Pyelovesicostomy as a Form of Urinary Reconstruction in Renal Transplantation

0022-534 7/86/1362-0372$02.00/0 Vol. 136, August

THE JOURNAL OF UROLOGY

Printed in U.S.A.

Copyright© 1986 by The Williams & Wilkins Co.

PYELOVESICOSTOMY AS A FORM OF URINARY RECONSTRUCTION IN RENAL TRANSPLANTATION JACOB RAJFER,* MARTIN A. KOYLE, RICHARD M. EHRLICH

AND

ROBERT B. SMITH

From the Division of Urology, Department of Surgery, UCLA School of Medicine, Harbor-UCLA Medical Center and Center for Health Sciences, Los Angeles, California

ABSTRACT

The development of ureteral obstruction or ureteral fistula formation in the renal transplant recipient usually requires surgical repair. This involves reconnecting the donor ureter to either the recipient ureter (ureteroureterostomy) or bladder (ureteroneocystostomy), or creating an anastomosis between the renal pelvis and recipient native ureter (pyeloureterostomy). Occasionally, the donor or recipient ureter is absent, necrotic or diseased so that a ureteroureterostomy, ureteroneocystostomy or pyeloureteral anastomosis cannot be performed. In 8 such cases we have performed a direct anastomosis between the donor renal pelvis and recipient bladder (pyelovesicostomy) with a followup of between 2 months and 11 years. In all 8 patients there has been no deterioration in renal function attributed to obstruction at the anastomotic site or to the free reflux between the bladder and renal pelvis. Because of the excellent shortterm and long-term results of pyelovesicostomy, this procedure should be considered as an excellent alternative to pyeloureterostomy, ureteroureterostomy and ureteroneocystostomy in the reconstruction of the upper urinary tract of the renal transplant patient. Urological complications of renal transplantation have been reported to occur in up to a third of the patients. 1-a The majority of these urological complications involve ureteral obstruction or urinary fistulas of either the bladder, ureter or renal pelvis. Obstruction to the ureter usually occurs secondary to either retroperitoneal fibrosis, lymphocele formation, high reimplantation on the dome of the bladder or a compromised ureteral vascular supply. The development of a urinary fistula is believed to be owing to either a compromised blood supply that occurs at the time of organ harvesting or, occasionally in the case of a vesical fistula, poor surgical technique in approximating the cystotomy. 4 - 6 In a small percentage of patients with either upper urinary tract obstruction or a fistula the entire donor ureter is diseased and cannot be used to correct the problem. While pyeloureteral anastomosis is the standard procedure of choice in such a situation if the recipient ureter is present, 7 our experience with 8 cases using the recipient bladder to bridge the ureteral defect (pyelovesicostomy) suggests that this may be an excellent alternative to pyeloureterostomy.

allow the dome of the bladder to reach the donor renal pelvis without tension. The dome of the bladder then is incised to a length similar to the opening in the renal pelvis and nonabsorbable sutures are used to create a watertight anastomosis between the bladder and the renal pelvis. If the bladder cannot reach the donor renal pelvis easily a flap of bladder wall similar to a Boari flap can be created to bridge the gap between the bladder and the renal pelvis. The bladder is not anchored to any part of the body wall, as is done in the standard psoas hitch procedure, because the kidney lies on top of the psoas muscle where these anchoring sutures normally are placed. A nephrostomy tube usually is left indwelling to provide proximal urinary drainage while a urethral catheter is always used for distal drainage. If used, internal stents are removed 6 to 8 weeks after pyelovesicostomy. The external catheters (urethral and/or nephrostomy) are removed after satisfactory healing of the anastomosis has been demonstrated by either cystography or a nephrostogram. RESULTS

MATERIALS AND METHODS

The medical records of more than 400 patients who underwent renal transplantation between January 1970 and December 1985 at the UCLA Medical Center, and between January 1980 and December 1985 at the Harbor-UCLA Medical Center were reviewed. Following transplantation 8 patients underwent a pyelovesicostomy to relieve either total obstruction or necrosis of the donor ureter and/or renal pelvis. These 8 charts then were abstracted for age and sex of the patient, whether a cadaveric or living related kidney was transplanted, anatomy of the recipient urinary tract, time between transplant and pyelovesicostomy and followup (serum creatinine and cystography) of the pyelovesicostomy. A pyelovesicostomy was defined as the anastomosis between the donor renal pelvis and recipient bladder using the intact bladder wall itself (7 patients) or the creation of a Boari flap from the anterior wall of the bladder (1 patient). The procedure is performed by mobilizing the bladder as much as possible to Accepted for publication March 31, 1986. * Requests for reprints: Division of Urology, Box 5, Harbor-UCLA Medical Center, 1000 W. Carson St., Torrance, California 90509. 372

