Contributors of Campbell-Walsh-Wein, 12th edition
Mohammed Shahalt, Stephen V. Jackman, and Timothy D. Averch
Hematuria
Postoperative hematuria is usually related to the urothelial trauma from ureterovesical anastomosis, stents, and catheters. This risk is increased in patients taking anticoagulation and antiplatelet agents. Mostly it is self-limiting. Significant hematuria is uncommon and requires careful bladder irrigation due to the fresh ureterovesical anastomosis and rarely requires cystoscopy for clot evacuation and fulguration. Hematuria is more frequent after the Politano-Leadbetter type of implantation.
After renal biopsy, hematuria requires immediate evaluation with ultrasound to rule out arteriovenous (AV) fistula. About 70% of AV fistula resolve spontaneously. If an AV fistula persists, it will require angiogram and selective embolization. Acute onset hematuria with pain and tenderness over the graft associated with low urine output requires urgent evaluation with ultrasound (US) to rule out vascular thrombosis.
Evaluation of asymptomatic microscopic hematuria (AMH) follows the American Urology Association (AUA) guidelines for general population; with the additional differential diagnoses of a retained stent, ureteritis and hemorrhagic cystitis from viruses (BK, adeno virus, and cytomegalovirus [CMV]). Viral cytopathic changes could be seen on cytology and confirmed by urine BK virus titer.
Ureteral stent management
Ureteral stenting in transplantation is known to protect against ureteric obstruction and urine leak. But there is risk of microbial colonization of the stent and urinary tract infection (UTI), including pyelonephritis and graft dysfunction irrespective of the dwell time.
Early stent removal before the third postoperative week has been shown to reduce the incidence of UTI without discernible effect on the incidence of urine leak and obstruction. Most patients are on cotrimoxazole for prophylaxis against pneumocystis, but patient-specific antimicrobial prophylaxis for high-risk patients is recommended.
Stenting and timing of removal should be individualized based on various factors, including the quality of ureter, bladder, bladder outflow issues; integrity of the anastomosis; difficulty of the surgery from body habitus; scarring from prior radiation or surgery; and comorbidities.
Retained stent
Difficulty in removing a stent could be secondary to error of including the stent in the suture line and requires delayed removal after dissolution of the suture. If earlier removal is required, there is a need endoscopic suture transection. Routine removal of stents with accelerated encrustation could be difficult.
Stents left in for prolonged periods (either intentionally or forgotten) are uncommon and lead to encrustation. Patients rarely manifest the classical symptoms of ureteral obstruction due to the denervation of kidney graft. Common presentations are recurrent UTIs, decrease in urine output, progressive decline in renal function, and pain or discomfort from graft swelling and peritoneal irritation.
Prevention
Documentation and effective communication and timely removal of the stent are essential to avoid this iatrogenic complication.
Diagnosis and treatment
Computed tomography (CT) scan should be performed to assess the burden of encrustation and management planning. Percutaneous nephrostomy will be required initially to relieve the obstruction and improve the renal function, which could be used for antegrade access for further procedures if required. A combination of various modalities is used in managing the encrusted stents (percutaneous nephrolithotomy, antegrade/retrograde intrarenal surgery, and extracorporeal wave shock lithotripsy) ( Fig. 23.1 , UNN Box 23.1 ).
Hematuria and ureteral stent management
Majority of postop hematuria is self-limiting.
Consider duplex ultrasound for severe or persistent hematuria after renal biopsy to rule out arteriovenous (AV) fistula.
Sudden onset of anuria and hematuria requires evaluation with ultrasound to rule out vascular thrombosis
Ureteral stent decreases ureteral stricture and urinary leak.
Individualized plan for stent removal 2–3 weeks posttransplantation.
Urinary leak
Urine leak and ureteric obstruction comprise the most early urologic complication. The risk factors are ureteric ischemia from various causes (long ureter, multiple arteries), procurement and implantation techniques, and bladder dysfunction ( Box 23.1 ).
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Excessively long ureter and lower pole artery: ischemia
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Premature removal of bladder and/or ureteric drainage
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Technical problem such as suture dehiscence, ureteric twisting, or kinking
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Acute urine retention or bladder catheter obstruction
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Necrosis of renal parenchyma, ischemia, multiple arteries
Diagnosis
Urine leak should be suspected when the drain output is high with diminished urine output and raising serum creatinine. Other manifestations are leaking edematous wound, swelling of the scrotum and thigh, wound dehiscence, and disproportionate pain. US/CT scan will show edematous wound and fluid collection. Creatinine of the fluid from the wound/drain will be significantly higher than serum creatinine. CT cystogram and radionuclide studies may be required.
Treatment
The initial management is urinary diversion and drainage of the collection from the surgical site to protect the vascular anastomoses and to improve graft function and the condition of the patient. This is achieved by a Foley catheter and a percutaneous nephrostomy with antegrade stenting of the ureter if the ureter is not stented. Retrograde stent placement can be challenging with potential for further disruption of the anastomosis. Monitoring the drain output and graft function will guide further management. Periodic imaging may be required. The Foley catheter and nephrostomy tube can be removed on resolution of leak. Persistent urine leak despite adequate diversion and drainage requires exploratory surgery for ischemic ureter or a major leak.
Early exploration and reconstruction should be considered in patients with persistent leak despite maximal drainage because of the lower success rate of conservative management, the ease of early surgery secondary to lack of significant adhesions and fibrosis, and the decreased risk of subsequent ureteric stricture. The surgical option depends on the quality of the transplanted ureter, native ureter, and bladder. They are revision of ureterovesical anastomosis if the ureteric remnant is vascular and healthy, ureteroureterostomy to the native ureter, Boari flap, and pyelovesicostomy.
Ureteral obstruction
Ureteral obstruction can be early (<3 months) or late (>3 months). The causes of early obstruction are mostly technical from defective anastomosis, edema, lack of stent, redundant ureter, and extrinsic compression (seroma, lymphocele, hematoma, and abscess). Diagnosis is made with US showing hydronephrosis with renal dysfunction ( Box 23.2 ).
Early ureteral obstruction (<3 months)
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Technical error during ureteroneocystostomy anastomosis
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Forgoing ureteral stent
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Anastomotic edema
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Redundant ureter
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Extrinsic compression (lymphocele, hematoma, abscess)
Late ureteral obstruction (>3 months)
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Stones
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Ureteral strictures
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Lymphocele
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Fibrosis: postoperative scarring, ischemia, and infection related
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