Gerald T. Cook

Ten Years of Experience with Vascular Complications in Renal Transplantation

From 1970 to 1980, 341 consecutive renal transplants were performed in 307 patients at our hospital. Operative technique was uniform and performed by a single surgeon. Acute arterial thrombosis occurred in 12 kidneys (3.5 per cent) and venous thrombosis occurred in 3 (0.9 per cent). All of these kidneys were lost. Renal artery stenosis, diagnosed in 17 kidneys (4.9 per cent), resulted from surgical technique or rejection and was associated with hypertension in all cases. Of these kidneys 5 responded to drug therapy alone, 4 to transluminal angioplasty and 5 to surgical reconstruction. Three grafts were lost. Vascular complications occurred in 9 per cent of our patients. The results suggest that factors other than surgical technique alone can contribute to the incidence of vascular complications.

SUCCESSFUL RENAL TRANSPLANTATION IN PATIENTS WITH T-CELL REACTIVITY TO DONOR

A positive crossmatch due to T-cell reactivity against donor cells is considered a strong contraindication to renal transplantation because of the risk of graft loss from rejection. However, the significance of T-cell reactivity before but not at the time of transplantation is unknown. To determine whether transplantation can be successful under these circumstances, graft survival was observed in 15 highly sensitised patients whose T cells were reactive to donor sera before but not at the time of transplantation. All patients have been followed up for at least 1 year post transplant. Immunosuppression was by azathioprine, prednisone, and rabbit antithymocyte sera. 9 (60%) have functioning grafts and a mean serum creatinine of 1.6 mg/dl. Early non-function occurred in 12 patients. One graft was lost to early acute humoral rejection and two other to chronic rejection. 14 of the 15 had a fall in reactivity to a panel of normal lymphocytes before transplant. 4 of the 15 had donor-specific B-cell antibodies at the time of transplantation and 3 of these lost their grafts because of rejection.

Percutaneous Needle Biopsy of the Transplanted Kidney: Technique and Complications

Over 11 1/2 years, 420 percutaneous needle biopsies were obtained from the transplanted kidneys of 205 patients at one institution. The procedure was performed by one nephrologist and 55 nephrology trainees. No limit was placed on the number of biopsies performed on one kidney, and the highest number was seven. The complications were macroscopic hematuria in 28 biopsies, prolonged hematuria (greater than 24 hours) in eight, transient anuria in five, and prolonged anuria requiring surgical intervention in one. Perinephric hematoma occurred in three patients; retroperitoneal hematoma led to compression of the iliac vein in one. None of these complications led to loss of the transplant. It is suggested that the freedom from serious complication is related to the safety of the technique and the precautions applied to preparation of the patient. These are described in detail.

Surgical Treatment of the Massively Dilated Ureter in Children. Part I. Management by Cutaneous Ureterostomy

One of the major therapeutic challenges facing the pediatric urologist is the massively dilated ureter. When conservative measures, such as relief of obstruction or treatment of infection, have failed or are likely to fail, surgical treatment must be directed at the massive dilatation itself. These circumstances were encountered in 366 massively dilated ureters in 244 children during a 10-year period. Loop and/or terminal cutaneous ureterostomy was used to manage 125 of these ureters in 74 children. Indications for temporary non-intubated proximal urinary diversion included uncontrolled infection, sepsis, azotemia, significant ureteral redundancy and tortuosity, and questionable over-all renal function. Advantages of loop ureterostomy included more proximal drainage and less stomal problems but terminal ureterostomy required a significantly lesser number of surgical procedures in reconstructing the urinary tract. Temporary splinting of the ureter in dry ureteral reimplantations has diminished markedly the incidence of ureterovesical complications. No instances of permanent vesical contracture were noted after long periods of defunctionalization. After initial reconstruction of 47 cutaneous ureterostomies good results by all parameters were obtained in 68 per cent. Additional surgical procedures in selected initial failures have resulted in a final success rate of 85 per cent.

