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Urological complications and effects of double-j catheter in ureterovesical anastomosis after cadaveric kidney transplantation
Urological Complications and Effects of Double-J Catheter in Ureterovesical Anastomosis After Cadaveric Kidney Transplantation M. Junjie, X. Jian, Y. Lixin, and B. Xiwen
A
LTHOUGH UROLOGICAL complications (UC) after kidney transplantation are uncommon, the morbidity of UC has been decreased to approximately 2 ; 5% by parallel incision extravesical ureteroneocystostomy.1– 4 It is very severe and an even lead to losing the kidney grafts; therefore, we in this study attempt to modify the extravesical ureteroneocystostomy (MEU) in which there is no special submucosal tunnel procedure, and maintain the double-J (D-J) catheter to improve the morbidity of UC. PATIENTS AND METHODS Six hundred patients with ESRD, including 365 male and 235 female, mean age 42.5 6 11.7 years, underwent cadaveric kidney transplantation from May 1992 to August 1996. The patients were divided in 3 groups: 95 patients in Group I from May 1992 to May 1993, 58 male and 37 female, mean age 36.5 6 8.7 years, without any stents; 114 patients in Group II from June 1993 to May 1994, 71 male and 43 female, mean age 40.2 6 10.4 years, with D-J catheter for 3 ; 4 weeks, and removed by cystoscope; 391 patients in Groups III from June 1994 to August 1996, 263 male and 155 female, mean 45.9 6 18.1 years, with D-J Catheter in 5 ; 7 days and drained out itself by a 10 silk suture fixed on end of D-J catheter in bladder while the patients urinated after urinary catheter was removed postoperatively. Immunosuppressive therapy was the same in 3 groups; no vesical diseases were found before surgery. MEU was used. The bladder was filled and a blunt dissection about 1 cm2 was carefully made in dissected muscle until mucosa on the lateral bladder wall of the ipsilateral iliac fossa was exposed and a “window” was created with a diameter of just more than the orifice of the ureter by scissoring exposed mucosa. The redundant part of ureter was severed over 3 ; 5 cm left and an incision about 2 ; 3 mm was made at the end of ureter. Direct anastomosis of the ureter to the edge of the bladder mucosa was sutured with a 5-0 absorbable suture and care was taken to ensure that there was no tension and kink. Then the distal ureter was pushed into the bladder about 3 ; 4 mm to form a cuffing papilla and a muscular tannel was made by suturing the perivesical muscle and tissue over the distal ureter not less than 1 cm, and anchoring stitches were placed at the connection of ureter approaching the bladder, but not too tightly. All of the patients were observed for 1 year after transplantation.
RESULTS
This MEU technique was less complicated than either Leadbetter-Politano5 or extravesical1 and the parallel incision extravesicl ureteroneocystostomy3,4 procedure took
15 ; 20 mins for a skilled surgeon. UC occurred in 34 patients (see Table 1). There was no significant difference between any 2 groups within 3 groups. Five of 7 cases with urinary fistula in group II were cured by prolonged use of the D-J catheter, anti-infection and bladder drainage, while ureteric leakage occurred D-J catheter hadn’t been removed out yet. Two patients with obstruction in Group III had no retrograde infection and were found to have ureteral stenosis and retrograde contrast medium from bladder to renal pelvis in radiography. Sites of leakage in 8 of 15 cases were from ureteroneocystostomy, 2 of them were from bladder closure, 2 from middle ureter and 3 were unknown. What were proved in re-operation and by radiourography. All of fistulae occurred within one month postoperatively. UC in 16 patients was confirmed which contributed to artificial factors, including stoma stenosis in 8 patients, urinary leakage caused by distal ureter necrosis in 6 without rejection, and 2 from bladder closure. Eight patients had no relationship with surgical technique including preexisting stones in 3, preexisting ureterostenosis, cystirrhagia, and irritation signs of bladder, respectively, in 1, and leakage caused by infection of the incisional wound in 2. 10 patients is not certain. DISCUSSION AND CONCLUSION
Morbidity of UC was 5.7% (34/600), similar to some reports with parallel incision extravesical ureteronecystoctomy3,4 and witzel-Sampson-Lich technique.1 There was a UC rate of 8.7% and 7.7%, respectively, in Groups I and II that we thought was due to un-skilled surgical techniques for this new modified muscular tannel ureteroneosystostomy. There were more patients with stoma stenosis and fistula caused by operating technique, 5 and 4 of 16 patients contributing to artificial factors in total 209 patients (95 in Group I 1 114 in Group II), which decreased to 7 patients (stoma stenosis in 3 and fistula in 4) of 16 patients (Group III) 2 years later (4.3% vs 1.7%, P ' .07), and morbidity From the Department of Kidney Transplantation, NanFang Hospital, Tong He, Guang Zhou, China. Address reprint requests to Dr M. Junjie, Nan Fang Hospital, Department of Kidney Transplantation, Tong He, Guang Zhou 510515, Peoples Republic of China.
