Retrograde balloon dilation >10 weeks after renal transplantation for transplant ureter stenosis – our experience and review of the literature

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Abstract

Objective

Despite many efforts to prevent ureteric stenosis in a transplanted kidney, this complication occurs in 3–5% of renal transplant recipients. Balloon dilatation (BD) is a possible minimally invasive approach for treatment, but reports to date refer only to the antegrade approach; we analysed our experience with retrograde BD (RBD) and reviewed previous reports.

Patients and methods

From October 2008 to February 2011, eight patients after renal transplantation (RTX) underwent RBD for transplant ureteric stenosis at our hospital. We retrospectively analysed the outcome and reviewed previous reports.

Results

The eight recipients (five men and three women; median age 55 years, range 38–69) were treated with one or two RBDs for transplant ureteric stenosis. There were no complications. The median (range) time after RTX was 4.5 (2.5–11) months. Long-term success was only achieved in one recipient, while five patients were re-operated on (three with a new implant, two by replacement of transplanted ureter with ileum) after a median (range) of 2.8 (0.7–7.0) months after unsuccessful RBD(s). For two recipients the success remained unclear (one graft loss due to other reasons, one result pending). When the first RBD was unsuccessful there was no improvement with a second.

Conclusion

RBD is technically feasible, but our findings and the review of previous reports on antegrade ureteric dilatation suggest that the success rate is low when the ureter is dilated at ⩾10 weeks after RTX. From our results we cannot recommend RBD for transplant ureteric stenosis at ⩾10 weeks after RTX, while previous reports show favourable results of antegrade BD in the initial 3 months after RTX.

Related collections

Most cited references 34

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The urological complications of renal transplantation: a series of 1535 patients.

E Streeter, Ross Cranston, Robert M. D. Little … (2002)

To determine the incidence of urological complications of renal transplantation at one institution, and relate this to donor and recipient factors. A consecutive series of 1535 renal transplants were audited, and a database of donor and recipient characteristics created for risk-factor analysis. An unstented Leadbetter-Politano anastomosis was the preferred method of ureteric reimplantation. There were 45 urinary leaks, 54 primary ureteric obstructions, nine cases of ureteric calculi, three bladder stones and 19 cases of bladder outlet obstruction at some time after transplantation. The overall incidence of urological complications was 9.2%, with that for urinary leak or primary ureteric obstruction being 6.5%. One graft was lost because of complications, and there were three deaths associated directly or indirectly with urological complications. There was no association with recipient age, cadaveric vs living-donor transplants, or cold ischaemic times before organ reimplantation, although the donor age was slightly higher in cases of urinary leak. There was no association with kidneys imported via the UK national organ-sharing scheme vs the use of local kidneys. The management of these complications is discussed. The incidence of urological complications in this series has remained essentially unchanged for 20 years. The causes of these complications and techniques for their prevention are discussed.

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Late ureteral stenosis following renal transplantation: risk factors and impact on patient and graft survival.

M hourmant, J Soulillou, J-P Rigaud … (2006)

The aim of this retrospective study of a cohort of 1787 consecutive kidney transplantations was to analyze the risk factors associated with the occurrence of ureteral stenosis and the impact of ureteral stenosis on graft and patient survival. Between January 1990 and December 2002, 1787 renal transplantations were performed at our center. Only stenosis observed after the first month, were considered. Among the parameters studied were: donor age and serum creatinine before procurement; recipient age, cold ischemia time, delayed graft function (DGF), number of arteries and the presence of a double J stent. The follow-up parameters were the number and timing of acute rejection episodes, cytomegalovirus (CMV) infection, acute pyelonephritis, renal function and death. Ureteral stenosis occurred in 4.1% of patients and was correlated with donor age > 65 years (p = 0.001), kidneys with more than 2 arteries (p = 0.009) and DGF (p = 0.016). Ureteral stenosis did not affect 10-year patient and graft survival rates, which were respectively 90% and 64% for the stenosis group, 86% and 63% for the no-stenosis group (p = NS). These data suggest an important role for donor age, number of renal arteries and DGF for the occurrence of ureteral stenosis following renal transplantation.

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Treatment of renal transplant ureterovesical anastomotic strictures using antegrade balloon dilation with or without holmium:YAG laser endoureterotomy.

Blaine Kristo, P Schulam, Robert Phelan … (2003)

To report our results after antegrade endoscopic treatment of ureteral stenosis with balloon dilation with or without holmium laser endoureterotomy. Ureteral stenosis is the most common long-term urologic complication of renal transplantation. From July 2000 to October 2002, 9 renal transplant patients with ureteral obstruction diagnosed by an increase in serum creatinine and radiologic evidence presented for endoscopic treatment. All patients were treated with nephrostomy tube drainage followed by antegrade flexible nephroureteroscopy and balloon dilation of the stricture. Three patients required holmium laser endoureterotomy during the same procedure because of fluoroscopic and endoscopic evidence of persistent stricture. All patients were treated with ureteral stents and nephrostomy tubes postoperatively. The median follow-up was 24 months (range 6 to 32). The site of stenosis was at the ureterovesical anastomosis in all patients, and the mean stricture length was 0.28 cm. Two patients had previously undergone ureteroneocystostomy for prior ureteral stenosis. Six patients (66%) required only balloon dilation, and 3 patients (33%) also required holmium laser endoureterotomy. The median ureteral stent and nephrostomy tube duration was 40 and 62 days, respectively. The mean serum creatinine level was 2.3 mg/dL at presentation and 1.7 mg/dL at the last follow-up visit. After a median follow-up of 24 months, the ureteral patency and graft function rates were both 100%. No perioperative complications occurred. Balloon dilation with or without holmium laser endoureterotomy was successful and safe in this group of renal transplant patients with short ureterovesical anastomotic strictures.

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Author and article information

Contributors

Markus Giessing

Journal

Journal ID (nlm-ta): Arab J Urol

Journal ID (iso-abbrev): Arab J Urol

Title: Arab Journal of Urology

Publisher: Elsevier

ISSN (Print): 2090-598X

ISSN (Electronic): 2090-5998

Publication date PMC-release: 13 September 2011

Publication date (Print): June 2011

Publication date (Electronic): 13 September 2011

Volume: 9

Issue: 2

Pages: 93-99

Affiliations

[a ]Department of Urology, Heinrich Heine University Hospital Duesseldorf, Germany

[b ]Department of Nephrology, Heinrich Heine University Hospital Duesseldorf, Germany

[c ]Department of General, Visceral and Pediatric Surgery, Heinrich Heine University Hospital Duesseldorf, Germany

[d ]Department of Vascular Surgery, Heinrich Heine University Hospital Duesseldorf, Germany

Author notes

[* ]Corresponding author. Address: Heinrich Heine Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany. Tel.: +49 211 81 17980; fax: +49 211 81 18676. markus.giessing@ 123456med.uni-duesseldorf.de

Article

Publisher ID: S2090-598X(11)00034-9

DOI: 10.1016/j.aju.2011.06.014

PMC ID: 4150591

SO-VID: 9e2f7639-65d8-47bc-9648-9459585c9fb4

License:

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

History

Date received : 18 April 2011

Date revision received : 15 June 2011

Date accepted : 29 June 2011

Retrograde balloon dilation >10 weeks after renal transplantation for transplant ureter stenosis – our experience and review of the literature

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