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Conservative Non-Operative Management of Ureteral Fistulas Following Renal Allografts
Vol. 112, November Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1974 by The Williams & Wilkins Co.
CONSERVATIVE NON-OPERATIVE MANAGEMENT OF URETERAL FISTULAS FOLLOWING RENAL ALLOGRAFTS SUVAS G. DESAI, J. WILLIAM McROBERTS, ARTHUR A. HELLEBUSCH
AND
ROBERT G. LUKE
From the Division of Urology, Department of Surgery and the Renal Division, Department of Medicine, University of Kentucky Medical Center, Lexington, Kentucky
Urinary fistulas in renal transplant cases are a dreaded and potentially serious complication. The morbidity and mortality rates have been high in most reported series. 1-• Early operative intervention generally has been recommended to avoid wound sepsis, septicemia and death. 1 • •, 7 - 9 We herein report successful conservative, non-operative management of 2 patients with ureterocutaneous fistulas following renal transplantation and urge that conservative treatment be seriously considered as an alternative to operative intervention in selected patients. CASE
REPORTS
Case 1. F. H., a 39-year-old woman with polycystic kidneys and end stage renal disease, underwent bilateral nephrectomy and total abdominal hysterectomy in September 1972. Three weeks later she received a kidney transplant from her brother (1-haplotype match) with a submucosal tunnel ureteroneocystostomy. The operation was uneventful and the graft functioned immediately. Urine output on the first day was 2,400 cc. A 99 m Accepted for publication May 3, 1974. Read at annual meeting of American Urological Association, St. Louis, Missouri, May 19-23, 1974. 1 Kiser, W. S., Hewitt, C. B. and Montie, J. E.: The surgical complications of renal transplantation. Surg. Clin. N. Amer., 51: 1133, 1971. 2 Martin, D. C., Mims, M. M., Kaufman, J. J. and Goodwin, W. E.: The ureter in renal transplantation. J. Urol., 101: 680, 1969. 3 Rees, R. W.: Urinary fistulae following renal transplantation. Proc. Roy. Soc. Med., 65: 473, 1972. 'Starzl, T. E., Groth, C. G., Putnam, C. W., Penn, I., Halgrimson, C. G., Flatmark, A., Gecelter, L., Brettschneider, L. and Stonington, 0. G.: Urological complications in 216 human recipients of renal transplants. Ann. Surg., 172: 1, 1970. 'Thompson, R. W., Hall, C. L., Newman, C. E., Barnes, A. D., Blainey, J. D. and Edwards, P. D.: Urinary fistulae following cadaveric human renal transplantation. In: Dialysis Transplantation Nephrology. Proceedings gf Tenth Congr_ess of European Dialysis and Transplant Association. Edited by J. F. Moorhead, R. A. Baillod and C. Mion, vol. 10, 1973. 6 Walsh, A.: Some practical problems in kidney transplantation. Transplant. Proc., l: 178, 1969. 7 Palmer, J. M., Kountz, S. L., Swenson, R. S., Lucus, Z. J. and Cohn, R.: Urinary tract morbidity in renal transplantation. Arch. Surg., 98: 352, 1969. • Weil, R., Simmons, R. L., Tallent, M. B., Lillehei, R. C., Kjellstrand, C. M. and Najarian, J. S.: Prevention of urological complications after kidney transplantation. Ann. Surg., 174: 154, 1971. •Yunis, E. J., Gatti, R. A. and Amos, D. B.: Tissue Typing and Organ Transplantation. New York: Academic Press, p. 206, 1973. 10 Aquino, H. C., Preston, D. F. and Luke, R. G.: 99m
