- Email: [email protected]
Urological complications after 2084 consecutive kidney transplantations
ELSEVIER
Urological Complications Kidney Transplantations H. Makisalo,
After 2084 Consecutive
B. Eklund, K. Salmela, H Isoniemi.
L. Kylbnen,
T
HE INCIDENCE of urological complications (UC) after the renal transplantation in large series has ranged from 2.5% to 14.7% depending partly on the criteria used in the assessment of problems.‘-5 Although some association has been found between UC and multiple episodes of acute rejection and pediatric or male recipient, they mainly seem to arise from a technical error.‘,2,4Vs Although not unanimously affirmed, the technique of ureteroneocystostomy used does not seem to influence on the incidence of complications. 6,7 Improvement in the treatment of the donors and the recipients, in the preservation of the organs and in the suture materials used could be expected to influence favourably on the prevalence of UC as experienced in most centres.’ However, in some materials the development has been the opposite because of increasing numbers of ureteral strictures.4 We wanted to evaluate the incidence and contributing factors of UC after the renal transplantation during the “modern era” of the transplantation surgery. PATIENTS
AND
METHODS
Urological complications after 2,084 consecutive kidney transplantations performed at Helsinki University Hospital between August 1981 and December 1995 were retrospectively analysed. In 7% of cases a living related allograft was used, and in 16.3% the procedure was a retransplantation, 13.6% of which was a second graft and 2.7% a third or fourth graft. The mean age of the patients was 41.1 years (range, 1.1 to 71.1 years) and the male to female ratio was 1.4:1. The immunosuppressive regimen was triple therapy with prednisolone, azathioprine (AZT) and cyclosporine A in 70% of patients whereas 30% of patients received prednisolone and AZT only. Highly immunized patients received monoclonal antibody treatment in addition to the triple therapy in induction. Episodes of acute rejection were treated with 3 mg/kg biweekly of methylprednisolone for 5 days. In 81% of cases the hypogastric artery was used for arterial anastomosis. A modified Leadbetter-Politano (LP) technique was used for the ureteric implantation secured with ureteric stents for 3 days before 1984 in 14% of all cases. The bladder was distended with up to 200 mL of saline solution before opening. The urothelial anastomosis was completed using 5/O polydioxanone suture (PDS) and the bladder closed in two layers with 4/O PDS. No suction drains were used. A Foley catheter was left in the bladder for 5 days. Renal function was monitored daily for 3 to 6 weeks after the transplantation by plasma creatinine levels. Ultrasound was used for special indications and for a regular follow-up since 1989. Percutaneous nephrostomy and antegrade
0041-1315/97/$17.00 PII SO041 -1345(96)00044-9
K. Hdckerstedt,
L. Halme, and J. Ahonen
pyelography were readily performed if indicated and the nephrostomy retained for securing the renal function as needed.’ In case of a ureteral stricture, an internal/external stent was inserted for 6 to 8 weeks. If the treatment with nephrostomy or stenting failed an operative reconstruction was completed usually 3 months later. If the ureteroneocystostomy was dehisced during the first postoperative days the reconstruction was performed without delay. Lymphoceles causing symptoms were marsupialised operatively into the abdominal cavity. The ureteral calculi were treated using the extracorporeal shockwave lithotripsy (ESWL). The follow-up time was between 6 months and 14 years 10 months (median, 7 years 4 months). Complications regarded as urological were ureteral stenoses, urine leaks, urinary calculi, ureteral or bladder clots requiring treatment and lymphoceles necessitating a drainage procedure. Statistical analyses were done with Student’s t-test and chi-square tests. RESULTS In 4.2% of patients a urological complication was encountered after the kidney transplantation. A lymphocele necessitated a drainage procedure in 1%. Blood clot was evacuated from the bladder in 0.5% of cases. ESWL was needed for treatment of ureteral calculi in three cases. In 2.5% of patients nephrostomy and antegrade pyelography were performed as ureteral stenosis or urine leak were suspected. Excluding nephrostomies, diagnostic only, or applied for ureteral clots or edema, the incidence of “serious” UC was 1.7%. A urine leak was found in 1% of all patients and a ureteral stricture in 0.5%. A combined leakage and stricture was found in 0.2% of cases. Of these serious complications 11.5% could be treated with an internal/external stent, whereas 33% of cases required open surgical reconstruction. A significantly higher incidence of diabetes, 36% versus 23% (P < .05) and technical difficulties during the surgery, 46% versus 22% (P < .Ol) were found in the patients of the complication group compared with the controls. Episodes of acute rejection were also more frequently (P < .Ol)
From the Division of Transplantation, Fourth Department of Surgery, Helsinki University Hospital, Helsinki, Finland. Address reprint requests to Heikki Makisalo, MD, Division of Transplantation, Fourth Department of Surgery, Helsinki University Hospital, Kasarmikatu 11-13, FIN-00130, Helsinki, Finland.
