June Issue.indd

G. Thevendran, M. A. Al-Akraa, P. Sweny, O.N. Fernando
Department of Renal Transplant Surgery, Royal Free Hospital, London, UK

Correspondence to: G. Thevendran, Department of Renal Transplant Surgery, Royal Free Hospital, London, UK

Introduction

Keywords: Kidney transplantation, pyeloureterostomy, calycoureterostomy
Surg J R Coll Surg Edinb Irel., 2 June 2004, 176-178

Stenosis and necrosis of the ureter are amongst the severe complications after renal transplantation. Several surgical techniques like simple nephrostomy or native pyeloureterostomy using the native ureter have been applied for repair. We report a case of modification to the conventional pyeloureterostomy where the native ureter was anastomosed to the transplant calyx to restore continuity of the urine collecting system. This technique is recommended as a feasible alternative when secondary reconstruction by native pyeloureterostomy is not possible

INTRODUCTION
Ureterovesicotomy is now almost a universally accepted technique for reconstructing the urinary tract during renal transplantation. When primary reimplantation of the transplanted ureter fails due to obstruction, leakage, fistula formation, ischaemia or reflux, pyeloureterostomy may be used to reconstruct the urine collecting system with the recipient’s ipsilateral ureter.¹ We report a conventional native pyelouretrostomy (NPUS) due to a damaged renal pelvis. The native ureter, thus, was anastomosed to the middle pole transplant calyx.

CASE
A 57-year old female presented with a history of recurrent urinary tract infections and persistent coughs. Five years prior, she underwent a live unrelated renal transplant in her native country. On subsequent follow-up there, she underwent a ureteric reimplantation. On return to the United Kingdom she presented with a persistent cough and worsening urinary symptoms.

Serial urine cytology and cultures showed numerous polymorphs but no lymphocytes or consistent growth. Cystoscopy revealed thick debris in the bladder and a cluster of stones around the site of ureteric implantation. Biopsy confirmed chronic inflammatory change. The patient remained symptomatic with progressive dysuria and a worsening cough. Tuberculosis was diagnosed on the basis of a combination of urine, bone marrow cultures and computed tomography (CT) guided abdominal lymph node biopsy. Antituberculous treatment was commenced but the urinary symptoms remained refractory to numerous courses of antibiotics. The patient was subsequently admitted as an emergency with septicaemia; the likely source being from multi-resistant Escherichia coli ( Ecoli) cultured from the urine. An acute deterioration in urine output and worsening of renal function was noted. Retrograde urography suggested an obstructive picture with likely rupture of the graft pelvis. (Figure 1) A nephrostomy was inserted and a surgical opinion sought for possible exploration of the graft and reconstruction of the collecting system.

At laparotomy, dense fibrosis hindered isolation of the transplant ureter up to the calyceal system. The transplant kidney was mobilised but attempts to dissect the renal pelvis from the posterior aspect of the kidney failed. The right native ureter was mobilised and its end spatulated. Anastomosis of the proximal end of the native ureter to the middle transplant calyx was performed. An intra-operative nephrostogram demonstrated a patent collecting system with no evidence of obstruction (Figure 2). Post-operative recovery was unremarkable and the double J stent was removed at six weeks
(Figure 3).

Figure 2: A patent and smooth-calibrated native ureter from the upper pole transplant calyx to bladder. Multiple strictures of the transplant (donor) ureter

DISCUSSION
Ureteric complications after renal transplantation have been reported in 2.9-13.4% of renal transplants.^2,3 A wide range of techniques has been described for reconstructing the urine collecting system including contralateral pyeloureterostomy, interposition of an intestinal conduit and pyelovesicotomy with or without a Boari flap.⁴ Since Leadbetter et al. first described end-to-end pyeloureterostomy, most surgeons have used this technique to reconstruct short, necrotic or stenosed ureters with the ipsilateral native ureter.⁵ In a study of 48 patients requiring secondary urinary tract reconstruction, Schult et al. (2000) discussed newer endoscopic techniques but concluded that NPUS is a safe and definitive technique of handling ureteric complications afer renal transplantation.⁶

CONCLUSION
This case illustrates a modification of the conventional NPUS in secondary urinary tract reconstruction. There are several likely causes of the obstructed transplant kidney in this patient. Stricturing from an infected refluxing system or fibrosis from possible tuberculosis or ischaemia may have been responsible. Indeed, fibrosis was partly to blame for difficulty in visualising and mobilising the transplant ureter in the pelvis during the time of the exploration. We believe, that in such a case where there is complicated anatomy, reconstruction with anastomosis of the proximal native ureter to the transplant calyx is a reliable modification to the conventional NPUS.

REFERENCES
1. Anderson MJ, Middleton RG. Secondary pyeloureterostomy with an intact ureter. J Urol 1982;128: 247-48.
2. Kashi SH, Lodge JPA, Giles GR, Irving HC. Ureteric complications of renal transplantation. Br J Urol 1992; 70: 139-43.
3. Kinnaert P, Hall M, Janssen F, Vereerstraten P, Toussaint C, Van Geertruyden J. Ureteral stenosis after kidney transplantation : true incidence and longterm follow-up after surgical correction. J Urol 1985;133:17-20.
4. Rajfer J, Koyle MA, Ehrlich RM, Smith RB. Pyelovesicostomy as a form of urinary reconstruction in renal transplantation. J Urol 1986;136: 372-50.
5. Leadbetter GW, Jr Monaco AP, Russell PS. A technique for reconstruction of the urinary tract in renal transplantation. Surg, Gynec & Obstet 1966; 123 : 839-41.
6. Schult M, Kuster J, Kliem V, Brunkhorst R, Nashan B, Oldhafer KJ, Schlitt HJ. Native pyeloureterostomy after kidney transplantation : experience in 48 cases. Transpl Int 2000; 13: 340-43.