pertechnetate renal scan (Tc. scan) and 1311 hippuran renogram immediately postoperatively showed satisfactory blood flow and function. 10 After the first post-transplantation week the steroid dosage was reduced by 5 mg. on alternate days. The patient did well initially. However, at 4 weeks post-transplantation graft tenderness and a decrease in urine output were noted. Cystography showed no urinary extravasation and radioisotope studies showed decreased graft function. A Tc. scan showed adequate blood flow to the graft. Right retrograde ureteropyelography showed no obstruction or extravasation. Diagnosis was acute rejection and the patient was treated with 1 gm. prednisone intravenously 3 times a day on alternate days and placed on hemodialysis for 2 weeks because of increasing azotemia. Six weeks postoperatively the patient had a wound infection and the abdominal incision was opened widely at the subcutaneous level. Wound cultures showed coagulase-positive Staphylococcus aureus and Bacteroides. The patient was given keflin and erythromycin. Nevertheless, the wound drainage began to increase, although the total urinary output returned to normal levels. A week later the wound drainage increased further and straw-colored, yellowish fluid was noted in the abdominal incision. A cystogram was negative. Indigo carmine injected intravenously was seen in the wound drainage in 5 to 10 minutes. Excretory urography (IVP) showed a faint transplant nephrogram and a small puddle of contrast medium in the pelvis, consistent with a ureteral leak. Retrograde pyelography confirmed the diagnosis of a lower ureterocutaneous fistula (fig. 1, A). The total urinary output through the bladder had now decreased to 400 cc and the wound drainage continued to increase. The patient had fever spikes to 102F. The wound was opened more widely. Steroid dosage was decreased more rapidly by a 5 mg. reduction every day. On this regimen the patient became afebrile, blood urea nitrogen (BUN) decreased to 36 mg. per cent and creatinine decreased to 2.3 mg. per cent. However, 10 weeks post-transplantation urinary drainage still continued through the fistula tract. The white count was 5,300, BUN 49 mg. per cent and creatinine 2.8 mg. per cent. Twelve weeks later the BUN decreased to 26 mg. per cent and creatinine to 2.0 mg. per cent,
572
Pertechnetate Uptake in the Transplanted Kidney. In: Proceedings of the Dialysis Transplant Forum, p. 83, 1971.
NON-OPERATIVE MANAGEMENT OF URETERAL FISTULAS
FIG. 1. A, retrograde pyelogram shows extravasation of contrast medium from transplant ureter, confirming ureteral fistula. B, IVP 25 weeks later shows good graft function. There is no evidence of fistula.
although considerable amounts continued to drain through the ureterocutaneous fistula. Since the patient did not have any systemic effects she was discharged from the hospital. She was given 45/35 mg. prednisone on alternate days and 100 mg. azathioprine daily. She voided 400 cc per day and the rest of the urinary output (1,400 cc) was through the fistula site. About 18 weeks post-transplantation a decreasing amount of urine was noted coming from the fistula and a commensurate increase was noted in the voided amounts. The patient continued to be afebrile and the prednisone dosage had been decreased to 30/20 mg. on alternate days. The 24hour creatinine clearance was 33 cc per minute. Twenty-five weeks later an IVP showed good function of the renal graft and no evidence of a ureterocutaneous fistula (fig. 1, B). The BUN was 32 mg. per cent and creatinine was 2.3 mg. per cent. Eight months post-transplantation the patient was doing well. The wound had healed completely and she was back on her job as a registered nurse in an emergency room. Case 2. A. H., a 45-year-old white woman with chronic renal failure and hypertension, was hospitalized with a BUN of 133 mg. per cent and a creatinine of 10.4 mg. per cent. She was placed on hemodialysis. The presumptive diagnosis was chronic glomerulonephritis. She received a live donor transplant from her son on September 22, 1972. The donor kidney was a 1-haplotype match and the urinary anastomosis was done with a submucosal tunnel ureteroneocystostomy. Intraoperatively, the arterial anastomosis had to be revised because of an atheromatous
