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Intravesical Ligation as a New Technique to Manage a Refluxing Native Ureter Without Simultaneous Nephrectomy in Renal Transplantation
Intravesical Ligation as a New Technique to Manage a Refluxing Native Ureter Without Simultaneous Nephrectomy in Renal Transplantation J.A. Guzmán ABSTRACT Background. This article aims to describe an original technique to correct refluxing native ureters observed during a prerenal transplantation study. The correction is performed by intravesical ligation of the native refluxing ureters at the same time as renal transplantation without simultaneous nephrectomy. Methods. Between January 2004 and December 2010 we performed intravesical ligation of a refluxing ureter simultaneous with a transplantation procedure without a concomittant native nephrectomy in 12 of 345 subjects (3.47%). The 8 bilateral and 4 unilateral ligations were performed on 11 cadaveric and 1 living-related nonidentical donor transplantations. The implantation of the kidney donor ureter was performed anatomically in the bladder trigone through a transvesical ureteroneocystostomy with a transmural, submucosal antireflux tunnel. Results. Early and late postoperative recovery was satisfactory in all patients. There was no documented kidney area pain, proven urinary tract infection, morbidity or mortality attributed to the procedure. Conclusions. Intravesical ligation is a practical technique to manage vesicoureteral reflux into the native ureters simultaneously with the ureteral implantation of the kidney donor in a single surgical renal transplant procedure without native kidney nephrectomy. ESICOURETERAL reflux (VUR), an abnormal condition in children or adults, is associated with urinary tract infections (UTIs), promotes the formation of renal scars and decreases glomerular filtration. VUR damages transplanted kidneys and is a risk factor for UTI, especially if associated with bladder dysfunction. To eliminate reflux, ligation of the native ureter is recommended because immunosuppressed patients show a high probability of UTIs that threaten the patient’s life and the transplanted kidney’s function. Although the true incidence of VUR is potentially significant, it has not been established due the inappropriateness to subject all asymptomatic patients to control cystography. When reflux is diagnosed it must be corrected because of the long-term risk to the donor kidney function.1 When VUR is detected in a pretransplantation study, the standard practice is surgical correction in the months before renal transplantation.2 A surgical antireflux procedure in pretransplantation patients increases medical, anesthetic, and surgical risks, as well as costs. Furthermore, persistent
V
reflux or obstruction is one of the most common surgical complications of this procedure. Control cystography can show whether the reflux has been corrected. If obstruction develops, an invasive test is necessary, consisting of either retrograde or direct percutaneous pyelography. The present study offers a new technique to correct a refluxing native ureter discovered during a pretransplantation study. The proposed technique recommends that correction be performed by intravesical ligation at the same time of the renal transplantation. Based on experience with acute obstruction, nephrectomy of the native kidney is routinely practiced in this setting among immunosuppressed patients seeking to preFrom the Fundación Universitaria de Ciencias de la Salud, Facultad de Medicina, Servicios de Urología y Transplante Renal, Hospital de San José, Bogotá, Colombia. Address reprint requests to Jesus Alfonso Guzman, MD, Carrera 49 # 93 54, Bogotá, Colombia. E-mail: jeguz16@ yahoo.com
0041-1345/12/$–see front matter http://dx.doi.org/10.1016/j.transproceed.2012.03.062
© 2012 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
2940
Transplantation Proceedings, 44, 2940 –2944 (2012)
INTRAVESICAL LIGATION
vent infectious complications related to renal obstruction.3 However, there are benefits of preserving the endocrine and metabolic functions of the native kidney, even though the ureter is ligated. Vesicoureteral reflux does not develop in renal transplanted patients, when the donor ureter has been implanted with a suitable transmural and submucosal tunnel.4 A refluxing transplanted ureter may be treated conservatively and should only be corrected if there is evidence of recurrent episodes of sepsis from the urinary tract or a kidney infection.5 Careful tunneling of the donor ureteral anastomosis is necessary to achieve graft survival.6 The presence of reflux is associated with poor graft survival regardless of infection.7,8 METHODS Selection and Description of Patients In the cases were defined as subjects with a refluxing native ureter discovered by voiding cystography in a patient on the waiting list for renal transplantation. The patients displayed unilateral or bilateral native refluxing ureters. Our medical-ethical board authorized correction of the native refluxing ureter (unilateral or bilateral) by intravesical ligation without simultaneous nephrectomy during renal transplantation from a cadaveric or living-related unrelated donor. All the patients signed informed consent forms.
