Indian Journal of Transplantation

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 13  |  Issue : 2  |  Page : 86--90

Contemporary management of urological complications in renal transplant: Analysis from a single-center with review of the literature


Pritesh Jain, Dilip Kumar Pal 
 Department of Urology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India

Correspondence Address:
Dr. Dilip Kumar Pal
Institute of Post Graduate Medical Education and Research, 242, AJC Bose Road, Kolkata - 700 020, West Bengal
India

Abstract

Context: Urological complications are inevitable in renal transplantation; however, their occurrence and brunt on graft survival can be downsized. The aim of our study was to analyze and review the literature on various urological complications and their management in renal transplant patients. Materials and Methods: We reviewed all cases of urological complications in renal transplantation managed at our institution from January 2010 to March 2017. Results: Urological complications arose in 29 renal transplant patients amidst the study period with median identification time of 24 days (range 0–1500 days). Ten (34.5%) patients developed complications pertaining to ureteric handling and reimplantation followed by significant lymphocele in 9 (31%) patients. Four (13.8%) cases succumbed to vascular anastomosis-related complications. Out of 29 patients, 45% of these complications manifested within a month posttransplant. Complications were tackled individually. Sixteen (55%) cases were treated with either endoscopic or minimally invasive methods, whereas 13 (45%) cases required open surgery. Two grafts were lost as a consequence of vascular complications and a fatality which was directly or indirectly linked with urological complication. Remaining all treated patients improved on follow-up. Conclusion: Comprehensive preoperative recipient evaluation, meticulous organ procurement, and integrated multidisciplinary teamwork are helpful in achieving optimal outcome of transplant. Endourological and minimally invasive procedures are emerging as main modality in the management of these complications; however, many cases still requires contemporary surgical management.



How to cite this article:
Jain P, Pal DK. Contemporary management of urological complications in renal transplant: Analysis from a single-center with review of the literature.Indian J Transplant 2019;13:86-90


How to cite this URL:
Jain P, Pal DK. Contemporary management of urological complications in renal transplant: Analysis from a single-center with review of the literature. Indian J Transplant [serial online] 2019 [cited 2019 Aug 25 ];13:86-90
Available from: http://www.ijtonline.in/text.asp?2019/13/2/86/261839


Full Text



 Introduction



Renal transplantation is currently the treatment of choice for end-stage renal disease, providing patients with a better quality of life and better survival than any of the various modalities of renal replacement therapy. With a better knowledge of their mechanisms of onset and progress in surgical techniques occurrence of urological complications in postrenal transplantation has declined with time, and currently, their incidence does not exceed 10%.[1],[2],[3] These complications may emerge during the early postoperative period, during the 1st month, or later, several years after transplantation. When expeditiously treated, most of these complications do not affect long-term graft survival significantly but are accountable for high morbidity and excessive costs.[4],[5] Patients with these complications must be managed in a specialized unit to ensure optimal preservation of graft function and graft survival. The aim of our study was to analyze and review the literature on various urological complications and their management in renal transplant patients. Our study is an assortment of various aspects of urological complications in renal transplantation which might help in lessening their occurrence and their brunt on graft survival.

 Materials and Methods



This retrospective study was carried out from January 2010 to March 2017, in the Department of Urology of a tertiary care hospital of Eastern India. The approval from the Institutional Ethical Committee was taken. The series comprised 314 consecutive renal transplants including nine cadaveric donor transplants. We scrutinized the medical anamnesis of all the patients and analyzed parameters including etiology, predisposing factors, treatment undertaken, and outcome. All patients were followed up at the center for at least 5 years after surgery.

Transplant surgical team comprised of consultant surgeons from urology and vascular surgery department along with residents. All grafts were placed preferably in the right iliac fossa except in a few cases depending on anatomical factors. Ureteric reimplantation was done in all patients by extravesical modified Lich–Gregoir technique with tunneling of ureter. Double-J (DJ) stent was placed in 202 patients out of 314 based on intraoperative decision. Vascular anastomosis was implemented according to graft renal vessels and recipient iliac vessels configurations. Pelvic drains were placed in all cases and removed once drain output became insignificant. Indwelling Foley's catheters were removed at 5–7 postoperative day and DJ stents in 2–3 weeks in sterile urine.

