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Ureteral complications in renal transplant recipients successfully treated with interventional radiology.

Transplant Proc. 2008 Nov;40(9):3170-2

Authors: Kaskarelis I, Koukoulaki M, Georgantas T, Bairamidis E, Kokkinos C, Ieronymou M, Vougas V, Drakopoulos S

Abstract
INTRODUCTION: Ureteral complications in renal transplantation occur in approximately 8% of renal transplant recipients, occasionally leading to graft loss. This retrospective study presents a single-center experience in managing ureteral complications with interventional radiology as well as the long-term graft function and recipient survival.
PATIENTS AND METHODS: We analyzed 21 renal transplant recipients with ureteral problems.
RESULTS: Nine patients experienced urinary leak, six patients had ureteric obstruction, and six patients had obstruction preceded by leak. Median recipient age was 48 (range, 20-63) years; 71% (15/21) of the patients were male and 66.6% (14/21) of transplants were derived from cadaveric donors. Ureteral complications were diagnosed at a mean of 18 days (range, 12-47) after renal transplantation. Initially a percutaneous nephrostomy was performed, followed by antegrade placement of a nephroureteral stent. In cases with ureteral obstruction, ureteral balloon dilation was performed prior to placement of the stent. Median time to the procedure was 53 days, and median follow-up for the purposes of this study was 57 months. Renal graft function improved following treatment of the ureteral complication. Mean serum creatinine values prior to and after the intervention were 4.8 +/- 2.12 and 1.79 +/- 0.58 mg/dL, respectively (P < .0001). Functional renal grafts were observed at the first, third, and fifth posttransplantation year among 100%, 95.2% and 80.9% of patients, respectively. It should be further noted that no graft was lost due to a ureteral complication.
CONCLUSIONS: Interventional radiology was successful in treating immediate and long-term ureteral problems among renal transplant recipients with preservation of good renal function and patient survival.

PMID: 19010224 [PubMed - indexed for MEDLINE]

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Urinary leak after renal transplantation proven by SPECT-CT imaging.

Clin Nucl Med. 2007 Nov;32(11):883-5

Authors: Talanow R, Neumann D, Brunken R, Bybel B, Wu G

PMID: 18075430 [PubMed - indexed for MEDLINE]

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Case of emphysematous pyelonephritis in a renal allograft.

Clin Transplant. 2005 Aug;19(4):559-62

Authors: Fujita S, Watanabe J, Reed AI, Hemming AW, Solis D, Netzel TC, Banull K, Schain DC, Howard RJ

Abstract
Emphysematous pyelonephritis is a rare, but serious complication after renal transplantation. This is a case report of a 49-yr-old female who had a renal transplant for diabetic nephropathy. She presented to ER with about 1 wk history of right lower abdominal pain and fever 15 months after the transplant. She had gross hematuria and mental status changes just prior to presentation. A computed tomography (CT) scan of the abdomen showed extensive retroperitoneal and extraperitoneal air dissecting from the transplanted kidney in the right lower quadrant to the level of the mediastinum. There was air in the urinary bladder. These findings were highly suggestive of extensive emphysematous pyelonephritis. The patient was taken to the operating room emergently and underwent a transplant nephrectomy. Blood culture and urine culture were subsequently positive for Salmonella (serogroup O 6, 8 or C2). Initial blood culture also yielded Enterobacter cloacae. The patient was treated with imipenem, cefepime, flagyl, and diflucan empirically: this was later changed to complete a 6-wk course of ciprofloxacin upon discharge. Her hospital course was complicated by a urinary leak; she was discharged to home on day 21. This is the 12th reported case of emphysematous pyelonephritis occurred in a renal transplant recipient.

PMID: 16008605 [PubMed - indexed for MEDLINE]

Emphysematous urinoma in a renal transplant patient.