plaque which blocked an effective flow through the hypogastric artery. The patient had acute tubular necrosis postoperatively and needed hemodialysis for approximately 3 weeks. Two weeks post-tram,plantation she had a wound hematoma evacuated. At this time urinary output was 700 cc in hours, BUN 63 mg. per cent and creatinine :3.8 mg. per cent. Tc. scan showed decreased blood flow the transplant kidney. A transplant biopsy showed changes consistent with cellular rejection. Acute rejection superimposed on acute tubular necrosis was diagnosed. Accordingly, she was given l gm. prednisone intravenously 3 times a day on alternate days, along with 4,000 units heparin intravenously every 4 hours for 1 week. She also had l.ocal graft irradiation 150R times 4 on alternate days. Urinary output had increased to 2,200 cc 3 weeks postoperatively. BUN was 62 mg. per cent with a creatinine of 0.8 mg. per cent. She was now taking 60 mg. prednisone and 50 mg. daily (the latter because of a decreasing white blood count). The prednisone was further by 5 mg. on alternate days. The discharged from the hospital 6 weeks later with BUN of 65 mg. per cent and creatinine of 1.6 mg. per cent. When the patient was discharged from the hospital prednisone dosage was 60/30 mg. alternate days. Six weeks post-transplantation she was talized because of straw-colored, yellowish drainage from the wound. A cystogram revealed bladder extravasation. Retrograde raphy confirmed the suspected diagnosis of terocutaneous fistula (fig. 2, A). Since the was doing well and had no systemic manifestations
574
DESAI AND ASSOCIATES
Fie:;. 2. A, retrograde pyelogram shows extravasation of contrast medium from lower transplant ureter. B, IVP 16 weeks later shows good graft function. There is no evidence of fistula.
she was followed closely on decreasing doses of prednisone. Two weeks later she was discharged from the hospital taking 45/30 mg. prednisone on alternate days and 100 mg. imuran daily. Twelve weeks post-transplantation the voided urinary output was 300 cc daily. BUN was then 32 mg. per cent and creatinine was 1. 7 mg. per cent. She was taking 30 mg. prednisone daily and afebrile. Some urine was still draining from the fistula, although it was half the previous amount. The voided urine volume had now increased to about 2,000 cc. She was taking 30/20 mg. prednisone on alternate days and this dosage was further reduced by 2.5 mg. on alternate days. Sixteen weeks post-transplantation the ureterocutaneous fistula had closed completely and the patient continued to feel well. BUN was 31 mg. per cent and creatinine was 1.5 mg. per cent, with a creatinine clearance of 31 ml. per minute. IVP showed normal graft function (fig. 2, B). Prednisone was reduced to 30 mg. on alternate days. She has done well subsequently and the creatinine clearance has increased currently to 40 ml. per minute. The patient is a fully rehabilitated, active housewife. DISCUSSION
Most authors, while generally reporting good results with conservative management of vesicocutaneous fistulas, recommend early operative intervention when a ureteral fistula develops following renal transplantation. 1 • 4 • 7 - 9 The collective experience is summarized in the table. 1-•, 6 • 7 • 11 , 12 11 Prout, G. R., Jr., Hume, D. M., Lee, H. M. and Williams, G. M.: Some urological aspects of 93 consecutive renal homotransplants in modified recipients. J. Urol., 97: 409, 1967. 12 Malek, G. H., Uehling, D. T., Daouk, A. A. and Kisken, W. A.: Urological complications of renal transplantation. J. Urol., 109: 173, 1973.
