- Email: [email protected]
Controversy in Renal Transplantation: Antireflux Versus Non-Antireflux Ureteroneocystostomy
0022-5347/79/1212 - 0156$02.00/0 Vol. 121, February Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
CONTROVERSY IN RENAL TRANSPLANTATION: ANTIREFLUX VERSUS NON-ANTIREFLUX URETERONEOCYSTOSTOMY BRUCE A. LUCAS, J. WILLIAM MCROBERTS, JOHN J. CURTIS
AND
ROBERT G. LUKE
From the Departments of Surgery and Medicine, Divisions of Urology and Renal Medicine, University of Kentucky School of Medicine, Lexington, Kentucky
ABSTRACT
A comparison of 118 consecutive nephroureteral allografts suggests that ureteroneocystostomy provides excellent results with (60 cases) or without (52 cases) an antireflux procedure. Reflux was noted in less than 10 per cent of each group after transplantation and no morbidity could be attributed to reflux when it was found. There was no obstruction or anastomotic leakage in either group. The advantages of each procedure are discussed. Since the early days of renal allotransplantation urologic complications have plagued the transplant surgeon. In most programs ureteral complications have caused greater morbidity and mortality than vascular complications. 1- 4 Most urologists have found ureteroneocystostomy to be more reliable than ureteropyelostomy or ureteroureterostomy whenever anatomic considerations in the donor and recipient permit a choice of primary procedures. 1- 7 Additionally, availability of the recipient ureter is desirable if a secondary procedure is ever necessary. During the 1960s modifications of the Politano-Leadbetter, 8 Glenn-Anderson9 and Paquin10 types of ureteroneocystostomy were widely favored whenever ureteral reimplantation was done in transplant or non-transplant situations. Although these antireflux techniques are highly successful in achieving excellent long-term results in non-transplant patients with vesicoureteral reflux or obstruction some programs report postoperative ureteral complication rates as high as 20 to 30 per cent in transplant patients. 11- 13 Patient mortality can approach 50 per cent or more when ureteral problems occur.11 The high risk considerations of kidney transplantation, especially the poor healing and susceptibility to infection from massive immunosuppressive therapy, accentuate the importance of a consistently reliable procedure to establish continuity of the urinary tract. Furthermore, elimination of the need for early urinary tract instrumentation or reoperation will minimize post-transplant morbidity and death. In choosing a reimplantation technique, highest priority goes to avoidance of ureteral obstruction or leakage of urine in the early postoperative period when the risks of sepsis are greatest. Therefore, the prevention of vesicoureteral reflux is of second order priority. With these considerations in mind Whittier and associates reported a favorable experience with a non-antireflux technique in 29 patients. 14 Herein we compare 2 methods of ureteroneocystostomy used in our renal transplant center, one an antireflux technique and the other not.
The procedure to create the hiatus with a tonsil clamp (fig. 1, A) and to bring the ureter into the bladder is identical for both techniques (fig. 1, B). The ureter is spatulated for approximately 1 cm. In the antireflux technique no attempt is made to create a standard submucosal tunnel. Instead, the mucosa is incised and undermined for 2 to 3 cm. parallel to the ipsilateral interureteral ridge. The ureter is placed in the 2 cm. trough. Two sutures of 4-zero chromic catgut secure the ureter to the vesical neck and 2 sutures evert the spatulation corners. No sutures are used at the hiatus, either inside or outside the bladder. The end-to-side procedure involves an oblique hiatus through the bladder wall with no submucosal tunnel or trough. Usually, 4 sutures of 4-zero chromic catgut are used (fig. 2). All other technical features of the transplant operation are the same. Standard vascular anastomoses are done before ureteroneocystostomy. A soft 5F catheter is passed up to the renal pelvis to check for ureteral angulation before the bladder is closed in 3 layers. The ureter is not stented. Penrose drains were never used and hemovacs were not used routinely during the last 12 months of study. The urethral Foley catheter is removed 24 hours postoperatively or whenever gross hematuria clears sufficiently. Postoperative care includes routine sequential renal scanning and early percutaneous renal biopsy when indicated. Cystography is done before retrograde ureteropyelography as part of the investigation of poor early graft function, graft failure not responding to anti-rejection therapy or chronic diminution of renal function. Cystograms also may be done after the transplantation to evaluate urinary tract infection. Routine cystograms are done before the transplantation but not postoperatively. No patients had vesicoureteral reflux or urinary tract infection at the time of the transplant. Bilateral nephrectomy is done routinely before transplantation in patients with chronic pyelonephritis and nephroureterectomy is done for reflux. Excretory urography (IVP) is performed early postoperatively as indicated clinically and routinely at 1, 2, 5 and 10 years.