2941
massive, 1 grade I, 2 grade III, and 4 grade V—and in 4 patients, it was unilateral—right grade III (Table 1). The immediate postoperative examinations were remarkable all patients, none of whom experienced pain in their kidney areas. Eight patients reported no urinary infections, but 4 UTIs were documented by febrile episodes that responded to proper management. Three subjects experienced acute rejection episodes, and 2 evolved to chronic rejection. Eight patients experienced immediate diuresis, and 4 had delayed graft function. In 1 patient, the transplanted kidney was removed (transplantectomy) on suspicion of hyperacute rejection, which was not verified by histopathological examination. Another patient displayed chronic rejection that required transplantectomy. The native kidneys did not show any changes (Table 2). There was no morbidity or mortality attributed to the procedures. At 5- year follow-up examinations, there were 10 patients with functioning transplanted kidneys under immunosuppression. The 12 patients with native ligation of the refluxing intravesical ureter without simultaneous nephrectomy did not develop painful areas; there were no changes in the initial pathology on ultrasound control evaluation. DISCUSSION
Technical Information Surgical technique. The kidney transplantation technique was followed by cystotomy identifying the trigone and the refluxing native ureteral orifices. After catheterization with a Nelaton No 6, a suture was placed in the terminal ureter and the ureter was pulled into the bladder achieving a complete dissection of 1.5 cm before placement of a transfixing Vicryl 4-0 suture; using two 4-0 chrome catgut sutures, to the the bladder mucosa ureteral orifice was closed posteriorly. If the reflux was bilateral, the patient underwent the same procedure on the contralateral side. The donor ureter was then implanted in the trigone using a transmural ureteroneocystostomy with a submucosal antireflux tunnel, 1 cm above the native ipsilateral ureteral orifice. The bladder was closed with a single suture of 3-0 chromic catgut on two levels, the first approximating the mucosa and detrusor muscle and the second approximating the serosa (Fig 1). The native kidney was left in place. The bladder catheter was removed at 5 days. During the hospital stay, we evaluated the presence of low back pain. After discharge, follow-up was performed regularly following our guidelines for postoperative management including evaluation of pain and UTIs.
RESULTS
Between January 1978 and December 2010, 12 of 345 (3.47%) evaluated patients showed vesicoureteral reflux before renal transplantation. Ligation of a native refluxing intravesical ureter was performed without simultaneous nephrectomy of the native kidney. The cohort included 6 men of 8, 19, 20, 22, 26, and 42 years old, and 6 women of 15, 18, 26, 33, 38, and 41 years old. Eleven subjects were underwent dialysis, 1 was predialysis 1 patient received a nonidentical living-related donor kidney, and 11 received cadaveric kidneys. In 8 patients, the reflux was bilateral—1
Most patients with chronic renal failure are oliguric or anuric, but those who produce varying amounts of urine and who are not yet on dialysis (as was our patient with bilateral grade IV vesicoureteral reflux with a daily urine output of more than 1000 mL per day) do not develop significant pain after ureteral ligation in the immediate or late postoperative period. This result has a physiological cause: the effect of obstruction on ureteral function depends on its duration, the urinary flow rate, and the presence or absence of infection. In acute obstruction, fluid stagnation of urine occurs within the collecting system, with increasing basal intraluminal intraureteral pressure. There is an increase in both the length and diameter of the ureter. The increase in intraluminal pressure depends on whether the kidney continues to produce urine. The increase in size results from elevation of the intraluminal pressure and the increased urine retained in the ureter.9,10 The first phase, characterized by an elevated intraluminal pressure and renal blood flow (RBF), takes approximately 1 to 1.5 hours. The second phase is manifested by a decrease in RBF and a continued increase in intraureteral pressure that lasts until the hours of obstruction. The final phase is manifested by a greater decrease in RBF, accompanied by a greater, more progressive decrease in intraluminal pressure. It has been experimentally shown that the tubulointerstitial reaction occurs after obstruction secondary to the unilateral ureteral ligation. The process is characterized by tubular cell apoptosis, inflammatory changes with macrophages infiltration, and the presence of interstitial fibroblasts with increased expression of tumor necrosis factor-␣. Ureteral ligation without
2942
GUZMAN
Fig 1.