Simmons, Najarian and others advise urgent re-exploration with reimplantation of the ureter into the bladder, nephrostomy or performance of a pyeloureterostomy to the host ureter.• They caution that delaying definitive repair will frequently lead to infection, the development of necrotic aneurysms, loss of kidney and death. Starzl and associates state that with a urinary leak the urgency of establishment of a watertight urinary system has no parallel in standard urologic practice.• Their policy has been to attempt to surgically close all fistulas before the supervention of wound sepsis. In their series 10.9 per cent (6 of 55) had a urinary leak. Of these 3 patients with a ureteroneocystostomy had ureteral fistulas and they all occurred in the first 3 weeks. The treatment was reimplantation in 1 with death directly attributed to the complication, nephrectomy of the transplant in the second and a ureteroureterostomy in the third with satisfactory results. In a series of 146 transplant patients Martin and associates report a mortality rate of 35.3 per cent (6 of 17 patients) with urinary fistulas. 2 All deaths were secondary to infection with other complications. There were 14 ureteral (2 pelvic) fistulas -all managed by surgical intervention. Walsh states that urinary fistulas in renal transplantation are always a serious complication often followed by infection and death. 6 He believes that in view of the high mortality rate it would be better to remove the transplanted kidney rather than run the risks associated with a persistent fistula. In his series 3 of 31 patients had urinary fistulas and all 3 died. However, he does not specify how many of them were ureteral fistulas. Malek and associates concur and advise graft removal in the presence of a urinary fistula and wound infection. 12 In their review of the literature
NON-OPERATIVE MANAGEMENT OF URETERAL FISTULAS
Review of fistulas-complications and mortality ;\]o_ Trans-
Reference
plants
l\!Ialek and associates 12 Walsh'
Palmer and associates 7
94 1:30
:n 256
Kiser and associates 1
No. Fistulas
Type of Fistula
Operative Repair
Nephrectomy
Vesical
7 4
7
(ureteral) 5 (2 multiple)
22
(TUlJ-1 vr.l 16 (sepsis
IVKartin and associates
2
142
17
14
3
~
6
2
1 (W)
6
10
5 (W)
extravasation) 6
3
(")
Starzl and associates~ Rees' Prout and as~;ociates 11 Present study
2:,4 61
9 9
96
5
114
IO
9 4 (2/2 ops.) 2 3
1 2
Ureteral
1 (W) 11 (VV)
3
7 15
27
Death
4 4 (2 unrelated causes)
4
16 (pyelouret. fi) 14 (pyetouret. 2} 9
3
5
6
4 (1 nephrocui .) (1 pyelocut I
I (nephrocut.)
found that among 1,301 renal with data there were 174 (13.3 per cent) and 57 (32.7 per cent) Ureteral fistulas were not rnentioned per se. Kiser and associates had 12 m whom ureteral fistulas a month or more after 1 In these cases repair was unsuccessful and succeeded in further the life oi' the Under these circumstances and associates found the incidence fistulas to be 12 per cent in a total of 130 1' Four of these patients had ureteral fistulas after a ureteroneocystostomy. One died and 1 had a after a temporary ureteroileos-
cent renal function deteriorated and it was and irreversible in 3 tients. do not mention the of uretera! fistulas. and associates had an 11 per cent
m
scesses in 6 and in 4 it was the direct cause of death. There were 4 infarcts associated with caliceal fistul2.s in their series. Five years earlier we had a similar experience with a patient with a infarct and a ca!iceal fistula. proceN., Chisholm, G. D. and renal fistulae after
dures death secondary to Rees reports 6 ureteral fistulas in his series of 3 All underwent ment. Three 2
reconstruction is if VVith dubious function they too recommend removal. Palmer and associates had 1 patJent ureteral fistula (36 who died of 2 weeks ful attempt at reanastornosis with intubabor, ' had a 27 per cent incidence of ureternl fistulas a marked that perhaps a more conservative would have led to spontaneous resolution In support of these statements describe 2 with fistulas ureteral. anastomosis in whom spontaneous tion did occur after ~nc,rn.~~+ had failed correct the leakage. We have had a similar ence in l who had a spontaneous dow.te the fistula after 2 unsuccessful attempts at its closure. The initial our own intervention in ureteral fistu.las resul.ts, led us to a conserv2tive we have described Several factors may have contributed to successful outcome in these 2 patients. to promote
45: 28, 1973.
Dormont, J. and Bach, and Practice. li Wilkins Co., p. 204, 1972.
Luke, R. G. and Hellebuscb, of corticosteroid
transplantation. Amer. J. Med., 53: 159,
afte.c
576
DESAI AND ASSOCIATES
ences indicate that conservative management of ureterocutaneous fistulas, even in the presence of wound infection, should be given serious consideration. SUMMARY
Two patients with ureterocutaneous fistulas 6 weeks post-renal transplantation were successfully
managed by non-operative treatment and rapidly tapered alternate day steroid therapy. The renal grafts were preserved and the patients ultimately did well with closure of the fistulas. We urge that conservative treatment be seriously considered as an alternative to operative intervention in selected patients with this difficult and potentially lethal complication.
