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Volume: 21 Issue: 9 September 2023

FULL TEXT

ARTICLE
Pyelovesicostomy as an Alternative Surgical Treatment for Complex Ureteral Lesions After Kidney Transplant

Objectives: We evaluated the feasibility, safety, and long-term outcomes of pyelovesicostomy as an alternative surgical treatment for complex ureteral lesions after kidney transplant. Material and Methods: A single-center, retrospective, observational cohort study was conducted on 5 adult kidney transplant recipients who underwent pyelovesicostomy between January 2000 and June 2023. The collected data included patient demog-raphics, surgery indication, time from transplant to pyelovesicostomy, procedure details, and kidney function at various time points after surgery. Primary outcomes were allograft function and complications. Results: The 5 patients (4 female, 1 male) had a mean age of 65.8 years and mean body mass index of 26.8. Indications were complex ureteral lesions. The time between transplant and reoperation ranged from 4 days to 12 years. Renal function improved for all patients, with a progressive decrease in mean serum creatinine concentration. The mean follow-up period extended to 7 years. One patient died with the graft still functional at 20 years after the operation, whereas the remaining 4 patients continue to live with functional grafts. Conclusions: Our study suggests that pyelovesicos-tomy may provide a potent alternative for the management of complex ureteral lesions after kidney transplant. We have observed good short-term and long-term outcomes in specific patients, pointing toward a promising avenue of treatment worth further exploration. This reaffirms the importance of a personalized approach in medicine, to consider each patient’s unique conditions and characteristics during therapeutic decisions.


Key words : Allograft function, Kidney transplantation, Observational cohort study, Perioperative management, Surgical complications

Introduction

Kidney transplant remains the preferred treatment modality for patients with end-stage renal disease, offering improved quality of life and survival rates compared with long-term dialysis.1,2 Despite the significant progress achieved in surgical techniques and perioperative management, urological comp-lications, primarily ureteral lesions, remain a challenging issue, affecting morbidity and graft survival rates.

The incidence of urological complications after kidney transplant ranges between 3.7% and 6.0%.3-5 These complications, especially urine leak and ureteral stricture, remain the most common type of surgical complication after kidney transplant. Preservation of the peri-ureteric tissue during kidney retrieval, Lich-Gregoir ureteroneocystostomy technique, and routine prophylactic ureteral stenting have been shown to decrease the incidence of these complications. Routine postoperative allograft ultrasonography is important for early detection of these complications.6

Most urological complications can be traced back to technical errors during retrieval, bench dissection, or implant.7 Most leaks occur at the distal portion of the ureter, most commonly at the site of the ureteroneocystostomy.8 Distal ureteral ischemia and necrosis secondary to compromised blood supply is thought to be the main reason for early ureteral complications in most patients in the absence of technical difficulties during the transplant.9

Most recipients can be effectively managed percutaneously, avoiding the morbidity associated with open surgery. The prognosis is generally excellent if recognized and treated successfully in a timely manner.6 Of those cases that are not successfully managed conservatively and endoscopically, surgical revision with a ureteroneocystostomy to restore the normal continuity of the excretory urinary system is recommended. Alternatives are ureteroureterostomy between transplanted ureter and ipsilateral native ureter, ileal interposition, and pyelovesicostomy (PVS).

Pyelovesicostomy has been proposed as a viable alternative for management of complex ureteral lesions, particularly when standard ureteroneo-cystostomy is impractical or has previously failed. The initial description of the direct anastomosis of the renal pelvis to the urinary bladder (Figure 1) for drainage was reported in 1929 for renal dystopia and hydronephrosis.10 In 1971, Lindstedt and colleagues performed the first PVS on a 32-year-old renal transplant patient.11 They followed the patient for 9 years and reported a normal blood pressure, sterile urine, and stable creatinine. Intravenous pyelogram revealed prompt renal excretion, good drainage, and minimal postvoid residual.

The PVS technique has not been widely adopted due to concerns about long-term outcomes and the complexity of the procedure. However, advancements in surgical techniques and instrumentation coupled with a better understanding of the procedure’s indications and potential benefits have recently led to a resurgence of interest in PVS. The paucity of studies focusing on PVS in the management of complex ureteral lesions after kidney transplant limits our understanding of the technique’s effectiveness and safety. Most of the available evidence is based on small case series or isolated case reports, which necessitates further research on larger patient cohorts.

We present a retrospective analysis of 5 cases from our department in which PVS was performed as an alternative surgical treatment for complex ureteral lesions after kidney transplant. We aimed to add valuable insights into the technique’s feasibility, safety, and long-term outcomes, potentially contributing to an improved understanding and broader acceptance of this technique within the medical community.