MATERIALS AND METHODS
Our 101 patients received 118 consecutive renal allografts between September 1972 and December 1975 (table 1). All but 6 of these allografts included anastomosis of a single donor ureter to the recipient bladder. The 6 cases excluded from this study were 2 hyperacute rejections, 2 ureteroileostomies, 1 ureteroureterostomy and 1 double ureter. The 112 ureteroneocystostomies were done either by an antireflux technique (60 cases, J. W. McR.) or by a simple end-to-side technique (52 cases, B. A. L.). The 2 groups are compared. Accepted for publication January 27, 1978.
RESULTS
The 97 patients (64 male and 33 female), ranging in age from 7 to 59 years, have been followed for 12 to 52 months. Sixty-nine patients have life-supporting renal allograft function and 3 patients have died. The other 25 patients continue to require dialysis while awaiting retransplantation. Of the 112 grafts 65 (58 per cent) still function. No obstruction or leakage at the ureteral anastomosis has been seen in 112 transplants. Vesicoureteral reflux in the transplant ureter, present in less than 10 per cent of the cases studied in both groups (7. 7 per cent, antireflux technique and 156
ANTIREFLUX VERSUS NON-ANTIREFLUX URETERONEOCYSTOSTOMY
IV
1
9.4 per cent, non-antireflux technique), has not been associated with morbidity (table 2). Urologic complications not related to the technique of ureteroneocystostomy have been responsible for graft loss in only 1 case - an imported cadaver kidney that was infected primarily and removed on day 4. Since August 1974 an IVP has been done as soon as lifesupporting renal function is established and repeated whenever indicated. All but 1 of the 34 living related donor allografts since then functioned for at least 1 week and these 33 recipients all had an IVP within the first week after the transplant. Most studies were done 1 or 2 days postoperatively. No evidence for ureteral obstruction or extravasation was present in the 13 antireflux or 21 end-to-side cases in contrast to the early obstructive appearance of many reimplanted ureters in non-transplant situations.
157
unlikely to lead to reflux even if there is no submucosal tunnel. The 2 described techniques for ureteroneocystostomy in nephroureteral allografting have been uniformly reliable without a significant difference in the incidence of reflux. Early anastomotic partial obstruction, seemingly inherent in the classic techniques of submucosal tunnel reimplantation of ureters, has been obviated. While the 1 to 5-year followup of these patients is quite
DISCUSSION
Our data show that both techniques described for ureteroneocystostomy provide acceptable methods to establish continuity of the urinary tract in the renal transplant patient. Both techniques usually permit easy endoscopic catheterization when necessary. Although other techniques now in use may prove to be equally acceptable some ureteral reimplantation procedures entail greater risks of early obstruction from submucosal tunnels or infection from indwelling catheters. Our non-antireflux technique is quick and easy, while subjecting the patient to a minimal risk of significant reflux. Those surgeons who prefer an antireflux technique may be attracted to the absence of intravesical obstruction provided by the trough, later to become a submucosal tunnel. The surprisingly low incidence of reflux in our series compared to the patients of Powis15 and Yadav16 and their associates may be related to the obliquity of the hiatus through the detrusor in both techniques. Alternatively, it may be true that implantation of a normal ureter into a normal bladder base is TABLE
1. Renal transplants from September 1972 to December 1975:
118 consecutive cases with 101 patients No. Single ureter, 117 cases U reteroiieocystostomy: Antireflux technique, 60 Non-antireflux technique, 52 Ureteroureterostomy U reteroileostomy Hyperacute rejection Double ureter, 1 case, common sheath Total
112 1 2 2 _l 118
FIG. 2. A, both techniques involve bringing allograft ureter into bladder. Bl, non-antireflux technique is begun with partial transection and spatulation of ureter; 4 or 5-zero chromic catgut apical suture is placed as shown. Each corner of spatulated ureter has similar suture placed and then ureteral transection is completed. Fourth suture secures ureter to bladder muscle and mucosa medially. B2, all 4 sutures are tied and cut after small catheter is passed to renal pelvis and withdrawn. Occasionally, 5 or 6 sutures are used. Stoma is flush or has small nipple. Cl, antireflux technique begins with creation of submucosal trough and spatulation of divided ureter. No sutures are placed at bladder hiatus. C2, end of ureter is secured medially by 4 sutures of 4-zero chromic catgut. Mucosa will grow over ureter from edges of trough.
