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Ureteropyelostomy and Ureteroneocystostomy in Renal Transplantation: Postoperative Urological Complications
THE JOURNAL OIF UROLOGY
Vol. 118, July, Part l Printed in U.S.A.
Copyright © 1977 by The Williams & Wilkins Co.
URETEROPYELOSTOMY AND URETERONEOCYSTOSTOMY IN RENAL TRANSPLANTATION: POSTOPERATIVE UROLOGICAL COMPLICATIONS STANLEY H. GREENBERG, ALAN J. WEIN, LEONARD J. PERLOFF
AND
CLYDE F. BARKER
From the Division of Urology, Department of Surgery, University ofPennsylvania School of Medicine, the Renal Transplant Service, Hospital of the U niuersity of Pennsylvania, and the Veterans Administration Hospital, Philadelphia, Pennsylvania
ABSTRACT
Ureteropyelostomy offers a suitable alternative to ureteroneocystostomy as a primary method of urinary reconstruction after renal transplantation. In a total of 108 such procedures 12 urological complications occurred. 1 patient had graft loss directly attributable to these complications. ~·v"'"''·vu., complications after renal transplantation are a common source of morbidity and mortality. U reteroneocystostomy has become the preferred method of urinary tract reconstruction in transplant recipients because of the relatively low incidence of postoperative fistula formation and urinary obstruction. 1- 11 In a communication we reported a favorable experience with the use of ureteropyelostomy in renal transplantation. 12 Herein we present our results with ureterove11osw1nv and ureteroneocystostomy, and compare them to literature.
Late ureteral obstruction at the anastomotic site occurred in 2 additional patients (1.9 per cent) and both required a dis-
membered pyeloplasty, 5 and 30 months postoperatively. Although 1 of these repairs was complicated by a postoperative fistula that required cystoscopic placement of a ureteral stent both were successful ultimately. Another patient had late ureteral obstruction secondary to the formation of a lymphocele, which was managed successfully by internal drainage. Only 1 graft was lost because of early or late complications attributable to ureteropyelostomy and no deaths attributable to this procedure occurred. U reteroneocystostomy. Fistulas developed postoperatively in 3 of the 47 patients (6.4 per cent). One of these, an anterior vesicocutaneous fistula, closed after a week of Foley catheter drainage. Two fistulas originating at the site of reimplantation were closed successfully by repeat reimplantation in 1 case and by ureteropyelostomy using the recipient ureter in the other. Early postoperative obstruction at the ureterovesical junction occurred in 3 patients (6.4 per cent). Two grafts were salvaged by ureteropyelostomy and repeat reimplantation was successful in the third case. Two other patients had early radiologic evidence of partial ureterovesical junction obstruc·· tion, which resolved spontaneously. No instances of late obstruction directly attributable to the ureteroneocystostomy have been noted to date. One patient had late obstruction secondary to a lymphocele, which was drained internally with a good result. No grafts were lost and no patients died because of complications directly attributable to the ureteroneocystostomy.
METHODS
Of 155 renal transplantations performed between February 1966 and October 1975, 111 were subsequent to our original in 1972. The initial method of urinary tract reconstruction was ureteropyelostomy in 108 cases and ureteroneocystosin 47 cases. Ureteropyelostomy was performed according described previously. 12 The anastomosis was 2 rows of continuous 5-zero chromic catgut suture: 1 anterior and 1 posterior. No stent or nephrostomy was used. The bladder was drained a Foley catheter for 24 hours and retroperitoneal hernovac suction drainage was used. Ureteroneocystostomy was done with a modification of the technique. A ureteral stent was not used routinely. A catheter was left indwelling for 48 to 72 hours and retrohemovac suction drainage was used. RESULTS
Postoperative anastomotic leakage deve1,uu,eu in 9 of the 108 patients (8.3 per cent) who underwent ureteropyelostomy (table 1). In case 7 no site of extravasation could be demonstrated radiographically and spontaneous closure occurred. surgical intervention was required in the other 8 cases. In case 5 a cystoscopically placed silicone ureteral stent was successful but in case 6 this approach failed and 2 explorations with revision or reanastomosis and p1c,cemEm1 of a stent were necessary before complete closure occurred. The site of the leakage was not apparent at in case 2 and a ureteral stent was used successusing the contralateral ureter was nPrtorrriPrl i.n cases 3 9. In case 3 subsequent sepsis and failure necessitated nephrectomy but in case 9 complete occurred. The other 3 patients with fistulas underwent reanastomosis or revision of the anastomosis with good results.
