Results of a previously unreported extravesical ureteroneocystostomy technique without ureteral stenting in 500 consecutive kidney transplant recipients

Abstract

Urologic complications can still occur following kidney transplantation, sometimes requiring multiple radiological and/or surgical procedures to fully correct the problem. Previously proposed extravesical ureteral reimplantation techniques still carry non-negligible risks of the patient developing urologic complications. About 10 years ago, a new set of modifications to the Lich-Gregoir technique was developed at our center, with the goal of further minimizing the occurrence of urologic complications, and without the need for initial ureteral stent placement. It was believed that an improvement in the surgical technique to minimize the risk of developing urologic complications was possible without the need for stent placement at the time of transplant. In this report, we describe the advantages of this technique (i.e., mobilized bladder, longer spatulation of the ureter, inclusion of bladder mucosa with detrusor muscle layer in the ureteral anastomosis, and use of a right angle clamp in the ureteral orifice to ensure that it does not become stenosed). We also retrospectively report our experience in using this technique among 500 consecutive (prospectively followed) kidney transplant recipients transplanted at our center since 2014. During the first 12mo post-transplant, only 1.4%(7/500) of patients developed a urologic complication; additionally, only 1.0%(5/500) required surgical repair of their original ureteroneocystostomy. Five patients(1.0%) developed a urinary leak, with 3/5 having distal ureteral necrosis, and 1/5 subsequently developing a ureteral stricture. Two other patients developed ureteral stenosis, one due to stricture and one due to ureteral stones. These overall results are excellent when compared with other reports in the literature, especially those in which routine stenting was performed. In summary, we believe that the advantages in using this modified extravesical ureteroneocystostomy technique clearly help in lowering the early post-transplant risk of developing urologic complications. Importantly, these results were achieved without the need for ureteral stent placement at the time of transplant.

Fig 1. Visual of the arterial anastomosis, venous anastomosis, bladder incision, and ureteral preparation.

Bladder incision is 3cm, and the ureteral spatulation is 2cm.

Fig 2. Visual of the heel and apex suturing of the ureter so as to anchor it medially to the bladder mucosa with some detrusor layers (BMDL) while also keeping it open.

A) Placing the suture at the apex and heel of the ureter; B) Cross-section showing the suture including BMDL; C) Placing both anchor sutures at either site including BMDL. D) Cross-section showing the wide opening of the transplanted ureter.

Fig 3. Visual of the ureteral anastomosis to the bladder mucosa with some detrusor layers BMDL and creation of an anti-reflux tunnel using the remaining detrusor muscle.

The upper left circle (Anastomosis) shows the right angle introduced into the ureteral opening to ensure that it is not stenosed or incorporated by the running suture. The right lower circle (Tunneling) shows the right angle introduced into the tunnel once finished making sure that is not too tight.