Background - Ureteral complications after kidney transplantation represent a significant cause of morbidity causing renal dysfunction a potentially leading to allograft loss. We present technique and results of surgical management of ureteral complications of kidney transplantation. A variety of approaches and techniques were utilized to correct ureteral strictures and vesicoureteral reflux (VUR).
Methods - A prospective database from October 2011 to February 2024 identified renal transplant recipients who had ureteral complications of kidney transplantation requiring surgical management. Patient underwent surgical correction with pyelo-ureterostomy, uretero-ureterostomy or pyelo-calycostomy. Indications for either transplant ureteral stricture or vesico-ureteral reflux causing pyelonephritis were assessed. Preopertive evaluation included Technetium 99-m mercaptoacetyltriglycine renal scan to assess residual native renal function and either a video cysto-urethrogram or cystoscopy and retrograde pyelography. Postoperative patency was evaluated with either cystograms or antegrade nephrograms in conjunction with a Technetium 99-m mercaptoacetyltriglycine study
Results -Twelve patients were followed for a mean follow up time of 61.75 months (range 9–111). Four cases of VUR causing pyelonephritis and 8 cases of clinically significant ureteral strictures were identified. Nine minimally-invasive transplant-to-native ipsilateral pyeloureterostomies, 2 transplant-to-native ureteroureterostomies, and 1 transplant-to-native ureterocalycostomy were performed. Ten cases were performed robotically, 1 case laparoscopically, and 1 with open technique. No recurrent episodes of pyelonephritis were observed in patients treated for VUR. In 1 case there was evidence of recurrent ureteral obstruction. One case was converted from robotic to open technique. The case approached with open technique, the case converted from robotic to open, and the case complicated by recurrent obstruction, were all cases of donor kidneys transplanted in the ipsilateral iliac fossa.
Conclusions - Surgical reconstruction of kidney transplant ureters for ureteral strictures and VUR with ipsilateral native ureter is feasible and effective with relatively low complication rate. In most cases it can be performed with minimally invasive techniques. The presence of donor allografts transplanted in ipsilateral iliac fossa might lead to higher conversion and complication rate.