COMMENT
Because urological complications in the typically debilitated renal transplant recipient who is on immunosuppresssion may have disastrous sequelae, it is important to know the incidence of such complications associated with each type of urinary reconstruction. The over-all incidence of urological complications in recently reported series has ranged from 0.9 to 26 per cent and mortality rates attributed to these complications have ranged from Oto 20 per cent (table 2). 1-1s Starzl and associates reported over-all complication rates that were rela-tively constant for both types of urinary reconstructive procedures. 1 Specific complications are more variable. Urinary fistulas are more common with ureteropyelostomy, whereas ureteral obstruction and ureteral slough occur more frequently with reimplantation procedures (table 2). Several authors have reported an extremely low incidence of all types of complications after ureteroneocystostomy.2· 12 Although a slightly higher complication rate has been reported by most other investigators this procedure is still preferred to
for publication November 12, 1976. at annual meeting of Mid-Atlantic Section, American UroAssociation, Dorado Beach, Puerto Rico, September 261, 1976.
17
18
GREENBERG AND ASSOCIATES TABLE
1. Ureteropyelostomy: patients with urinary fistulas
Day of Onset Donor
Case No. 1
2 3 4 5
6
7 8
9
Treatment Diuresis
Fistula
Relative Relative Relative Relative Cadaver Cadaver
1 1 30 1 1 10
4 2 30 14 14 15
Cadaver Relative Relative
1 1 1
1 1 1
TABLE
Rsult
Exploration, reanastomosis
Exploration, ureteral stent Exploration, transureteropyelostomy Exploration, revision anastomosis, ureteral stent U reteral stent Ureteral stent Exploration, reanastomosis, ureteral stent Exploration, revision anastomosis, nephrostomy, ureteral stent Observation Exploration, reanastomosis, nephrostomy, ureteral stent Exploration, transureteropyelostomy
Sequelae of Complications (%)
No. Pts. Obstruction
Leak or Fistula Starzl and associates' Belzer and associates 2 Weil and associates 3 Malek and associates' Bewick and associates' Salvatierra and associates'; Marx and associates' Colfry and associates 8 Barry and associates" Konnak and associates 10 Donohue and associates" Leary and associates 12 Holden and associates 13 Present series
Closure, 2 wks. Closure, 1 wk. Closure, 4 wks.
2. Ureteroneocystostomy and ureteropyelostomy: postoperative urological complications Complications (%)
Reference
Closure, immediate Closure, 1 wk. Failure, nephrectomy Closure, 6 wks. Closure, 2 wks. No improvement No improvement Closure, 6 wks.
178 220 118 93 196 540 85 125 172 170
88 221 141 47
U reteroneocystostomy 1. 7 5.1 1.8 1.4 4.3 7.1 0.6 2.0 8.8 4.7 1.8 0 0.5 5.7 6.4
Total*
0 5.1
9.0 5.0 2.5 6.5 13.3
0 3.2 0.6 1.8 0 0.5 2.8 6.4
3.5 12.0 8.1 7.0 3.4 0.9 13.5 15.0
0 0 0 1.9
12.5 25.7 11.4 11.7 7.9 11.1
Graft Lo3st
0.9 2.1
0
Mortalityt 1. 7 0 0 1.0 4.0
1.7
0 3.2 0.6
3.4 0.5 2.1 0
0 0 1.4 0
Ureteropyelostomy
Starzl and associates 1 Weil and associates 3 Donohue and associates 1 ' Leiter and associates 14 Whelchel and associates 15 Present series
56 70 44 43 114 108
10.7 11.4
11.7 7.9 8.3
3.6 20.0 6.8 4.7 2.6 0.9
2.3 0.9 0
* Includes extravasation, fistula, obstruction, lymphocele, ureteral slough, ureteral obstruction owing to angulation or fibrosis and hemorrhage related to the urinary reconstruction.
t
Occurring as a direct result of complications related to the urinary reconstruction.
