The Ureter in Renal Transplantation

Vol. 101, May Printed in U.S.A.

THj;J JOURNAL OF UROLOGY

Copyright © 1969 by The Williams & Wilkins Co.

THE URETER IN RENAL TRANSPLANTATION DONALD C. MARTIN, MATT M. MIMS, JOSEPH J. KAUFMAN AND WILLARD E. GOODWIN From the Department of Surgery (Urology), UCLA School of Medicine and the Wadsworth Hospital, Veterans Administration Center, Los Angeles, California

A reliable technique for surgical management of the ureter is necessary for successful renal transplantation. Technical difficulty with urinary drainage continues to be a major factor in the failure of renal transplants. Difficulty with vascular anastomoses may be apparent immediately and allows prompt correction, but surgical misadventure with the ureter more often manifests itself in the postoperative period when corrective measures require reoperation. A chronic urinary fistula may lead to infection and set the stage for a disastrous chain of events. This report encompasses our experience with the ureter of 142 human renal transplants during the past 11 years. Kidneys were obtained from 79 living donors and 63 cadaveric donors. HISTORICAL NOTE

Various methods of providing urinary drainage in renal transplantation were used in the early cases of human transplants. Ureterocutaneous anastomosis was frequently necessary in transplantation to the thigh and other sites.1 Transplantation to the iliac fossa with ureterocutaneostomy was described by Ktiss. 2 Merrill and associates combined the iliac vascular anastomoses with ureterovesicostomy in the first successful renal transplant in identical twins. 3 Their technique continues to be the most frequently used at most transplantation centers. Ureteroureterostomy was described by Lawler and associates with transplantation to the renal Accepted for publication June 14, 1968. Read at annual meeting of American Urological Association, Miami Beach, Florida, May 1316, 1968. 1 Hume, D. M., Merrill, J.P., Miller, B. F. and Thorn, G. W.: Experiences with renal homotransplantation in the human: report of 9 cases. J. Olin. Invest., 34: 327, 1955. 2 Kuss, R., Teinturier, J. and Milliez, P.: Quelques essais de greffe de rein chez l'homme. Mem. Acad. chir., 77: 755, 1951. 3 Merrill, J. P., Murray, J. E., Harrison, J. H. and Guild, W. R.: Successful homotransplantation of the human kidney between identical twins. J.A.M.A., 160: 227, 1956.

fossa. 4 Ureteropyelostomy has been described by Kuss in transplantation to the renal fossa and by Leadbetter in transplantation to the iliac fossa. 5 Pyelopyelostomy has recently come to our attention during a visit of Gil Vernet of Barcelona, Spain to UCLA. He has successfully used this technique in 35 cases. SURGICAL TECHNIQUES

UreteroveS'ical anastomoS'is. We had the most favorable results with anastomosis of the ureter of the renal graft to the recipient bladder (table 1). This procedure was readily accomplished when sufficient ureter was taken with the kidney and the transplant was placed in the iliac fossa. It was the preferred method when the recipient had abnormal ureters. N ephrectomy in the donor must be done in a manner to preserve blood supply to the ureter from the renal vessels. Dissection was not done in the hilum of the graft to insure good ureteral blood supply. Extraneous fibrous tissue was cleared from the side of the bladder to avoid extrinsic pressure on the ureter of the graft. To achieve a precise mucosa-to-mucosa anastomosis, an anterior cystotomy ,vas made. The ureter was drawn into the bladder (posterior to the spermatic cord in the male patient) through an entry cystotomy at the junction of the lateral wall and floor of the bladder (fig. I, A and B). A I-inch submucosal tunnel was developed by dissection medial and inferior to the entry site (fig. 1, C and D). The bladder mucosa was incised to provide a suitable bed for the spatulated ureter on the floor of the bladder near the ipsilateral anatomical ureterovesical junction. The ureter was cut to length after the kidney had been positioned in its 4 Lawler, R. H., West, J. W., McNulty, P. H., Clancy, E. J. and Murphy, R. P.: Homotransplantation of the kidney in the human; a preliminary report. J.A.M.A., 144: 844, 1950. 5 Leadbetter, G. W., Jr., Monaco, A. P. and Russell, P. S.: A technique for reconstruction of the urinary tract in renal transplantation. Surg., Gynec. & Obst., 123: 839, 1966.

