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Fistule urinaire par nécrose de l'uretère. Visualisation sur le scanner d'une volumineuse collection autour du greffon rénal, qui s'opacifie 60 minutes après l'injection de produit de contraste.
Source publication
Introduction:
Urinary fistula and ureteral stenosis occur respectively in 2-5% and 2-7.5% after kidney transplantation. The aim of the study was to do an overview about the complex management of these complications.
Material and methods:
A bibliographical research in French and English language was carried out. Debates on the topic held within a...
Contexts in source publication
Context 1
... avec injection de produit de contraste permet la visualisation de l'extravasation du produit de contraste et donc d'établir le diagnostic. Il faut cependant disposer de clichés suffisamment tardifs car l'extravasation du produit de contraste peut être tardive lorsque l'urinome est compressif (Fig. 4). L'injection de produit de contraste iodé est souvent nécessaire pour permettre un diagnostic anatomique précis. Il doit être discuté même s'il existe une insuffisance ...
Context 2
... voie médiane. Il est donc recommandé de mettre en place une sonde double J dans l'uretère natif homolatéral en début d'intervention pour faciliter son repérage. Si le greffon doit être décollé pour aborder le pyé-lon à sa face postérieure (rein gauche transplanté à gauche ou rein droit à droite), cette manoeuvre est plus facile par voie iliaque. (Fig. ...
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Citations
Renal transplantation is the treatment-of-choice for a significant number of patients with end-stage renal disease. Prophylaxis, diagnosis and treatment of infections are cornerstones in the management of transplant patients. There are a number of opportunistic and rare pathogens in the immunosuppressed transplant patient population, whose early detection is essential for an optimized and targeted treatment. As the immunosuppressive regimen is adopted after transplantation and due to a potentially delayed reactivation of latent diseases, certain infections can occur in defined time intervals following transplantation. The present review summarizes the common and some of the rare diseases caused by the broad microbiological spectrum in kidney transplant recipients and the respective therapeutic options.
Background:
Ureteric stenosis (US) is the most common urologic complication after kidney transplantation. In this dual-center retrospective study we compared the efficacy and safety of open surgery versus interventional radiology for the management of US.
Methods:
From 2009 to January 2016, US was treated by surgical revision in 22 (7.8%) out of 281 recipients at one center (group 1) and managed by percutaneous nephrostomy with antegrade nephroureteral stenting (PNAS) in 22 (14.2%) out of 155 recipients at the other center (group 2).
Results:
Three patients in group 1 required reintervention and again were treated with open surgery. With a mean follow-up of 42.1 ± 38.7 months, graft function improved in all but one patients (95%). Three patients in group 2 were admitted with relapse of US not amenable to 2nd PNAS, and 2 of them were managed with surgery. These 3 and 2 other cases with improved graft function after PNAS lost their grafts and returned to hemodialysis. The remaining 17 patients (77%) still have functioning grafts. There was no statistically significant difference between the efficacy of PNAS and open surgery for the management of post-transplantation US. However; a benefit in favor of open surgery existed for type 2 urinary tract obstruction in terms of decreased reintervention rate and much better protection of the graft function and survival.
Conclusions:
Both interventional radiology and open surgery have acceptable efficacy rates in the management of ureteric complications after renal transplantation. Open surgery is a better treatment option for type 2 obstruction.
OBJECTIVES
To describe kidney transplantation surgical techniques and to propose strategies in high-risk recipients.
MATERIAL AND METHODS
Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov/) and Embase (http://www.embase.com/) database using the following keywords, alone or in association, "renal transplantation; peripheral arterial disease; obesity; third and fourth transplantation; robotic-assisted kidney transplant; anticoagulant therapy; dual kidney transplant". Articles were selected according to methods, language of publication and relevance. The reference lists were used to identify additional historical studies of interest. Both prospective and retrospective series, in French and English, as well as review articles and case-reports were selected. A total of 1949 articles were analyzed for arterial disease and anticoagulant therapy, 1083 for obesity, 663 for dual kidney transplants, 458 for third and subsequent procedures and 84 for robotic-assisted kidney transplantation. After careful selection, 304 publications were eligible for our review.
RESULTS
Surgical assessment of future recipients is a pivotal step to anticipate technical difficulties, to interrupt clopidogrel or direct oral anticoagulants and to propose a revascularization procedure when necessary. Lack of data regarding obese recipients does not allow us to conclude about best surgical care or optimal timing but suggest that an early global management of obesity in chronic kidney disease patients is mandatory to improve access to a successful transplantation. In neurologic bladder and congenital anomalies, urodynamics and bladder function must be assessed prior to the onset of oliguria to intend an early treatment. Urinary diversion may be performed prior to or after transplantation with similar survival outcome and comparable rates of infections. Because of a rigorous selection of donors, the French dual kidney transplant program provides satisfactory outcomes, but fails in convincing surgical teams nationwide. Third and subsequent transplant procedures remain a surgical and immunological challenge, with an increased morbidity and a moderate decline in transplant survival only when donors are extended criteria' with extensive duration of waiting time between procedures. Robotic-assisted kidney transplantation is a recent technique requiring methodical evaluation.
CONCLUSION
Kidney transplantation in challenging recipients implies a global understanding of patients' prognosis and benefits versus dialysis, in the context of the attribution of a valuable resource awaited by other patients on waiting list.
Copyright © 2016 Elsevier Masson SAS. All rights reserved.
Résumé
Objectif
Rapporter la nature, l’incidence, les outils diagnostiques et les moyens thérapeutiques des complications chirurgicales de la transplantation rénale.
