TREATMENT OF TRANSPLANT URETERAL STENOSIS WITH ENDOURETEROTOMY

Vol. 161.412-414. February 19% Printed in U S A .

TREATMENT OF TRANSPLANT URETERAL STENOSIS WITH ENDOURETEROTOMY ERDAL ERTURK DANIEL T. BURZON

AND

DAVID WALDMAN

From the Departments of Urologic Surgery and Radwlogy, University of Rochester, Rochester, New York

ABSTRACT

Purpose: The safety and efficacy of treating renal transplant ureteral stenosis with the Acucise* endoureterotomy catheter are described. Materials and Methods: We treated 4 women and 3 men 31 to 63 years old (mean age 45) with Acucise endoureterotomyfor distal (6)and proximal (1)ureteral stenosis. Diagnosis was based on increasing serum creatinine and hydronephrosis on ultrasound, and confirmed by antegrade nephrostogram. One patient had recurrence and, therefore, 8 procedures were performed. Mean followup was 13 months (range 7 to 21). Results: Technical success was 100%.One patient had a recurrent stricture and was successfully re-treated. Of the patients 3 had chronic rejection and renal failure, and 4 had stable renal function. All ureters remain patent to date. Conclusions: Treatment of short ureteral stenosis with Acucise endoureterotomy in a renal transplant is safe and effective. Furthermore, it can be performed in an ambulatory setting with minimal morbidity. This procedure should be considered as the initial approach for distal ureteral stenosis in the transplanted kidney. Kcr WORDS: hydronephrosis,ureter, renal transplantation

TABLE1. Patient characteristics Ureteral complications following renal transplantation continue to cause significant morbidity.' Although the inciTimeto dence was recently reported to be decreasing, these compli- pt. -~ g e sex End Renal stenosis Disease (mos.) cations can lead to graft loss. Meticulous harvesting and transplantation technique with judicious use of steroids may T B - 6 3 - F 9 Refl~ Distalpartial 14 Unknown Distalpartial have contributed to the decline of ureteral complications.2 K A - 3 4 - M L P 4 0 M Congenitalmal- Distalpartial 192 Early recognition and treatment are critical for preserving formation kidney function. Similar survival rates have been reported A T - 3 1 - M Reflux DiataI complete 4 for grafts with or without ureteral complications when an GW - 54 - F Polycystic kidney Distal complete 3 120 aggressive approach has been used for diagnosis and treat- PS - 47 - F Diabetesmellitus Distalpartial ment.3 Classically surgery has been the preferred approach 0 s - 4 4 - F Hy~ertenaion proximalpar24 for the treatment of ureteral complications. Currently nontial invasive endourological techniques are being used more hquently for diagnosis and treatment.4 Short-term results in 3 patients treated with the Acucise endoureterotomy catheter TABLE 2. Pretreatment Drocedures have been previously reported.6 We report our results in 7 procedure patients treated with this balloon endoureterotomy techBalloon dilation nique.

k::

Percutaneous reestablishment of ureteral patency Ureteral reimplantation Uretemlithotomy Am&e endoureterotomv

PATIENTS AND METHODS

Between November 1995 and June 1997, 8 endoureterotomy procedures were performed on 3 men and 4 women 31 to 63 years old (mean age 45 years). Patient characteristics are summarized in table 1. These were select patients with ureteral stenosis less than 1 cm. All patients underwent

Ureteral Reimplant Tecbniaue

Extravesical Extravesical LeadbetterPolitano Extravesical Extravesical LeadbetterPolitano Extravesical

No. 4 2 1 1 1

ma10.7 to 1.1 mgJdl.1 and hydronephrosis on ultrasound. An antegrade nephrostogram was done in all cases to confirm cadaveric renal transplantation. One patient had a proximal the diagnosis and assess the exact nature of the stenosis. ureteral stenosis, while the remaining 6 had distal ureteral Rejection was ruled out by renal biopsy when appropriate. etenosis. Ureteral obstruction was partial in 5 and complete Technical properties of the Acucise catheter have been dein 2 patienta. Average interval to stenosis was 52 months scribed previously.6 The catheter comprises a low pressure 8 (range 3 to 192).Multiple procedures before endoureterotomy mm. balloon and 150 p.cutting wire outside the balloon. The included 4 balloon dilations that ultimately failed and re- balloon is placed into the ureter over a guide wire, positioned quired endoureterotomy (table 2). One patient had under- under fluoroscopy at the level of the stenosis and activated with gone ureteral reimplant, 1 ureterolithotomy and 1 balloon a surgical cutting current. While pressure is being applied to endoureterotomy. The 2 patients with complete obstruction the balloon, expansion of the stenotic area can be noted on required percutaneous reestablishment of the ureteral pa- fluoroscopy. All procedures were performed with the patient tency (part A of figure). under general anesthesia. Two treatments were performed Diagnosis was based on increasing serum creatinine (nor- retrograde with a cystoscope while 6 were performed antegrade from a previously placed nephrostomy access. Care Accepted for publication September 25, 1998. Applied Medical Systems, Laguna Hills, California. was taken to place the cutting wire anterior for distal ure412