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permanent bed in the iliac fossa. The minimum length of ureter that would reach the bladder without tension was preferred to insure good blood supply. The ureter was spatulated and several interrupted sutures of 4-zero plain catgut were used for the mucosa-to-mucosa anastomosis. vVe believe it is important to secure the ureter in the bladder with sutures through the full thickness of the ureter, picking up the bladder muscle as well as mucosa. The suture through the apex of TABLE

1. Type of primary anastomo&is No. Cases

U reterocutaneous .. Ureterovesical. .. Ureteroureteral. ... Ureteropelvic .. . Pyelopel vie .. . Ureteroilea,l ..

4

127 6 2 2

1

142

681

the spatulated ureter may take a little adventitia of the ureter to evert the mucosa (fig. This further minimizes the likelihood of the ureteral opening withdrawing from the bladder, the most common complication in ureterovesica.l anastomosis. The entry cystotomy was closed at the mucosa: level only with a running suture of 4-zero plain catgut. The anterior cystotomy was closed in 3 layers as we used no catheter in cadaveric renal transplantation and withdrew the urethral catheter after .2 days in transplantation from a living donor. A ureteral stent was not used as we feel it ma.y embarrass the blood supply of the ureter. The technique described is very similar to the Politano-Leadbetter ureterovesicoplasty to pre·· vent reflux. We develop a submucosal. tunnel for this reason and have seen no problems with reflux. One of us (M.lVLJ\I.) made the ureterovesical anastomosis near the dome of the bladder witb

Fm. :!. Ureterovesical. anastomosis. A and B, site of ureteral entry into bladder. C and D, develop· ment of submucosal tunnel..

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~

Everting suture·

mucosa anastomosis

FIG. 2. Ureterovesical mucosa-to-mucosa anastomosis with everting suture at apex of spatulated ureter.

l

'

a short submucosal tunnel. In this location the anastomosis was rapidly accomplished, but subsequent catheterization for a retrograde study was difficult or impossible. Ureteroureterostomy. Ureteroureterostomy was performed as the primary form of urinary drainage in 6 patients and as a conective operation in 4 cases. We spatulated both ends of the ureter and used a running suture of 4-zero plain catgut (fig. 3). Stents were not generally used. The thin ureteral wall made it difficult to achieve a watertight closure and the small ureteral lumen may be liable to stenosis. End-to-side ureteroureterostomy was used twice when the recipient kidney remained above the transplant. A temporary fistula in one of these patients closed spontaneously. Uret,eropyelostomy. Ureteropyelostomy had the advantage of providing a large lumen for anastomosis. We have had little experience with this procedure but it has been reported to produce good results. The spatulated ureter of the recipient was anastomosed with a running suture to the pelvis of the renal graft. Although nephrostomy drainage was used in an early case, it has not been used since.

Frn. 3. Ureteroureterostomy, IVP 3 months postoperatively.

Pyelopyelostomy. This technique takes advantage of the large lumen of the recipient renal pelvis for anastomosis to the renal pelvis of the graft. It was used in renal transplantation to the lumbar fossa (fig. 4). The renal pelvis of the recipient was dissected out of the renal hilum after ligation of the major renal vessels. Blood supply to the renal pelvis and upper ureter must be carefully preserved via the lumbar and spermatic vessels. The anastomosis was made (with fine catgut using a running suture technique) in the hilum of the graft. Ureteroileal anastomosis. An ileal conduit has been used to divert the urine in patients with unsatisfactory bladder function. 6 Our one experience with this technique resulted in an infected vascular anastomosis with hemorrhage and subsequent death of the recipient. A similar course of events was described in 2 of 7 cases by Kelly. 6 We believe that only patients with normal lower urinary tract function should be selected as recipients at the present time. Urewrocutaneous anastomosis. Ureterocut,aneous anastomosis was used in 4 patients early in this series. The kidneys were transplanted to the 6 Kelly, W. D., Merkel, F. K. and Markland, C.: Ileal urinary diversion in conjunction with renal homotransplantation. Lancet, 1: 222, 1966.

URETER IN RENAL TRANSPLANTATION

IVG

683

Ao

B

Fm. 4. Pyelopyelostomy TABLE

2. Complications

Obstruction Ureterovesical anastomosis Early ..................................... 5 Late..................... . ............ 2 Fistula Ureterovesical anastomosis ................. . 10 Ureteroureteral anastomosis ................ 3 Ureteropelvic anastomosis .................. O Pyelopelvic anastomosis. . . . . . . . . . . . . . . . . . . . 1 Vesicocutaneous ............................ 3 thigh in 2 cases and to the abdomen in 2 cases. We see little or no indication for this technique with our current concepts of recipient selection. COMPLICATIONS

The principal complications to be described involve obstruction or formation of a fistula (table 2). Urinary infections invariably occurred in patients with chronic fistulas, but were cleared in most patients with correction of the fistula. Vesicoureteral reflux was not seen in those patients tested. Patients with stable function and no infection were not tested routinely for reflux, so the true incidence is not known. However, freedom from infection is satisfactory evidence that reflux was not a clinical problem. Obstruction. We had 7 cases of ureteral obstruction in 127 patients with ureterovesical anastomosis. Five appeared immediately postoperatively and 2 occurred later.