© 1998 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
0041-1345/98/$19.00 PII S0041-1345(98)00909-9
Transplantation Proceedings, 30, 3013–3014 (1998)
3013
3014
JUNJIE, JIAN, LIXIN ET AL Table 1. Morbidity, Classification, Contributing Factors and Results of UC in 600 Renal Transplant Recipients Results UC
No. (%)
Group I (n 5 95) Ureteral stone Stoma stenosis Urinary fistula Group II (n 5 114) Stoma stenosis Urinary fistula Group III (n 5 391) Stoma stenosis Stone Preexistent uneterostenosis Urinary fistula Uretrorrhagia Unknown causes obstruction Cystirrhagia Irritation sign of bladder Total (n 5 600)
8 (8.7) 2 3 3 9 (7.7) 2 7 17 (4.3) 3 2 1 5 2 2 1 1 34 (5.7)
Contributing factors (No. patients)
Preexist (1) Suture placement (3) Necrosis (2), infection (1) Suture placement (2) Necrosis (2), infection (1) Suture placement (3) Preexist (2) Necrosis (2), closure (2)
Urinary catheter D-J and urinary catheter
Re-operation
Cure
Modifacation
Lost
P
6 1 2 3 4 2 2 13 3 1 1 4 2 1 1
6 1 3 2 7 1 6 10 2 1 1 4 1
1 1
1
NS*
1 1
NS*
1 4
NS*
23
1 1 3 1
1 1 1 2 1
1 23
5
6
* NS, not significant
also decreased to 4.3% in Group III with the surgical technique improved. This indicates that this MEU can be accepted. MEU were concluded following advantages, (1) it need not open the bladder and make submucosal tannel that leads to rather easy performance, and it only takes about 15 ; 20 mins for a skilled surgeon, with less infection and minimized vesical complications. (2) There is minimal damage to the blood supply to the part of bladder wall that will benefit from re-vascularization of the distal ureter due to a careful blunt dissection instead of incision; no patient was found to have a devascularization and chronic ischemic fibrosis of distal ureter in re-operation. (3) Anti-reflux effect was proved. We did not find retrograde infection and obstruction and there were only two patients with unknown etiological obstruction which could not be caused by muscular tannel leading to reflux by cyst-pelvis radiography. This MEU has some disadvantages. More patients with stoma stenosis were found. The sutures may have been too tight because ureterovesical junction leakage was a concern; on the other hand, the stoma cannot be watched for extravesical anastomosis. The other disadvantage was more distal ureter (6 cases) in which necrosis occurred without
any rejection in our groups, although we had shortened the length of the ureter and minimized the damage of the bladder wall. We thought it was certainly associated with damage of blood supply of the ureter from the ‘‘golden triangle.’ Our study shows that maintaining the D-J catheter for a short time (less than 4 weeks) in ureter did not improve the morbidity of UC. Most of the leakage and stenosis occurred after D-J catheter was removed. But the D-J catheter did not increase risk of UC, and it benefited the reestablishment of the ureter without reoperation, while leakage occurred while the D-J catheter was still remaining.