Surgical technique diagram.
simultaneous nephrectomy is safe in renal transplantation; it has not been associated with morbidity and mortality secondary to the procedure. Infection has not been an associated problem. Patients who produce urine and have had no prior hydronephrosis can later develop obstruction,
but surprisingly, they do not complain of pain beyond the normal postsurgical transplantation discomfort. This observation can be explained physiologically as the sequence of responses in the second phase of acute obstruction. Moderate hydronephrosis does not require medical or surgical
INTRAVESICAL LIGATION
2943
Table 1. Characteristics of Patients With Intravesical Ligation of the Native Refluxing Ureter in Renal Transplantation Patient No.
1 2 3 4 5 6 7 8 9 10 11 12
Age (y)
Sex (M/F)
Dialysis
Donor Type
Reflux
Degree of Reflux
15 20
F M M F M F M F M M F F
Hemodialysis Predialysis Peritoneal hemodialysis Hemodialysis Peritoneal Hemodialysis Hemodialysis Hemodialysis Hemodialysis Hemodialysis Peritoneal Hemodialysis
Cadaveric ULD Cadaveric Cadaveric Cadaveric Cadaveric Cadaveric Cadaveric Cadaveric Cadaveric Cadaveric Cadaveric
Bilateral Bilateral Bilateral Right Bilateral Right Right Bilateral Bilateral Right Bilateral Bilateral
Massive Right I, left I III III V III III V V* III Right III, left II V
38 8 41 26 26 22 42 33 18
Abbreviations: M, male; F, female; ULD, unrelated living donor. *Double left incomplete collecting system.
intervention such as nephrectomy.9,10 In the absence of consequences from ureteral ligation, it is not reasonable to remove the native kidney, which maintains endocrine and metabolic functions despite losing its excretory and hemodynamic functions. The incidence of VUR in the population being evaluated for renal transplantation is approximately 8%. In our study of 345 pretransplantation patients, VUR was only discovered in 12 patients (3.47%). The cause of persistent UTIs in transplanted patients can be reflux in to the native system. Bladder dysfunction also contributes to the persistence of infections. Only 2% of children with end-stage renal disease (ESRD) have reflux nephropathy; 0.5% of ESRD patients of all ages have reflux nephropathy as the primary cause associated with UTI.7 The presence of reflux is associated with poor graft survival, regardless of whether there is infection.7 When a patient is suitable for kidney transplantation and vesicoureteral reflux is discovered on the pretransplantation study, the standard practice is surgical correction in the months before renal transplantation. Persistence of reflux and obstruction are common surgical complications. Cystography can show whether the reflux has been corrected. If obstruction develops, an invasive test
is necessary, consisting of either retrograde or direct percutaneous pyelography. If obstruction appears in a dialysis patient, ligature should be performed without simultaneous nephrectomy. Native kidney nephrectomy is routinely practiced in immunosuppressed patients with the goal of preventing infectious complications related to renal obstruction, based on experience with acute obstruction.10 Because there are benefits to preserve endocrine and metabolic functions of the native kidney, it is best to preserve the native kidney although the ureter is tied. For a patient with necrosis of the middle third of the transplanted ureter Guzman (1978) performed a ureteropyeloplasty using the native right ureter to reconstruct the urinary tract with ligation at the middle third without simultaneous nephrectomy.11 Baquero et al (1985)12 and Lord et al (1991)13 did not recommend native nephrectomy when performing either a pyeloureterostomy or a ureteroureterostomy to reconstruct the urinary tract in renal transplantation. In 1998, Erturk et al14 recommended correction of reflux, but warned against prophylactic nephrectomy. In 2002, Gallentine and Wright15 showed that it was safe to ligate the proximal ureter without removing the native kidney in the same surgical procedure as transplantation simultaneous with pyeloureterostomy or end-to-end
Table 2. Clinical Outcomes Postintravesical Ureteral Ligation of the Native Refluxing Ureter in Renal Transplantation Patient No.