Am J Kidney Dis. 2001 Nov;38(5):E29

Authors: Rao PS, Ravindran A, Elsamaloty H, Modi KS

Abstract
Urinary infection is a common complication after kidney transplantation. In some instances, especially with Escherichia coli infections, there is formation and collection of gas in the parenchyma and collecting system of the kidney, giving rise to the condition of emphysematous pyelonephritis. Such a process could occur in collections of urine (urinoma) secondary to ureteric leak in the transplant kidney. This process has not been described so far. In this report, we describe the first case of an infected urinoma with an interesting radiologic finding, a so-called emphysematous urinoma.

PMID: 11684581 [PubMed - indexed for MEDLINE]

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Ureteral obstructions and leaks after renal transplantation: outcome of percutaneous antegrade ureteral stent placement in 44 patients.

Radiology. 1998 Oct;209(1):159-67

Authors: Bhagat VJ, Gordon RL, Osorio RW, LaBerge JM, Kerlan RK, Melzer JS, Bretan PN, Wilson MW, Ring EJ

Abstract
PURPOSE: To analyze the outcome of percutaneous antegrade ureteral stent placement for treatment of ureteral stenoses and leaks after renal transplantation.
MATERIALS AND METHODS: Antegrade pyelography and percutaneous ureteral stent placement were performed in 45 patients with ureteral obstruction (n = 40), leak (n = 3), or both (n = 2). Obstructions were graded as mild, moderate, or complete, and as early (< or = 3 months after transplantation) or late (> 3 months).
RESULTS: The outcome of stent placement was successful in 25 (57%) patients (average follow-up, 30 months). The ureteroneocystostomy (UNC) was the most common site of obstructions (22 of 41), leaks (four of five), and successful outcomes (16 of 22). Moderate obstructions were most common (29 of 41) and responded best to treatment (17 of 29). Eighteen (69%) of 26 early obstructions and five (33%) of 15 late obstructions were successfully managed percutaneously. All complications (12 of 45 patients) were minor, with infections the most common (n = 7). No mortality or allograft loss was attributable to stent placement.
CONCLUSION: Ureteral stents are safe and effective for the treatment of obstructions and leaks and are particularly effective for early and UNC obstructions. These stents may also be useful for temporary drainage.

PMID: 9769827 [PubMed - indexed for MEDLINE]

Update on the use of percutaneous nephrostomy/balloon dilation for the treatment of renal transplant leak/obstruction.

J Vasc Interv Radiol. 1997 Jul-Aug;8(4):649-53

Authors: Fontaine AB, Nijjar A, Rangaraj R

Abstract
PURPOSE: Retrospective evaluation of the efficacy of percutaneous nephrostomy and nephroureteral stent placement for treatment of post-transplant ureteral leak, and percutaneous nephrostomy and balloon dilation for treatment of post-transplant ureteral obstruction.
PATIENTS AND METHODS: Data were reviewed for all patients who underwent percutaneous therapy for complications after renal transplantation between January 1985 and June 1995. A total of 61 patients with complications (leak, n = 17; obstruction, n = 44) had been treated. Patients underwent percutaneous nephrostomy followed by antegrade placement of a nephroureteral stent. In addition, all patients with obstruction also underwent ureteral balloon dilation. Follow-up ranged from 9 weeks to 24 months. Positive outcome was defined as nonsurgical closure of leak, significant improvement in renal function, and removal of the nephroureteral stent with maintenance of stable renal function.
RESULTS: Regarding ureteral leak, 10 of 17 patients (59%) healed after treatment. Seven patients (41%) did not respond and went on to surgical repair. All patients with early (n = 13) ureteral obstruction (< 3 months after transplantation), had improved renal function (P < .025). Sixty-two percent of patients with early obstruction were cured (tube out with stable renal function) and 38% went to surgery for ureteral repair. In patients with late (n = 31) obstruction (> 3 months after transplantation), renal function improved in only 58% (P < .01). Only 16% of patients with late obstruction were cured (tube out with stable renal function). Ureteral obstruction was persistent in the remaining patients and did not respond to multiple balloon dilations. All complications were minor and included 23 of 61 (38%) patients with urinary tract infections and nine of 61 (14%) patients with limited hematuria.
CONCLUSION: Percutaneous nephrostomy is very effective in improving renal function in patients with early obstruction. It is moderately successful in treating ureteral leak. Ureteral balloon dilatation is moderately effective for treatment of obstruction in the early (< 3 months) postoperative period. However, balloon dilation is minimally successful in curing ureteric obstruction occurring more than 3 months after transplantation.