THE JOURNAL OF UROLOGY
Copyright © 1974 by The Williams & Wilkins Co.
CONSERVATIVE NON-OPERATIVE MANAGEMENT OF URETERAL FISTULAS FOLLOWING RENAL ALLOGRAFTS SUVAS G. DESAI, J. WILLIAM McROBERTS, ARTHUR A. HELLEBUSCH
AND
ROBERT G. LUKE
From the Division of Urology, Department of Surgery and the Renal Division, Department of Medicine, University of Kentucky Medical Center, Lexington, Kentucky
Urinary fistulas in renal transplant cases are a dreaded and potentially serious complication. The morbidity and mortality rates have been high in most reported series. 1-• Early operative intervention generally has been recommended to avoid wound sepsis, septicemia and death. 1 • •, 7 - 9 We herein report successful conservative, non-operative management of 2 patients with ureterocutaneous fistulas following renal transplantation and urge that conservative treatment be seriously considered as an alternative to operative intervention in selected patients. CASE
REPORTS
Case 1. F. H., a 39-year-old woman with polycystic kidneys and end stage renal disease, underwent bilateral nephrectomy and total abdominal hysterectomy in September 1972. Three weeks later she received a kidney transplant from her brother (1-haplotype match) with a submucosal tunnel ureteroneocystostomy. The operation was uneventful and the graft functioned immediately. Urine output on the first day was 2,400 cc. A 99 m Accepted for publication May 3, 1974. Read at annual meeting of American Urological Association, St. Louis, Missouri, May 19-23, 1974. 1 Kiser, W. S., Hewitt, C. B. and Montie, J. E.: The surgical complications of renal transplantation. Surg. Clin. N. Amer., 51: 1133, 1971. 2 Martin, D. C., Mims, M. M., Kaufman, J. J. and Goodwin, W. E.: The ureter in renal transplantation. J. Urol., 101: 680, 1969. 3 Rees, R. W.: Urinary fistulae following renal transplantation. Proc. Roy. Soc. Med., 65: 473, 1972. 'Starzl, T. E., Groth, C. G., Putnam, C. W., Penn, I., Halgrimson, C. G., Flatmark, A., Gecelter, L., Brettschneider, L. and Stonington, 0. G.: Urological complications in 216 human recipients of renal transplants. Ann. Surg., 172: 1, 1970. 'Thompson, R. W., Hall, C. L., Newman, C. E., Barnes, A. D., Blainey, J. D. and Edwards, P. D.: Urinary fistulae following cadaveric human renal transplantation. In: Dialysis Transplantation Nephrology. Proceedings gf Tenth Congr_ess of European Dialysis and Transplant Association. Edited by J. F. Moorhead, R. A. Baillod and C. Mion, vol. 10, 1973. 6 Walsh, A.: Some practical problems in kidney transplantation. Transplant. Proc., l: 178, 1969. 7 Palmer, J. M., Kountz, S. L., Swenson, R. S., Lucus, Z. J. and Cohn, R.: Urinary tract morbidity in renal transplantation. Arch. Surg., 98: 352, 1969. • Weil, R., Simmons, R. L., Tallent, M. B., Lillehei, R. C., Kjellstrand, C. M. and Najarian, J. S.: Prevention of urological complications after kidney transplantation. Ann. Surg., 174: 154, 1971. •Yunis, E. J., Gatti, R. A. and Amos, D. B.: Tissue Typing and Organ Transplantation. New York: Academic Press, p. 206, 1973. 10 Aquino, H. C., Preston, D. F. and Luke, R. G.: 99m
pertechnetate renal scan (Tc. scan) and 1311 hippuran renogram immediately postoperatively showed satisfactory blood flow and function. 