FIG. 1. A, hiatus through bladder wall is always started obliquely from outside bladder, starting as far cephalad, medial and posterior as possible and aiming toward vesical neck. B, hiatus is spread just enough to permit passage of ureter into bladder and ureter is checked for twisting, kinking and redundancy.
158
LUCAS AND ASSOCIATES TABLE
2. Complications related to ureteroneocystostomy
Total cases Anastomotic complications: Obstruction Leak Vesicoureteral reflux*
Antireflux Technique No.(%)
Non-Antireflux Technique No.(%)
60
52
0 0 2/26 (7. 7)
0 0 3/32 (9.4)
* No morbidity has been attributed to reflux when present.
encouraging long-term evaluation of patient survival, graft survival, uroradiographic changes and urinary tract infections will be required to confirm the low incidence of morbidity attributable to the techniques described. If the recent report by Mathew and associates, 17 implicating reflux in long-term graft failure, is confirmed by other groups, prevention of reflux may take a higher priority in the minds of all transplant surgeons.
plantation. J. Urol., 97: 623, 1967. 10. Paquin, A. J.: Ureterovesical anastomosis: the description and evaluation of technique. J. Urol., 82: 573, 1959. 11. MacLean, L. D., MacKinnon, K. G., Inglis, F. G. and Dossetor, 12.
13. 14. 15.
16. 17.
REFERENCES
1. Anderson, E. E., Glenn, J. F., Seigler, H. F. and Stickel, D. L.: Urologic complications in renal transplantation. J. Urol., 107: 187, 1972.
2. Malek, G. H., Uehling, D. T., Daouk, A. A. and Kisken, W. A.: Urological complications of renal transplantation. J. Urol., 109: 173, 1973. 3. Straffon, R. A.: Renal transplantation. In: Urologic Surgery. Edited by J. F. Glenn and W. Boyce. New York: Harper & Row Publishers, Inc., p. 919, 1975. 4. Kiser, W. S., Hewitt, C. B. and Montie, J. E.: The surgical complications of renal transplantation. Surg. Clin. N. Amer., 51: 1133, 1971. 5. Starzl, T. E., Groth, C. G., Putnam, C. W., Penn, I., Halgrimson, C. G., Flatmark, A., Gecelter, L., Brettschneider, L. and Stonington, 0. B.: Urologic complications in 216 human recipients of renal transplants. Ann. Surg., 172: 1, 1970. 6. Prout, G. R., Jr., Hume, D. M., Lee, H. M. and Williams, G. M.: Some urologic aspects of 92 consecutive renal homotransplants in modified recipients. J. Urol., 97: 409, 1967. 7. Murray, J.E. and Harrison, J. H.: Surgical management of fifty patients with kidney transplants including eighteen pairs of twins. Amer. J. Surg., 105: 205, 1963. 8. Politano, V. A. and Leadbetter, W. F.: An operative technique for the correction of vesicoureteral reflux. J. Urol., 79: 932, 1958. 9. Glenn, J. F. and Anderson, E. E.: Distal tunnel ureteral reim-
J.B.: When should renal allografts be removed? Arch. Surg., 99: 269, 1969. Straffon, R. A., Kiser, W. S., Stewart, B. H., Hewitt, C. B., Gifford, R. W., Jr. and Nakamoto, S.: Four years clinical experience with 138 kidney transplants. J. Urol., 99: 479, 1968. Palmer, J.M., Kountz, S. K., Swenson, R. S., Lucas, Z. J. and Cohn, R.: Urinary tract morbidity in renal transplantation. Arch. Surg., 98: 352, 1969. Whittier, F., Staab, E., Rhamy, R., Elliott, R. and Ginn, H. E.: Vesicoureteral reflux after renal transplantation. J. Urol., 111: 747, 1974. Powis, S. J. A., Barnes, A. D. and Dawson-Edwards, P.: Vesicoureteric reflux after renal transplantation. Brit. Med. J., 3: 279, 1971. Yadav, R. V. S., Johnson, W., Morris, P. J., Sprague, P., Yoffa, D. and Marshall, V. C.: Vesico-ureteric reflux following renal transplantation. Brit. J. Surg., 59: 33, 1972. Mathew, T. H., Kincaid-Smith, P. and Vikraman, P.: Risks of vesicoureteric reflux in the transplanted kidney. New Engl. J. Med., 297: 414, 1977.