PMID: 9232583 [PubMed - indexed for MEDLINE]

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[Functional MR urography in patients with kidney transplantation].

Radiologe. 1997 Mar;37(3):233-8

Authors: Knopp MV, Dörsam J, Oesingmann N, Piesche S, Hawighorst H, Wiesel M, Schad LR, van Kaick G

Abstract
PURPOSE: To assess the value of functional magnetic resonance urology for the noninvasive postoperative evaluation of renal transplants.
METHODS: A saturation inversion projection sequence allows the selective imaging of strongly T1 weighted signal from the MR contrast agent. A control slab leads to images comparable to conventional urography which can be acquired as a sequence with four images per minute.
RESULTS: 15 patients with urologic questionable findings after renal transplantation were studied. FMRU revealed in 6 patients normal findings, in 6 moderate dilatation of the renal pelvis without any urodynamic relevant obstruction. 3 pathologic findings, ureteral leak, ureteropelvic-junction obstruction and ureteral stenosis were diagnosed and consequently surgically treated. The imaging quality in all studies was diagnostic and urologically relevant.
CONCLUSION: FMRU can be used as a noninvasive technique for the assessment of renal transplant in cases with suspicion of complication in the excretory system.

PMID: 9182313 [PubMed - indexed for MEDLINE]

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Diagnosis of duodenal leaks from kidney-pancreas transplants in patients with duodenovesical anastomoses: value of CT cystography.

AJR Am J Roentgenol. 1995 Aug;165(2):349-54

Authors: Bischof TP, Thoeni RF, Melzer JS

Abstract
OBJECTIVE: This study was undertaken to assess the value of CT cystography, using scans made with full bladder distention by a combination of iodinated contrast material and air and scans made after active voiding, for detecting duodenal segment leaks in patients with kidney transplants and pancreas transplants associated with small duodenal segments and duodenovesical anastomoses.
SUBJECTS AND METHODS: 18 patients with such kidney-pancreas transplants underwent CT cystography for clinically suspected leaks from the duodenal segment. Six patients had two examinations, resulting in 24 CT cystograms. The CT protocol consisted of an initial series of pelvic scans (plain CT) without oral, IV, or bladder contrast material; CT cystogram with the bladder fully distended by iodinated contrast material and air; and, if the findings were negative, CT after voiding. If no leak was demonstrated, the remainder of the abdomen to the liver dome was examined. Diagnoses were proved by surgery or cystoscopy (n = 11) and clinical follow-up examinations (n = 13).
RESULTS: Overall, bladder-duodenal segment leaks were demonstrated in 11 of 12 studies: one by plain CT, seven by full CT cystography, and four by CT after voiding following negative findings on full CT cystography. One surgically proved leak was missed by CT cystography owing to a large amount of pelvic fluid. In 12 studies without a leak, CT cystography results correlated well with clinical follow-up studies. There were no false-positive results. Sensitivity was 92%, specificity was 100%, and accuracy was 96%.
CONCLUSION: CT cystography with a dedicated protocol is an accurate way to diagnose leaks of the duodenal segment in patients with bladder-drained kidney-pancreas transplants if administration of air combined with contrast material into the bladder and CT after voiding are used.

PMID: 7618555 [PubMed - indexed for MEDLINE]

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Imaging of en bloc renal transplants: normal and abnormal postoperative findings.

