|Year : 2019 | Volume
| Issue : 3 | Page : 184-187
Posttransplant vesical calculi – A case series
Dimple Kumar Chanamolu, Ravi Koti Reddy Kolatham, T Narendar, V L. N Murthy Pisapati
Department of Urology and Renal Transplantation, Kamineni Institute of Medical Sciences, Nalgonda, Telangana, India
|Date of Submission||23-Feb-2019|
|Date of Decision||05-May-2019|
|Date of Acceptance||06-Jun-2019|
|Date of Web Publication||17-Sep-2019|
Prof. V L. N Murthy Pisapati
Department of Urology and Renal Transplantation, Kamineni Institute of Medical Sciences, Narketpally, Nalgonda - 508 254, Telangana
Source of Support: None, Conflict of Interest: None
Background: The occurrence of posttransplant vesical calculi is rare. Suture material, used during ureteroneocystostomy, both absorbable and nonabsorbable have been implicated as the nidus for stone formation. We report five cases of renal transplant recipients, who developed vesical calculi several years after renal transplantation, and the nidus was the prolene suture. Methods: Between 1997 and 2010, 344 renal transplants were performed which included both cadaver and live-related transplantations. The ureteroneocystostomy was performed by modified Lich-Gregoir technique using 6–0 prolene as the suture material. All cadaver transplants and some of the live cases were stented. The Foley catheter was removed between 3 and 5 days, and DJ stent was removed between 4 and 6 weeks postoperatively. Standard triple drug immunosuppression was given and followed up at regular intervals. Results: Five patients developed small vesical calculi between 10 and 21 years after transplantation at the site of ureteroneocystostomy, and prolene suture was the nidus. There were three ureteric leaks postoperatively, two were due to ureteric necrosis requiring reconstruction, and one was due to anastomotic leak which subsided on prolonged bladder drainage. There was one case of ureteric obstruction in the immediate postoperative period which was stented. Conclusion: Nonabsorbable suture material, however fine it is, prompts stone formation in the long run and should be avoided during ureteroneocystostomy.
Keywords: Posttransplant vesical calculi, prolene suture, renal transplant
|How to cite this article:|
Chanamolu DK, Kolatham RK, Narendar T, Pisapati V L. Posttransplant vesical calculi – A case series. Indian J Transplant 2019;13:184-7
| Introduction|| |
The incidence of stone disease after renal transplantation is very low. Factors predisposing to stone formation are hyperparathyroidism, hypercalciuria, recurrent urinary tract infection (UTI), and hypocitraturia due to renal tubular acidosis. Less common risk factors include outflow obstruction, foreign bodies such as stents, nephrostomy tubes, suture materials, and donor lithiasis. Formation of vesical calculi on the suture material which was used for ureteroneocystostomy has been reported in the past.,,
Ureteroneocystostomy is one of the important steps in the surgical procedure of renal transplantation. Any technical fault can lead to urinary leak, ureteric obstruction, or vesicoureteral reflux which results in increased morbidity or even graft loss. The anastomoses between ureter and bladder should be done meticulously like a vascular anastomosis. Extravesical ureteroneocystostomy (Lich-Gregoir technique) is the most common technique used, and the suture material is the choice of the surgeon. The spatulated ureter is anastomosed to the mucosa of the bladder with a running absorbable or nonabsorbable suture. In general, absorbable suture material like catgut, polyglycolic acid, and other synthetic absorbable sutures are used as nonabsorbable sutures (silk and prolene) prone to form stones when exposed to urine. However, stone formation had been reported with absorbable sutures too.,, Fine polypropylene vascular nonabsorbable sutures (6-O) were recommended by a few surgeons without any stone formation. The prolene suture runs smoothly in tissues, inert, do not cause any tissue reaction, precisely bring the two mucosal surfaces together, and will be covered by urothelium soon preventing exposure to urine.
