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The Ureter in Pediatric Renal Allotransplantation
T:m;
VoL
JOURNAL OF UJROLOGY
Dec em.he,~
Copyright © 1977 lby The Williams & Wilkins Co.
inUBA
MARTIN G. MCLOUGHLIN From the James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland
ABSTRACT
The urnteral v~,.,,,~,u~-~ of 26 renal The catastrophic events =•A'"""'"~'""U as an aggressive treatment i.s t1u.,.:,Yua,"'"""''"·· A total of 1,372 old has been done with the
~,,u,v,~•=
in children less than 16 years
United States. 1 This
graft from a cadaveric source. for hemorrhage was done.
has presented
MATERIAL
The:re were 20 children between received 26 renal 1norr<1·tt" from 17 cadaveric relatives. The survival is 48 per cent 1). The survival for 5 years is 62 per cent 2). There were 2 urete:ral
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MONTHS AFTER TRANS~1 LANTIHIOI\I Fm. L Over-all renal a!lograft survival followed more than 5 years.
CASE REPORTS
DISCUSSION
Accepted for ;;~~:"·;;.~t1v,. Current address: 855 W. 10th Ave., Suite
The
Golrurlfllbrna,
Columbia, renal Canada. 1041
1042
MCLOUGHLIN
Fm. 3. A, retrograde pyelogram demonstrates ureteral obstruction with hydronephrosis. B, IVP reveals good function and prompt drainage with no hydronephrosis. cent, with a mortality of 33 per cent, directly attributed to these complications. 2- 7 The etiology of these complications is varied and includes inflammation, rejection of the ureter and delayed wound healing in the uremic patient who is immunosuppressed. The observation that urinary extravasation results in poor graft survival rates is exemplified in case 1. 5 This patient, after undergoing multiple attempts to salvage the drainage system from the functioning renal graft, finally died of infection and septicemia. The rationale that early nephrostomy diversion and internal splinting may have resulted in salvage must be considered. The low incidence of extravasation in the pediatric graft population reviewed herein as compared to a recent review of the adult population is evident. 8 The small numbers reviewed do not provide any rationale to this difference but do provide insight into the fact that leakage of urine in the renal allotransplant in children is a catastrophic complication. Once diagnosis of extravasation has been ascertained an operation should be done immediately. If the transplant ureter is the site of leakage this should be tied off and reconstruction performed, using the recipient ureter with the transplant pelvis. The reconstructed ureteral pyelostomy can be splinted internally with a No. 8 feeding tube into the bladder that is removed 10 days postoperatively. If the primary reconstruction of the ureteral leak fails, necessitating re-exploration, reconstruction should be done but at this time a diverting nephrostomy should be placed. Surgical exploration for a bladder leak is facilitated by placement of a Foley catheter preoperatively. After identification of the leak and reconstruction the watertightness of the anastomosis can be diagnosed by infusion of sterile milk through the urethral catheter. 9 This prevents staining of the tissues and allows space for repeat infusions and inspection. Stringent use of antibiotic therapy and close scrutiny of the dosage of steroids infused could keep the incidence of secondary infection to a minimum. The presentation of ureteral obstruction 3 months after placement of a renal allograft in case 2 was a diagnostic dilemma. A retrograde pyelogram showed stenosis of the middle third of the transplant ureter. Sonography ruled out the possibility of a lymphocele obstructing this area of the ureter. Exploration revealed a stenotic segment with a dilated proximal and distal portion of the transplant ureter. The transplant ureter was removed and pathology indicated hyalinization of the vessels in the stenotic region. The remaining ureter was then anastomosed to the transplant pelvis with a ureteral pyelostomy using internal splinting with a No. 8