10 After the first post-transplantation week the steroid dosage was reduced by 5 mg. on alternate days. The patient did well initially. However, at 4 weeks post-transplantation graft tenderness and a decrease in urine output were noted. Cystography showed no urinary extravasation and radioisotope studies showed decreased graft function. A Tc. scan showed adequate blood flow to the graft. Right retrograde ureteropyelography showed no obstruction or extravasation. Diagnosis was acute rejection and the patient was treated with 1 gm. prednisone intravenously 3 times a day on alternate days and placed on hemodialysis for 2 weeks because of increasing azotemia. Six weeks postoperatively the patient had a wound infection and the abdominal incision was opened widely at the subcutaneous level. Wound cultures showed coagulase-positive Staphylococcus aureus and Bacteroides. The patient was given keflin and erythromycin. Nevertheless, the wound drainage began to increase, although the total urinary output returned to normal levels. A week later the wound drainage increased further and straw-colored, yellowish fluid was noted in the abdominal incision. A cystogram was negative. Indigo carmine injected intravenously was seen in the wound drainage in 5 to 10 minutes. Excretory urography (IVP) showed a faint transplant nephrogram and a small puddle of contrast medium in the pelvis, consistent with a ureteral leak. Retrograde pyelography confirmed the diagnosis of a lower ureterocutaneous fistula (fig. 1, A). The total urinary output through the bladder had now decreased to 400 cc and the wound drainage continued to increase. The patient had fever spikes to 102F. The wound was opened more widely. Steroid dosage was decreased more rapidly by a 5 mg. reduction every day. On this regimen the patient became afebrile, blood urea nitrogen (BUN) decreased to 36 mg. per cent and creatinine decreased to 2.3 mg. per cent. However, 10 weeks post-transplantation urinary drainage still continued through the fistula tract. The white count was 5,300, BUN 49 mg. per cent and creatinine 2.8 mg. per cent. Twelve weeks later the BUN decreased to 26 mg. per cent and creatinine to 2.0 mg. per cent,
572
Pertechnetate Uptake in the Transplanted Kidney. In: Proceedings of the Dialysis Transplant Forum, p. 83, 1971.
NON-OPERATIVE MANAGEMENT OF URETERAL FISTULAS
FIG. 1. A, retrograde pyelogram shows extravasation of contrast medium from transplant ureter, confirming ureteral fistula. B, IVP 25 weeks later shows good graft function. There is no evidence of fistula.
although considerable amounts continued to drain through the ureterocutaneous fistula. Since the patient did not have any systemic effects she was discharged from the hospital. She was given 45/35 mg. prednisone on alternate days and 100 mg. azathioprine daily. She voided 400 cc per day and the rest of the urinary output (1,400 cc) was through the fistula site. About 18 weeks post-transplantation a decreasing amount of urine was noted coming from the fistula and a commensurate increase was noted in the voided amounts. The patient continued to be afebrile and the prednisone dosage had been decreased to 30/20 mg. on alternate days. The 24hour creatinine clearance was 33 cc per minute. Twenty-five weeks later an IVP showed good function of the renal graft and no evidence of a ureterocutaneous fistula (fig. 1, B). The BUN was 32 mg. per cent and creatinine was 2.3 mg. per cent. Eight months post-transplantation the patient was doing well. The wound had healed completely and she was back on her job as a registered nurse in an emergency room. Case 2. A. H., a 45-year-old white woman with chronic renal failure and hypertension, was hospitalized with a BUN of 133 mg. per cent and a creatinine of 10.4 mg. per cent. She was placed on hemodialysis. The presumptive diagnosis was chronic glomerulonephritis. She received a live donor transplant from her son on September 22, 1972. The donor kidney was a 1-haplotype match and the urinary anastomosis was done with a submucosal tunnel ureteroneocystostomy. Intraoperatively, the arterial anastomosis had to be revised because of an atheromatous