EDITORIAL COMMENT The authors are to be congratulated for the large series of transplants uncomplicated by obstructed or leaking ureters. The fact that these authors used 2 different techniques with equal success contributes to the concept that the precise technique of ureteroneocystostomy is not as important as the maintenance of good blood supply to the ureter. The preservation of ureteral blood supply seems to me the vital principle involved and ischemia may occur in 4 clinical settings that must be avoided to achieve these good results: 1) constriction of the distal ureter in a tight or angulated submucosal tunnel, 2) devascularization of the ureter at the time of organ removal by failing to take surrounding tissue with the ureter, 3) implantation of the entire ureter in instances in which pediatric kidneys are grafted into adults or in cases in which either iliac arterial or venous host vessels are unsatisfactory and the ureter must be placed superiorly into the aorta and vena cava, and 4) failure to recognize and anastomose an inferior polar artery of the kidney transplant that may provide important blood supply to the ureter. G. Melville Williams Division of Transplantation and Vascular Surgery Service The Johns Hopkins Hospital Baltimore, Maryland
THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
CONTROVERSY IN RENAL TRANSPLANTATION: ANTIREFLUX VERSUS NON-ANTIREFLUX URETERONEOCYSTOSTOMY BRUCE A. LUCAS, J. WILLIAM MCROBERTS, JOHN J. CURTIS
AND
ROBERT G. LUKE
From the Departments of Surgery and Medicine, Divisions of Urology and Renal Medicine, University of Kentucky School of Medicine, Lexington, Kentucky
ABSTRACT
A comparison of 118 consecutive nephroureteral allografts suggests that ureteroneocystostomy provides excellent results with (60 cases) or without (52 cases) an antireflux procedure. Reflux was noted in less than 10 per cent of each group after transplantation and no morbidity could be attributed to reflux when it was found. There was no obstruction or anastomotic leakage in either group. The advantages of each procedure are discussed. Since the early days of renal allotransplantation urologic complications have plagued the transplant surgeon. In most programs ureteral complications have caused greater morbidity and mortality than vascular complications. 1- 4 Most urologists have found ureteroneocystostomy to be more reliable than ureteropyelostomy or ureteroureterostomy whenever anatomic considerations in the donor and recipient permit a choice of primary procedures. 1- 7 Additionally, availability of the recipient ureter is desirable if a secondary procedure is ever necessary. During the 1960s modifications of the Politano-Leadbetter, 8 Glenn-Anderson9 and Paquin10 types of ureteroneocystostomy were widely favored whenever ureteral reimplantation was done in transplant or non-transplant situations. Although these antireflux techniques are highly successful in achieving excellent long-term results in non-transplant patients with vesicoureteral reflux or obstruction some programs report postoperative ureteral complication rates as high as 20 to 30 per cent in transplant patients. 11- 13 Patient mortality can approach 50 per cent or more when ureteral problems occur.11 The high risk considerations of kidney transplantation, especially the poor healing and susceptibility to infection from massive immunosuppressive therapy, accentuate the importance of a consistently reliable procedure to establish continuity of the urinary tract. Furthermore, elimination of the need for early urinary tract instrumentation or reoperation will minimize post-transplant morbidity and death. In choosing a reimplantation technique, highest priority goes to avoidance of ureteral obstruction or leakage of urine in the early postoperative period when the risks of sepsis are greatest. Therefore, the prevention of vesicoureteral reflux is of second order priority. With these considerations in mind Whittier and associates reported a favorable experience with a non-antireflux technique in 29 patients. 14 Herein we compare 2 methods of ureteroneocystostomy used in our renal transplant center, one an antireflux technique and the other not.
