C)o1
Reprinted
from
AKKALS
OF
SURGERY,
Vol. 172,
No.1,
July
1970
Copyright © 1970
by
J.
B.
Lippincott
Company
Printed in
U.
S. A.
Urological Complications in 216
Human
Recipients
of Renal Transplants
T. E.
STARZL,
M.D., PH.D., C. G.
GROTH,
M.D., C. W.
PuTNAM,
M.D.,
I.
PENN,
M.D., C. G.
HALGRIMSON,
M.D.,
A.
FLATMARK,
M.D.,
L.
GECELTER,
M.D.,
L.
BRETTSCHNEIDER,
M.D., O. G.
STONINGTON,
M.D.
From
the
Department
of
Surgery
and
the
Division
of
Urology, University
of
Colorado School of Medicine
and
Veterans Administration Hospital,
Denver, Colorado
FOR
the
most part,
the
surgical technics
of kidney transplantation have
been
stan-
dardized.
3
,
8,
10,
11,11,25
The
least satisfactory
aspect of this operation
is
provision of uri-
nary drainage as will
be
demonstrated
by
an
analysis of the urologic complications
encountered
in
216 consecutive recipients
of renal grafts
at
the Colorado General
and
Denver
Veterans Administration Hospitals.
The
Denver
series
is
a useful one
with
which to
study
the attributes
and
deficien-
cies of urinary drainage procedures,
not
only because of the large numbers of pa-
tients,
but
also because all operations re-
ported
were performed
at
least one year
ago, thereby assuring reasonably long fol-
Submitted
for
publication
September
8, 1969.
This
work
was
supported
by
United
States
Public
Health
Service grants AM-12148,
AI-AM-
08898, AM-06344, AM-07772, AI-041S2, FR-OOOSI
and
FR-00069.
1
low-up. Furthermore,
it
has
been
possible
to compare the alternative methods of
ureteroneocystostomy
and
ureteroureteros-
tomy, since a large
number
of reconstruc-
tions were performed
with
each method.
Finally, considerable information was ac-
quired
on
treatment
of early
and
late
com-
plications which followed
either
type of
ureteral reconstruction.
Case
Material
Two
hundred
sixteen patients, aged 3 to
57 years,
had
renal transplantations from 1
to 7% years ago. A
number
of
the
recipi-
ents received more
than
one kidney
so
that
the
total
number
of homografts used was
234.
One
hundred
seventy-two of these or-
gans
were
obtained from family members
(including three identical twins).
The
other
62
were either from cadaveric donors
or
non-related volunteers. Since the source of
2
STARZL AND OTHERS
Annals of Surgery
July
1970
FIG.
1.
Ureteroneocystostomy:
A.
The
incision
in
the
dome of
the
bladder
is usually no more
than
1.5 cm.
B.
Development of
the
submucosal
tunnel.
Often
the
more lateral counterincision
is
not necessary. C, D. Placement of
the
ureter
within the tunnel.
The
passage
through
the
mus-
cular layers should
be
widely dilated.
the
kidney
did
not influence
the
incidence
or
type of urologic complications to a sta-
tistically significant degree,
the
distinction
of donor source will not
be
discussed fur-
ther.
In
presenting the results of urinary tract
reconstruction, all statistics will
be
based
upon
the relation of complications to
the
total
number
of transplantations. However,
a note may also
be
in
order concerning the
fate of the patients.
One
hundred
fifty-five
of
the
recipients (71.6%) survived
at
least
1 year. Between
12
months
and
the sixth
post-transplantation year, 23 of these 155
patients
died
leaving a population of 132
(61
%)
which
is
being studied after one to
7~
years. Thirty-three living patients
with
the
longest follow-up have survived from
5~
to 7% years postoperatively.
The
general technics of immunosuppres-
sion
used
in
all
but
identical twins have
been
described elsewhere,25
and
included
azathioprine, prednisone, actinomycin C
and
local homograft irradiation.
In
addi-
tion,
the
last 101 patients received adjuvant
therapy with heterologous antihuman-lym-
phocyte globulin (ALG)
prepared
from the
serum of immunized horses."8
Urine cultures for aerobic
and
anaerobic
bacteria were
obtained
two or
three
times
a week during hospitalization
and
once a
week or less frequently after discharge.
If
these were positive, specific antibiotic ther-
apy
was administered which was based
upon sensitivity determinations.
In
the
re-
sults,
data
will
not
be
given
on
the high
incidence of bacteriuria
22,
25
in
the early
post-transplantation
period
which has con-
sistently
been
35
to
40%. However, atten-
tion will
be
drawn
to those patients who
were
left
with
chronic urinary
tract
infec-
tions.