1 2 3 4 5 6 7 8 9 10 11 12
POP Pain
IVU Postop
Rejection
Immediate Outcome
Late Evolution
No No No No No No No No No No No No
No No No No Yes Yes No No Yes Yes No No
Chronic Acute-chronic
Delayed function Immediate diuresis Immediate diuresis Immediate diuresis Delayed function Delayed function Delayed function Immediate diuresis Immediate diuresis Immediate diuresis Immediate diuresis Immediate diuresis
Transplantectomy Functioning kidney Functioning kidney Functioning kidney Transplanctectomy Functioning kidney Functioning kidney Functioning kidney Functioning kidney Functioning kidney Functioning kidney Functioning kidney
Acute-chronic Acute
Abbreviations: POP, post-operative pain; UTI, urinary tract infections.
Native Kidneys
No No No No No No No No No No No No
change change change change change change change change change change change change
2944
ureteroureterostomy. In 2003, Khoubehi and Williams16 reported that during a period of 21 years, 43 renal transplant recipients underwent ligation of the native ureter without nephrectomy, most of them as a secondary procedure for ureteral complications, such as obstruction, and some of them as a primary procedure due to a short donor ureter. Six of 278 patients underwent nephrectomy of the native kidney after ureteral ligation due to persistent pain.15,16 At the lateral end of the ureteroureterostomy, the ureters do not need to be ligated, and similarly, nephrectomy is not required if there is no evidence of vesicoureteral reflux at the pretransplantation evaluation. If ureteral reflux occurs into the native system beyond the level of the anastomosis, it is desirable and necessary to leave a double J stent when performing ureteroureterostomy. This report showed an initial experience with intravesical ligation of a refluxing native ureter without a simultaneous nephrectomy during renal transplantation of a cadaveric or living-related/-unrelated donor. This technique achieves complete elimination of the native refluxing ureter a condition that represents an advantage compared with pretransplantation procedures. If the reflux persists as a complication, it implies additional surgery until proper correction is obtained. Our technique avoids unnecessary pretransplantation surgeries and their complications to eliminate VUR in the recipient. For the patient and the surgical team, it represents an advantage to perform the correction of the native refluxing ureter and the kidney transplantation simultaneously. Depending on the surgical timing, intravesical ligation may be performed before or after the actual renal transplantation portion of the procedure. This technique avoids dissection of the perivesical ureter, which compromises bladder innervation when correcting vesicoureteral reflux before renal transplantation. Extraand intravesical ureteroneocystostomy with a transmural and submucosal tunnel in the simultaneously transplanted kidney implant is performed via a cystotomy. Implantation of the ureter near the native ureteral orifice facilitates endoscopic retrograde pyelography, ureteroscopy, or placement of double J ureteral stents when necessary in the postsurgical period. When an extravesical technique (LichGregoire) is used, the native refluxing ureter must be tied close to the uretero-vesical junction. The extravesical technique does not place the donor ureter in a normal anatomical fashion at the trigone, which makes it difficult or impossible to catheterize when any renal or urinary tract disease occurs in the transplanted kidney. In conclusion, this study described intravesical ligation of the recipient native ureter as a practical technique to eliminate vesicoureteral reflux in the native ureter discov-
GUZMAN
ered during a pretransplantation study, regardless of the degree and extent of urine production, simultaneously with donor kidney ureteral implantation (cadaveric or livingrelated or -unrelated) in a single surgical procedure. The technique was safe and free of postoperative mortality. Nephrectomy was not indicated because of the desire to maintain endocrine and metabolic functions of the kidney. ACKNOWLEDGMENT Thanks to Merileidy Plazas from the FUCS Research Division and Ana y Adriana Guzmán Ruiz.