0 1997 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
152
Transplantation Proceedings, 29, 152-l 53 (1997)
UROLOGICAL
COMPLICATIONS
found in patients with a lymphocele formation compared with the controls. Acute rejection was not, however, overrepresentated in the group comprising ureteral strictures and urine leaks only. No significant difference was found in the 5-year graft or patient survival between the patients with or without UC, 61% versus 65%, and 76% versus 81%, respectively. Only one kidney was lost because of pelvic necrosis and one patient died of septic complications after ureteral necrosis and urine leak. DISCUSSION
UC has been regarded as a devastating and dangerous entity after renal transplantation. However, the incidence of complications in the present material was low, 4.2% altogether and 1.7% if verified ureteral strictures and urine leaks are concerned, and the outcome favourable after treatment. Only one patient and an additional graft were lost as a sequela of UC. The low incidence of ureteral strictures and urine leaks supports the recent report on the safety of the LP technique in the ureteroneocystostomy.’ Some studies have emphasized the role of acute rejection in inducing UC.4 In the present study, episodes of acute rejection associated with the development of lymphoceles but not with ureteral strictures or urine leaks. Earlier, lymph has been suggested to exude from the renal capsule and hilus during acute rejection leading to formation of lymphocele.’ We could also record an earlier suspected6 but not reliably confirmed finding of diabetes as a contributing factor in emerging of UC. In concordance with earlier findings’ we noted that technical difficulties during the transplantation procedure
153
were more frequently found in the complication group. In fact, the policy of maintaining the transplant procedure only in hands of consultant surgeons taking care of the patient postoperatively as well may have a significant influence on the low incidence of UC in the present study. CONCLUSION
Although UCs after the renal transplantation cannot be totally avoided, a low incidence can be reached and the graft loss kept almost negligible with prompt detection and judicious management of the complications. Along with safer percutaneous stenting technique the treatment policy of complications seems to shift increasingly towards more conservative lines, thus reducing the need for open surgical interventions. REFERENCES 1. Jaskowski A, Jones RM, Murie JA, et al: Br J Surg 74:922, 1987 2. Loughlin KR, Tilney NL, Richei JP: Surgery 95:296, 1984
3. Sumrani NB, Lipkowitz GS, Hong JH, et al: Transplant Proc 21:1957, 1989 4. Rigg KM, Proud G, Taylor RMR: Transpl Int 7:120, 1994 5. Ghasemian SMR, Guleria AS, Khawand NY, et al: Clin Transpl 10~218, 1996 6. Thrasher JB, Temple DR, Spees EK: J Urol 144:1105, 1990 7. Hakim NS, Benedetti E, Pirenne J, et al: Clin Transpl 8504, 1994 8. Eklund B, Edgren J, Laasonen L, et al: Transpl Proc 16:1304, 1984 9. Khauli RB, Stoff JS, Lovewell T, et al: J Urol 150:22, 1993