Matériels et méthodes
Une recherche bibliographique exhaustive à partir de Medline (http://www.ncbi.nlm.nih.gov/) et Embase (http://www.embase.com/) a été réalisée entre 1960 et 2016 en utilisant les mots clés suivants « complications chirurgicales ; fistule ; lymphocèle ; sténose ; thrombose » en combinaison avec le mot clef « transplantation rénale » dans le champ « Titre/Résumé ». Les articles obtenus ont ensuite été sélectionnés sur leur méthodologie. Ainsi 7618 articles ont été identifiés dont plus spécifiquement 981 pour les complications vasculaires, 1016 pour les complications urinaires et 239 pour les lymphocèles. Après élimination des doublons et sélection, 190 articles ont été revus et sélectionnés.
Résultats
L’incidence des complications chirurgicales de la transplantation rénale varie de 1 à 30 % selon les séries ; elles sont souvent rapportées de façon incomplète et leur prise en charge est rarement consensuelle. Les techniques d’angioplastie ont apporté une amélioration sensible du traitement des complications vasculaires du transplant à moyen et long terme. Les facteurs de risque de thromboses des vaisseaux du transplant sont le rein droit, la présence d’artères multiples du transplant, l’existence d’une artériopathie chez le donneur ou le receveur, les troubles hémodynamiques per-procédure, la présence d’une néphropathie diabétique ou un antécédent d’accident thromboembolique chez le receveur. Les complications urinaires et la lymphocèle, si elles ne mettent pas en jeu la survie du transplant, sont responsables d’une morbidité conséquente pour le receveur. L’anastomose pyélo-urétérale d’emblée ou de rattrapage fait partie des principales options thérapeutiques des sténoses et fistules urétérales.
Conclusion
La prévention des complications chirurgicales de la transplantation nécessite une préparation minutieuse du transplant, et un respect rigoureux des bonnes pratiques chirurgicales. Les comorbidités de plus en plus importantes des receveurs sélectionnés, et des donneurs marginaux, n’ont pas permis de diminuer significativement la morbidité globale de la transplantation rénale.
Introduction:
The use of transplants from extended criteria donors increases the number of urological complications after renal transplantation. Two different anastomosis techniques used to restore urinary continuity are compared in this study.
Patients and methods:
Retrospective study, bi-center over a period of 5 years. One hundred and seventy six patients operated at Hospices Civils de Lyon benefited from ureteroneocystostomy according to De Campos-Freire (group 1) and 167 patients operated at the Necker Hospital in Paris had a pyelo-ureterostomy (group 2). The various urological complications (fistulas, strictures, seromas, haematomas and vesico-ureteric reflux) and their care were compared. Risk factors were sought.
Results:
The waiting time before transplantation was longer in group 2 than in group 1 (51 and 33.84 months) as the percentage of anuric patients (52.9 % against 32.9 %) (P<0.001). The cold ischemic time was shorter in group 1 (939.3minutes on average against 1325.3minutes for group 2) (P<0.001). A double J stent was put in place in 97.6 % of cases in group 2 against 84.2 % for group 1 (P<0.001). We did not find any significant difference in the occurrence of stenosis and fistulas (major complications) between the 2 groups. There were more minor complications (hematoma, seroma and vesico-ureteric reflux) in group 1 (P=0.033). There was a difference in the treatment of these complications, especially stenosis (P=0.024) with a significantly more conservative approach in group 2. Multivariate analysis found anuria, sex of recipients and donor age as independent risk factors in the onset of complications and the double J stent as a protective factor.
Conclusion:
This study does not demonstrate the superiority of a urinary anastomosis technique. The establishment of a double J stent reduces the risk of complications. Analysis of risk factors allows to propose a decision tree to guide the surgical strategy, particularly in the population of anuric recipients.
Level of evidence:
5.
Acute renal failure due to ureter compression after a mesh-plug inguinal repair in a kidney transplant recipient has not been previously reported to our knowledge. A 62-year-old man, who successfully underwent kidney transplantation from a deceased donor 6 years earlier, was admitted for elective repair of a direct inguinal hernia. The patient underwent an open mesh-plug repair of the inguinal hernia with placement of a plug in the preperitoneal space. We did not observe the transplanted ureter and bladder during dissection of the inguinal canal. Immediately after surgery, the patient became anuric, and a graft sonography demonstrated massive hydronephrosis. The serum creatinine level increased rapidly, and the patient underwent an emergency reoperation 8 hours later. During surgery, we did not identify the ureter but, immediately after plug removal, urine output increased progressively. We completed the hernia repair using the standard technique, without plug interposition, and the postoperative course was uneventful with complete resolution of graft dysfunction 3 days later.
Furthermore, we reviewed the clinical features of complications related to inguinal hernia surgery. An increased risk of urological complications was reported recently in patients with a previous prosthetic hernia repair undergoing kidney transplantation, mainly due to the mesh adhesion to surrounding structures, making the extraperitoneal dissection during the transplant surgery very challenging. Moreover, older male kidney transplant recipients undergoing an inguinal hernia repair may be at higher risk of graft dysfunction due to inguinal herniation of a transplanted ureter.
Mesh-plug inguinal hernia repair is a safe surgical technique, but this unique case suggests that kidney transplant recipients with inguinal hernia may be at higher risk of serious urological complications. Surgeons must be aware of the graft and ureter position before proceeding with hernia repair. A prompt diagnosis with graft sonography and abdominal computed tomography scan and emergency surgery may avoid the need for nephrostomy and may resolve graft dysfunction more rapidly.