REFERENCES 1. Mathew TH, Kincaid-Smith P, Vikrama P: Risks of vesicoureteric reflux in the transplanted kidney. N Engl J Med 297:414, 1977 2. Casale P, Grady RW, Mitchell ME, et al: Recurrent tract Infection in the post-transplant reflux nephropathy patient: is reflux in the native ureter the culprit? Pediatric Transplantation 9:324, 2005 3. Craig JC, Irwig LM, Knight JF, et al: Does treatment of vesicoureteric reflux in childhood prevent end-stage renal disease attribute to reflux nephropathy? Pediatrics 105:1236, 2000 4. Sheinfeld J, Linke CL, Talley TE, et al: Selective pretransplantation nephrectomy: indications and perioperative management. J Urol 133:0379, 1985 5. Coulthard MC, Keir MJ: Reflux nephropathy in kidney transplant, dimercapto succinic acid demonstrate by scanning. Transplantation 82:205, 2006 6. Waltzer WC, Zincke H, Leary F, et al: Urinary tract reconstruction in renal transplantation. Urology 3;233, 1980 7. Grunberger T, Gnant M, Sautner T, et al: Impact of vesicoureteral reflux on graft survival in renal transplantation. Proc Transplant 25:1058, 1993 8. Anonymous: Incidence and prevalence of ESRD. Am J Kidney Dis 30S40, 1997 9. Barney RD: The effects of ureteral obstruction: experimental and clinical. Surg Gynecol Obstetr 15:290, 1912 10. Gulmi FA, Felsen D, Vaughan ED: In Walsh PC, Retik AB, Vaughan ED, et al (eds): Campbell’s Urology, 8th ed. Philadelphia: WB Saunders Co; 2002, p 411 11. Guzman JA, Ordóñez D, Torres M, et al: Urological complications in renal transplantation. Acta Médica Colombiana 7:139, 1982 12. Baquero A, Ginsberg PC, Kaschak D, et al: Experience with pyeloureterostomy associated with simple ligation of native ureter without ipsilateral nephrectomy in renal transplantation. J Urol 133:386, 1985 13. Lord RH, Peper T, Williams G: Without pyeloureterostomy ureteroureterostomy and native nephrectomy in renal transplantation. Br J Urol 67:349, 1991 14. Erturk E, Burzon DT, Orloff M, et al: Outcomes of patients with vesicoureteral reflux after-kidney transplantation: the effect of pretransplantation surgery on urinary tract infections post transplant. Urology 51:27, 1998 15. Gallentine ML, Wright FH: Ligation of the native ureter in renal transplantation. J Urol 167:29, 2002 16. Khoubehi B, Williams G: Letters to the Editor. J Urol 169:292, 2003
V
reflux or obstruction is one of the most common surgical complications of this procedure. Control cystography can show whether the reflux has been corrected. If obstruction develops, an invasive test is necessary, consisting of either retrograde or direct percutaneous pyelography. The present study offers a new technique to correct a refluxing native ureter discovered during a pretransplantation study. The proposed technique recommends that correction be performed by intravesical ligation at the same time of the renal transplantation. Based on experience with acute obstruction, nephrectomy of the native kidney is routinely practiced in this setting among immunosuppressed patients seeking to preFrom the Fundación Universitaria de Ciencias de la Salud, Facultad de Medicina, Servicios de Urología y Transplante Renal, Hospital de San José, Bogotá, Colombia. Address reprint requests to Jesus Alfonso Guzman, MD, Carrera 49 # 93 54, Bogotá, Colombia. E-mail: jeguz16@ yahoo.com
0041-1345/12/$–see front matter http://dx.doi.org/10.1016/j.transproceed.2012.03.062
© 2012 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
2940
Transplantation Proceedings, 44, 2940 –2944 (2012)
INTRAVESICAL LIGATION
vent infectious complications related to renal obstruction.3 However, there are benefits of preserving the endocrine and metabolic functions of the native kidney, even though the ureter is ligated. Vesicoureteral reflux does not develop in renal transplanted patients, when the donor ureter has been implanted with a suitable transmural and submucosal tunnel.4 A refluxing transplanted ureter may be treated conservatively and should only be corrected if there is evidence of recurrent episodes of sepsis from the urinary tract or a kidney infection.5 Careful tunneling of the donor ureteral anastomosis is necessary to achieve graft survival.6 The presence of reflux is associated with poor graft survival regardless of infection.7,8 METHODS Selection and Description of Patients In the cases were defined as subjects with a refluxing native ureter discovered by voiding cystography in a patient on the waiting list for renal transplantation. The patients displayed unilateral or bilateral native refluxing ureters. Our medical-ethical board authorized correction of the native refluxing ureter (unilateral or bilateral) by intravesical ligation without simultaneous nephrectomy during renal transplantation from a cadaveric or living-related unrelated donor. All the patients signed informed consent forms.