ureteropyelostomy because it requires less technical finesse, leaves more options open for a secondary reconstruction of the urinary tract (should this be necessary) and does not require a nephrectomy in the recipient prior to transplantation. On the other hand, with ureteropyelostomy no bladder incision or dissection is required, a shorter period of catheter drainage is necessary, there is a lower incidence of anastomotic obstruction and ischemic complications involving the distal ureter, and retrograde ureteral catheterization for diagnostic or therapeutic purposes is easier. The prognosis for the transplant recipient with a postoperative urinary fistula has become more positive than earlier reports indicated. 14- 17 Advocates of immediate surgical intervention18 and those who have had success with conservative managementrn, 17 stress the importance of adequate drainage of the wound and of the urinary tract itself, either by an intraluminal stent or by nephrostomy. In our experience the decision to undertake an early surgical exploration and attempt an anastomotic revision is best dictated by the severity of the leakage and the other exigencies of the specific clinical situation. Although some grafts can be saved only by secondary urinary tract reconstruction, as long as the surgical wound and the urinary tract are properly drained and uninfected, many fistulas will heal within a reasonable interval with conservative management. In our series the rate of graft loss directly attributable to complications ofureteropyelostomy, 0.9 per cent, was slightly lower than those reported by other centers using this tech-
nique (table 2) and compares favorably to that associated with ureteroneocystostomy. Therefore, although ureteroneocystostomy remains the preferred method of initial urinary reconstruction in most transplantation centers, we believe that ureteropyelostomy can be a satisfactory alternative. In addition, it should be familiar to all transplant surgeons as a technique of secondary reconstruction in patients with major urological complications after ureteroneocystostomy. REFERENCES
1. Starzl, T. E., Groth, C. G., Putnam, C. W., Penn, I., Halgrim-
2. 3.
4. 5.
6.
son, 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. Belzer, F. 0., Kountz, S. L., Najarian, J. S., Tanagho, E. A. and Hinman, F., Jr.: Prevention of urological complications after renal allotransplantation. Arch. Surg., 101: 449, 1970. 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. Malek, G. H., Uehling, D. T., Daouk, A. A. and Kisken, W. A. Urological complications of renal transplantation. J. Urol., 109: 173, 1973. Bewick, M., Collins, R. E. C., Saxton, H. M., Ellis, F. G., McColl, I. and Ogg, C. S.: The surgery and problems of the ureter in human renal transplantation. Brit. J. Urol., 46: 493, 1974. Salvatierra, 0., Jr., Kountz, S. L. and Belzer, F. 0.: Prevention of ureteral fistula after renal transplantation. J. Urol., 112:
URINARY RECONSTRUCTION IN TRANSPLANTATION
445, 1974. '7. Marx, W. L., Halasz, N. A, "'"·~~~"UHH, A. P. and Gittes, R. F.: ·-·-·--·v-· complications in transplantation. J. Urol., 1974. E. S. and McDonald, 8. A. J. transplantation. J.
14.
15.
9. Barry
1
Lawson, R. K., Strong, D. and Hodges, C. V.: cu1uµ,11c,u.,v1.tb in 173 kidney transplants. J. Urol., 16.
10.
R. Finkbeiner, A., Turcotte, J. G. D. ~·vtrcmoci ureteroneocystostomy in 170 -·····~···-·· patients. J. Urol., 113: 299, 1975. ., Hostetter, M., J. and Madura, J.: Ure-
17.
cv1.uu•mrnc"-' 1n
12. Leary, F. J., Woods, lems in renal 13. Holden, S., O'Brien,
18.
19
Walton, K. N.: Urologic complications in renal transplantation. Urology, 5: 182, 1975. Leiter, E., Kim, K. H., Glabman, 8., Haimov, M., Burrows, L. and Brendler, H.: Urinary reconstruction anastomosis in human renal transplants. J. 1973. Whelchel, D. J., Cosimi, A. B., Young, H. H., II and Russell, P. S.: Pyeloureterostomy reconstruction in human renal transplantation. Ann. Surg., 181: 61, 1975. Mrnrehouse, D. D., Macramalla, E. A., Guttmann, R. D., Beau· doin, J-G., Farrer, P.A. and MacKinnon, K. J.: The conservative management of urinary fistulas following renal allografts. J. Urol., 110: 1973. Desai, 8. G., McRoberts, W., Hellebusch, A. A. and Luke, G.: Conservative non-operative management of ureteral fistulas following renal allografts. J. Urol., 112: 572, 1974. Hoch, W. H., Kest, L., Cohen, S., Newmark, K. and Supravesical urinary fistulas after transplantation. Gynec. & Obst., 139: 82, 1974.