We report five cases of vesical calculi occurring 6–21 years after renal transplantation at the site of ureteroneocystostomy and the nidus was found to be prolene. All the vesical calculi were managed by endoscopic methods. It is perplexing to note the cause for such a long lag period for stone formation in our cases.
| Methods|| |
Between 1997 and 2010, prolene 6-O vascular suture (11-mm double-arm round-body needle, Ethicon) was used in 344 cases of renal transplant recipients, both live Live Related Donor (LRD) and cadaver (CdTx) during ureteroneocystostomy by modified Lich-Gregoir technique in two centers by the corresponding author. The spatulated ureter was anastomosed to bladder mucosa by continuous suture starting at the heel from both sides with a double-arm needle and tied at the toe of the spatulated ureteric end. Both the needles were brought through the detrusor 5 mm away from cystotomy and fixed externally so that the knot stays on the serosal surface of the bladder [Figure 1]. The cystotomy incision was closed with 3–0 vicryl suture. The anastomosis was done anterolaterally in the middle of the bladder. The urethral Foley was removed between 3 and 5 days of postoperative period. Most of the cases were stented (all CdTx cases), and the DJ stent was removed in the 4th week after transplant. The ureteroneocystostomy site was examined cystoscopically for prolene suture whether covered by urothelium during stent removal.
|Figure 1: The knot of the prolene suture used for ureteroneocystostomy was outside the bladder (arrow)|
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| Results|| |
There were three cases of urine leak postoperatively (<1%): one on the 2nd postoperative day (from the anastomotic site) and the second and third cases on day 7 and day 9, respectively (due to distal ureteric necrosis). There was one case of ureteric obstruction in the immediate postoperative period which was managed by stenting. The anastomotic leak was treated conservatively, and two cases of ureteric necrosis required Boari flap reconstruction. Cystoscopic examination during stent removal in the 4th week postoperative did not reveal any exposed suture at the site of ureteroneocystostomy. Standard protocols of immunosuppression and follow-up were observed.
A 39-year-old male patient presented with recurrent attacks of febrile UTI of 6-month duration. He underwent live-related renal transplantation in 2004 and presented in 2018. The urine culture was grown Escherichia coli which was sensitive to ceftriaxone and sulbactam combination. Complete blood counts showed leukocytosis (Total Count(TC): 16,300 cmm3) and hemoglobin of 16 g/dl, and renal parameters were normal (blood urea [BU]: 34 mg/dl/and serum creatinine [sCr]: 1.4 mg/dl). Ultrasonography of the kidney, ureter, and bladder area showed echogenic calculi, and noncontrast computed tomography (NCCT) of the abdomen confirmed 8- and 6-mm calculi in the bladder at the site of ureteroneocystostomy [Figure 2]a. Cystoscopy under regional anesthesia showed the calculi hanging on to the prolene suture at the site of neo-ureteric orifice in the anterior wall [Figure 2]b. Both calculi were dropped down after cutting the suture with endo scissors and later disintegrated with lithoclast [Figure 2]c. The suture was excised close to the bladder mucosa so that the end of the suture is withdrawn inside. Follow-up after 3 months showed sterile urine.
|Figure 2: (a) Computed tomography scan: Two vesical calculi at the site of ureteroneocystostomy, (b) endoscopic view of the vesical calculi hanging to prolene suture, (c) disintegrated vesical calculi and prolene suture (blue)|
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A 42-year-old male underwent live-related renal transplant in 2012, and the donor is the mother. Graft functioning was well as evidenced by his biochemical values of BU and sCr being 23 and 1.2 mg/dl, respectively. However, after 6 years, he presented with recurrent attacks of febrile UTI for the past 6 months in May 2018. NCCT showed 8-mm vesical calculus near the ureteroneocystostomy site. Cystoscopy showed calculus adherent to prolene suture. The stone as well as the prolene suture was disintegrated endoscopically using 200-μ fiber with holmium laser [Figure 3]. The patient was asymptomatic after the procedure in the follow-up period of 6 months.
|Figure 3: Endoscopic view of the vesical calculus with prolene suture, 200 μ laser fiber (blue) was also shown|
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A 26-year-old male underwent cadaver renal transplantation in 2006 and presented to us in 2014 with complaints of burning and frequent micturition of 4-month duration. His graft function was normal. Urine examination showed plenty of pus cells and positive for culture (E. coli). The plain computed tomography scan confirmed a 10-mm calculus on the right side of the bladder near the ureteroneocystostomy site. He was advised to undergo surgery but did not turn up.
A 35-year-old patient underwent live-related transplant in 1997 and presented to another center in 2012 with lower urinary tract symptoms and diagnosed having vesical calculus adherent to nonabsorbable suture at the ureteroneocystostomy site which was removed endoscopically (personal communication).