Intravenous urograms were obtained dur-
ing
the
first few postoperative weeks; these
were
repeated
every 3 to 6 months.
Double
dose injection
or
infusion technics were
used
on
occasion,
and
in
a few cases cys-
tourethrograms or retrograde pyelograms
were necessary.
Operative
Procedures
Ureteroneocystostomy
Urinary drainage of 178 of
the
234 kid-
neys was established
at
the
time of trans-
plantation
by
ureteroneocystostomy.
The
technic used
23
is
summarized
in
Figures 1
and
2.
The
principles involved are forma-
tion
of
a capacious submucosal
bladder
tunnel for
the
ureter
(Fig.
1)
and
the crca-
tion of a slightly everted hood with its tip
(Fig. 2).
The
ureteral nipple
is
placed
within a few millimeters of
the
natural
ureteral orifice on
that
side,
the
most con-
venient location usually
being
just lateral
and
superior to the patient's own ureteral
orifice.
The
utmost precaution should
be
Volume
172
Kumber
1
COMPLICATIONS IN RECIPIENTS OF RENAL TRANSPLANTS
3
taken
not
to injure
the
latter
structure.
If
cystoscopy becomes necessary
in
the
post-
operatiye period, it
is
easy to visualize
both
the
original
and
the
new
ureteral
orifice if
the ureteroneocystostomy has
been
placed
in
the
recommended location.
A
number
of technical details
are
de-
signed to insure against postoperative leak-
age of urine from
either
the
cystotomy
or
the
implantation site. An accurate mucosa
to mucosa approximation
at
the
uretero-
neocystostomy
is
important
(Fig.
2).
More-
over, a small cystotomy
is
used (Fig.
lA).
After completing
the
implantation,
the
cys-
totomy
is
closed in three layers using
an
inner row of continuous 4-0 chromic
catgut
through only
the
mucosa, a
middle
row of
the same
suture
material
through
muscle,
and
an
outer
layer of
interrupted
4-0 silk.
Special care
is
necessary to
prevent
post-
operative hemorrhage from
the
implanta-
tion site.
The
homograft
ureter
tends
to
become progressively more hyperemic for
a
number
of hours aftcr transplantation.
Consequently, failure to control small
bleeding
points
in
the
ureteral
tip
may
re-
sult in relatively major
and
progressive
hemorrhage
after
the
operation
is
finished.
The
transplant
wounds are
not
usually
drained.
Ureteral
splints or catheters are
avoided. A
bladder
catheter
which
is
placed
immediately before operation
is
ordinarily removed on
the
following morn-
ing
to
prevent
the
attendant
bacterial con-
tamination described
by
Hinman
et
aU
U
reteroureterostomy
In
55 instances,
the
initial reconstruction
of
the
urinary
tract
was
with
ureteroureter-
ostomy.
In
most, this
procedure
was per-
formed even
though
ureteroneocystostomy
would
have
been
feasible. However, in a
minority, ureteroureterostomy was selected
because the homograft
ureter
was too
short
to reach the
bladder
or
because of
other
technical factors such as scarring of
the
bladder
from previous operation.
In
al-
most all
of
these patients, bilateral nephrec-
lH.
~
K'I['
"
,,/7'
.','
'r:
...
,.¥.~.'
. . '
'{~
FIG.
2. Ureteroneocystostomy
(cont.):
Trim-
ming of the ureter, formation of a flat nipple,
and
uretero-vesical anastomosis.
The
sutures are
placed
with
5-0 or 6-0 plain
catgut
on a swaged needle.
tomy
and
splenectomy were carried
out
through
an
upper
midline incision ( Fig.
3A)
either
on
the
day
of transplantation
or
at
some time previously; in
the
few excep-
tions only
the
host kidney on
the
side of
the
proposed
transplant
was excised.
When
the
recipient's kidneys were removed,
the
ureters
were
tied
just below
the
uretero-
pel vic junction (Fig.
3A),
taking care
to
include only the
ureter
in
these ligatures.
It
was
then
possible
to
deliver
the
remain-
ing
ureter
into
the
ipsilateral iliac fossa
(Fig. 3B)
without
a single instance of sig-
nificant hemorrhage from
the
intervening
retroperitoneal space.
The
final mobilization of
the
portion of
the
recipient's own
ureter
to
be
used for
anastomosis
is
usually
not
begun
until
the
homograft has
been
revascularized in its
extra peritoneal
bed
(Fig.
3C).
At
this time,
the
autologous
ureter
is
freed
by
incising
the
filmy areolar layer
that
binds
it
to
the
-----------_
..
_---
4
STARZL
AND
OTHERS
Annals
of
Surgery
July
1970
]l,.
FIG.
3. Ureteroureterostomy:
A.