plaque which blocked an effective flow through the hypogastric artery. The patient had acute tubular necrosis postoperatively and needed hemodialysis for approximately 3 weeks. Two weeks post-tram,plantation she had a wound hematoma evacuated. At this time urinary output was 700 cc in hours, BUN 63 mg. per cent and creatinine :3.8 mg. per cent. Tc. scan showed decreased blood flow the transplant kidney. A transplant biopsy showed changes consistent with cellular rejection. Acute rejection superimposed on acute tubular necrosis was diagnosed. Accordingly, she was given l gm. prednisone intravenously 3 times a day on alternate days, along with 4,000 units heparin intravenously every 4 hours for 1 week. She also had l.ocal graft irradiation 150R times 4 on alternate days. Urinary output had increased to 2,200 cc 3 weeks postoperatively. BUN was 62 mg. per cent with a creatinine of 0.8 mg. per cent. She was now taking 60 mg. prednisone and 50 mg. daily (the latter because of a decreasing white blood count). The prednisone was further by 5 mg. on alternate days. The discharged from the hospital 6 weeks later with BUN of 65 mg. per cent and creatinine of 1.6 mg. per cent. When the patient was discharged from the hospital prednisone dosage was 60/30 mg. alternate days. Six weeks post-transplantation she was talized because of straw-colored, yellowish drainage from the wound. A cystogram revealed bladder extravasation. Retrograde raphy confirmed the suspected diagnosis of terocutaneous fistula (fig. 2, A). Since the was doing well and had no systemic manifestations
574
DESAI AND ASSOCIATES
Fie:;. 2. A, retrograde pyelogram shows extravasation of contrast medium from lower transplant ureter. B, IVP 16 weeks later shows good graft function. There is no evidence of fistula.
she was followed closely on decreasing doses of prednisone. Two weeks later she was discharged from the hospital taking 45/30 mg. prednisone on alternate days and 100 mg. imuran daily. Twelve weeks post-transplantation the voided urinary output was 300 cc daily. BUN was then 32 mg. per cent and creatinine was 1. 7 mg. per cent. She was taking 30 mg. prednisone daily and afebrile. Some urine was still draining from the fistula, although it was half the previous amount. The voided urine volume had now increased to about 2,000 cc. She was taking 30/20 mg. prednisone on alternate days and this dosage was further reduced by 2.5 mg. on alternate days. Sixteen weeks post-transplantation the ureterocutaneous fistula had closed completely and the patient continued to feel well. BUN was 31 mg. per cent and creatinine was 1.5 mg. per cent, with a creatinine clearance of 31 ml. per minute. IVP showed normal graft function (fig. 2, B). Prednisone was reduced to 30 mg. on alternate days. She has done well subsequently and the creatinine clearance has increased currently to 40 ml. per minute. The patient is a fully rehabilitated, active housewife. DISCUSSION
Most authors, while generally reporting good results with conservative management of vesicocutaneous fistulas, recommend early operative intervention when a ureteral fistula develops following renal transplantation. 1 • 4 • 7 - 9 The collective experience is summarized in the table. 1-•, 6 • 7 • 11 , 12 11 Prout, G. R., Jr., Hume, D. M., Lee, H. M. and Williams, G. M.: Some urological aspects of 93 consecutive renal homotransplants in modified recipients. J. Urol., 97: 409, 1967. 12 Malek, G. H., Uehling, D. T., Daouk, A. A. and Kisken, W. A.: Urological complications of renal transplantation. J. Urol., 109: 173, 1973.