The ages, gender and type of transplant (cadaveric or living related) of the 8 patients who underwent a pyelovesicostomy are listed in the table. Only patient 2 had undergone bilateral nephrectomy before renal transplantation. In 6 patients the graft was placed in the right iliac fossa and in 2 it was placed in the left fossa. Of the kidneys 6 were harvested from cadavers and 2 were from living related donors. A pyelovesicostomy was the primary reconstructive procedure performed in 6 patients following renal transplantation. In case 4 the pyelovesicostomy was performed as a salvage procedure after a pyeloureteral anastomosis had been done for total ureteral obstruction, and in case 2 ureteroneocystostomy had been performed for ureteral stenosis. In these latter 2 patients the original surgical procedures (pyeloureterostomy and ureteroneocystostomy) failed to correct the ureteral obstruction. The decision to perform a pyelovesicostomy was based on whether the recipient ureter was absent (case 2) or if it had been used previously (case 4), the renal pelvis was totally or partially necrotic and a pyeloureterostomy could not be performed adequately (cases 1, 7 and 8), and the surgeon's choice of reconstructing the ureteral defect (cases 3, 5 and 6).

PYELOVES1COST0iit1Y

373

REI"{P'~L TRANSPLANTATIOr,J

Summary of 8 patients who underwent pyelouesicostomy after renal transplantation Pt. -Sex-Age No. l-M-37 2-F-59 3-M-39 4-M-44

5-F-27 6-M-61 7-F-28 8-M-31

rrransplant

Pathological Condition of Ureter

Cadaveric Cadaveric Living related Cadaveric Cadaveric Cadaveric Living related Cadaveric

Necrosis Obstruction Obstruction Obstruction Obstruction Necrosis Necrosis Necrosis

Followup of Pyelovesicostomy (mos.)

Serum Creatinine at Last Followup (mg./dl.)

26

1.2 3.0

8

140 38 9 7 5 2

1.3

1.4 1.2 2.3 1.3 1.7

Date of Transplantation

Date of Pyelovesicostomy

6/20/83 1/13/76 6/17/70 9/30/81 12/2/84 4/26/85 5/20/85 11/11/85

7/2/83 2/27/85* 1/74 9/22/82t 2/24/85 4/30/85 5/31/85 11/26/85

* Ureteroneocystostomy done on November 30, 1981. t Pyeloureterostomy done on November 30, 1981.

FIG. 2. Patient 6. Cystogram after pyelovesicostomy for ureteral necrosis shows free reflux.

FIG. 1. Patient 2. Cystogram after pye!ovesicostomy for long-standing ureteral obstruction.

which ranged between 2 months and 11 demonstrated between the bladder and renal all 8 patients 1 to None of the 8 n»,n<>·nrn in our series the grafts. In 7 who had undergone pyelovesicostomy has patients the creatinine was between 1.2 and 2.0 mg./dl. In patient 2, in whom obstruction resulted from total ureteral stenosis, preoperative creatinine was 5.3 mg./dl. and postoperative creatinine at 1 year was 3.0 mg./dl. DISCUSSION

Total obstruction or necrosis of the donor ureter is a rare complication of renal transplantation. In such cases continuity between the donor renal pelvis and recipient bladder must be established. The most common method of rectifying such a problem is via pyeloureterostomy. 1 However, in certain patients the recipient ureter may not be present or it may be diseased such that it cannot be used without jeopardizing the graft. Furthermore, pyeloureterostomy is not a simple procedure to perform in a transplant patient and it is associated with a somewhat significant failure rate. 1 In these instances use of the bladder to bridge the gap between the upper and lower urinary

tract must be considered. Our success in 8 patients in whom a pyelovesicostomy was performed to bridge this gap has con vinced us that this is the procedure of choice in these selected cases. Pyelovesicostomy was first described in 1973 by Herwig and Konnak who used this procedure in 2 patients who had received living related grafts. 8 In 1 patient a previous pyeloureterostomy had failed to provide adequate upper tract drainage. While both patients had normal renal function at the time of the report, only 1 was followed for more than 1 year. In 1975 Lindstedt and associates reported normal renal function 33 months later in a patient who had received a cadaveric kidney and had a pyelovesicostomy performed for total ureteral necrosis. 9 In 1983 Toguri and associates described a patient who had received a cadaveric graft and underwent this procedure because of ureteral necrosis, and renal function was normal 18 months later. 10 These initial cases attest to the efficacy of this procedure in renal transplantation. In addition to these 4 renal transplant patients, pyelovesicostomy also has been reported in patients with normal renal function who had had the entire ureter removed as a result of other urological diseases. Pettersson and associates first described use of this procedure in a patient with multiple urothelial tumors of the renal pelvis and ureter who underwent total ureterectomy because of the primary disease. 1 1.1 2 Urinary continuity was established by renal autotransplantation and pyelovesicostomy, which allowed for direct visualization of the renal pelvis by cystoscopy to monitor the remaining urothelium. These same investigators used the procedure in patients with obstruction to the ureteropelvic junction following pyeloplasty 13 and in those with recurrent renal calculi so that spontaneous passage of the calculi into the bladder could occur. 14 Pyeloves-