AJR Am J Roentgenol. 1993 Jan;160(1):75-81

Authors: Memel DS, Dodd GD, Shah AN, Zajko AB, Jordan ML, Shapiro R, Hakala TR

Abstract
OBJECTIVE: Cadaveric kidneys from donors less than 5 years old, previously considered inferior graft material, are now being successfully transplanted en bloc into children and adults. On the basis of our experience with 132 patients, we describe the general principles of the procedure and review the spectrum of normal and abnormal imaging findings in patients who have undergone this promising transplantation procedure.
MATERIALS AND METHODS: Paired cadaveric kidneys obtained from donors less than 5 years old (mean age, 24 months) were transplanted en bloc to 132 patients (mean age, 37 years) at our institution between 1981 and 1991. All available medical, surgical, pathologic, and imaging records were retrospectively reviewed to define the surgical technique, 1-year survival rate of the graft, appearance of the transplant on postoperative imaging studies, and the prevalence of and imaging findings caused by vascular, urinary, infectious, and neoplastic complications after transplantation. Complications were confirmed by a definitive imaging study, surgical exploration, or study of a pathologic specimen.
RESULTS: Paired donor kidneys were transplanted en bloc extraperitoneally into the recipient's right or left iliac fossa, with intact portions of the donor aorta and inferior vena cava anastomosed to the recipient's external iliac artery and vein. One-year graft survival was 70% during the first 8 years of the study and 78% during the last 2 years. Postoperative imaging, particularly sonography and scintigraphy, clearly depicted the normal individual kidneys, urinary collecting systems, and en bloc vasculature. Postoperative complications were vascular (arterial stenoses and thromboses, venous thromboses, and pseudoaneurysms) in 18%, urinary (obstruction and anastomotic leak) in 11%, infectious (caliceal fungal balls) in 1%, and neoplastic (posttransplant lymphoma) in 1%. The complications involved one kidney in 60% of the patients and both kidneys in 40%. The imaging findings caused by these complications were similar to those caused by complications occurring after transplantation of single cadaveric kidneys; however, their detection was more difficult because of the complexity of the en bloc graft.
CONCLUSION: Because of the shortage of available donor organs, en bloc renal transplantation will most likely become increasingly popular. Familiarity with the imaging appearance of the normal transplant and of posttransplantation complications will allow radiologists to perform effective postoperative imaging evaluations.

PMID: 8416653 [PubMed - indexed for MEDLINE]

[Value of tomodensitometry with injection and late images for the diagnosis of urinary leaks in kidney transplants].

Prog Urol. 1992 Apr;2(2):234-40

Authors: Barrou B, Bitker MO, Lugagne PM, Launay O, Luciani J, Jacobs C, Chatelain C

Abstract
Between May 1985 and May 1990, 263 renal transplantations were performed in 254 patients, with 4 kidney-pancreas double grafts. 12 urinomas were observed, i.e. 4.56%. In one half of cases, clinical examination alone was able to establish the diagnosis of urinoma, but in the other 6 cases, complementary investigations were required. Post-contrast computed tomography with late images (between 6 and 24 hours after the injection) would appear to be the most useful investigation. Performed in 6 cases, this examination established the diagnosis of urinoma in 5 cases and also suggested the mechanism of the leak, which was always confirmed at operation. The positive diagnosis is based on extravasation of contrast agent which is clearly visible, even in the presence of low concentrations due to impaired renal function. This extravasation occurred early in 3 cases, but was delayed in 2 cases, emphasising the importance of late images. Other investigations appear to be less useful either because of a lack of sensitivity or because of imprecise anatomical information. The severity of urine leaks and the need for rapid treatment justify post-contrast computed tomography with late images in any case of suspected urinoma.

PMID: 1302059 [PubMed - indexed for MEDLINE]

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Renal transplant pyelocaliectasis: role of duplex Doppler US in evaluation.

Radiology. 1991 May;179(2):425-8

Authors: Platt JF, Ellis JH, Rubin JM

Abstract
To distinguish the obstructed from the nonobstructed dilated collecting system of transplanted kidneys without interventional diagnostic measures, the authors prospectively evaluated duplex Doppler analysis (determination of resistive index [RI]) in 35 renal transplant patients with pyelocaliectasis. Proof of the presence or absence of obstruction was obtained at interventional procedures in 18 patients and at clinical follow-up in 17. Thirteen kidneys were obstructed (mean RI, .81 +/- .06), while 22 had nonobstructive dilatation (mean RI, .66 +/- .07). The RI difference was statistically significant (P less than or equal to .01). Of 21 kidneys with a normal RI, only two had obstruction. In both of these, the obstruction was associated with a significant peritransplant collection of fluid due to a ureteral leak. In the seven obstructed transplanted kidneys with follow-up, the mean RI was .82 +/- .06 before nephrostomy and .67 +/- .05 after nephrostomy. Obstruction was a common cause of an elevated RI (greater than or equal to .75). Other causes of transplant dysfunction can be associated with an elevated RI and nonobstructed dilatation. More important, a normal RI should strongly argue against obstruction unless a ureteral leak is also present.