feeding tube. This feeding tube, which was removed from the bladder 10 days postoperatively, provided a means of internal diversion without external contamination. The patient recovered and was discharged from the hospital with a creatinine of 1.0 mg. per cent. The etiology of this middle third ureteral stenosis is speculative with hyalinization of the vessels producing the ischemic stenosis as a possibility. SUMMARY
The need to diagnose early ureteral complications of renal allotransplantation in children and manage them surgically immediately has been emphasized. The treatment of ureteral extravasation with primary reconstruction and internal splinting has been discussed. The need to divert proximally patients who have ureteral extravasation as a result of failure at reconstruction has been suggested. The treatment of obstruction with corrective operation and internal splinting also has been documented. REFERENCES
1. Advisory Committee to the Renal Transplant Registry: The 12th report of the Human Renal Transplant Registry. J.A.M.A., 233: 787, 1975. 2. Edelbrock, H. H., Riddell, H., Mickelson, J. C., Grushkin, C. M., Lieberman, E. and Fine, R. N.: Urological aspects of renal transplantation in children. J. Urol., 106: 934, 1971. 3. Barry, J. M., Lawson, R. K., Strong, D. and Hodges, C. V.: Urologic complications in 173 kidney transplants. J. Urol., 112: 567, 1974. 4. Martin, D. C., Mims, M. M., Kaufman, J. J. and Goodwin, W. E.: The ureter in renal transplantation. J. Urol., 101: 680, 1969. 5. Bewick, M., Collins, R. E. C., Saxton, H. M., Ellis, F. S., McColl, I. and Ogg, C. S.: The surgery and problems of the ureter in human renal transplantation. Brit. J. Urol., 46: 493, 1974. 6. Williams, G., Birtch, A. G., Wilson, R. E., Harrison, J. H. and Murray, J. E.: Urological complications of renal transplantations. Brit. J. Urol., 42: 21, 1970. 7. Marx, W. L., Halasz, N. A., McLaughlin, A. P. and Gittes, R. F.: Urological complications in renal transplantation. J. Urol., 112: 561, 1974. 8. Smolev, J. K., McLoughlin, M. G., Rolley, R., Sterioff, S. and Williams, G. M.: The surgical approach to urological complications in renal allotransplant recipients. J. Urol., 117: 10, 1977. 9. McLoughlin, M. G. and Williams, G. M.: Infusion of sterile milk to document watertight urothelial closure. Urology, 7: 525, 1976.
VoL
JOURNAL OF UJROLOGY
Dec em.he,~
Copyright © 1977 lby The Williams & Wilkins Co.
inUBA
MARTIN G. MCLOUGHLIN From the James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland
ABSTRACT
The urnteral v~,.,,,~,u~-~ of 26 renal The catastrophic events =•A'"""'"~'""U as an aggressive treatment i.s t1u.,.:,Yua,"'"""''"·· A total of 1,372 old has been done with the
~,,u,v,~•=
in children less than 16 years
United States. 1 This
graft from a cadaveric source. for hemorrhage was done.
has presented
MATERIAL
The:re were 20 children between received 26 renal 1norr<1·tt" from 17 cadaveric relatives. The survival is 48 per cent 1). The survival for 5 years is 62 per cent 2). There were 2 urete:ral
100\ _J
'~:\ 'if
C[
90-
=:) (I)
70-
> > 800:::
80~\
_J
70~ \ <( ~> 60 '~
f-
0.: ::i
f-
z 60 w
>
-
50
----
~ -
(fJ
f-
40-
50
C[
~----------
I
0.
10
20
__J
I
30
40
50
MONTHS J'.1FTER TRAI\JSPLMHi\TIOI\!
l.L
cc 30
Fm. 2. Over-all patient survival followed more than 5
20t
trol infection and :reverse the shock-like ~.,·-·0 •·m·-.~ the died. 2. E. J., a
10
0
10
20
30
40
::50
60
MONTHS AFTER TRANS~1 LANTIHIOI\I Fm. L Over-all renal a!lograft survival followed more than 5 years.