Urological Complications Kidney Transplantations H. Makisalo,
After 2084 Consecutive
B. Eklund, K. Salmela, H Isoniemi.
L. Kylbnen,
T
HE INCIDENCE of urological complications (UC) after the renal transplantation in large series has ranged from 2.5% to 14.7% depending partly on the criteria used in the assessment of problems.‘-5 Although some association has been found between UC and multiple episodes of acute rejection and pediatric or male recipient, they mainly seem to arise from a technical error.‘,2,4Vs Although not unanimously affirmed, the technique of ureteroneocystostomy used does not seem to influence on the incidence of complications. 6,7 Improvement in the treatment of the donors and the recipients, in the preservation of the organs and in the suture materials used could be expected to influence favourably on the prevalence of UC as experienced in most centres.’ However, in some materials the development has been the opposite because of increasing numbers of ureteral strictures.4 We wanted to evaluate the incidence and contributing factors of UC after the renal transplantation during the “modern era” of the transplantation surgery. PATIENTS
AND
METHODS
Urological complications after 2,084 consecutive kidney transplantations performed at Helsinki University Hospital between August 1981 and December 1995 were retrospectively analysed. In 7% of cases a living related allograft was used, and in 16.3% the procedure was a retransplantation, 13.6% of which was a second graft and 2.7% a third or fourth graft. The mean age of the patients was 41.1 years (range, 1.1 to 71.1 years) and the male to female ratio was 1.4:1. The immunosuppressive regimen was triple therapy with prednisolone, azathioprine (AZT) and cyclosporine A in 70% of patients whereas 30% of patients received prednisolone and AZT only. Highly immunized patients received monoclonal antibody treatment in addition to the triple therapy in induction. Episodes of acute rejection were treated with 3 mg/kg biweekly of methylprednisolone for 5 days. In 81% of cases the hypogastric artery was used for arterial anastomosis. A modified Leadbetter-Politano (LP) technique was used for the ureteric implantation secured with ureteric stents for 3 days before 1984 in 14% of all cases. The bladder was distended with up to 200 mL of saline solution before opening. The urothelial anastomosis was completed using 5/O polydioxanone suture (PDS) and the bladder closed in two layers with 4/O PDS. No suction drains were used. A Foley catheter was left in the bladder for 5 days. Renal function was monitored daily for 3 to 6 weeks after the transplantation by plasma creatinine levels. Ultrasound was used for special indications and for a regular follow-up since 1989. Percutaneous nephrostomy and antegrade
0041-1315/97/$17.00 PII SO041 -1345(96)00044-9
K. Hdckerstedt,
L. Halme, and J. Ahonen
pyelography were readily performed if indicated and the nephrostomy retained for securing the renal function as needed.’ In case of a ureteral stricture, an internal/external stent was inserted for 6 to 8 weeks. If the treatment with nephrostomy or stenting failed an operative reconstruction was completed usually 3 months later. If the ureteroneocystostomy was dehisced during the first postoperative days the reconstruction was performed without delay. Lymphoceles causing symptoms were marsupialised operatively into the abdominal cavity. The ureteral calculi were treated using the extracorporeal shockwave lithotripsy (ESWL). The follow-up time was between 6 months and 14 years 10 months (median, 7 years 4 months). Complications regarded as urological were ureteral stenoses, urine leaks, urinary calculi, ureteral or bladder clots requiring treatment and lymphoceles necessitating a drainage procedure. Statistical analyses were done with Student’s t-test and chi-square tests. RESULTS In 4.2% of patients a urological complication was encountered after the kidney transplantation. A lymphocele necessitated a drainage procedure in 1%. Blood clot was evacuated from the bladder in 0.5% of cases. ESWL was needed for treatment of ureteral calculi in three cases. In 2.5% of patients nephrostomy and antegrade pyelography were performed as ureteral stenosis or urine leak were suspected. Excluding nephrostomies, diagnostic only, or applied for ureteral clots or edema, the incidence of “serious” UC was 1.7%. A urine leak was found in 1% of all patients and a ureteral stricture in 0.5%. A combined leakage and stricture was found in 0.2% of cases. Of these serious complications 11.5% could be treated with an internal/external stent, whereas 33% of cases required open surgical reconstruction. A significantly higher incidence of diabetes, 36% versus 23% (P < .05) and technical difficulties during the surgery, 46% versus 22% (P < .Ol) were found in the patients of the complication group compared with the controls. Episodes of acute rejection were also more frequently (P < .Ol)
From the Division of Transplantation, Fourth Department of Surgery, Helsinki University Hospital, Helsinki, Finland. Address reprint requests to Heikki Makisalo, MD, Division of Transplantation, Fourth Department of Surgery, Helsinki University Hospital, Kasarmikatu 11-13, FIN-00130, Helsinki, Finland.