A 45-year-old woman, a transplant recipient 21 years ago, was evaluated for low backache. She underwent renal transplant at the age of 24 years and her husband was the donor. Her renal function was normal (sCr: 0.7 mg %). NCCT of the abdomen revealed 6-mm calculus at the level of ureteric anastomosis on the anterior wall of the bladder [Figure 4]. At present, she is under follow-up.
|Figure 4: Computed tomography scan showing vesical calculus at the site of ureteroneocystostomy|
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| Discussion|| |
The occurrence of vesical calculi in a renal transplant patient at the site of ureteroneocystostomy was first reported by O'Dea et al. in 1975. There have been reports of the development of vesical calculi following complications of primary bladder closure and other surgical interventions for urological complications in the postrenal transplant period. Presentation of vesical calculi in postrenal transplant patients varies from incidental detection to symptoms of UTI and hematuria. Rhee et al. reported four cases of vesical stones following combined pancreatic and renal transplantation, where exposed sutures were found to be the nidus for calculus formation.
Even though urinary tract reconstruction with nonabsorbable sutures has been described generally, many prefer absorbable sutures for risk of stone formation. The ideal suture should be very fine, runs smoothly in tissues, inert not causing inflammation, not to be lithogenic, and should hold the tissues together for sufficient time until healing takes place. A study was performed to compare the urological complications of chromic catgut 4–0 (natural absorbable suture) with fine prolene 6–0 (synthetic nonabsorbable suture) in ureterovesical anastomosis (modified Lich method). No stone was detected at ureterovesical anastomotic site or in the bladder in both the groups after 18 months of follow-up. This study tried to prove that chance of urologic complications with prolene suture is not more than chromic catgut suture and it can be used for ureterovesical anastomosis. Since the knot- and cut-free ends of prolene were outside the bladder, only small amount of prolene was exposed to urine, and this was covered by urothelium sooner than later. However, the follow up in that study was only 18 months and our data revealed it took much longer time (6 to 21 years) to develop stones over the prolene suture. Kaminski et al. reported that in rats which have alkaline urine and great susceptibility to stone formation, production of stone on prolene suture was more possible than chromic catgut suture. In mice, chance of stone formation was equal on both sutures. In dogs, no stone is produced on both sutures. Lock et al. reported 6 patients with stone formation on vicryl suture (absorbable suture) in the renal pelvis, 2 years after surgery. Klein and Goldman in1997 reported 7 patients with infective and calcium oxalate stone formation on prolene suture after kidney transplantation. In 1999, Kehinde et al. evaluated 7 patients with bladder stone after the use of nonabsorbable sutures (nylon, prolene, and silk). Watanabe et al. reported 3 patients with bladder stone, 3–15 months posttransplantation after use of absorbable sutures (polyglyconate and polydioxanone).
Urinary stone formation following kidney transplantation is a rare complication with an incidence rate of 1.8%. Hyperparathyroidism, hypercalciuria, recurrent UTI, and hypocitraturia are the most common risk factors, but often, there are multiple factors which predispose to stone formation. However, the present discussion was focused mainly on suture material as a nidus for stone formation. Suture or mesh erosion is a well-known complication of hernia repair, sling operations for stress urinary incontinence, and sacrocolpopexy. Hence, it could be suture erosion of prolene in the present cases occurring as a long-term complication exposing the suture to urine resulting in stone formation. Erosion may result from an inflammatory reaction due to infection of the foreign body or, possibly, due to an immunological response to the graft or suture material. Do the nonabsorbable sutures predispose to increased incidence of UTI and thereby lead to stone formation? In our own published analysis and others reported from Babol University study,, there was no increased incidence of UTI with nonabsorbable suture. The reported incidence of urological complications following the transplantation was between 1% and 15% in the literature., In the present study, this was extremely low (<1%) and we ascribed this not only to the meticulous technique we followed but also for the fine suture material used in ureteroneocystostomy.