Simmons, Najarian and others advise urgent re-exploration with reimplantation of the ureter into the bladder, nephrostomy or performance of a pyeloureterostomy to the host ureter.• They caution that delaying definitive repair will frequently lead to infection, the development of necrotic aneurysms, loss of kidney and death. Starzl and associates state that with a urinary leak the urgency of establishment of a watertight urinary system has no parallel in standard urologic practice.• Their policy has been to attempt to surgically close all fistulas before the supervention of wound sepsis. In their series 10.9 per cent (6 of 55) had a urinary leak. Of these 3 patients with a ureteroneocystostomy had ureteral fistulas and they all occurred in the first 3 weeks. The treatment was reimplantation in 1 with death directly attributed to the complication, nephrectomy of the transplant in the second and a ureteroureterostomy in the third with satisfactory results. In a series of 146 transplant patients Martin and associates report a mortality rate of 35.3 per cent (6 of 17 patients) with urinary fistulas. 2 All deaths were secondary to infection with other complications. There were 14 ureteral (2 pelvic) fistulas -all managed by surgical intervention. Walsh states that urinary fistulas in renal transplantation are always a serious complication often followed by infection and death. 6 He believes that in view of the high mortality rate it would be better to remove the transplanted kidney rather than run the risks associated with a persistent fistula. In his series 3 of 31 patients had urinary fistulas and all 3 died. However, he does not specify how many of them were ureteral fistulas. Malek and associates concur and advise graft removal in the presence of a urinary fistula and wound infection. 12 In their review of the literature
NON-OPERATIVE MANAGEMENT OF URETERAL FISTULAS
Review of fistulas-complications and mortality ;\]o_ Trans-
Reference
plants
l\!Ialek and associates 12 Walsh'
Palmer and associates 7
94 1:30
:n 256
Kiser and associates 1
No. Fistulas
Type of Fistula
Operative Repair
Nephrectomy
Vesical
7 4
7
(ureteral) 5 (2 multiple)
22
(TUlJ-1 vr.l 16 (sepsis
IVKartin and associates
2
142
17
14
3
~
6
2
1 (W)
6
10
5 (W)
extravasation) 6
3
(")
Starzl and associates~ Rees' Prout and as~;ociates 11 Present study
2:,4 61
9 9
96
5
114
IO
9 4 (2/2 ops.) 2 3
1 2
Ureteral
1 (W) 11 (VV)
3
7 15
27
Death
4 4 (2 unrelated causes)
4
16 (pyelouret. fi) 14 (pyetouret. 2} 9
3
5
6
4 (1 nephrocui .) (1 pyelocut I
I (nephrocut.)
found that among 1,301 renal with data there were 174 (13.3 per cent) and 57 (32.7 per cent) Ureteral fistulas were not rnentioned per se. Kiser and associates had 12 m whom ureteral fistulas a month or more after 1 In these cases repair was unsuccessful and succeeded in further the life oi' the Under these circumstances and associates found the incidence fistulas to be 12 per cent in a total of 130 1' Four of these patients had ureteral fistulas after a ureteroneocystostomy. One died and 1 had a after a temporary ureteroileos-
cent renal function deteriorated and it was and irreversible in 3 tients. do not mention the of uretera! fistulas. and associates had an 11 per cent
m
scesses in 6 and in 4 it was the direct cause of death. There were 4 infarcts associated with caliceal fistul2.s in their series. Five years earlier we had a similar experience with a patient with a infarct and a ca!iceal fistula. proceN., Chisholm, G. D. and renal fistulae after
dures death secondary to Rees reports 6 ureteral fistulas in his series of 3 All underwent ment. Three 2
reconstruction is if VVith dubious function they too recommend removal. Palmer and associates had 1 patJent ureteral fistula (36 who died of 2 weeks ful attempt at reanastornosis with intubabor, ' had a 27 per cent incidence of ureternl fistulas a marked that perhaps a more conservative would have led to spontaneous resolution In support of these statements describe 2 with fistulas ureteral. anastomosis in whom spontaneous tion did occur after ~nc,rn.~~+ had failed correct the leakage. We have had a similar ence in l who had a spontaneous dow.te the fistula after 2 unsuccessful attempts at its closure. The initial our own intervention in ureteral fistu.las resul.ts, led us to a conserv2tive we have described Several factors may have contributed to successful outcome in these 2 patients. to promote
45: 28, 1973.
Dormont, J. and Bach, and Practice. li Wilkins Co., p. 204, 1972.
Luke, R. G. and Hellebuscb, of corticosteroid
transplantation. Amer. J. Med., 53: 159,
afte.c
576
DESAI AND ASSOCIATES
ences indicate that conservative management of ureterocutaneous fistulas, even in the presence of wound infection, should be given serious consideration. SUMMARY
Two patients with ureterocutaneous fistulas 6 weeks post-renal transplantation were successfully
managed by non-operative treatment and rapidly tapered alternate day steroid therapy. The renal grafts were preserved and the patients ultimately did well with closure of the fistulas. We urge that conservative treatment be seriously considered as an alternative to operative intervention in selected patients with this difficult and potentially lethal complication.