2941
massive, 1 grade I, 2 grade III, and 4 grade V—and in 4 patients, it was unilateral—right grade III (Table 1). The immediate postoperative examinations were remarkable all patients, none of whom experienced pain in their kidney areas. Eight patients reported no urinary infections, but 4 UTIs were documented by febrile episodes that responded to proper management. Three subjects experienced acute rejection episodes, and 2 evolved to chronic rejection. Eight patients experienced immediate diuresis, and 4 had delayed graft function. In 1 patient, the transplanted kidney was removed (transplantectomy) on suspicion of hyperacute rejection, which was not verified by histopathological examination. Another patient displayed chronic rejection that required transplantectomy. The native kidneys did not show any changes (Table 2). There was no morbidity or mortality attributed to the procedures. At 5- year follow-up examinations, there were 10 patients with functioning transplanted kidneys under immunosuppression. The 12 patients with native ligation of the refluxing intravesical ureter without simultaneous nephrectomy did not develop painful areas; there were no changes in the initial pathology on ultrasound control evaluation. DISCUSSION
Technical Information Surgical technique. The kidney transplantation technique was followed by cystotomy identifying the trigone and the refluxing native ureteral orifices. After catheterization with a Nelaton No 6, a suture was placed in the terminal ureter and the ureter was pulled into the bladder achieving a complete dissection of 1.5 cm before placement of a transfixing Vicryl 4-0 suture; using two 4-0 chrome catgut sutures, to the the bladder mucosa ureteral orifice was closed posteriorly. If the reflux was bilateral, the patient underwent the same procedure on the contralateral side. The donor ureter was then implanted in the trigone using a transmural ureteroneocystostomy with a submucosal antireflux tunnel, 1 cm above the native ipsilateral ureteral orifice. The bladder was closed with a single suture of 3-0 chromic catgut on two levels, the first approximating the mucosa and detrusor muscle and the second approximating the serosa (Fig 1). The native kidney was left in place. The bladder catheter was removed at 5 days. During the hospital stay, we evaluated the presence of low back pain. After discharge, follow-up was performed regularly following our guidelines for postoperative management including evaluation of pain and UTIs.
RESULTS
Between January 1978 and December 2010, 12 of 345 (3.47%) evaluated patients showed vesicoureteral reflux before renal transplantation. Ligation of a native refluxing intravesical ureter was performed without simultaneous nephrectomy of the native kidney. The cohort included 6 men of 8, 19, 20, 22, 26, and 42 years old, and 6 women of 15, 18, 26, 33, 38, and 41 years old. Eleven subjects were underwent dialysis, 1 was predialysis 1 patient received a nonidentical living-related donor kidney, and 11 received cadaveric kidneys. In 8 patients, the reflux was bilateral—1
Most patients with chronic renal failure are oliguric or anuric, but those who produce varying amounts of urine and who are not yet on dialysis (as was our patient with bilateral grade IV vesicoureteral reflux with a daily urine output of more than 1000 mL per day) do not develop significant pain after ureteral ligation in the immediate or late postoperative period. This result has a physiological cause: the effect of obstruction on ureteral function depends on its duration, the urinary flow rate, and the presence or absence of infection. In acute obstruction, fluid stagnation of urine occurs within the collecting system, with increasing basal intraluminal intraureteral pressure. There is an increase in both the length and diameter of the ureter. The increase in intraluminal pressure depends on whether the kidney continues to produce urine. The increase in size results from elevation of the intraluminal pressure and the increased urine retained in the ureter.9,10 The first phase, characterized by an elevated intraluminal pressure and renal blood flow (RBF), takes approximately 1 to 1.5 hours. The second phase is manifested by a decrease in RBF and a continued increase in intraureteral pressure that lasts until the hours of obstruction. The final phase is manifested by a greater decrease in RBF, accompanied by a greater, more progressive decrease in intraluminal pressure. It has been experimentally shown that the tubulointerstitial reaction occurs after obstruction secondary to the unilateral ureteral ligation. The process is characterized by tubular cell apoptosis, inflammatory changes with macrophages infiltration, and the presence of interstitial fibroblasts with increased expression of tumor necrosis factor-␣. Ureteral ligation without
2942
GUZMAN
Fig 1.