At present, polydioxanone(PDS) 6-0 double-arm synthetic absorbable sutures (Ethicon) are being used at our center since 2013, and no stone has been reported till date. (PDS) provides prolonged wound support by retaining the tissue integrity longer than other synthetics absorbable suture material. The PDS suture is a good alternative for having all the virtues of prolene, but absorbable and costs lesser (MRP: Rs.650 vs. Rs.750, single suture) than prolene. The vesical calculi and the prolene sutures can be removed eminently by endoscopic techniques using laser.
| Conclusion|| |
Ureteric complications were very low in our series, and we ascribe this due to perfect technique which was facilitated using fine vascular suture material during ureteroneocystostomy. Even though the incidence of vesical stone formation was extremely low in the present series, nonabsorbable suture material, even fine prolene should be avoided during ureteroneocystostomy in transplant recipients as they erode and cause vesical stone formation in the long run. Synthetic absorbable fine suture material like PDS is eminently suitable for this purpose.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Akbarzadeh-Pasha A, Oliaei F, Sorkhi H, Gholizadeh-Pasha AR. Urological complications of absorbable and non absorbable suture in ureteral anastomosis in kidney transplantation. WASJ 2013;24:708-11.
O'Dea MJ, Zincke H, Rivers TA, Leary FJ. Occurrence of vesical calculus following renal transplantation. Br J Urol 1975;47:424.
Healey GB, Warren MM. Stone formation on polypropylene suture. J Urol 1979;121:836-7.
Sajiv CT, Pawar B, Bansal V, Mammen KJ. Vesical calculus in a post renal transplant patient – A short case report NS Chawla. Indian J Nephrol 2003;13:41-2. [Full text]
McDonald JC, Landreneau MD, Hargroder DE, Venable DD, Rohr MS. External ureteroneocystostomy and ureteroureterostomy in renal transplantation. Ann Surg 1987;205:428-31.
Rhee BK, Bretan PN Jr., Stoller ML. Urolithiasis in renal and combined pancreas/renal transplant recipients. J Urol 1999;161:1458-62.
Jaffers GJ, Cosimi AB, Delmonico FL, LaQuaglia MP, Russell PS, Young HH 2nd
, et al.
Experience with pyeloureterostomy in renal transplantation. Ann Surg 1982;196:588-93.
Kaminski JM, Katz AR, Woodward SC. Urinary bladder calculus formation on sutures in rabbits, cats and dogs. Surg Gynecol Obstet 1978;146:353-7.
Lock UC, von Pokrzywnitzki W, Weissbach L. Calculus formation after kidney pyeloplasty due to suture material. Urologe A 1998;37:522-5.
Klein FA, Goldman MH. Vesical calculus: An unusual complication of renal transplantation. Clin Transplant 1997;11:110-2.
Kehinde EO, Ali Y, Al-Hunayan A, Al-Awadi KA, Mahmoud AH. Complications associated with using nonabsorbable sutures for ureteroneocystostomy in renal transplant operations. Transplant Proc 2000;32:1917-8.
Watanabe Y, Itoh S, Mitsuhata N. Bladder stone at an ureterovesical anastomotic site after renal transplantation: A report of three cases. Hinyokika Kiyo 2005;51:97-100.
Kim H, Cheigh JS, Ham HW. Urinary stones following renal transplantation. Korean J Intern Med 2001;16:118-22.
Cundiff GW, Varner E, Visco AG, Zyczynski HM, Nager CW, Norton PA, et al.
Risk factors for mesh/suture erosion following sacral colpopexy. Am J Obstet Gynecol 2008;199:688.e1-5.
Murthy PV, Ramreddy CH, Ramachandraiah G, Kiran Kumar D, Vidyasagar S, Devraj R. Can the double-j ureteric stent be dispensed? A prospective randomized study in renal transplant recipients. Austin J Nephrol Hypertens 2017;4:1063.
Lipke M, Schulsinger D, Sheynkin Y, Frischer Z, Waltzer W. Endoscopic treatment of bladder calculi in post-renal transplant patients: A 10-year experience. J Endourol 2004;18:787-90.
Praz V, Leisinger HJ, Pascual M, Jichlinski P. Urological complications in renal transplantation from cadaveric donor grafts: A retrospective analysis of 20 years. Urol Int 2005;75:144-9.
Shoskes DA, Hanbury D, Cranston D, Morris PJ. Urological complications in 1,000 consecutive renal transplant recipients. J Urol 1995;153:18-21.
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