Timely clinical observation and daily serum biochemistry were done to monitor and identify any deflection in graft function. During the initial period of our study, we performed bedside ultrasonography (USG) with Doppler, whenever there were signs of vascular urological complications. As most vascular complications are silent and present with graft dysfunction, hence from 2015 we started USG and Doppler as routine in postoperative period. According to the clinical scenario, further investigations were executed in the form of: abdominal USG with or without Doppler, renal scintigraphy, intravenous pyelography, cystourethrography, and antegrade or retrograde ureteropyelography. Complications were classified, based on time of their manifestation within 1 month (early complication) or more than 1 month (late complication), their type and treatment required (conservative and/or surgical). A database was created for their proper record and documentation.

Patients who developed significant urological complications and required some kind of intervention were included in the analysis. The complications were diagnosed based on clinical symptoms, kidney function markers, and various imaging modalities as suitable. All urological complications were categorized according to the Clavien–Dindo classification of surgical complications.[6] Patients with perirenal collections not compromising renal function, mild hematuria, wound infections, and urinary tract infection (UTI) were excluded from the study. Modality of management was implied on severity of symptoms and complication type however, wherever feasible minimally invasive procedures were enforced. Treatment was conceded successful based on normalization of anatomy with the improvement of renal function. Follow-up of patients was done according to the respective surgical procedure.

 Results



A total of 314 renal transplants were performed during our study period including nine cadaveric donor transplants. Cadaveric transplant figures though deficient are gaining momentum and will become more popular in coming years in our country. [Table 1] depicts number of donor, recipients their sex distribution, and mean age. There was significant gender-related discrepancy in live donors as well as recipient. Totally 209 (68.5%) were female donors as compared to males 96 (31.5%). In related donors, female donor contributes 78.5% as compared to male who had only 21.25%. Regarding recipients 253 (80.6%) cases were male as compared to females 61 (19.4%). [Table 2] enumerates surgical techniques of vascular anastomosis and ureteric reimplantation. The most common renal vessel anastomosis was end-to-end to internal iliac artery (IIA) in 51.6% cases, followed by external iliac artery (EIA) in end-to-side manner in 39.5% cases. In scenarios with multiple renal arteries, we used both IIA and EIA for anastomosis. We did not use inferior epigastric artery as we were able to manage all six cases of multiple donor arteries through anastomosis with iliac arteries. Overall, urological complications occurred in 9.2% of the cases (29/314). The most common among them was related to ureter and ureteric reimplant which affected 10 (34.5%) patients followed by significant lymphocele in 9 (31%) patients. Complications related to vascular anastomosis were seen in 4 (13.8%) cases which lead to graft loss in two cases [Table 3].{Table 1}{Table 2}{Table 3}

Patients with ureteric stricture were evaluated by antegrade pyelogram, retrograde pyelogram, or nephrostogram when nephrostomy tube was placed. In three patients who had short-segment stenosis of ureter, DJ stent was placed whereas in one patient balloon dilation was successful. In two patients with narrow stricture and moderate hydronephrosis, reimplantation was done. All patients improved both anatomically and functionally. DJ stents were initially changed and removed on subsequent follow-up. One patient presented with urinary leak following DJ stent removal had long-segment ureteral ischemia that the patient was managed with pyelovesicostomy. A 45-year-old male patient developed hydronephrosis and recurrent UTI with deteriorating renal function after 4 months of surgery. Voiding cystourethrogram revealed Grade 4 Vesico-ureteral reflux (VUR). In this patient, revision ureteric reimplantation was done.

Nine patients developed symptoms related to lymphocele such as pain, abdominal lump, and ureteric compression. Three cases were managed with simple subcutaneous drainage, five cases managed with sclerotherapy after percutaneous drainage whereas in one patient fenestration into peritoneal cavity was done when other method failed.