REFERENCES 1. Thrasher JB, Temple DR, Spea EK, et al: J Urol 144:1105, 1990 2. Shah S, Nath V, Gopalkrishnan G, et al: Brit J Urol 62:412, 1988 3. Gibbons WS, Barry JM, Hefty TR: J Urol 148:38, 1992 4. Hefty TR, J Urol 134:455, 1985 5. Proat GR, Hame DM, Lee HM: J Urol 97:409, 1967
A
LTHOUGH UROLOGICAL complications (UC) after kidney transplantation are uncommon, the morbidity of UC has been decreased to approximately 2 ; 5% by parallel incision extravesical ureteroneocystostomy.1– 4 It is very severe and an even lead to losing the kidney grafts; therefore, we in this study attempt to modify the extravesical ureteroneocystostomy (MEU) in which there is no special submucosal tunnel procedure, and maintain the double-J (D-J) catheter to improve the morbidity of UC. PATIENTS AND METHODS Six hundred patients with ESRD, including 365 male and 235 female, mean age 42.5 6 11.7 years, underwent cadaveric kidney transplantation from May 1992 to August 1996. The patients were divided in 3 groups: 95 patients in Group I from May 1992 to May 1993, 58 male and 37 female, mean age 36.5 6 8.7 years, without any stents; 114 patients in Group II from June 1993 to May 1994, 71 male and 43 female, mean age 40.2 6 10.4 years, with D-J catheter for 3 ; 4 weeks, and removed by cystoscope; 391 patients in Groups III from June 1994 to August 1996, 263 male and 155 female, mean 45.9 6 18.1 years, with D-J Catheter in 5 ; 7 days and drained out itself by a 10 silk suture fixed on end of D-J catheter in bladder while the patients urinated after urinary catheter was removed postoperatively. Immunosuppressive therapy was the same in 3 groups; no vesical diseases were found before surgery. MEU was used. The bladder was filled and a blunt dissection about 1 cm2 was carefully made in dissected muscle until mucosa on the lateral bladder wall of the ipsilateral iliac fossa was exposed and a “window” was created with a diameter of just more than the orifice of the ureter by scissoring exposed mucosa. The redundant part of ureter was severed over 3 ; 5 cm left and an incision about 2 ; 3 mm was made at the end of ureter. Direct anastomosis of the ureter to the edge of the bladder mucosa was sutured with a 5-0 absorbable suture and care was taken to ensure that there was no tension and kink. Then the distal ureter was pushed into the bladder about 3 ; 4 mm to form a cuffing papilla and a muscular tannel was made by suturing the perivesical muscle and tissue over the distal ureter not less than 1 cm, and anchoring stitches were placed at the connection of ureter approaching the bladder, but not too tightly. All of the patients were observed for 1 year after transplantation.
RESULTS
This MEU technique was less complicated than either Leadbetter-Politano5 or extravesical1 and the parallel incision extravesicl ureteroneocystostomy3,4 procedure took
15 ; 20 mins for a skilled surgeon. UC occurred in 34 patients (see Table 1). There was no significant difference between any 2 groups within 3 groups. Five of 7 cases with urinary fistula in group II were cured by prolonged use of the D-J catheter, anti-infection and bladder drainage, while ureteric leakage occurred D-J catheter hadn’t been removed out yet. Two patients with obstruction in Group III had no retrograde infection and were found to have ureteral stenosis and retrograde contrast medium from bladder to renal pelvis in radiography. Sites of leakage in 8 of 15 cases were from ureteroneocystostomy, 2 of them were from bladder closure, 2 from middle ureter and 3 were unknown. What were proved in re-operation and by radiourography. All of fistulae occurred within one month postoperatively. UC in 16 patients was confirmed which contributed to artificial factors, including stoma stenosis in 8 patients, urinary leakage caused by distal ureter necrosis in 6 without rejection, and 2 from bladder closure. Eight patients had no relationship with surgical technique including preexisting stones in 3, preexisting ureterostenosis, cystirrhagia, and irritation signs of bladder, respectively, in 1, and leakage caused by infection of the incisional wound in 2. 10 patients is not certain. DISCUSSION AND CONCLUSION
Morbidity of UC was 5.7% (34/600), similar to some reports with parallel incision extravesical ureteronecystoctomy3,4 and witzel-Sampson-Lich technique.1 There was a UC rate of 8.7% and 7.7%, respectively, in Groups I and II that we thought was due to un-skilled surgical techniques for this new modified muscular tannel ureteroneosystostomy. There were more patients with stoma stenosis and fistula caused by operating technique, 5 and 4 of 16 patients contributing to artificial factors in total 209 patients (95 in Group I 1 114 in Group II), which decreased to 7 patients (stoma stenosis in 3 and fistula in 4) of 16 patients (Group III) 2 years later (4.3% vs 1.7%, P ' .07), and morbidity From the Department of Kidney Transplantation, NanFang Hospital, Tong He, Guang Zhou, China. Address reprint requests to Dr M. Junjie, Nan Fang Hospital, Department of Kidney Transplantation, Tong He, Guang Zhou 510515, Peoples Republic of China.