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RAJFER AND ASSOCIATES

FIG. 3. Patient 4. A, nephrostogram shows bifid collecting system with ureteral obstruction after pyeloureteral anastomosis that subsequently re-stenosed. B, cystogram after pyelovesicostomy demonstrates reflux. C, excretory urogram 6 months after pyelovesicostomy reveals almost normal upper tracts.

icostomy also has been used in primary reconstruction of the ureteropelvic junction in ectopic pelvic kidneys with an obstructed ureteropelvic junction. 15 The success of pyelovesicostomy like any other surgical procedure is measured in part by its complication rate. In the renal transplant population the pyelovesicostomy should not be prone to strictures at the anastomotic site and the free reflux that occurs as a result of the procedure should not impair renal function. In our series and in a review of the literature postoperative stricture at the anastomotic site has not been reported. This is most likely owing to the fact that there is a wide anastomosis between the bladder and the renal pelvis, 2 structures each with an excellent vascular supply. In our patient 7, because of obvious necrosis of the ureter and renal pelvis, the bladder was anastomosed close to the infundibula of the calices, which also visually appeared, and was necrotic on biopsy. Nevertheless, 3 months later a successful anastomosis was seen on cystography. For diverting the urine a nephrostomy tube 16· 17 was used in 7, while all 8 patients had a urethral catheter post-pyelovesicostomy. Once internal stents became commercially available they were used in addition to the nephrostomy and urethral catheters. The external catheters were removed after healing of the anastomosis was demonstrated. If used, the internal stent was removed cystoscopically 6 to 8 weeks later. In cases 6 and 8 healing of the anastomosis took approximately 4 weeks, and all catheters and stents were left in until that time. However, in most patients the anastomosis healed completely by 2 weeks. Pyelovesicostomy may be performed through the original transplant incision, particularly in the early post-transplant period when adhesions to the kidney are minimal. In the late post-transplant period the procedure may be accomplished much easier through an intra-abdominal approach, since not only the renal pelvis but also the bladder is identified easily. Preoperatively, it is important to know whether the donor kidney was a native left or right kidney, since knowledge of where the renal pelvis lies will facilitate its identification. Reflux following renal transplantation has always been considered a potential cause of graft failure since the report of Mathew and associates, who demonstrated in patients with vesicoureteral reflux an increased rate of graft failure with specific glomerular changes in these grafts. 18 In patients with a pyelovesicostomy there is additional reason for concern because the reflux in all such patients should be of the high pressure type, which is believed to be detrimental to the kidney. How-

ever, Danforth and associates demonstrated in the dog that 1 year after renal autotransplantation and pyelovesicostomy there was no significant impairment in renal function as measured by inulin clearance and para-aminohippuric acid transport.19 Ranch and associates evaluated 20 humans who had undergone this procedure for either urothelial cancer, recurrent obstruction following conventional pyeloplasty or passage of recurrent calculi, and found no change in the urinary flow rate or any clinically significant disturbance to the sensory and motor function of the bladder. 20 There was an insignificant increase in the residual urine of these patients but none had a reduction in functional bladder capacity. Since the pyelovesicostomy none of our 8 patients has experienced graft failure and none has had diminution in renal function that could be ascribed to the effects of reflux on the graft. Indeed, on cystography and/or antegrade pyelography there has been no demonstration of an increase in the size of the renal calices from the pre-pyelovesicostomy status. In addition to pyelovesicostomy with or without a Boari bladder flap, calicovesicostomy and ureterocalycostomy, which is the anastomosis between a lower pole renal calix and with the bladder or ureter, respectively, also have been reported to be efficacious in establishing urinary continuity in the renal transplant recipient with loss of a major part of the ureter. 21 ·22 We believe that these latter 2 procedures should be reserved for those patients whose renal pelvis is inaccessible as a result of a previous operation or if the kidney has been put into the ipsilateral iliac fossa, in which case the renal pelvis is posterior and may be difficult to reach. In summary, pyelovesicostomy appears to be an excellent alternative to pyeloureterostomy in the renal transplant recipient with total ureteral necrosis or obstruction. With proximal and distal urinary drainage, healing of the anastomosis appears to be universal. Despite the presence of urinary reflux following the procedure, there does not appear to be any functional, anatomical or physiological complications that would warrant not using this procedure more often in the difficult reconstructive cases in which the donor and/or recipient ureter is diseased. REFERENCES

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