Two patients developed significant hematoma in the early intraoperative period, on exploration; hematoma was evacuated, although no active bleeder was identified. Three male patients developed urethral stricture one was managed with optical internal urethrotomy whereas two required urethroplasty. Out of four patients with vascular complications, two had undergone graft nephrectomy whereas two were managed by reexploration and angioplasty. A 58-year-old female diagnosed with renal vein thrombosis (RVT) based on clinical and Doppler findings was immediately explored and graft renal vein thrombectomy was done. Due to early diagnosis and exploration, urine output and kidney function gradually improved, and the patient got free from dialysis in next week. A 66-year-old male patient presented with sudden onset of anuria accompanied by pain and tenderness over the graft site after few hours of transplant. USG Doppler showed the absence of both arterial and venous Doppler signal suggestive of renal artery thrombosis (RAT). Catheterization and thrombectomy were done; however, renal function did not improve and the patient eventually lost the kidney. Another patient presented with decrease in urine output and worsening hypertension after 2 weeks of surgery. Based on Doppler USG, renal artery stenosis (RAS) was suspected which was confirmed on arteriogram at the site of the anastomosis of the donor artery to the native artery. In this patient, percutaneous transluminal balloon renal angioplasty was done. Poststenting angiogram showed good blood flow in the entire renal arterial system. Creatinine levels gradually decreased and the patient became independent of dialysis. All treated patients were followed for minimum 1 year with improvement in both anatomy and function.

 Discussion



Urological complications were a major cause of significant morbidity and mortality in the early era of renal transplant. Currently, it is estimated that in large transplant centers the incidence of surgical complications is not more than 10%.[1],[2],[3] With improvement in surgical techniques in both organ procurement from donor and transplantation in recipient along with management of complications with less invasive endourological treatment, morbidity associated with such complications has decreased significantly in last decades. Organ procurement, whether live or cadaver donor, requires specific care to preserve the ureteral blood supply by carrying a significant margin of periureteral tissue. Maintaining short durations of warm and cold ischemic times, and proper length of ureter are also important in preventing ureteric ischemia. Likewise, during bench preparation, perirenal fat bordered by the ureter and lower pole of the kidney (“golden triangle”) should be preserved. Lower pole renal artery is commonly the end artery supplying the ureter thus must be preserved. Upper pole arteries should also be preserved in cases of multiple ureters.[7]

Most frequent complications after renal transplantation are related to ureterovesical anastomosis which ranges from 5% to 10% in different scenarios.[8],[9] Urinary leak, fistula, and VUR may be consequences of technical errors, external compression, rotation, unsuspected donor calculus, ischemia, intraluminal blockage, and rarely obstruction by ureteral carcinoma or fungus ball.[2] Early urinary leaks within 1–4 days are mostly related to technical problems. Symptoms related to leakage include decreased urine output with the maintenance of renal function, unexplained graft dysfunction, pelvic fluid collection, fever, graft tenderness, and lower extremity edema. USG, cystogram, antegrade pyelogram and especially renal scans are of the utmost importance in the evaluation of the graft. Conservative management by urinary drainage is successful most of the times and if fails surgical reconstruction is required. Extent of the ureteral necrosis, local, and systemic condition of the patient at the time of surgery will determine surgical technique. We encountered two cases of urinary leak and in one patient required revision of ureterovesical anastomosis while other patients leak stopped on ureteral stenting.

Ureteric strictures in transplant recipients, especially of late onset, should be evaluated for infections such as tuberculosis, BK virus, and cytomegalovirus which can produce ureteritis and ultimately stricture.[10] Managing ureteral stenosis at the site of reimplantation can be addressed by several endourology techniques such as ureteral meatotomy, dilation with balloon, and implant of stent. Such techniques are competent enough in managing small lesions; however, open surgery with reconstruction of the excretory pathway remains to be gold standard. In our study, out of 6 patients with stenosis, only two patients required reimplantation. VUR affects around 2%–86% of recipients, which might be attributed to extravesical techniques and intentional wide anastomosis to prevent stenosis. Another reason might be due to ureteral fibrosis secondary to rejection.[11],[12] A 5-year follow-up study concluded that VUR is not associated with any decrease in graft function or survival. Furthermore, among patients who developed VUR, 4.5% became symptomatic eventually requiring hospital admission.[12] Those manifesting recurrent UTI and reflux nephropathy should be treated. During our study period, only one patient was treated for significant VUR.