Materials and Methods

This single-center, retrospective, observational cohort study consisted of 5 adult kidney transplant recipients who underwent PVS at our institution between January 1, 2000, and June 30, 2023. Basic demographic data and specific clinical data of the patients were recorded. There were no missing values in the data used in the analyses. The collected patient data included sex, age, body mass index, primary cause of end-stage renal disease, surgery indication, time from transplant to PVS, PVS width and technique, length of the procedure and blood loss, length of hospital stay, length of follow-up, complications, and kidney function (before procedure and then 7 days, 30 days, and 1 year after surgery). Follow-up data were obtained through laboratory analysis from routine posttransplant checkups.

Before PVS, computed tomography urography was performed in each patient (together with 3D reconstruction when possible). Regarding surgical technique, an open approach via a previous Gibson incision was used for extraperitoneal access to the iliac fossa. A U-shaped incision in the renal pelvis was made to create a wide-mouth flap. The newly created stoma (diameter 10-15 mm) was sutured to a longitudinal incision in the bladder using full-thickness continuous absorbable 4-0 sutures (Vicryl; Ethicon). To achieve a tension-free anastomosis, adequate mobilization of the bladder was necessary, and in 1 patient a psoas hitch was used (another option would be also Boari flap). One silicone drain was placed, and no nephrostomy or ureteral stent was needed. The urinary catheter was removed postoperatively in 5 to 7 days.

Results

Among our 5 patients (4 female, 1 male), the mean age was 65.8 years (range 50-76 years), and body mass index was 26.8 (range 20.1-35). The cause of end-stage renal disease was hypertensive nephropathy for 1 patient, diabetic nephropathy for 1 patient, and autosomal dominant polycystic kidney diseases for 3 patients. All patients received a kidney from a deceased donor. Indications for PVS were complex ureteral lesions: 1 patient had ureteral stricture and failure to place a ureteral stent, temporarily on nephrostomy; 1 patient had ureteral stricture after unsuccessful surgical revision of the uretero-neocystostomy; and 3 patients had urinary leakages (together with ureteral necrosis in 1 patient).

The time between the transplant and the subsequent reoperation varied significantly and ranged from 4 days to 12 years, with an average of 44 months. Renal functions improved for all the patients as indicated by the progressive decrease in mean serum creatinine concentration: mean preoperative level was 3.45 mg/dL (range 1.75-5.06), dropping to 1.89 mg/dL (range 0.94-2.94) 7 days after surgery, 1.92 mg/dL (range 1.09-3.57) 30 days after surgery, and ultimately to 1.80 mg/dL (range 0.97-3.06) 1 year after surgery. The average duration of hospital stay was 13.6 days (range 8-23 days).

Within the initial 30 days after surgery, 2 patients required readmission due to urinary tract infection (UTI), although the origin of these infections was traced back to their native polycystic kidneys. The mean follow-up period extended to 7 years (range 1.5-20 years). Of the patients monitored, 1 patient died with the graft still functional 20 years after operation, while the remaining 4 patients continue to live with functional grafts. Throughout the follow-up period, no acute pyelonephritis of the transplanted kidney or recurrent ureteral strictures were observed. At 4.5 years after the reconstruction, 1 patient underwent ileal resection due to stran-gulated hernia (Table 1).

Discussion

Our analysis of 5 cases from our department emphasizes the potential of PVS as a feasible alternative for management of complex ureteral lesions after kidney transplant. The outcomes observed in our study add to the growing body of evidence that supports the use of this technique under specific circumstances.

In the context of ureteral complications, standard techniques such as ureteroneocystostomy are often the first-line approach. However, in certain cases, these traditional methods might be impractical or unsuccessful. This is where our study posits PVS as a viable alternative, showcasing its efficacy in a small, selected patient cohort.

From a surgical standpoint, the technical demands of PVS are often considered a drawback. The procedure requires a high level of surgical expertise, particularly when treating complex cases or in reoperation scenarios. In our cohort, we found that with adequate surgical experience and careful patient selection, the procedure can be performed with minimal complications and yield promising results. This highlights the importance of surgical skill and expertise in the successful execution of this procedure.