Incision for
bilateral
nephrectomy
and
splenectomy
(a).
The
ureter
is
tied
just
below
the
ureteropelvic junc-
tion.
The
lower incision
(b)
is
for kidney trans-
plantation. B. Recipient site for transplantation,
showing the recipient
ureter
being
delivered into
the
iliac fossa
by
gentle traction. C,
D.
The
vas-
cular anastomoses have
been
completed.
The
do-
nor
and
recipient ureters
are
positioned to
be
ad-
jacent
to
each
other
and
are tailored.
medially reflected retroperitoneal tissue.
Great
care
is
taken to
protect
the
blood
supply.
One
or
more small twigs from
the
branches of
the
hypogastric artery
can
al-
most always
be
found passing to
the
pos-
terior wall of the midpelvic ureter; these
can
usually
be
preserved.
The
homograft
and
recipient ureters are
then
tailored to
an
appropriate length (Fig.
3D
). These segments should
be
cut
with
some extra length since a
redundant
recon-
structed
ureter
is
preferable to one
with
tension
on
the
anastomosis.
The
ureteral
arteries of
both
segments
are
suture ligated
with
6-0 silk
near
the
site of
the
transec-
tions.
A single layer anastomosis
is
performed
with
6-0
or
7-0 silk which
is
swaged
on
fine
cardiovascular needles. Usually eight su-
tures are used. These pass through all
layers of
the
wall except
the
mucosa (Fig.
4A
and
B).
It
is convenient to
start
with
two corner sutures
and
to use these
in
guid-
ing
the
subsequent
placement of others.
For
the
back
row,
the
ureter
is
turned
(Fig.
4C ).
If
the
anterior
half
of
the
anastomosis
is
examined
at
this time from within
the
lumen,
it
should
not
be
possible to detect
the
previously placed silk.
If
intraluminal
silk
can
be
seen,
the
sutures
were
too
deeply
placed
and should
be
removed.
The
possibility of developing
an
acute
urinary fistula is increased
if
through
and
through sutures
are
used, since fluid tends
to leak
out
through
the
needle holes. How-
ever,
if
the
technic
is
scrupulously fol-
lowed, the intact mucosa serves
as
a water-
seal (Fig.
4D).
Ureteral splints
or
cathe-
ters are
not
used.
The
wounds are often
drained.
The
bladder
catheter
is
removed
the morning after operation.
Ureteropyelostomy
This procedure was used initially
in
only
one
patient
and
for a special indication.
After revascularizing
the
renal homograft,
FIG.
4. Ureteroureterostomy
(cont.):
Single
layer anastomosis
performed
with
6-0 or
7-0
silk
swaged
on
fine cardiovascular needles.
In
D
is
shown a longitudinal section
with
correct place-
ment
of
the
silk sutures.
Note
the
intact
mucosa,
with
no sutures extending into
the
lumen.
V
ol
u
me
i
72
:\l
um
~
c
r
i
COMPLICATIONS
IN R
EC
IP
LE
I TS
OF
RE
NA
L TRA:\'SPLA0:TS
Fi
G.
5.
Lat
e intravenous urograms in
pati
nts whose urinary tracts were reconstructed sa
ti
s-
fa
ctorily
with
urcte
roJl
eocys
to
stomy. A. Six years post-transplantation.
Th
e donor w
as
a
11
0n-
twin brother. Note th small caliber of the ureter
(arrow).
B.
Six
years and 2 months after
transplantation from an older brother. Note the
small size of the ureter
(arrow).
bl
ee
ding
from
the
cut
end of the
tran
s-
planted
ureter
was almost
imp
ossible to
control.
Ev
entually
it
was realized that this
was
du
e to venous h
yper
tension which af-
fected all of
the
uret
er
but
not the pelvis.
Th
e recipient
ur
eter was anastomosed enu-
to-end to the
narrow
neck of the
homograft
pe
l
vis
using essentially
th
e
same
technic
as
described above for
ur
eteroureterostomy.
Th
ere ,vere no postoperative complications.
Outcome
of
Primary
Ureteroneo-
cystostomy
5
Th
e majority of the 178 prim
ary
uretero-
neocystostomies were
sat
isfactory on
both
a sho
rt
and
long-term basis (
Fig
.
5).
How-
ever, postoperative difficulties direc
tl
y as-
cr
ibable to the uret
er
ovesical anastomosis
were observed
after
16
(9.
0
'}"o
) of the
tr
ans-
plantations.
These
proved
to
be
far more
life
thr
e
atening
if
they evolv
ed
during the
first 1 h months posttransplantation
than
if
FI
G.
5C
. A paternal homograft 5% years after
transplantat
io
n.
The
ureteroneocystostomy site is
well seen
(arrow).