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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 16  |  Issue : 3  |  Page : 106-108

Early post-transplant ureterovesical junction obstruction managed by an endourological procedure: a case report


1 Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and MRC, Belgaum, Karnataka, India
2 Department of Biotechnology and Microbiology, Karnatak University, Dharwad, Karnataka, India

Date of Submission13-Jul-2016
Date of Acceptance07-Nov-2016
Date of Web Publication2-Jan-2017

Correspondence Address:
Rajendra B Nerli
Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and MRC, Nehru Nagar, Belgaum 590010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-9165.197378

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  Abstract 

The most common urological complication after renal transplantation is ureteral obstruction. Traditionally, open surgical reconstruction was often the preferred method for correcting this problem. Today, a number of minimally invasive techniques are available to treat these complications. We report a case of early post-transplant ureteric obstruction at the vesicoureteric junction managed by endourologic procedures.

Keywords: Catheterization, graft survival, kidney transplantation, stent, ureteral obstruction


How to cite this article:
Magdum PV, Nerli RB, Patil SM, Ghagane SC, Karuppasamy S, Musale A. Early post-transplant ureterovesical junction obstruction managed by an endourological procedure: a case report. J Egypt Soc Nephrol Transplant 2016;16:106-8

How to cite this URL:
Magdum PV, Nerli RB, Patil SM, Ghagane SC, Karuppasamy S, Musale A. Early post-transplant ureterovesical junction obstruction managed by an endourological procedure: a case report. J Egypt Soc Nephrol Transplant [serial online] 2016 [cited 2017 Jun 26];16:106-8. Available from: http://www.jesnt.eg.net/text.asp?2016/16/3/106/197378


  Introduction Top


When compared with maintenance dialysis, renal transplantation affords patients with end-stage renal disease better long-term survival and a better quality of life [1]. Renal transplantation is associated with drastically improved 5-year survival rates (85.5 vs. 35.8%) in comparison with dialysis, while costing the healthcare system nearly three times less [2]. Although kidney transplantation is associated with significant survival and cost benefits, urologic complications after surgery may occur. Streeter et al. [3] reported an overall major urologic complication rate of 9.2% after 1535 consecutive renal transplants. Ureteral complications were the most common, with urine leak and obstruction occurring in 2.9 and 3.0% of the recipients, respectively.

Another recent series reported a urologic complication rate of 8% [4] after renal transplantation. Urine leak occurred in 1.8% of men and 4% of women, whereas ureteral stricture formation was observed in 2.4% of men and 1.2% of women. Vesicoureteral reflux after transplantation is common, with an incidence ranging from 50 to 86% [5],[6]. We report a case of early ureterovesical junction obstruction after surgery that was managed by endourological techniques.


  Case report Top


A 44-year-old married woman underwent live unrelated (donor − stepmother) donor transplant. The immediate postoperative urine output and vital parameters were within normal range. Serum creatinine settled down to 0.8 mg% on the sixth postoperative day. On the seventh postoperative day, her urine outputs started reducing (150–60 ml/h). Serum creatinine incresaed to 0.9 mg% on the seventh postoperative day and to 1.2 mg% on the eighth postoperative day. An emergency ultrasonography revealed mild dilatation of the pelvicalyceal system of the transplanted kidney and dilatation of the ureter up to the bladder. Computed tomography ([Figure 1]) confirmed the same. Diethylenetriaminepentaacetic acid (DTPA) radionuclide scan ([Figure 2]) showed mildly reduced cortical function of the transplanted kidney with delayed images showing mild tracer retention (glomerular filtration rate: 50 ml/min).
Figure 1 CT KUB showing mild dilatation of the pelvicalyceal system of the transplanted kidney and dilatation of the ureter up to the bladder. CT, computed tomography; KUB, kidneys, ureters, and bladder.

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Figure 2 DTPA radionuclide scan showing mildly reduced cortical function of the transplanted kidney with delayed images showing mild tracer retention.

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A diagnosis of obstruction to the transplanted ureter at the vesicoureteric junction was made. The patient was taken-up for emergency retrograde ureteric catheter insertion. Retrograde stenting was unsuccessful, as the orifice was covered with yellowish plaque ([Figure 3]). The percutaneous antegrade approach was used to insert the guide wire into the pelvicalyceal system. The guide wire was manipulated down the ureter into the bladder, and antegrade ureteric stenting was performed using a 6-Fr ureteric DJ stent. In the poststenting period, the urine outputs improved and the serum creatinine settled down to 0.8 mg%. Once the patient improved clinically, the patient was counseled for a permanent endourologic procedure to dilate the lower ureter. Direct vision endoureterotomy using holmium laser was performed. The patient improved clinically.
Figure 3 Endoscopic image showing the presence of plaque (sloughed off mucosa) at the ureteric orifice.