Vol. 118, July, Part l Printed in U.S.A.
Copyright © 1977 by The Williams & Wilkins Co.
URETEROPYELOSTOMY AND URETERONEOCYSTOSTOMY IN RENAL TRANSPLANTATION: POSTOPERATIVE UROLOGICAL COMPLICATIONS STANLEY H. GREENBERG, ALAN J. WEIN, LEONARD J. PERLOFF
AND
CLYDE F. BARKER
From the Division of Urology, Department of Surgery, University ofPennsylvania School of Medicine, the Renal Transplant Service, Hospital of the U niuersity of Pennsylvania, and the Veterans Administration Hospital, Philadelphia, Pennsylvania
ABSTRACT
Ureteropyelostomy offers a suitable alternative to ureteroneocystostomy as a primary method of urinary reconstruction after renal transplantation. In a total of 108 such procedures 12 urological complications occurred. 1 patient had graft loss directly attributable to these complications. ~·v"'"''·vu., complications after renal transplantation are a common source of morbidity and mortality. U reteroneocystostomy has become the preferred method of urinary tract reconstruction in transplant recipients because of the relatively low incidence of postoperative fistula formation and urinary obstruction. 1- 11 In a communication we reported a favorable experience with the use of ureteropyelostomy in renal transplantation. 12 Herein we present our results with ureterove11osw1nv and ureteroneocystostomy, and compare them to literature.
Late ureteral obstruction at the anastomotic site occurred in 2 additional patients (1.9 per cent) and both required a dis-
membered pyeloplasty, 5 and 30 months postoperatively. Although 1 of these repairs was complicated by a postoperative fistula that required cystoscopic placement of a ureteral stent both were successful ultimately. Another patient had late ureteral obstruction secondary to the formation of a lymphocele, which was managed successfully by internal drainage. Only 1 graft was lost because of early or late complications attributable to ureteropyelostomy and no deaths attributable to this procedure occurred. U reteroneocystostomy. Fistulas developed postoperatively in 3 of the 47 patients (6.4 per cent). One of these, an anterior vesicocutaneous fistula, closed after a week of Foley catheter drainage. Two fistulas originating at the site of reimplantation were closed successfully by repeat reimplantation in 1 case and by ureteropyelostomy using the recipient ureter in the other. Early postoperative obstruction at the ureterovesical junction occurred in 3 patients (6.4 per cent). Two grafts were salvaged by ureteropyelostomy and repeat reimplantation was successful in the third case. Two other patients had early radiologic evidence of partial ureterovesical junction obstruc·· tion, which resolved spontaneously. No instances of late obstruction directly attributable to the ureteroneocystostomy have been noted to date. One patient had late obstruction secondary to a lymphocele, which was drained internally with a good result. No grafts were lost and no patients died because of complications directly attributable to the ureteroneocystostomy.
METHODS
Of 155 renal transplantations performed between February 1966 and October 1975, 111 were subsequent to our original in 1972. The initial method of urinary tract reconstruction was ureteropyelostomy in 108 cases and ureteroneocystosin 47 cases. Ureteropyelostomy was performed according described previously. 12 The anastomosis was 2 rows of continuous 5-zero chromic catgut suture: 1 anterior and 1 posterior. No stent or nephrostomy was used. The bladder was drained a Foley catheter for 24 hours and retroperitoneal hernovac suction drainage was used. Ureteroneocystostomy was done with a modification of the technique. A ureteral stent was not used routinely. A catheter was left indwelling for 48 to 72 hours and retrohemovac suction drainage was used. RESULTS
Postoperative anastomotic leakage deve1,uu,eu in 9 of the 108 patients (8.3 per cent) who underwent ureteropyelostomy (table 1). In case 7 no site of extravasation could be demonstrated radiographically and spontaneous closure occurred. surgical intervention was required in the other 8 cases. In case 5 a cystoscopically placed silicone ureteral stent was successful but in case 6 this approach failed and 2 explorations with revision or reanastomosis and p1c,cemEm1 of a stent were necessary before complete closure occurred. The site of the leakage was not apparent at in case 2 and a ureteral stent was used successusing the contralateral ureter was nPrtorrriPrl i.n cases 3 9. In case 3 subsequent sepsis and failure necessitated nephrectomy but in case 9 complete occurred. The other 3 patients with fistulas underwent reanastomosis or revision of the anastomosis with good results.
