Renal autotransplantation for iatrogenic high-grade ureteric stricture

Abstract

A 47-year-old Hispanic woman developed a chronically obstructed left kidney, due to a long-segment ureteric stricture deemed not amenable to reimplantation, following left ovarian cyst excision in 2004. Therefore, a ureteral stent requiring exchange every 3 months was necessary, due to hydronephrosis, recurrent urosepsis, chronic pain, and a poor quality of life. Her medical history was complicated by hypertension, poorly controlled diabetes mellitus, and microalbuminuria, suggesting early diabetic nephropathy. A left nephrectomy was recommended. This was deferred, due to concern for progressive kidney failure associated with her comorbidities. A radionuclide Tc-99m MAG3 renal scan revealed differential perfusion as follows: 44% left kidney and 56% right kidney, with symmetrical uptake on the renogram phase and delayed excretion on the left, which were correctted following furosemide administration. A left ureteronephrectomy with autotransplantation of the left kidney and ureteroneocystostomy was performed in 2009. Since then, the patient has experienced no further complications or need for invasive procedures, with excellent diabetic control and stable renal function (eGFR > 60 mL/min/1.73 m(2)). This technique is seldom employed in the surgical management of complex ureteral injuries, but may be an alternative for appropriate cases.

Figure 1

Left ureteral stricture.

Figure 2

Left ureteral stricture (solid yellow arrow) and patent right ureter (interrupted yellow arrow).

Figure 3

9.8 mCi Tc-99m MAG3 Radionuclide differential renal scan with furosemide. Blood flow phase of the study shows relatively symmetric perfusion; blood flow to the left kidney is minimally decreased with respect to the right kidney. Differential perfusion is 44% to the left kidney and 56% to the right kidney. Renogram phase of the study shows symmetric uptake bilaterally, with only minimally delayed excretion to 17 minutes in the left kidney, suggesting a mildly patulous collecting system. Following Lasix administration, there is normal clearance of activity bilaterally.

Figure 4

Retrograde pyelogram defines the exact location of the stricture (yellow arrows) and assesses for viable ureter to be used at the time of the renal auto transplantation.