0 1997 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
152
Transplantation Proceedings, 29, 152-l 53 (1997)
UROLOGICAL
COMPLICATIONS
found in patients with a lymphocele formation compared with the controls. Acute rejection was not, however, overrepresentated in the group comprising ureteral strictures and urine leaks only. No significant difference was found in the 5-year graft or patient survival between the patients with or without UC, 61% versus 65%, and 76% versus 81%, respectively. Only one kidney was lost because of pelvic necrosis and one patient died of septic complications after ureteral necrosis and urine leak. DISCUSSION
UC has been regarded as a devastating and dangerous entity after renal transplantation. However, the incidence of complications in the present material was low, 4.2% altogether and 1.7% if verified ureteral strictures and urine leaks are concerned, and the outcome favourable after treatment. Only one patient and an additional graft were lost as a sequela of UC. The low incidence of ureteral strictures and urine leaks supports the recent report on the safety of the LP technique in the ureteroneocystostomy.’ Some studies have emphasized the role of acute rejection in inducing UC.4 In the present study, episodes of acute rejection associated with the development of lymphoceles but not with ureteral strictures or urine leaks. Earlier, lymph has been suggested to exude from the renal capsule and hilus during acute rejection leading to formation of lymphocele.’ We could also record an earlier suspected6 but not reliably confirmed finding of diabetes as a contributing factor in emerging of UC. In concordance with earlier findings’ we noted that technical difficulties during the transplantation procedure
153
were more frequently found in the complication group. In fact, the policy of maintaining the transplant procedure only in hands of consultant surgeons taking care of the patient postoperatively as well may have a significant influence on the low incidence of UC in the present study. CONCLUSION
Although UCs after the renal transplantation cannot be totally avoided, a low incidence can be reached and the graft loss kept almost negligible with prompt detection and judicious management of the complications. Along with safer percutaneous stenting technique the treatment policy of complications seems to shift increasingly towards more conservative lines, thus reducing the need for open surgical interventions. REFERENCES 1. Jaskowski A, Jones RM, Murie JA, et al: Br J Surg 74:922, 1987 2. Loughlin KR, Tilney NL, Richei JP: Surgery 95:296, 1984
3. Sumrani NB, Lipkowitz GS, Hong JH, et al: Transplant Proc 21:1957, 1989 4. Rigg KM, Proud G, Taylor RMR: Transpl Int 7:120, 1994 5. Ghasemian SMR, Guleria AS, Khawand NY, et al: Clin Transpl 10~218, 1996 6. Thrasher JB, Temple DR, Spees EK: J Urol 144:1105, 1990 7. Hakim NS, Benedetti E, Pirenne J, et al: Clin Transpl 8504, 1994 8. Eklund B, Edgren J, Laasonen L, et al: Transpl Proc 16:1304, 1984 9. Khauli RB, Stoff JS, Lovewell T, et al: J Urol 150:22, 1993