COMMENT
Because urological complications in the typically debilitated renal transplant recipient who is on immunosuppresssion may have disastrous sequelae, it is important to know the incidence of such complications associated with each type of urinary reconstruction. The over-all incidence of urological complications in recently reported series has ranged from 0.9 to 26 per cent and mortality rates attributed to these complications have ranged from Oto 20 per cent (table 2). 1-1s Starzl and associates reported over-all complication rates that were rela-tively constant for both types of urinary reconstructive procedures. 1 Specific complications are more variable. Urinary fistulas are more common with ureteropyelostomy, whereas ureteral obstruction and ureteral slough occur more frequently with reimplantation procedures (table 2). Several authors have reported an extremely low incidence of all types of complications after ureteroneocystostomy.2· 12 Although a slightly higher complication rate has been reported by most other investigators this procedure is still preferred to
for publication November 12, 1976. at annual meeting of Mid-Atlantic Section, American UroAssociation, Dorado Beach, Puerto Rico, September 261, 1976.
17
18
GREENBERG AND ASSOCIATES TABLE
1. Ureteropyelostomy: patients with urinary fistulas
Day of Onset Donor
Case No. 1
2 3 4 5
6
7 8
9
Treatment Diuresis
Fistula
Relative Relative Relative Relative Cadaver Cadaver
1 1 30 1 1 10
4 2 30 14 14 15
Cadaver Relative Relative
1 1 1
1 1 1
TABLE
Rsult
Exploration, reanastomosis
Exploration, ureteral stent Exploration, transureteropyelostomy Exploration, revision anastomosis, ureteral stent U reteral stent Ureteral stent Exploration, reanastomosis, ureteral stent Exploration, revision anastomosis, nephrostomy, ureteral stent Observation Exploration, reanastomosis, nephrostomy, ureteral stent Exploration, transureteropyelostomy
Sequelae of Complications (%)
No. Pts. Obstruction
Leak or Fistula Starzl and associates' Belzer and associates 2 Weil and associates 3 Malek and associates' Bewick and associates' Salvatierra and associates'; Marx and associates' Colfry and associates 8 Barry and associates" Konnak and associates 10 Donohue and associates" Leary and associates 12 Holden and associates 13 Present series
Closure, 2 wks. Closure, 1 wk. Closure, 4 wks.
2. Ureteroneocystostomy and ureteropyelostomy: postoperative urological complications Complications (%)
Reference
Closure, immediate Closure, 1 wk. Failure, nephrectomy Closure, 6 wks. Closure, 2 wks. No improvement No improvement Closure, 6 wks.
178 220 118 93 196 540 85 125 172 170
88 221 141 47
U reteroneocystostomy 1. 7 5.1 1.8 1.4 4.3 7.1 0.6 2.0 8.8 4.7 1.8 0 0.5 5.7 6.4
Total*
0 5.1
9.0 5.0 2.5 6.5 13.3
0 3.2 0.6 1.8 0 0.5 2.8 6.4
3.5 12.0 8.1 7.0 3.4 0.9 13.5 15.0
0 0 0 1.9
12.5 25.7 11.4 11.7 7.9 11.1
Graft Lo3st
0.9 2.1
0
Mortalityt 1. 7 0 0 1.0 4.0
1.7
0 3.2 0.6
3.4 0.5 2.1 0
0 0 1.4 0
Ureteropyelostomy
Starzl and associates 1 Weil and associates 3 Donohue and associates 1 ' Leiter and associates 14 Whelchel and associates 15 Present series
56 70 44 43 114 108
10.7 11.4
11.7 7.9 8.3
3.6 20.0 6.8 4.7 2.6 0.9
2.3 0.9 0
* Includes extravasation, fistula, obstruction, lymphocele, ureteral slough, ureteral obstruction owing to angulation or fibrosis and hemorrhage related to the urinary reconstruction.
t
Occurring as a direct result of complications related to the urinary reconstruction.