The procedure to create the hiatus with a tonsil clamp (fig. 1, A) and to bring the ureter into the bladder is identical for both techniques (fig. 1, B). The ureter is spatulated for approximately 1 cm. In the antireflux technique no attempt is made to create a standard submucosal tunnel. Instead, the mucosa is incised and undermined for 2 to 3 cm. parallel to the ipsilateral interureteral ridge. The ureter is placed in the 2 cm. trough. Two sutures of 4-zero chromic catgut secure the ureter to the vesical neck and 2 sutures evert the spatulation corners. No sutures are used at the hiatus, either inside or outside the bladder. The end-to-side procedure involves an oblique hiatus through the bladder wall with no submucosal tunnel or trough. Usually, 4 sutures of 4-zero chromic catgut are used (fig. 2). All other technical features of the transplant operation are the same. Standard vascular anastomoses are done before ureteroneocystostomy. A soft 5F catheter is passed up to the renal pelvis to check for ureteral angulation before the bladder is closed in 3 layers. The ureter is not stented. Penrose drains were never used and hemovacs were not used routinely during the last 12 months of study. The urethral Foley catheter is removed 24 hours postoperatively or whenever gross hematuria clears sufficiently. Postoperative care includes routine sequential renal scanning and early percutaneous renal biopsy when indicated. Cystography is done before retrograde ureteropyelography as part of the investigation of poor early graft function, graft failure not responding to anti-rejection therapy or chronic diminution of renal function. Cystograms also may be done after the transplantation to evaluate urinary tract infection. Routine cystograms are done before the transplantation but not postoperatively. No patients had vesicoureteral reflux or urinary tract infection at the time of the transplant. Bilateral nephrectomy is done routinely before transplantation in patients with chronic pyelonephritis and nephroureterectomy is done for reflux. Excretory urography (IVP) is performed early postoperatively as indicated clinically and routinely at 1, 2, 5 and 10 years.
MATERIALS AND METHODS
Our 101 patients received 118 consecutive renal allografts between September 1972 and December 1975 (table 1). All but 6 of these allografts included anastomosis of a single donor ureter to the recipient bladder. The 6 cases excluded from this study were 2 hyperacute rejections, 2 ureteroileostomies, 1 ureteroureterostomy and 1 double ureter. The 112 ureteroneocystostomies were done either by an antireflux technique (60 cases, J. W. McR.) or by a simple end-to-side technique (52 cases, B. A. L.). The 2 groups are compared. Accepted for publication January 27, 1978.
RESULTS
The 97 patients (64 male and 33 female), ranging in age from 7 to 59 years, have been followed for 12 to 52 months. Sixty-nine patients have life-supporting renal allograft function and 3 patients have died. The other 25 patients continue to require dialysis while awaiting retransplantation. Of the 112 grafts 65 (58 per cent) still function. No obstruction or leakage at the ureteral anastomosis has been seen in 112 transplants. Vesicoureteral reflux in the transplant ureter, present in less than 10 per cent of the cases studied in both groups (7. 7 per cent, antireflux technique and 156
ANTIREFLUX VERSUS NON-ANTIREFLUX URETERONEOCYSTOSTOMY
IV
1
9.4 per cent, non-antireflux technique), has not been associated with morbidity (table 2). Urologic complications not related to the technique of ureteroneocystostomy have been responsible for graft loss in only 1 case - an imported cadaver kidney that was infected primarily and removed on day 4. Since August 1974 an IVP has been done as soon as lifesupporting renal function is established and repeated whenever indicated. All but 1 of the 34 living related donor allografts since then functioned for at least 1 week and these 33 recipients all had an IVP within the first week after the transplant. Most studies were done 1 or 2 days postoperatively. No evidence for ureteral obstruction or extravasation was present in the 13 antireflux or 21 end-to-side cases in contrast to the early obstructive appearance of many reimplanted ureters in non-transplant situations.