© 1998 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
0041-1345/98/$19.00 PII S0041-1345(98)00909-9
Transplantation Proceedings, 30, 3013–3014 (1998)
3013
3014
JUNJIE, JIAN, LIXIN ET AL Table 1. Morbidity, Classification, Contributing Factors and Results of UC in 600 Renal Transplant Recipients Results UC
No. (%)
Group I (n 5 95) Ureteral stone Stoma stenosis Urinary fistula Group II (n 5 114) Stoma stenosis Urinary fistula Group III (n 5 391) Stoma stenosis Stone Preexistent uneterostenosis Urinary fistula Uretrorrhagia Unknown causes obstruction Cystirrhagia Irritation sign of bladder Total (n 5 600)
8 (8.7) 2 3 3 9 (7.7) 2 7 17 (4.3) 3 2 1 5 2 2 1 1 34 (5.7)
Contributing factors (No. patients)
Preexist (1) Suture placement (3) Necrosis (2), infection (1) Suture placement (2) Necrosis (2), infection (1) Suture placement (3) Preexist (2) Necrosis (2), closure (2)
Urinary catheter D-J and urinary catheter
Re-operation
Cure
Modifacation
Lost
P
6 1 2 3 4 2 2 13 3 1 1 4 2 1 1
6 1 3 2 7 1 6 10 2 1 1 4 1
1 1
1
NS*
1 1
NS*
1 4
NS*
23
1 1 3 1
1 1 1 2 1
1 23
5
6
* NS, not significant
also decreased to 4.3% in Group III with the surgical technique improved. This indicates that this MEU can be accepted. MEU were concluded following advantages, (1) it need not open the bladder and make submucosal tannel that leads to rather easy performance, and it only takes about 15 ; 20 mins for a skilled surgeon, with less infection and minimized vesical complications. (2) There is minimal damage to the blood supply to the part of bladder wall that will benefit from re-vascularization of the distal ureter due to a careful blunt dissection instead of incision; no patient was found to have a devascularization and chronic ischemic fibrosis of distal ureter in re-operation. (3) Anti-reflux effect was proved. We did not find retrograde infection and obstruction and there were only two patients with unknown etiological obstruction which could not be caused by muscular tannel leading to reflux by cyst-pelvis radiography. This MEU has some disadvantages. More patients with stoma stenosis were found. The sutures may have been too tight because ureterovesical junction leakage was a concern; on the other hand, the stoma cannot be watched for extravesical anastomosis. The other disadvantage was more distal ureter (6 cases) in which necrosis occurred without
any rejection in our groups, although we had shortened the length of the ureter and minimized the damage of the bladder wall. We thought it was certainly associated with damage of blood supply of the ureter from the ‘‘golden triangle.’ Our study shows that maintaining the D-J catheter for a short time (less than 4 weeks) in ureter did not improve the morbidity of UC. Most of the leakage and stenosis occurred after D-J catheter was removed. But the D-J catheter did not increase risk of UC, and it benefited the reestablishment of the ureter without reoperation, while leakage occurred while the D-J catheter was still remaining.
REFERENCES 1. Thrasher JB, Temple DR, Spea EK, et al: J Urol 144:1105, 1990 2. Shah S, Nath V, Gopalkrishnan G, et al: Brit J Urol 62:412, 1988 3. Gibbons WS, Barry JM, Hefty TR: J Urol 148:38, 1992 4. Hefty TR, J Urol 134:455, 1985 5. Proat GR, Hame DM, Lee HM: J Urol 97:409, 1967