Surgical Treatment of the Massively Dilated Ureter in Children. Part II. Management by Primary Reconstruction

AbstractTreatment of the massively dilated ureter is one of the major therapeutic challenges facing the pediatric urologist. When conservative measures, such as treatment of infection or relief of obstruction, fail or are likely to fail surgical treatment must be directed at the ureteral dilatation itself. These circumstances were encountered in 244 children with 366 massively dilated ureters during a 10-year period. In evaluating the surgical management of the massively dilated ureter in children a retrospective analysis of primary ureteral tailoring and/or preliminary nephrostomy and subsequent reconstruction in 131 children with 171 massively dilated ureters was done. In these instances sepsis, azotemia, and ureteral tortuosity and redundancy were not significant enough to indicate long-term non-intubated diversion. Transvesical and extravesical tailoring procedures were evaluated. Of those in whom preliminary nephrostomy was applied ureteral dilatation decreased to such an extent that non-tailored rei...

Upper Tract Management when Posterior Urethral Valve Ablation is Insufficient

Of 105 boys with posterior urethral valves managed during a 10-year period most were managed by primary valve ablation. However, 39 of these boys required concomitant or additional procedures to 71 massively dilated ureters because of azotemia, infection and/or progressive upper tract deterioration. In 17 boys 25 ureters could be reconstructed primarily by varying degrees of ureteral tailoring. When there was severe infection, azotemia and/or doubt as to the function of the affected renal unit, staged reconstruction was initiated by cutaneous ureterostomy. One-fourth of these ureterostomy diverted children died of azotemia despite free urinary drainage. Those who went on to have staged reconstruction, despite multiple surgical procedures, retained intact urinary systems with acceptable function.

Primary massive reflux in children.

Over a ten-year period, of more than 1,000 children whose primary vesicoureteral reflux was treated surgically, there were 54 children with 80 single ureters which were massively dilated. Primary reconstruction with ureteral tailoring was done in 25 ureters with a success rate of 92 per cent. Forty-five ureters were temporarily diverted because of uncontrolled infection and/or azotemia. In almost half of these instances, temporary diversion resulted in improvement in ureteral caliber to such an extent that nontailored reimplantation could be performed with a success rate of 87 per cent. Six kidneys were removed and four have been maintained in the diverted state with severe renal dysplasia. Eighty-eight per cent of the refluxing megaureters were reconstructed with a success rate of 89 per cent.

Bilateral Orthotopic Ureteroceles Causing Massive Ureteral Dilatation in Children

AbstractThree male subjects less than 1 year old presented with febrile urinary infection and were found to have bilateral orthotopic ureteroceles in single ureters, causing massive upper tract dilatation. Excision of each ureterocele with bilateral tailored reimplantation corrected successfully the pathology in each child.

The Influence of Etiology on the Surgical Management and Prognosis of the Massively Dilated Ureter in Children

The massively dilated ureter is a major therapeutic challenge that faces the pediatric urologist. In those instances when more conservative measures, such as control of infection or correction of the primary pathology, have failed or are likely to fail surgical treatment must be directed to the massively dilated ureter itself. The goals of reconstructive procedures are the elimination of residual urine, effective ureteral peristalsis, and efficient and/or urgent urinary drainage. We encountered these clinical settings in 244 children with 366 massively dilated ureters from 1965 through 1974. The underlying pathologic processes included primary megaureter, refluxing megaureter, posterior urethral valves, ureteral duplication with upper role ectopic ureterocele or lower pole refluxing megaureter, simple ureterocele, ureterovesical junction obstruction, neurogenic vesical dysfunction, prune belly syndrome and acquired (iatrogenic) megaureter. The results of several reconstructive techniques are reviewed according to the excretory urogram, cystogram, renal function studies and the presence or absence of urinary infection. Analysis of the results with respect to the underlying pathologic entity responsible for the massively dilated ureter indicates that the etiology is a crucial factor in determining whether surgical treatment should be recommended and the type of surgical treatment that will most likely be successful.

Surgical Management of Massive Neurogenic Hydronephrosis

Permanent urinary diversion has been the standard recommended treatment of massive dilatation of the upper tracts in the child with neurogenic vesical dysfunction. Reimplantation of relatively normal caliber ureters into neurogenic bladders has been shown to be effective. However, attempts to save urinary diversion in 39 neurogenic megaureters have been unrewarding, with the salvage rate of 15 per cent, and 64 per cent have been diverted permanently. Upper tract decompression by continuous or intermittent catheterization, nephrostomy or end cutaneous ureterostomy was used in this series. When ureteral caliber responded to decompression a reasonable success rate from non-tailored reimplantation may be anticipated. However, in those instances in which ureteral caliber failed to respond or when tailoring or ureteral caliber was done in conjunction with reconstruction the success rate was much lower.