesical anastomosis (ie, leakage, stenosis, and reflux), with a frequency of 1% to 30% in different series. We present the results of pyeloureterostomy using the recipient's ureter. METHODS: From 1988 to 1996, 570 cadaveric renal grafts were performed at our institution. A Lich Gregoir ureterovesical anastomosis was used in every case. Complications involving the anastomosis occurred in 19 cases (3.3%), with 10 stenoses (1.7%), 6 cases of leakage (1.1%), and 3 of reflux (0.5%). The mean donor age was 36.2 years, and the mean duration of cold ischemia was 29.4 hours. The mean recipient age was 41.3 years. Corrective surgery was performed 0.09 years (range 0.01 to 0.22) after transplantation for leakage, 1.13 years (range 0.14 to 5.11) for stenosis, and 5.55 years (range 0.51 to 9.71) for reflux. The recipient's ureter was stented with a ureteral catheter before median laparotomy, except in 3 cases of early leakage (less than 3 days). The recipient's ureter was cut, without the need for ipsilateral nephrectomy, and sutured to the graft pelvis. A nephroureterostomia stent (Gil Vernet stent) (12 cases) or a double J ureteral stent (7 cases) was used for urinary drainage. RESULTS: One graft was lost on day 1 through renal vein thrombosis. Percutaneous nephrostomy was performed on day 2 to clear an obstruction of the double J ureteral stent in one case, and a double J ureteral stent was inserted on day 2 because the nephrouretrostomia stent was incorrectly positioned in another case. Pyelographic controls on day 15 were normal in every case. The mean follow-up was 2.25 years (range 0.24 to 6.1) (2.9 years for leakage, 2.08 years for stenosis, and 1.44 years for reflux). One patient died with a functional graft 3 years after surgery. One graft was lost 4 years after surgery through chronic rejection. There were no complications affecting the ipsilateral kidney. No further ureteral complications occurred after surgery. The mean creatinine level 3 years after surgery was 1.59 mg/dL. CONCLUSIONS: Pyeloureterostomy is a safe and permanent treatment for complications of ureterovesical anastomosis and gives excellent results. The technique requires stenting of the recipient's ureter and graft drainage with a nephroureterostomia stent or a double J ureteral stent.

[Results of pyeloureteral anastomoses onto the native ureter after complication of ureterovesical anastomosis in kidney transplantation]. / Résultats des anastomoses pyélourétérales sur uretère propre après complication de l'anastomose urétérovésicale en transplantation rénale.

OBJECTIVES: Complications of the ureterovesical anastomosis after renal transplantation are the most frequent surgical complications, estimated to occur in 3 to 20% of cases, depending on the series. Various techniques have been used to treat anastomotic leaks, stenoses or reflux. We present the results of pyeloureterostomy using the recipient's own ureter. MATERIAL AND METHODS: 520 cadaver kidney renal transplantations were performed between 1988 and 1996. The ureterovesical anastomosis was performed according to the Lich Gregoir technique. Sixteen recipients (3%) developed an anastomotic complication: 9 stenoses (1.7%), 6 leaks (1.1%), 1 reflux (0.2%). The mean age of the donor was 37 years and the mean cold ischaemia time was 30 hours. There were 8 right kidneys and 8 left kidneys, transplanted in the right iliac fossa in 11 cases and left iliac fossa in 5 cases. The mean age of the recipients was 42 years, and they were transplanted for nephropathy in 15 cases and uropathy in 1 case. Surgical revision was performed 1 month after transplantation for anastomotic leaks and after 14 months for stenoses. In every case, the native ureter was identified by a ureteric catheter via a midline incision except for 3 cases of early anastomotic leak (< 3 days). The native ureter was sectioned without associated ipsilateral nephrectomy then anastomosed to the renal pelvis of the transplant, which was then drained by a Gil-Vernet catheter (10 cases) or ureteric stent (6 cases). RESULTS: One transplant was lost on D1 due to renal vein thrombosis. One nephrostomy was inserted on D2 due to obstruction of the ureteric stent. Follow-up pyelography on D15 was normal in every case. The mean follow-up was 2.5 years (2.9 years for anastomotic leaks, 2.2 for stenoses, 3.6 for reflux). One patient died with a functional renal transplant 3 years after the operation and one transplant was lost due to chronic rejection 4 years later. No complications involving the native kidney ipsilateral to the anastomosis were observed and there were no repeated ureteric complications. Mean creatinine 3 years after the operation was 141 mumol/l. CONCLUSION: Pyeloureterostomy is a reliable technique in the case of complications of the ureterovesical anastomosis. Pyeloureterostomy via a midline incision allowed one-stage definitive treatment of all anastomotic complications of the ureterovesical anastomosis with a low morbidity.