TREATMENT OF TRANSPLANT URETERAL. STENOSIS WITH ENDOURETEROTOMY

413

A, complete occlusion of distal ureter. Catheter is filled with contrast material and passed down occluded ureter. Note soft tissue impression of distal and ureteral insertion site. B , small incision is made from ureter into bladder using Bugbee cutting wire seen within bladder C , following use of Acucise catheter 10F nontapered nephroureteral stent is placed.

teral stenosis. The only patient with proximal stenosis was evaluated with spiral computerized tomography for vascular anatomy and the cutting catheter was placed posterolateral safely. Four patients were treated as an ambulatory admission and 3 required 1-day hospitalization. Patients who underwent procedures through a nephrostomy tract were discharged home with a 10F nephroureteral stent, which was left to drain for 1week and then clamped. "he patients who underwent retrograde procedures had a 7F Double-J* ureteral stent inserted. These patients were discharged home with an indwelling Foley catheter for 1 week. Either a nephrostogram or retrograde pyelogram was performed between 6 and 8 weeks before catheter removal. Followup comprised serial ultrasound and monitoring of serum creatinine. RESULTS

Treatment results are summarized in table 3. All procedures resulted in successful dilation of the stenosis. Four patients maintained stable renal function. Two patients with graft failure and who required dialysis were lost to followup. One patient had renal failure secondary to chronic rejection. These 3 patients did not have any evidence of ureteral obstruction. One patient had re-stenosis a t 2 months requiring re-treatment. At 7-month followup the patient had stable renal function. The 4 patients with stable renal function had a mean serum creatinine of 2.7 mg./dl. (range 2.4 to 3.0) preoperatively and 1.5 mg./dl. (range 1.1 to 2.1) at followup. Followup ranged from 6 to 21 months (mean 13).There were no immediate surgical complications. One patient had gross hematuria following vigorous activity and required rehospitalization 1 week aRer the procedure for observation. There were no blood transfusions. DISCUSSION

The incidence of urological complications following renal transplantation can be as high as 10%.Ureteral obstruction

* Medical Engineering Corp., New York, New York.