CASE REPORTS
DISCUSSION
Accepted for ;;~~:"·;;.~t1v,. Current address: 855 W. 10th Ave., Suite
The
Golrurlfllbrna,
Columbia, renal Canada. 1041
1042
MCLOUGHLIN
Fm. 3. A, retrograde pyelogram demonstrates ureteral obstruction with hydronephrosis. B, IVP reveals good function and prompt drainage with no hydronephrosis. cent, with a mortality of 33 per cent, directly attributed to these complications. 2- 7 The etiology of these complications is varied and includes inflammation, rejection of the ureter and delayed wound healing in the uremic patient who is immunosuppressed. The observation that urinary extravasation results in poor graft survival rates is exemplified in case 1. 5 This patient, after undergoing multiple attempts to salvage the drainage system from the functioning renal graft, finally died of infection and septicemia. The rationale that early nephrostomy diversion and internal splinting may have resulted in salvage must be considered. The low incidence of extravasation in the pediatric graft population reviewed herein as compared to a recent review of the adult population is evident. 8 The small numbers reviewed do not provide any rationale to this difference but do provide insight into the fact that leakage of urine in the renal allotransplant in children is a catastrophic complication. Once diagnosis of extravasation has been ascertained an operation should be done immediately. If the transplant ureter is the site of leakage this should be tied off and reconstruction performed, using the recipient ureter with the transplant pelvis. The reconstructed ureteral pyelostomy can be splinted internally with a No. 8 feeding tube into the bladder that is removed 10 days postoperatively. If the primary reconstruction of the ureteral leak fails, necessitating re-exploration, reconstruction should be done but at this time a diverting nephrostomy should be placed. Surgical exploration for a bladder leak is facilitated by placement of a Foley catheter preoperatively. After identification of the leak and reconstruction the watertightness of the anastomosis can be diagnosed by infusion of sterile milk through the urethral catheter. 9 This prevents staining of the tissues and allows space for repeat infusions and inspection. Stringent use of antibiotic therapy and close scrutiny of the dosage of steroids infused could keep the incidence of secondary infection to a minimum. The presentation of ureteral obstruction 3 months after placement of a renal allograft in case 2 was a diagnostic dilemma. A retrograde pyelogram showed stenosis of the middle third of the transplant ureter. Sonography ruled out the possibility of a lymphocele obstructing this area of the ureter. Exploration revealed a stenotic segment with a dilated proximal and distal portion of the transplant ureter. The transplant ureter was removed and pathology indicated hyalinization of the vessels in the stenotic region. The remaining ureter was then anastomosed to the transplant pelvis with a ureteral pyelostomy using internal splinting with a No. 8
feeding tube. This feeding tube, which was removed from the bladder 10 days postoperatively, provided a means of internal diversion without external contamination. The patient recovered and was discharged from the hospital with a creatinine of 1.0 mg. per cent. The etiology of this middle third ureteral stenosis is speculative with hyalinization of the vessels producing the ischemic stenosis as a possibility. SUMMARY
The need to diagnose early ureteral complications of renal allotransplantation in children and manage them surgically immediately has been emphasized. The treatment of ureteral extravasation with primary reconstruction and internal splinting has been discussed. The need to divert proximally patients who have ureteral extravasation as a result of failure at reconstruction has been suggested. The treatment of obstruction with corrective operation and internal splinting also has been documented. REFERENCES
1. Advisory Committee to the Renal Transplant Registry: The 12th report of the Human Renal Transplant Registry. J.A.M.A., 233: 787, 1975. 2. Edelbrock, H. H., Riddell, H., Mickelson, J. C., Grushkin, C. M., Lieberman, E. and Fine, R. N.: Urological aspects of renal transplantation in children. J. Urol., 106: 934, 1971. 3. Barry, J. M., Lawson, R. K., Strong, D. and Hodges, C. V.: Urologic complications in 173 kidney transplants. J. Urol., 112: 567, 1974. 4. Martin, D. C., Mims, M. M., Kaufman, J. J. and Goodwin, W. E.: The ureter in renal transplantation. J. Urol., 101: 680, 1969. 5. Bewick, M., Collins, R. E. C., Saxton, H. M., Ellis, F. S., McColl, I. and Ogg, C. S.: The surgery and problems of the ureter in human renal transplantation. Brit. J. Urol., 46: 493, 1974. 6. Williams, G., Birtch, A. G., Wilson, R. E., Harrison, J. H. and Murray, J. E.: Urological complications of renal transplantations. Brit. J. Urol., 42: 21, 1970. 7. Marx, W. L., Halasz, N. A., McLaughlin, A. P. and Gittes, R. F.: Urological complications in renal transplantation. J. Urol., 112: 561, 1974. 8. Smolev, J. K., McLoughlin, M. G., Rolley, R., Sterioff, S. and Williams, G. M.: The surgical approach to urological complications in renal allotransplant recipients. J. Urol., 117: 10, 1977. 9. McLoughlin, M. G. and Williams, G. M.: Infusion of sterile milk to document watertight urothelial closure. Urology, 7: 525, 1976.