Surgical technique diagram.
simultaneous nephrectomy is safe in renal transplantation; it has not been associated with morbidity and mortality secondary to the procedure. Infection has not been an associated problem. Patients who produce urine and have had no prior hydronephrosis can later develop obstruction,
but surprisingly, they do not complain of pain beyond the normal postsurgical transplantation discomfort. This observation can be explained physiologically as the sequence of responses in the second phase of acute obstruction. Moderate hydronephrosis does not require medical or surgical
INTRAVESICAL LIGATION
2943
Table 1. Characteristics of Patients With Intravesical Ligation of the Native Refluxing Ureter in Renal Transplantation Patient No.
1 2 3 4 5 6 7 8 9 10 11 12
Age (y)
Sex (M/F)
Dialysis
Donor Type
Reflux
Degree of Reflux
15 20
F M M F M F M F M M F F
Hemodialysis Predialysis Peritoneal hemodialysis Hemodialysis Peritoneal Hemodialysis Hemodialysis Hemodialysis Hemodialysis Hemodialysis Peritoneal Hemodialysis
Cadaveric ULD Cadaveric Cadaveric Cadaveric Cadaveric Cadaveric Cadaveric Cadaveric Cadaveric Cadaveric Cadaveric
Bilateral Bilateral Bilateral Right Bilateral Right Right Bilateral Bilateral Right Bilateral Bilateral
Massive Right I, left I III III V III III V V* III Right III, left II V
38 8 41 26 26 22 42 33 18
Abbreviations: M, male; F, female; ULD, unrelated living donor. *Double left incomplete collecting system.
intervention such as nephrectomy.9,10 In the absence of consequences from ureteral ligation, it is not reasonable to remove the native kidney, which maintains endocrine and metabolic functions despite losing its excretory and hemodynamic functions. The incidence of VUR in the population being evaluated for renal transplantation is approximately 8%. In our study of 345 pretransplantation patients, VUR was only discovered in 12 patients (3.47%). The cause of persistent UTIs in transplanted patients can be reflux in to the native system. Bladder dysfunction also contributes to the persistence of infections. Only 2% of children with end-stage renal disease (ESRD) have reflux nephropathy; 0.5% of ESRD patients of all ages have reflux nephropathy as the primary cause associated with UTI.7 The presence of reflux is associated with poor graft survival, regardless of whether there is infection.7 When a patient is suitable for kidney transplantation and vesicoureteral reflux is discovered on the pretransplantation study, the standard practice is surgical correction in the months before renal transplantation. Persistence of reflux and obstruction are common surgical complications. Cystography can show whether the reflux has been corrected. If obstruction develops, an invasive test
is necessary, consisting of either retrograde or direct percutaneous pyelography. If obstruction appears in a dialysis patient, ligature should be performed without simultaneous nephrectomy. Native kidney nephrectomy is routinely practiced in immunosuppressed patients with the goal of preventing infectious complications related to renal obstruction, based on experience with acute obstruction.10 Because there are benefits to preserve endocrine and metabolic functions of the native kidney, it is best to preserve the native kidney although the ureter is tied. For a patient with necrosis of the middle third of the transplanted ureter Guzman (1978) performed a ureteropyeloplasty using the native right ureter to reconstruct the urinary tract with ligation at the middle third without simultaneous nephrectomy.11 Baquero et al (1985)12 and Lord et al (1991)13 did not recommend native nephrectomy when performing either a pyeloureterostomy or a ureteroureterostomy to reconstruct the urinary tract in renal transplantation. In 1998, Erturk et al14 recommended correction of reflux, but warned against prophylactic nephrectomy. In 2002, Gallentine and Wright15 showed that it was safe to ligate the proximal ureter without removing the native kidney in the same surgical procedure as transplantation simultaneous with pyeloureterostomy or end-to-end
Table 2. Clinical Outcomes Postintravesical Ureteral Ligation of the Native Refluxing Ureter in Renal Transplantation Patient No.