Two cases of mild and questionable ureteral obstruction were handled conservatively and a catheter was introduced cystoscopically in one. Two cases of complete ureteral obstruction by a blood clot were seen during profuse diuresis. Both patients passed the obstructing clot spontaneously 12 hours later, whereupon the diuresis resumed. One patient required reoperation for initial ureteral obstruction due to tension on the ureterovesical anastomosis. The ureter was implanted higher in the bladder and the bladder was secured near the graft with immediate urine flow from the transplant. Two female recipients completed full-term pregnancy to deliver a healthy child by the vaginal route. One patient had no evidence of embarrassed urinary drainage,7 whereas the other had hydronephrosis late in the pregnancy with subsequent resolution after vaginal delivery (fig. 5). Two cases of later ureteral obstruction were seen. One was due to an occult perivesical apscess (fig. 6) and the other to moderate ureterovesical stenosis. The former patient was treated by surgical drainage of the abscess and the latter one is under observation since good renal function is present (fig. 7). 7 Kaufman, J. J., Dignam, W., Goodwin, W. E., Martin, D. C., Goldman, R. and Maxwell, M. H.: Successful normal childbirth after kidney homotransplantation. J.A.M.A., 200: 338, 1967.

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Fm. 5. IVP. A, 2 days before vaginal delivery. B, 4 months postpartum

Fm. 6. IVP. A, 4 months after transplantation no obstruction was noted. B, 6 months after transplantation there is hydronephrosis secondary to perivesical abscess. No obstruction was seen after ureteroureterostomy, ureteropyelostomy or pyelopyelostomy. Fistulas. The most troublesome and dangerous complications were urinary fistulas. All fistulas from the ureterovesical anastomosis required surgical intervention; none healed spontaneously (table 3). The mobility of the transplanted kidney and its ureter challenges the surgeon to construct a straight tension-free anastomosis. In ureterovesicoplasty done to prevent reflux, the ureter is relatively fixed behind the bladder and with-

drawal of the ureter from the bladder is rare. However, the ureter of a transplanted kidney is extremely mobile and, therefore, the graft must be seated in the iliac fossa prior to vesical anastomosis and not moved subsequently. Tension at the ureterovesical junction caused the ureter to withdraw into the perivesical space in 6 patients. The methods of dealing with resulting fistulas are outlined in table 3. The unsuccessful cases required nephrectomy or the patients died with the fistula and other complications. Six of 17 patients with fistulas died

URETER IN RENAL TRANSPLANTATION

Fm. 7. IVP 2 months following cadaver renal transplantation reveals hydronephrosis apparently due to ureterovesical obstruction. Renal function is good. Degree of dilatation will be followed radiographically. TABLE

3. Ureterovesical fistulas No. Cases

Etiology Tension ..................................... 6 Intubation --> ureteral necrosis ............... 1 Inflammation --> ureteral necrosis ............ 3 SucNo. cessCases ful

Treatment Re anastomosis to bladder ............... 4 Ureteroureteral anastomosis ............ 4 Bladder flap ............................ 2

2

1 1

because of the fistula and its concomitant infection with other complications. One ureter underwent necrosis as a result of vascular embarrassment due to a large (F8) ureteral catheter. The ureteral blood supply is tenuous and we feel any ureteral catheter carries a risk of compromising this blood supply. For this reason we do not routinely use ureteral catheters. Three ureters underwent necrosis 21 to 27

685

Fm. 8. Retrograde pyelogram 3 years following ureteroureterostomy to correct initial ureterovesical fistula. days postoperatively; the transplants showed signs of severe graft rejection or local inflammation. Studies of the ureter in laboratory animals have indicated that the inflammatory reaction in the kidney due to the homograft immunologic reaction is accompanied by an inflammatory reaction in the ureter. 8 One patient had a successful reconstruction with ureteroureterostomy, one with a bladder flap and the other patient died following ureteroureterostomy. Only two ureteral fistulas have occurred with ureterovesical anastomosis of 58 cadaver kidneys, Ureterovesical fistulas: When ureteral length and viability were adequate, reimplantation of the graft ureter to the recipient bladder was satisfactory. However, 2 of 4 patients so managed died with persistent fistulas, which indicated that a tension-free anastomosis was not achieved. Ureteroureteral anastomosis was an excellent 8 Robertshaw, G. E., Madge, G. E. and Kauffman, H. M., Jr.: Ureteral pathology in treated and untreated renal homografts. Surg. Forum, 17:

236, 1966.