PMID: 2014285 [PubMed - indexed for MEDLINE]

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Percutaneous treatment of urine leaks in renal transplantation patients.

Radiology. 1990 Mar;174(3 Pt 2):1049-51

Authors: Matalon TA, Thompson MJ, Patel SK, Ramos MV, Jensik SC, Merkel FK

Abstract
The data on post-renal transplantation urine leaks in 23 patients were retrospectively reviewed to assess the role of percutaneous urine-diverting procedures in their treatment. The leaks were confirmed by means of antegrade pyelography, and either a nephrostomy catheter or a nephroureteral stent was placed. Nephrostography was performed frequently to evaluate leak closure. Urinary diversion was continued for an average of 68 days. Leak closure was documented in 20 of 23 (87%) cases. In four patients, concomitant infection or multiorgan failure precluded adequate therapy. One patient developed a ureteral stricture after the urine-diverting procedure and required surgical correction. The results suggest that percutaneous urine-diverting procedures are a definitive treatment for post-renal transplantation urine leaks.

PMID: 2305088 [PubMed - indexed for MEDLINE]

Interventional radiology in the treatment of ureteric complications in transplant kidneys.

Australas Radiol. 1989 Aug;33(3):255-8

Authors: List A

Abstract
Eleven patients who had radiological procedures because of urinary leakage or ureteric obstruction in transplant kidneys are reviewed in order to judge the clinical efficacy of interventional radiological techniques in the management of these complications. Initial technical success was attained in 9/9 dilatation attempts and 17/21 (81%) stent placement attempts. It is thought that 9/11 (82%) patients benefited from the radiological attempts at treatment and at long term follow up 7 kidneys were still functioning, 3 failed due to rejection and one after failed renal artery surgery. The complication rate due to the radiological procedure was low, with one iatrogenic urine leak being the single major procedural complication. Two patients had urinary tract infections while stented and there were two patients with perirenal abscesses.

PMID: 2604635 [PubMed - indexed for MEDLINE]

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Urine leaks after renal transplantation: value of percutaneous pyelography and drainage for diagnosis and treatment.

AJR Am J Roentgenol. 1988 Sep;151(3):511-3

Authors: Smith TP, Hunter DW, Letourneau JG, Cragg AH, Darcy MD, Castaneda-Zuniga WR, Amplatz K

Abstract
We reviewed our experience with 12 renal transplant patients who had urine leaks to compare the accuracies of sonography and nuclear renography with that of antegrade pyelography in establishing the diagnosis. The leak was proved by surgery in 11 of the 12 cases. We also determined the role of diverting percutaneous nephrostomy drainage in the treatment of such leaks. The diagnosis was established by sonography in eight (67%) of the 12 patients. Nuclear renography, performed in nine patients, showed decreased renal function but showed the leak in only three (33%) of the nine cases. Antegrade pyelography, performed in all 12 patients, showed leakage in 10 (83%). In the other two patients, follow-up nephrostograms done within 24 hr showed leaks near the ureterovesical anastomotic site. Seven of 11 patients who were managed with a combination of percutaneous nephrostomy drainage and surgical reconstruction were treated successfully (i.e., a functioning graft was retained); however, only one patient was managed successfully by percutaneous methods alone. Antegrade pyelography is more accurate than sonography and nuclear renography in the detection of urine leakage after renal transplantation. However, percutaneous nephrostomy drainage appears useful only as an adjunct to surgery for treatment of this complication.

PMID: 3044039 [PubMed - indexed for MEDLINE]