1 2 3 4 5 6 7 8 9 10 11 12
POP Pain
IVU Postop
Rejection
Immediate Outcome
Late Evolution
No No No No No No No No No No No No
No No No No Yes Yes No No Yes Yes No No
Chronic Acute-chronic
Delayed function Immediate diuresis Immediate diuresis Immediate diuresis Delayed function Delayed function Delayed function Immediate diuresis Immediate diuresis Immediate diuresis Immediate diuresis Immediate diuresis
Transplantectomy Functioning kidney Functioning kidney Functioning kidney Transplanctectomy Functioning kidney Functioning kidney Functioning kidney Functioning kidney Functioning kidney Functioning kidney Functioning kidney
Acute-chronic Acute
Abbreviations: POP, post-operative pain; UTI, urinary tract infections.
Native Kidneys
No No No No No No No No No No No No
change change change change change change change change change change change change
2944
ureteroureterostomy. In 2003, Khoubehi and Williams16 reported that during a period of 21 years, 43 renal transplant recipients underwent ligation of the native ureter without nephrectomy, most of them as a secondary procedure for ureteral complications, such as obstruction, and some of them as a primary procedure due to a short donor ureter. Six of 278 patients underwent nephrectomy of the native kidney after ureteral ligation due to persistent pain.15,16 At the lateral end of the ureteroureterostomy, the ureters do not need to be ligated, and similarly, nephrectomy is not required if there is no evidence of vesicoureteral reflux at the pretransplantation evaluation. If ureteral reflux occurs into the native system beyond the level of the anastomosis, it is desirable and necessary to leave a double J stent when performing ureteroureterostomy. This report showed an initial experience with intravesical ligation of a refluxing native ureter without a simultaneous nephrectomy during renal transplantation of a cadaveric or living-related/-unrelated donor. This technique achieves complete elimination of the native refluxing ureter a condition that represents an advantage compared with pretransplantation procedures. If the reflux persists as a complication, it implies additional surgery until proper correction is obtained. Our technique avoids unnecessary pretransplantation surgeries and their complications to eliminate VUR in the recipient. For the patient and the surgical team, it represents an advantage to perform the correction of the native refluxing ureter and the kidney transplantation simultaneously. Depending on the surgical timing, intravesical ligation may be performed before or after the actual renal transplantation portion of the procedure. This technique avoids dissection of the perivesical ureter, which compromises bladder innervation when correcting vesicoureteral reflux before renal transplantation. Extraand intravesical ureteroneocystostomy with a transmural and submucosal tunnel in the simultaneously transplanted kidney implant is performed via a cystotomy. Implantation of the ureter near the native ureteral orifice facilitates endoscopic retrograde pyelography, ureteroscopy, or placement of double J ureteral stents when necessary in the postsurgical period. When an extravesical technique (LichGregoire) is used, the native refluxing ureter must be tied close to the uretero-vesical junction. The extravesical technique does not place the donor ureter in a normal anatomical fashion at the trigone, which makes it difficult or impossible to catheterize when any renal or urinary tract disease occurs in the transplanted kidney. In conclusion, this study described intravesical ligation of the recipient native ureter as a practical technique to eliminate vesicoureteral reflux in the native ureter discov-
GUZMAN
ered during a pretransplantation study, regardless of the degree and extent of urine production, simultaneously with donor kidney ureteral implantation (cadaveric or livingrelated or -unrelated) in a single surgical procedure. The technique was safe and free of postoperative mortality. Nephrectomy was not indicated because of the desire to maintain endocrine and metabolic functions of the kidney. ACKNOWLEDGMENT Thanks to Merileidy Plazas from the FUCS Research Division and Ana y Adriana Guzmán Ruiz.
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