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  Discussion Top


About 1–4.5% of patients undergoing renal transplantation develop ureteral obstruction [3],[4],[7]. Obstruction is most commonly seen in the distal ureter. Devascularization injury to the ureter, leading to intrinsic stricture formation, is the principle cause in nearly 90% of the cases [8]. Technical errors during the ureteroneocystostomy, extrinsic compression (e.g. hematoma, lymphocele, abscess), kinking of a redundant ureter, collecting system hematoma, a stone transplanted with the kidney, and anastomotic edema can be causes of obstruction during the early postoperative (<3 months) period. Late obstruction (>3 months) usually results from ureteral ischemia, but vasculitis secondary to acute rejection, lymphocele, fibrosis from immunosuppressant medications, and ureterolithiasis may also occur [1].

Risk factors for the development of ureteral strictures include donor age greater than 65 years, more than two allograft renal arteries, prolonged cold ischemia time, and a stentless anastomotic technique. Gonadal vessel preservation, retrieval modality (open vs. laparoscopic), and implantation technique (intravesical vs. extravesical) have not been associated with stricture formation [9]. The most common presentation of ureteric stricture/narrowing is asymptomatic deterioration of renal function. Renal insufficiency usually develops early in nonstented individuals and after stent removal in patients with stented anastomoses. Evaluation is usually carried out with either ultrasonography or computed tomography. Computed tomography remains advantageous because it can characterize the presence and the extent of hydroureter and can also identify sources of extrinsic and intrinsic obstruction.

Endourologic techniques such as retrograde ureteric double J stenting and/or percutaneous drainage have been routinely used to decompress the collecting system before undertaking open ureteral reconstruction. Retrograde ureteric stenting is often difficult and challenging as the ureteroneocystostomy is performed at the dome of the bladder. Hence, many consider percutaneous nephrostomy tube placement as the first-line intervention for ureteral obstruction. Several recent series have reported the use of primary balloon dilation, including a total of 94 patients. At a mean follow-up of 37.3 months (range: 17–78 months), the reported success rate was 51% (range: 44–62%). Repeat dilatation was effective only 25% of the time. One series found dilation within 3 months of transplantation to be associated with improved success (74 vs. 44%) [9].

Direct vision endoureterotomy has gradually become the preferred endourologic treatment option because it is more effective and safer than blind ureteral dilatation/incision. The endoureterotomy may be performed using a cold knife, electrocautery, or Holmium laser. The overall success rate from five series was 79% (range: 63–100%) at a mean follow-up of 29 months [9].


  Conclusion Top


Ureterovesical anastomotic stricture is the most common long-term urologic complication after renal transplantation. Traditionally, these strictures were managed by open surgical techniques. Today endourologic techniques can be undertaken in select patients (early presentation, partial obstruction, and distal strictures less than 1 cm) with direct vision endoureterotomy being the preferred technique.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Duty BD, Barry JM. Diagnosis and management of ureteral complications following renal transplantation. Asian J Urol 2015; 2:202–207.  Back to cited text no. 1
    
2.
US Department of Health and Human Services. Kidney disease statistics for the United States. Bethesda, MD: National Kidney and Urologic Diseases Information Clearinghouse, National Institutes of Health; 2011.  Back to cited text no. 2
    
3.
Streeter EH, Little DM, Cranston DW, Morris PJ. The urological complications of renal transplantation: a series of 1535 patients. BJU Int 2002; 90:627–634.  Back to cited text no. 3
    
4.
Lempinen J, Stenman J, Kyllonen L, Salmela K. Surgical complications following 1670 consecutive adult renal transplantations: a single center study. Scand J Surg 2015; 104:254–259.  Back to cited text no. 4
    
5.
Ostrowski M, Wlodarczyk Z, Wesolowski T, Gracz H, Sluzar T, Sienko J et al. Influence of ureterovesical anastomosis technique on the incidence of vesicoureteral reflux in renal transplant recipients. Ann Transplant 1999; 4:54–58.  Back to cited text no. 5
    
6.
Mastrosimone S, Pignata G, Maresca MC, Calconi G, Rabassini A, Butini R et al. Clinical significance of vesicoureteral reflux after kidney transplantation. Clin Nephrol 1993; 40:38–45.  Back to cited text no. 6
    
7.
Mano R, Golan S, Holland R, Livne PM, Lifshitz DA. Retrograde endoureterotomy for persistent ureterovesical anastomotic strictures in renal transplant kidneys after failed antegrade balloon dilation. Urology 2012; 80:255–259.  Back to cited text no. 7
    
8.
Kumar S, Ameli-Renani S, Hakim A, Jeon JH, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol 2014; 87:20140169.  Back to cited text no. 8
    
9.
Duty BD, Conlin MJ, Fuchs EF, Barry JM. The current role of endourologic management of renal transplantation complications. Adv Urol 2013; 2013:246520.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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