Prerequisites for this procedure are compliant urinary bladder and absence of subvesical obstruction.12 A primary concern associated with PVS relates to the uncontrolled reflux of urine into the renal pelvis, which could potentially lead to complications such as infections, graft failure, and deterioration of renal function. In past years, many researchers have delved into these issues. It was initially presumed that the reflux of urine could be a source of UTI. However, in a pivotal 1968 study, Lapides and colleagues proved that urine reflux does not inherently lead to UTI if a regimen of timed voiding is observed to maintain urine sterility.13 This groundbreaking finding has been substantiated by further research indicating that renal function is not adversely affected in the presence of sterile urine.14,15 The potential role of urine reflux to cause graft failure has also been a subject of interest.16 In our comprehensive review of PVS cases involving transplant patients, we found no evidence of renal allograft loss to this date. The reflux exposes the kidney to momentary spikes in renal pelvic pressure. Danforth and colleagues, in their 1980 study, used a canine model to investigate the immediate impacts of reflux on the structure and function of the kidney in the context of PVS.17 They monitored 3 animals with PVS in autotransplanted kidneys, along with 3 unoperated subjects (control). All 3 animals had free reflux of urine that was initiated at bladder pressures of less than 16 cm H2O. The animals were observed for 1 year, during which antibiotics were used to maintain urine sterility. After 1 year, histological examination revealed no anomalies in the glomeruli, tubules, or interstitium.

In a 1985 report, Ranch and colleagues presented urodynamic findings from 20 patients with PVS in autotransplanted kidneys.18 They conducted studies on urinary flow, postvoid residual, incidence of UTI, and cystometry before and after the PVS, with an average monitoring period of 31 months. They found no changes in urinary flow rates or the occurrence and severity of UTI. Cystometrograms showed no notable alterations in bladder sensory or motor functions. The only noticeable change was a minor increase in postvoid residual urine, which ranged from 5 to 50 mL.

Despite the age of these studies, urologists remain concerned about these complications. One valuable advantage observed in our study was the immediate postoperative improvement of kidney function. The long-term outcomes in terms of graft survival and complications were equally promising, emphasizing the potential role of PVS to facilitate the longevity of transplanted kidneys.

It is essential to consider the limitations of our study. The small sample size may not fully capture the broad spectrum of outcomes associated with this procedure. Moreover, our analysis is retrospective and thus may have inherent bias that must be considered during interpretation of the results. As such, our conclusions, while suggestive, should be considered with caution.

Moving forward, it will be crucial to conduct larger, preferably prospective, studies to ascertain the efficacy and safety of PVS in a broader population of kidney transplant recipients and include the possibility of mini-invasive procedures (laparoscopic, robotic-assisted).19,20 It would be interesting to investigate in particular the scenarios and patient characteristics for which this technique proves most effective, to pave the way for personalized therapeutic strategies in management of posttransplant ureteral complications.

Conclusions

In our analysis, we explored the implications and outcomes of PVS as an alternative surgical procedure for complex ureteral lesions after kidney transplant. Our investigation, although small in scale, has provided a unique perspective on this less commonly used technique, offering an invaluable foundation upon which further research can be built.

From a short-term perspective, we noted immediate improvement in kidney function. In the long-term, the procedure demonstrated promising results in terms of graft survival, which is the paramount concern in the realm of kidney transplantation. This prospect suggests the potential for the PVS technique to improve both the longevity and the quality of life for transplant recipients.

Although the results are indeed encouraging, it is crucial to remember that our study is confined to a small cohort of 5 patients. As such, the genera-lizability of our conclusions might be limited. More comprehensive studies, preferably multicenter projects with larger patient cohorts, are required to confirm these findings and elucidate the specific patient characteristics that would indicate PVS as the most suitable choice. Further research could also optimize the PVS technique and establish guidelines for its use in clinical practice.


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Volume : 21
Issue : 9
Pages : 712 - 716
DOI : 10.6002/ect.2023.0204


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From the 1Department of Urology, University Hospital Hradec Kralove, Czech Republic; the 2Charles University, Faculty of Medicine, Hradec Kralove, Czech Republic; the 3Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA; the 4Department of Surgery, University Hospital Hradec Kralove, Czech Republic; the 5Department of Anaesthesiology and Intensive Care, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic; and the 6Faculty of Health Sciences, Technical University of Liberec, Liberec, Czech Republic
Acknowledgements: This study was supported by the Charles University COOPERATIO Program, research area SURG. Other than described, the authors have not received any funding or grants in support of the presented research or for the preparation of this work and have no declarations of potential conflicts of interest.
Corresponding author: Pavel Navratil, Department of Urology, University Hospital Hradec Kralove, Sokolska 581, 500 05 Hradec Kralove, Czech Republic
E-mail: pavel.navratil2@fnhk.cz