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Fm. 9. Retrograde pyelograms. A, following pyelopyelostomy with pyelocutaneous fistula. B, fistula treated by ureteropyelostomy. method for restoring urinary drainage when the ureter of the graft was short (fig. 8). A bladder flap was fashioned in 2 cases for anastomosis to the short ureter, but it was difficult to achieve a water-tight anastomosis with primary healing. One patient treated with a bladder flap died of persistent leak and sepsis; the other patient had delayed healing and required prolonged catheter drainage. U'.reteroureteral fistulas: Two fistulas following primary ureteroureterostomy healed spontaneously. Another fistula persisted and contributed to septic death. One fistula following secondary ureteroureterostomy healed spontaneously. Pyelopelvic fistulas: In one of 2 patients with pyelopelvic anastomosis, necrosis of the recipient pelvis and upper ureter was successfully repaired by ureteropyelostomy (fig. 9). Vesicocutaneous fistulas: Two vesicocu taneous fistulas were the result of necrosis of the bladder wall, due either to infection or infarction. These were unsuccessfully reoperated upon but nonetheless closed spontaneously with slow healing by secondary intention. The third and minor leakage healed promptly on urethral catheter drainage. ADDITIONAL METHODS OF DEALING WITH URETER IN RENAL TRANSPLANTATION

Additional operative techniques to provide urinary drainage in renal transplantation should

be mentioned. None were used in our patients but have been described by others. Starzl made a direct end-to-end ureteroureterostomy with several interrupted non-absorbable sutures. A good result has been achieved in some cases. Retik described placing a small polyethylene tube (nephrostomy) through the parenchyma of the graft to provide drainage in combination with ureteroureterostomy. DISCUSSION

The late ureteral obstruction seen in 2 cases in our series has been reported by other investigators. Starzl reported 4 late ureteral strictures in 33 patients who were observed for more than 4 months. 9 Murray and Harrison had 5 cases of ureteral obstruction in 50 patients, 2 because of pressur-e of the spermatic cord, 2 by torsion of the ureter and one by blood clot. 10 Prout reported one case of hydronephrosis, following ureterovesical anastomosis in 93 transplants, which resolved spontaneously within the 2 months of observation. 11 9 Starzl, T. E., Marchioro, T. L., Porter, K. A., Moore, C. A., Rifkind, D. and Waddell, W. R.: Renal homotransplantation. Late function and complications. Ann. Intern. Med., 61: 470, 1964. 10 Murray, J. E. and Harrison, J. H.: Surgical management of fifty patients with kidney transplants including eighteen pairs of twins. Amer. J. Surg., 106: 205, 1963. 11 Prout, G. R., Jr., Hume, D. M., Lee, H. M.

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Straffon reported urinary extravasation due to ischemic necrosis of the ureter in 8 of 94 cadaveric kidney transplants; four resulted in graft failure. 12 Vesicoureteral reflux has not been a problem in our experience and has not been found in those patients specifically tested for it. Retrograde catheterization of the implanted ureter has been possible in most cases in which the ureter of the graft was implanted on the floor of the bladder, but has rarely been possible when the ureter wa~ implanted in the dome. and Williams, G. J\I.: Some urological aspects of 93 consecutive renal homotransplants in modified recipients. J. Urol., 97: 409, 1967. 12 Straffon, R. A., Stewart, B. IT., Kiser, vV. S., Hewitt, C. B., Nakamoto, S. and Kolff, W. J.: The use of ninety-four cadavcric kidneys for transplantation-clinical experience. Brit. J. UroL, 38: 640, 1966.

RESULTS

One hundred and forty-two renal trnnsplanl.,, were made in 136 patients. Kidneys were obtained from a living donor (all but ] 0 a dose relative) in 79 cases; 56 patients are alive, 48 with a functioning renal grnfL Kidneys wen' obtained from cadaveric donors in 63 cases; 42 recipients are alive, 34 with a functioning renal graft. CO:NCLUSIO:S.S

Careful management of the ureter in renal transplantation is necessary to avoid obstruction, fistula, ancl infection which may lead to failure ol the graft. Our results have improved ,vith increased clinical cxperiem:e. \Ve favor uretern· vesical anastomosis, as it was the most predictable and satisfactory in our lmnd,g. Othrnsurgic:al techniques are available and each has pnwiderl good re,~nlts in some cases.