157
unlikely to lead to reflux even if there is no submucosal tunnel. The 2 described techniques for ureteroneocystostomy in nephroureteral allografting have been uniformly reliable without a significant difference in the incidence of reflux. Early anastomotic partial obstruction, seemingly inherent in the classic techniques of submucosal tunnel reimplantation of ureters, has been obviated. While the 1 to 5-year followup of these patients is quite
DISCUSSION
Our data show that both techniques described for ureteroneocystostomy provide acceptable methods to establish continuity of the urinary tract in the renal transplant patient. Both techniques usually permit easy endoscopic catheterization when necessary. Although other techniques now in use may prove to be equally acceptable some ureteral reimplantation procedures entail greater risks of early obstruction from submucosal tunnels or infection from indwelling catheters. Our non-antireflux technique is quick and easy, while subjecting the patient to a minimal risk of significant reflux. Those surgeons who prefer an antireflux technique may be attracted to the absence of intravesical obstruction provided by the trough, later to become a submucosal tunnel. The surprisingly low incidence of reflux in our series compared to the patients of Powis15 and Yadav16 and their associates may be related to the obliquity of the hiatus through the detrusor in both techniques. Alternatively, it may be true that implantation of a normal ureter into a normal bladder base is TABLE
1. Renal transplants from September 1972 to December 1975:
118 consecutive cases with 101 patients No. Single ureter, 117 cases U reteroiieocystostomy: Antireflux technique, 60 Non-antireflux technique, 52 Ureteroureterostomy U reteroileostomy Hyperacute rejection Double ureter, 1 case, common sheath Total
112 1 2 2 _l 118
FIG. 2. A, both techniques involve bringing allograft ureter into bladder. Bl, non-antireflux technique is begun with partial transection and spatulation of ureter; 4 or 5-zero chromic catgut apical suture is placed as shown. Each corner of spatulated ureter has similar suture placed and then ureteral transection is completed. Fourth suture secures ureter to bladder muscle and mucosa medially. B2, all 4 sutures are tied and cut after small catheter is passed to renal pelvis and withdrawn. Occasionally, 5 or 6 sutures are used. Stoma is flush or has small nipple. Cl, antireflux technique begins with creation of submucosal trough and spatulation of divided ureter. No sutures are placed at bladder hiatus. C2, end of ureter is secured medially by 4 sutures of 4-zero chromic catgut. Mucosa will grow over ureter from edges of trough.
FIG. 1. A, hiatus through bladder wall is always started obliquely from outside bladder, starting as far cephalad, medial and posterior as possible and aiming toward vesical neck. B, hiatus is spread just enough to permit passage of ureter into bladder and ureter is checked for twisting, kinking and redundancy.
158
LUCAS AND ASSOCIATES TABLE
2. Complications related to ureteroneocystostomy
Total cases Anastomotic complications: Obstruction Leak Vesicoureteral reflux*
Antireflux Technique No.(%)
Non-Antireflux Technique No.(%)
60
52
0 0 2/26 (7. 7)
0 0 3/32 (9.4)
* No morbidity has been attributed to reflux when present.
encouraging long-term evaluation of patient survival, graft survival, uroradiographic changes and urinary tract infections will be required to confirm the low incidence of morbidity attributable to the techniques described. If the recent report by Mathew and associates, 17 implicating reflux in long-term graft failure, is confirmed by other groups, prevention of reflux may take a higher priority in the minds of all transplant surgeons.
plantation. J. Urol., 97: 623, 1967. 10. Paquin, A. J.: Ureterovesical anastomosis: the description and evaluation of technique. J. Urol., 82: 573, 1959. 11. MacLean, L. D., MacKinnon, K. G., Inglis, F. G. and Dossetor, 12.
