Ureteral length in live donor kidney transplantation; Does size matter?

The aim of this study was to evaluate the role of ureteral length on urological complications. Data were retrospective collected from the INEX-trial database, a RCT to compare the intravesical to the extravesical ureteroneocystostomy. Ureteral length was measured in 198 recipients and used to divide recipients into three categories based on interquartile ranges: short (≤8.5 cm), medium (8.6-10.9 cm) and long ureters (≥11 cm). Urological complications were defined as the number of percutaneous nephrostomy placements (PCN). Fifty recipients fell into the short, 98 into the medium and 50 recipients into the long ureter category. Median follow-up was 26 (range 2-45) months. There was no significant difference in number of PCN placements between the categories. There were 9 (18%) PCN placements in the short ureter category, 21 (20%) in medium ureter category and 10 (21%) in the long ureter category, P = 0.886. Risk factor analysis for gender, arterial multiplicity and type of ureteroneocystostomy showed no differences in PCN placements between the three ureteral length categories. We conclude that ureteral length alone does not seem to influence the number of urological complications.

A randomized controlled trial comparing intravesical to extravesical ureteroneocystostomy in living donor kidney transplantation recipients.

Urological complications after kidney transplantation are mostly related to the ureteroneocystostomy leading to significant morbidity, mortality, and high costs. The most commonly used techniques for the ureteroneocystostomy are the intravesical and the extravesical anastomosis. No evidence in favor of one of these two anastomoses exists. Our aim was to determine the technique with the best outcome regarding urological complications in a prospective randomized controlled trial (Netherlands Trial Register NTR2320). We randomized 200 consecutive recipients of a living donor kidney for either an intravesical or an extravesical anastomosis. The primary outcome was defined as placement of a percutaneous nephrostomy. No significant differences were found in the number of percutaneous nephrostomy placements or ureter reinterventions between both groups. Nevertheless, significantly fewer urinary tract infections occurred in the group with an extravesical anastomosis. In addition, this anastomosis was performed significantly faster compared with the intravesical anastomosis. Thus, extravesical ureteroneocystostomy was associated with significantly fewer urinary tract infections and might be preferable because of its surgical simplicity.

Independent risk factors for urological complications after deceased donor kidney transplantation.

Urological complications after kidney transplantation are mostly related to the ureteroneocystostomy, often requiring interventions with additional costs, morbidity and mortality. Our aim was to assess risk factors for urological complications in deceased donor kidney transplantation. Between January 2000 and December 2011, 566 kidney transplantations were performed with deceased donor kidneys. Recipients were divided in a group with, and a group without urological complications, defined as the need for a percutaneous nephrostomy catheter or surgical revision of the ureteroneocystostomy. Univariate and multivariate analyses were performed. Univariate analysis showed increased number of male donors (p = 0.041), male recipients (p = 0.002), pre-emptively transplanted recipients (p = 0.007), and arterial reconstructions (p = 0.004) in the group with urological complications. Less urological complications occurred in recipients on hemodialysis (p = 0.005). More overall surgical interventions (p<0.001), surgical site infections (p = 0.042), urinary tract infections (p<0.001) and lymphoceles (p<0.001) occurred in the group with urological complications. Multivariate analysis showed that male recipients (p = 0.010) and arterial reconstructions (p = 0.019) were independent risk factors. No difference was found between both groups in patient or graft survival. In conclusion, recipient male gender and arterial reconstruction are independent risk factors for urological complications after deceased donor kidney transplantation. Nevertheless, graft and recipient survival is not different between both groups.

Long-term outcome of kidney transplantation in patients with a urinary conduit: a case-control study.

PURPOSE: To study the short- and long-term outcomes of kidney transplantation in patients with a bladder augmentation or urinary diversion compared to patients with a kidney transplantation in a normal functional bladder. PATIENTS AND METHODS: Between January 2000 and March 2011, 13 patients received 16 grafts into a reconstructed urinary tract. We performed a retrospective case-control study and matched each patient to 4 controls for donor and recipient gender and year of transplantation. RESULTS: Short- and long-term complications of kidney transplantation occurred in 12 patients, varying from urinary tract infections to medical hospitalization with or without surgical or radiological intervention. In 5 patients, a percutaneous nephrostomy (PCN) was placed followed by surgical re-intervention. In three patients, the grafts failed as a result of chronic rejection and were re-transplanted. There was no graft loss as a result of surgical complications or the reconstructed urinary tract. One-year patient and graft survival was 100 %. After five years, all patients were alive and seven of nine grafts (77.8 %) were functioning. Mean follow-up time was 4.3 years. Among the controls, 55 grafts were transplanted in 52 patients. Ten patients received a PCN. Five patients needed surgical re-intervention. In three patients, transplantectomy was performed for ongoing rejection. Three patients were re-transplanted. One patient had a failing graft 7.5 years post-transplantation and became dialysis dependent. CONCLUSION: Kidney transplantation in patients with a reconstructed urinary tract has an increased complication rate. Nevertheless, the long-term results are comparable to patients with a normal urinary bladder.

Intravesical versus extravesical ureteroneocystostomy in kidney transplantation: a systematic review and meta-analysis.

Urological complications are still a major problem postoperatively with a reported incidence of up to 30%, associated with significant morbidity, mortality, prolonged hospital stay and high medical costs. To date, there is no evidence favouring either an extravesical or an intravesical approach. The purpose of this systematic review and meta-analysis is to determine if an intravesical or extravesical anastomosis in kidney transplantation is to be preferred. Comprehensive searches were conducted in PubMed, Embase and the Cochrane Library. Reference lists were searched manually. The methodology was in accordance with the PRISMA statement. Two randomized controlled trials and seventeen cohort studies were identified. Based on the meta-analysis, outcome was in favour of the extravesical anastomosis. A relative risk (RR) for stenosis of 0.67 (confidence interval (CI), 0.48-0.93; p = 0.02), for leakage 0.55 (CI 0.39-0.80; p = 0.001) for the total number of urological complications 0.56 (CI 0.41-0.76; p < 0.001) and for haematuria of 0.41 (CI 0.22-0.76; p = 0.005) was demonstrated. Based on our results, we conclude that there is evidence in favour of the extravesical ureteroneocystostomy for having a smaller amount of urological complications in kidney transplantation.