~

TABLE3. Treatment results

- ~~~-

~

pt.

TB KA LP AT

or leakage comprises a significant portion of these problems. Ureteral ischemia is thought to be a major contributing factor. Surgical treatment has been the mainstay of management. Several procedures have been described and gained * However, azotemia and immunosuppreswide ac~eptance.~, sion in these patients postoperatively can lead to significant morbidity and m ~ r t a l i t y .lo ~ .Percutaneous management of obstructed transplant ureter was initially described by Barbaric and Thompson.ll Further studies have demonstrated the advantages of percutaneous techniques. These techniques were not only diagnostic but also able to salvage select transplants without further surgical intervention.12 A major advantage of a percutaneous approach is to control an acute situation for a later definitive procedure. These techniques have a n integral role in the treatment of renal transplant recipients. Furthermore, current techniques, such as ureteral stenting during transplantation can prevent ureteral complications.13 Recent reports revealed successful percutaneous antegrade endoluminal balloon dilation of transplant ureteral stenosis with success rates between 70 and 80%.14s15However, a critical study by Streem et a1 showed that only about 50% of the patients had long-term patency,16 and ureteral stenosis secondary to ischemia treated with balloon dilation tended to recur. High incidence of significant periureteral fibrosis was also a contributing factor. Rather than relying on ureteral rupture with multiple tears a clean linear cut of the ureter appears to be a more rational approach. Conrad et al reported that 82% of ureters incised with a cold knife had long-term success.17 These findings and the potential advantages of endoureterotomy led to our study. Other advantages of this procedure are that no sophisticated instruments are required to access the ureter, minimal manipulation of the ureter is performed, thus avoiding iatrogenic injuries and it can be performed as an outpatient procedure with local anesthesia. One of our patients noticed significant bladder spasm during activation of the cutting wire and had to be given general

Method Antegrade percutaneous) Antegrade Retrograde icystoscogic) Antegrade

Preop. Creatinine (mg./dl.)

Current Status/ Creatinine imgJdl.)

GraR Function

2.5 2.4 4.1 2.6

Chronic rejection (dialysis) 1.3 Rejection (dialysis) 4.9 Chronic rejection 1.1 2.1 1.8

Yes Yes No Yes

Absent Absent Absent Abaent

18 21 15 14

Yes Yes Yes I es

Absent Recurrence' Kecurrence'

16 7 6

2.7 Retrograde 2.8 Retrograde 3.0 0s Antegrade 3.0 Antegrade * Treated again and with antegrade technique at 7-month followup renal function was stable.

GW PS

Ureteral Obstruction

Absent

Followup (mo.)

4 14

TREATMENT OF TRANSPLANT URETERAL STENOSIS WITH ENDOURETEROTOMY

anesthesia. Careful placement of the cutting wire makes immediate complications remarkably low. The procedure can be done retrograde or antegrade. We prefer the antegrade approach because it is easier t o study the patients postoperatively to assess the patency of the ureter. If the incision is made in the distal ureter, the bladder is filled and the catheter can be visualized cystoscopically which allows for more precise location. The catheter size and duration of stenting were arbitrarily selected in our study. During endoureterotomy we did not see significant extravasation in any patient. However, the balloon waist at the site of obstructiordocclusion disappeared in all cases (part C of figure). We elected to place the urinary tract at complete external drainage for approximately 1 week. Technically the success rate was 100% with minimal morbidity. One patient had recurrence and was re-treated. All patients had patent ureters with a mean followup of 13 months. We recommend Acucise endoureterotomy as the initial treatment of transplant ureteral stenosis that is relatively short. Long-term studies are needed to establish its efficacy. CONCLUSIONS

Acucise endoureterotomy was evaluated in '7 patients for the treatment of ureteral complications in the transplanted kidney. Of the patients 6 had distal ureteral complications and 1 had proximal stenosis. All 7 patients were successfully treated. One patient was re-treated for recurrent stenosis. Mean followup was 13 months (range 6 to 21)with all ureters patent. Treatment of distal ureteral stenosis or occlusions in the transplanted kidney can be safely performed with Acucise endoureterotomy in an ambulatory setting with a significantly low morbidity. This procedure should be considered an initial approach for distal ureteral stenosis or occlusion in the transplanted kidney. REFERENCES

1. Mundy, A. R.,Podesty, M. L., Bewick, M., Rudge, C. J . and Ellis, F. G.: The urological complications of 1.000 renal transplants. Brit. J. Urol., 5 3 397,1981. 2. Shoskes, D. A,, Hanbury, D., Cranston, D. and Moms, P. J.: Urological complications in 1,OOOconsecutive renal transplant recipients. J. Urol., 153: 18,1995. 3. Kashi. S. H., Lodge, J . P. A,, Giles, G. R. and Irving, H. C.: Ureteric complications of renal transplantation. Brit. J. Urol., 70: 139. 1992. 4. Irving, H.'C. and Kashi, H. S.: Complications of renal transplan-

tation and the role of interventional radiology. J. Clin. Ultrasound, 2 0 545, 1992. 5. Youssef, H. I., Jindal, R., Babayan, R. J.. Carpinito, G. A,, Idelson, B. A,, Bernard, B. D. and Cho, S. I.: The Acucise catheter: a new endourological method for correcting transplant ureteric stenosis. Transplantation, 57: 1398,1994. 6. Chandhoke, P. S.,Claymen, R. V. and Stone, A. M.: Endopyelotomy and endoureterotomy with the Acucise ureteral cutting balloon device: preliminary experience. J. Endourol., 7: 45, 1993. 7. Jeffers, G.J., Cosimi, A. B., Delmonico, F. L., LaQuaglia, M. P., Russel, P. S. and Young, H. H., 11: Experience with pyeloureterostomy in renal transplantation. Ann. Surg., 196: 588,1982. 8. Greenburg, S. H., Wein, A. J., Perloff, L. J . and Barker, C. F.: Ureteropyelostomy and ureteroneocystostomy in renal transplantation: postoperative urological complications. J. Urol., 118: 17,1977. 9. Oosterhof, G. 0.N., Hoitsma, A. J., Witjes, J. A. and Debruyne, F. M.: Diagnosis and treatment of urologic complications in kidney transplantation. Urol. Int., 4 9 99,1992. 10.Kinnaert, P., Hall, M., Janssen, F., Vereerstraeten, P., Toussaint, C. and Van Geertuyden, J.: Ureteral stenosis after kidney transplantation: true incidence and long-term followup after surgical correction. J. Urol., 133 17,1985. 11. Barbaric, Z.L. and Thompson, K. R.: Percutaneous nephrostomy in the management of obstructed renal transplants. Radiology, 126 639,1978. 12. Lieberman, R. P., Glass, N. R., Crummy, A. B., Sollinger, H. W. and Belzer, F. 0.:Non-operative percutaneous management of urinary fistulas and strictures in renal transplantation. Surg., Gynec. & Obst., 155 667,1982. 13. Benoit, G., Blanchet, P., Eschwege, P., Alexandre, L., Bensadoun, H. and Charpentier, B.: Insertion of double pigtail ureteral stent for prevention of urological complication in renal transplantation: a prospective randomized study. J . Urol., 156: 881,1996. 14. Voegeli, D. R., Crummy, A. B., McDermott, J. C. and Jensen, S. R.: Percutaneous dilitation of ureteral strictures in renal transplant patients. Radiology, 169 185,1988. 15. Benoit, G.,Alexandre, L., Moukarzel, M., Yataghene, Y., Charpentier, B. and Jardin, A,: Percutaneous antegrade dilation of ureteral strictures in kidney transplants. J. Urol., 150 37,1993. 16. Streem, S.B., Novick, A. C., Steinmuller, D. R., Zelch, M. G., Risius, B. and Geisinger, M. A.: Long-term efficacy of ureteral dilation for transplant ureteral stenosis. J. Urol., 140 32, 1988. 17. Conrad, S.S., Schneider, A. W., Tenschert, W., Meyer-Melderhon, W. H. and Huland, H.: Endourological cold-knife incision for ureteral stenosis after renal transplantation. J. Urol., 152 906, 1994.