Ureteric Complications and Urinary Tract Reconstruction Techniques in Renal Transplantation: A Surgical Essay

Abstract

Background/Objectives: Renal transplantation (RT) remains the gold standard for end-stage renal disease, offering superior outcomes versus dialysis. Despite advances, ureteric complications (leaks/strictures) persist, primarily from ischemic injury, posing substantial graft risks. We review etiology, incidence, and management strategies for post-RT ureteric complications, focusing on surgical reconstruction techniques. Methods: Literature assessment examined ischemic-related ureteric complications. Primary outcomes: incidence, success, complication rates, operative times, and long-term patency. Secondary outcomes: graft/patient survival and reoperation rates. Techniques evaluated included extravesical Lich-Gregoir (L-G) and transvesical Leadbetter-Politano (L-P) ureteroneocystostomy (UNC), Boari flap with psoas hitch, pyelo/ureteroureterostomy, pyelovesicostomy, and ureteroenterostomy. Surgical indications, procedural details, advantages, disadvantages, and quantitative outcomes were systematically analyzed. Results: Ureteric complication incidence ranged from 1 to 15%, with ischemic injury as the primary cause. L-G UNC demonstrated lower complication rates than L-P (6.15% vs. 8.33%) with reduced operative times. Pyelo/ureteroureterostomy achieved excellent salvage outcomes (>90% success, 3.9% reintervention rate). Boari flap provides a suitable option for extensive ureteric defects, consistently preserving graft function without stricture recurrences. Pyelovesicostomy showed 80% long-term success in complex cases. Ureteroenterostomy achieved comparable 5-year graft survival (63%) to standard drainage, despite higher infection rates (65%). Pyelovesicostomy and ureteroenterostomy remain important solutions for specific challenging scenarios. Conclusions: Urinary reconstruction technique selection should be individualized based on anatomical considerations, pathology, and surgical expertise. Comprehensive understanding of reconstruction techniques enables effective management of ureteric complications, preserving graft function and improving outcomes.

Keywords: kidney transplantation; long-term outcomes; native upper tract anastomosis; post-transplant care; pyeloureterostomy and ureteroureterostomy; strictures and urinary leaks; surgical challenges in urinary reconstruction; ureteric complications; ureteroenterostomy; ureteroneocystostomy.

Figure 1

Extravesical Lich–Gregoir ureteroneocystostomy surgical technique: (A) two small parallel sero-muscular incisions are made in the donor bladder wall, perpendicular to the planned ureteric coarse, and a submucosal tunnel is dissected, to pass the donor ureter through; (B) the bladder mucosa, bulging at the distal end of the submucosal tunnel, is incised and 5–10 mm opening is created to allow for the anastomosis; (C) the spatulated ureteric stump is brought to the bladder mucosa and the toe end of the ureter is secured to the full thickness of the bladder wall; (D) a mucosa-to-mucosa anastomosis is performed, using a fine slow-absorbable monofilament suture (e.g., 5-0 polydioxanone), usually in a running manner, between the full thickness of the ureter and the dissected bladder mucosa, at the level of the opening created. N.B.: original medical illustrations created by Marius Filip using professional graphic design software.

Figure 2

Transvesical Leadbetter–Politano ureteroneocystostomy surgical technique: (A) Through an anterolateral cystotomy, a separate oblique full-thickness posterior parietal stab incision is performed, superolateral to the ipsilateral native ureteric orifice, and then additionally dilated using a tunneling tool; (B) The ureter is then guided through the tunnel, into the bladder; (C) An additional mucosal incision can be performed (2 cm apart), to allow for additional tunnelization of the ureteric stump under the mucosa, which will then be prepared (transected and spatulated) and used for placing the inferior sutures of the anastomosis, i.e., incorporating bladder muscle to anchor the ureter securely within the submucosal tunnel; (D) The spatulated ureter is anastomosed to the bladder mucosa around the newly developed ureteric orifice, using fine absorbable sutures. N.B.: original medical illustrations created by Marius Filip using professional graphic design software.

Figure 3

Boari flap ureteroneocystostomy technique—illustration of surgical steps. N.B.: original medical illustrations created by Marius Filip using professional graphic design software.

Figure 4

Pyelovesicostomy—illustration of final aspect. N.B.: original medical illustrations created by Marius Filip using professional graphic design software.

Figure 5

Ureteroureterostomy technique—illustration of surgical steps. N.B.: original medical illustrations created by Marius Filip using professional graphic design software.

Figure 6

Clinical decision tree algorithm for systematic selection of ureteric reconstruction techniques in renal transplantation. Clinicians follow sequential binary decision points based on emergency indicators, viable ureter length, bladder quality, and native ureter status to reach technique-specific recommendations. Success rates represent contemporary outcomes from high-volume transplant centers.