Lymphocele is collection of the lymph around transplanted kidney which might accumulate from the graft hilum or iliac lymphatic vessels of recipient. The average incidence of lymphocele in the literature ranges from 0.6% to 16%; however, most lymphatic collections remain subclinical and resolve spontaneously.[13] Large lymphocele may become apparent clinically 1 week to 6 months posttransplant. Symptoms include bulging of abdomen, cutaneous extravasations of lymph, edema of ipsilateral lower limb, frequent urination, and ureteral obstruction. Computed tomography (CT) and Doppler USG are valuable in differentiating it from hematoma and diagnosis can be further confirmed by guided drainage for biochemical and cytological analysis. Unfortunately, an unparalleled approach to the treatment of a symptomatic lymphocele is yet to be defined. A flexible way of initially managing larger lymphocele is with prolonged external drainage, maintaining strict asepsis. If there is clinically significant recurrence, a sclerotherapy with povidone iodine, 5% ethanol, or antibiotics should be opted.[14] In refractory and complicated cases, the choice of procedure is laparoscopic or open lymphocele fenestration.[15] One novel method of introducing Tenckhoff catheter at the site of lymphocele tunneled to the abdomen has been described with advantages of outdoor procedure without anesthesia.[16] In our study, only one patient required fenestration, all other patents managed with drainage with or without sclerotherapy. Meticulous and precise ligation of even the smallest lymphatic channels during mobilization of the iliac vessels or use of common iliac vessels is among preventive strategies.[17]

Hematomas are inevitable in the immediate postoperative period. Fortuitously, these are small, insignificant and resolves spontaneously. Appearance of a hematoma is time dependent in various imaging techniques whereas on scintigraphy they emerge as a “cold defect.” Hematomas with discomfort, hypotension, failing hemoglobin, and transplant dysfunction usually require exploration as percutaneous drainage is mostly unsuccessful.

RAT is infrequent but nefarious vascular complications with 1%–4% reported frequency of occurrence.[18] Besides technical reasons, few other factors such as hypotension, thrombophilic states, poor cardiac output, cellular rejection, and acute tubular necrosis may contribute to RAT. Postoperatively, kidney graft loss is “silent” as signs and symptoms are negligible apart from loss of graft function. Renal scan, ultrasound Doppler, and arteriography are valuable in diagnosis. Loss of the graft is an imminent consequence; however, imperative surgical exploration may rescue graft function and early recovery in few cases. For RAS apart from technique failure, most of the contributing factors are similar to RAT, although intensity of RAS is lesser than RAT. Symptoms may appear within few days to 2 years and include severe hypertension and acute renal failure. Arteriography remains gold standard investigation; however, gadolinium-enhanced magnetic resonance imaging also has comparable efficacy. Mild stenosis can be appropriately managed conservatively or by diagnostic arteriography in combination with transluminal angioplasty and “stenting”. Surgery is reserved for lesions involving the anastomosis or encompassing it, and in cases of early RAS with success rate between 63% and 92%.[19] Another notorious but uncommon vascular complication is RVT with incidence between 0.9% and 4.5%.[20] It usually occurs in the 1st week after transplantation. There occurs magnitude of nonspecific symptoms including sudden onset of hematuria, oliguria, or anuria accompanied by local pain and swelling of the graft. On Doppler USG, there is increase in renal volume, absence of venous flow, and reverse diastolic flow in renal arteries. Although it has been reported that early surgical exploration and thrombectomy assures preservation of the graft, in cases with RVT, usually the kidney is no longer viable at the time of surgical exploration due to spread of intrarenal venous thrombus and prolonged hypertension. In most cases, nephrectomy is warranted. In our series, out of four patients with vascular complications, two required graft nephrectomy.

The incidence of nephrolithiasis in renal transplant recipients ranges from 1% to 5%.[21],[22] Etiology includes nonabsorbable sutures in urinary tract, foreign bodies, persistent UTI, incomplete bladder emptying, and metabolic abnormalities. Back table ureteroscopy and nephrolithotomy should be carried before transplantation. Clinical presentation is varied due to denervation of kidney. Noncontrast CT is investigation of choice and treatment is same as in native kidneys except having difficulty in retrograde ureteroscopy.

Sex inequality among transplant patients with predominance of male as recipient and females as donor is well documented, especially in developing countries, and our study also has same observations. Assertiveness, motivation, attitudes, inequality with respect to delivered therapy, and beliefs on the part of the patient may contribute to this inequality and warrants further investigation and possible intervention.

 Conclusion



Renal transplantation has evolved from an experimental procedure to the standard of care for many renal failure patients. The best outcomes are achieved with an integrated multidisciplinary team. Urological complications are inevitable, but their early recognition through high index of suspicion and ingenious use of imaging techniques may salvage these invaluable grafts. Minimally invasive modalities are the crowning stroke in their management and rectification of kidney function ultimately amplifying patient survival.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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