13. 14. 15.
16. 17.
REFERENCES
1. Anderson, E. E., Glenn, J. F., Seigler, H. F. and Stickel, D. L.: Urologic complications in renal transplantation. J. Urol., 107: 187, 1972.
2. Malek, G. H., Uehling, D. T., Daouk, A. A. and Kisken, W. A.: Urological complications of renal transplantation. J. Urol., 109: 173, 1973. 3. Straffon, R. A.: Renal transplantation. In: Urologic Surgery. Edited by J. F. Glenn and W. Boyce. New York: Harper & Row Publishers, Inc., p. 919, 1975. 4. Kiser, W. S., Hewitt, C. B. and Montie, J. E.: The surgical complications of renal transplantation. Surg. Clin. N. Amer., 51: 1133, 1971. 5. Starzl, T. E., Groth, C. G., Putnam, C. W., Penn, I., Halgrimson, C. G., Flatmark, A., Gecelter, L., Brettschneider, L. and Stonington, 0. B.: Urologic complications in 216 human recipients of renal transplants. Ann. Surg., 172: 1, 1970. 6. Prout, G. R., Jr., Hume, D. M., Lee, H. M. and Williams, G. M.: Some urologic aspects of 92 consecutive renal homotransplants in modified recipients. J. Urol., 97: 409, 1967. 7. Murray, J.E. and Harrison, J. H.: Surgical management of fifty patients with kidney transplants including eighteen pairs of twins. Amer. J. Surg., 105: 205, 1963. 8. Politano, V. A. and Leadbetter, W. F.: An operative technique for the correction of vesicoureteral reflux. J. Urol., 79: 932, 1958. 9. Glenn, J. F. and Anderson, E. E.: Distal tunnel ureteral reim-
J.B.: When should renal allografts be removed? Arch. Surg., 99: 269, 1969. Straffon, R. A., Kiser, W. S., Stewart, B. H., Hewitt, C. B., Gifford, R. W., Jr. and Nakamoto, S.: Four years clinical experience with 138 kidney transplants. J. Urol., 99: 479, 1968. Palmer, J.M., Kountz, S. K., Swenson, R. S., Lucas, Z. J. and Cohn, R.: Urinary tract morbidity in renal transplantation. Arch. Surg., 98: 352, 1969. Whittier, F., Staab, E., Rhamy, R., Elliott, R. and Ginn, H. E.: Vesicoureteral reflux after renal transplantation. J. Urol., 111: 747, 1974. Powis, S. J. A., Barnes, A. D. and Dawson-Edwards, P.: Vesicoureteric reflux after renal transplantation. Brit. Med. J., 3: 279, 1971. Yadav, R. V. S., Johnson, W., Morris, P. J., Sprague, P., Yoffa, D. and Marshall, V. C.: Vesico-ureteric reflux following renal transplantation. Brit. J. Surg., 59: 33, 1972. Mathew, T. H., Kincaid-Smith, P. and Vikraman, P.: Risks of vesicoureteric reflux in the transplanted kidney. New Engl. J. Med., 297: 414, 1977.
EDITORIAL COMMENT The authors are to be congratulated for the large series of transplants uncomplicated by obstructed or leaking ureters. The fact that these authors used 2 different techniques with equal success contributes to the concept that the precise technique of ureteroneocystostomy is not as important as the maintenance of good blood supply to the ureter. The preservation of ureteral blood supply seems to me the vital principle involved and ischemia may occur in 4 clinical settings that must be avoided to achieve these good results: 1) constriction of the distal ureter in a tight or angulated submucosal tunnel, 2) devascularization of the ureter at the time of organ removal by failing to take surrounding tissue with the ureter, 3) implantation of the entire ureter in instances in which pediatric kidneys are grafted into adults or in cases in which either iliac arterial or venous host vessels are unsatisfactory and the ureter must be placed superiorly into the aorta and vena cava, and 4) failure to recognize and anastomose an inferior polar artery of the kidney transplant that may provide important blood supply to the ureter. G. Melville Williams Division of Transplantation and Vascular Surgery Service The Johns Hopkins Hospital Baltimore, Maryland