Published on March 1, 2014
URINARY LEAKAGE IN RENAL TRANSPLANTATION Alp GURKAN, Serdar KACAR, Can VARILSUHA, Cezmi KARACA, Suleyman TILIF PRIVATE GOP HOSPITAL, ISTANBUL PRIVATE KENT HOSPITAL, IZMIR
Introduction Urinary leakage is one of the most difficult complications to deal with in renal transplantation procedures. The current rate of ureteral complications is approximately 10%. Urine leak following renal transplantation is usually secondary to ischemic necrosis of the ureter. We examined the factors effecting urinal leakage in our renal transplant patients.
Patients and Methods During the time period between Nov. 2005 and Feb. 2008, 138 renal transplantations have been performed in Izmir Kent and Istanbul G.O.P Hospitals. Double-J catheters were used randomly. All urinary anastomosis were performed by the method of Lich-Gregoir. The factors effecting urinal leakage in our renal transplant patients were analyzed. Chi-square and student-t tests were applied for statistical analysis by using SSPS 11.0
Demographics Deceased donor 44 (31.9%) Live-related donor 94 (68.1%) Mean age of donors 45.7 14.06 Mean age of recipients 38.4 11.61 Male/Female of recipients 84/54
Laparoscopic donor nephrectomy 47 (50%) Open donor nephrectomy 47 (50%) Double-J stent application 81 (58.7%) Multiple arteries 13 (9.4%) Acute rejection 16 episodes Delayed graft function 10 (7.2%)
Cold ischemia time (hour) 124 3–5 14 <2 Warm ischemia time (min) <3 85 2–6 29 7 – 12 17 13 - 24 7
Results 2-year patient survival 100 % 2-year graft survival 100 % Vascular complication 4.3 % Total Urinary leakage 7.2 % Urinary leakage with double-J 2.5 % Urinary leakage without double-J 14 %
• Statistically only two factors were found to be effecting urinary leakage: Double-J application and donor age • In the double-J group, 2 patients had urinary leakage. One of the leakages was seen postoperative 15th day, probably due to severe acute rejection episode. Both leakages were treated with suturing the hole. Mean donor age was found to be 45.2 in the patients whom urinary leakage was not seen, while 52.1 in the patients with urinary leakage.
Factors analyzed p Acute rejection 0.674 Acute tubular necrosis 0.203 Recipients gender 0.143 Delayed graft function 0.459 Usage of ATG 0.616 Donor gender 0.354 Multiple arteries 0.054 Warm ischemia time 0.199 Cold ischemia time 0.481
Factors analyzed p Double-J stent application 0.016 Donor type 0.176 Laparocopic donor nephrectomy 0.500 Donor age 0.025 Recipients age 0.270 Vascular complication 0.631
Discussion The incidence of urinary leakage was 7.2% in our series. The are many causes of urinary leakage, but vascular insufficiency is probably the most fundamental cause of ureteric necrosis or slough with subsequent urinary extravasation. We tried to avoid dissection of the renal hilum during harvesting to preserve the vascular supply of the ureter and to obtain sufficient ureteric length to avoid unnecessary tension.
In one of the studies it was shown that at 3 months there were significantly more cases of urinary leakage (8.9% vs 0.9%, p <0.008) and ureteral obstruction (7.7 % vs 0%, p <0.004) in the no-stent than in the stent group. In another series it was shown that surgical complication rates in renal transplantation recipients according to donor type (living versus cadaveric) and the status of stent use (with stent versus without stent) were 5.53% vs. 7.27% (p = 0.064) and 5.24% vs. 20% (p< 0.01) respectively.
Many centers prefer using double-J stents to reduce ureteric complications. But, complications due to application double-J stent itself can be seen. The most frequent complication is infection. Longer period of urethral catheterization may cause greater harm to the normal urethral flora and may lead to a higher incidence of urinary infection. When the urethral catheters are removed within 1-4 days of the renal transplant, the development of urinary infection is unusual. there is a significant increase in urinary tract infections, primarily beyond 30 days after transplantation. Stent removal within 4 weeks of insertion appears advisable.
Conclusion Although donor age was found to be one of the two factors effecting urinary leakage; insertion of double-J catheter was the only one, which the surgeon could be able to affect the course of the procedure. So, we suggest the insertion of double-J catheter in all renal transplantation procedures.
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