ureteropyelostomy because it requires less technical finesse, leaves more options open for a secondary reconstruction of the urinary tract (should this be necessary) and does not require a nephrectomy in the recipient prior to transplantation. On the other hand, with ureteropyelostomy no bladder incision or dissection is required, a shorter period of catheter drainage is necessary, there is a lower incidence of anastomotic obstruction and ischemic complications involving the distal ureter, and retrograde ureteral catheterization for diagnostic or therapeutic purposes is easier. The prognosis for the transplant recipient with a postoperative urinary fistula has become more positive than earlier reports indicated. 14- 17 Advocates of immediate surgical intervention18 and those who have had success with conservative managementrn, 17 stress the importance of adequate drainage of the wound and of the urinary tract itself, either by an intraluminal stent or by nephrostomy. In our experience the decision to undertake an early surgical exploration and attempt an anastomotic revision is best dictated by the severity of the leakage and the other exigencies of the specific clinical situation. Although some grafts can be saved only by secondary urinary tract reconstruction, as long as the surgical wound and the urinary tract are properly drained and uninfected, many fistulas will heal within a reasonable interval with conservative management. In our series the rate of graft loss directly attributable to complications ofureteropyelostomy, 0.9 per cent, was slightly lower than those reported by other centers using this tech-
nique (table 2) and compares favorably to that associated with ureteroneocystostomy. Therefore, although ureteroneocystostomy remains the preferred method of initial urinary reconstruction in most transplantation centers, we believe that ureteropyelostomy can be a satisfactory alternative. In addition, it should be familiar to all transplant surgeons as a technique of secondary reconstruction in patients with major urological complications after ureteroneocystostomy. REFERENCES
1. Starzl, T. E., Groth, C. G., Putnam, C. W., Penn, I., Halgrim-
2. 3.
4. 5.
6.
son, 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. Belzer, F. 0., Kountz, S. L., Najarian, J. S., Tanagho, E. A. and Hinman, F., Jr.: Prevention of urological complications after renal allotransplantation. Arch. Surg., 101: 449, 1970. 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. Malek, G. H., Uehling, D. T., Daouk, A. A. and Kisken, W. A. Urological complications of renal transplantation. J. Urol., 109: 173, 1973. Bewick, M., Collins, R. E. C., Saxton, H. M., Ellis, F. G., McColl, I. and Ogg, C. S.: The surgery and problems of the ureter in human renal transplantation. Brit. J. Urol., 46: 493, 1974. Salvatierra, 0., Jr., Kountz, S. L. and Belzer, F. 0.: Prevention of ureteral fistula after renal transplantation. J. Urol., 112:
URINARY RECONSTRUCTION IN TRANSPLANTATION
445, 1974. '7. Marx, W. L., Halasz, N. A, "'"·~~~"UHH, A. P. and Gittes, R. F.: ·-·-·--·v-· complications in transplantation. J. Urol., 1974. E. S. and McDonald, 8. A. J. transplantation. J.
14.
15.
9. Barry
1
Lawson, R. K., Strong, D. and Hodges, C. V.: cu1uµ,11c,u.,v1.tb in 173 kidney transplants. J. Urol., 16.
10.
R. Finkbeiner, A., Turcotte, J. G. D. ~·vtrcmoci ureteroneocystostomy in 170 -·····~···-·· patients. J. Urol., 113: 299, 1975. ., Hostetter, M., J. and Madura, J.: Ure-
17.
cv1.uu•mrnc"-' 1n
12. Leary, F. J., Woods, lems in renal 13. Holden, S., O'Brien,
18.
19
Walton, K. N.: Urologic complications in renal transplantation. Urology, 5: 182, 1975. Leiter, E., Kim, K. H., Glabman, 8., Haimov, M., Burrows, L. and Brendler, H.: Urinary reconstruction anastomosis in human renal transplants. J. 1973. Whelchel, D. J., Cosimi, A. B., Young, H. H., II and Russell, P. S.: Pyeloureterostomy reconstruction in human renal transplantation. Ann. Surg., 181: 61, 1975. Mrnrehouse, D. D., Macramalla, E. A., Guttmann, R. D., Beau· doin, J-G., Farrer, P.A. and MacKinnon, K. J.: The conservative management of urinary fistulas following renal allografts. J. Urol., 110: 1973. Desai, 8. G., McRoberts, W., Hellebusch, A. A. and Luke, G.: Conservative non-operative management of ureteral fistulas following renal allografts. J. Urol., 112: 572, 1974. Hoch, W. H., Kest, L., Cohen, S., Newmark, K. and Supravesical urinary fistulas after transplantation. Gynec. & Obst., 139: 82, 1974.