Thomas R. Hefty

Complications Following Unstented Parallel Incision Extra Vesical Ureteroneocystostomy in 1,000 Kidney Transplants

Between May 10, 1982 and September 1, 1990, 1,000 kidney transplant recipients underwent parallel incision extravesical ureteroneocystostomy for urinary tract reconstruction. Complications attributed to this surgical technique that required reoperation occurred in 2.1% of the recipients. These complications included urinary extravasation in 9 patients, ureteral necrosis in 3, ureteral obstruction in 3, ureteral bleeding in 3, ureteral implantation into thickened folds of peritoneum in 2 on chronic ambulatory peritoneal dialysis and ureteral implantation into an ovarian cyst in 1. Vesicoureteral reflux occurred in 0.4% of the ureteroneocystostomies, none of which was revised. No allografts were lost as a result of these complications. The principles of the technique are sound. One should be careful if the patient has a small, defunctionalized or scarred bladder, has undergone multiple pelvic operations or has had pelvic inflammatory disease.

Time-Related Recurrence Rates in Patients with Upper Tract Transitional Cell Carcinoma

Disagreement exists about the necessity and frequency of contrast medium imaging of the upper urinary tract in patients with transitional cell carcinoma. During a 10-year period 39 patients were treated for upper urinary tract transitional cell carcinoma. There were 3 contralateral recurrences in 33 patients treated by nephroureterectomy for the initial lesion. Of 4 patients treated initially by segmental ureterectomy or partial renal pelvectomy 1 had an ipsilateral recurrence 3 years later. Two patients with bilateral upper tract transitional cell carcinoma were treated by simple nephrectomy combined with simultaneous contralateral segmental ureterectomy or renal pelvectomy. Both patients had no evidence of recurrent tumor after 4 years of followup. Of the 39 patients with upper tract transitional cell carcinoma 6 had multiple bladder tumors or carcinoma in situ documented on biopsy before the development of an upper tract tumor. The interval between the treatment for the last bladder tumor or carcinoma in situ was 1 year in 4 patients, 2 1/2 years in 1 and 5 years in 1. Of these 6 patients 2 had bilateral upper tract tumor occurring at different times. Both patients had multiple bladder tumors diagnosed between the development of each upper tract lesion. Annual contrast medium imaging of the upper urinary tract is recommended in patients who have had multiple bladder tumors and in those who have undergone treatment for upper urinary tract transitional cell carcinoma.

Significance of delayed graft function in cyclosporine-treated recipients of cadaver kidney transplants.

Many transplant teams are reluctant to initiate cyclosporine immunosuppression in recipients of cadaver kidney grafts with delayed graft function (DGF). The renal function of cadaver kidney grafts in cyclosporine-treated recipients was compared in 47 recipients with DGF and 57 without DGF. Regardless of initial renal function, all recipients received prednisone, azathioprine, and oral cyclosporine 5 mg/kg/day or its intravenous equivalent. All kidneys were flushed with ice-cold intracellular electrolyte solution and cold-stored for 15–54 hr (mean of 31 hr) prior to transplantation at our hospital between April 10, 1985 and November 30, 1986. Rejection crises were treated with high-dose steroids or OKT3. Cyclosporine was discontinued during courses of OKT3. Recipients with DGF had significantly higher one-month serum creatinine nadirs (2.6±1.8 mg/dl vs. 1.5 ± 0.5 mg/dl). Actuarial graft survivals were not significantly different at one year (82.2±5.5% vs. 82.6±6.4%, all graft losses included). Mean serum creatinine levels at six months and twelve months after grafting were not significantly different (1.7±0.4 mg/dl vs. 1.8±1.2 mg/dl and 2.0±0.5 vs. 1.7±0.7 mg/dl, respectively). Delayed graft function following cadaver kidney transplantation does not adversely affect intermediate term function of kidney grafts flushed with intracellular electrolyte solution and cold-stored until transplantation when a low-dose cyclosporine induction protocol is used and cyclosporine is discontinued during OKT3 administration.

Acute lumbosacral plexopathy in diabetic women after renal transplantation

Renal transplantation is an accepted treatment for patients with end stage renal disease from insulin-dependent diabetes mellitus. Acute lumbosacral plexopathy developed following renal transplantation in 4 female patients with insulin-dependent diabetes mellitus between January 1, 1981 and June 30, 1988. In all 4 patients the internal iliac artery was used for revascularization of the renal allograft with ligation of the anterior and posterior divisions. Within 24 hours of surgery they complained of ipsilateral buttock pain, numbness in the leg and weakness below the knee. This complication has not been observed in nondiabetic patients at our institution, nor in diabetic patients when the internal iliac artery was not used. However, lumbosacral plexopathy occurred in 4 of 27 (14.8%) female patients with insulin-dependent diabetes mellitus when the internal iliac artery was used (p less than 0.001). Age, duration of insulin-dependent diabetes mellitus, hypertension, cigarette smoking history and kidney donor were not significant predictors of this complication. This unusual and newly recognized complication appears to result from ischemia of the lumbosacral plexus following ligation of the internal iliac artery in patients with severe small vessel disease.

Hernias after Transpubic Urethroplasty

We report 2 cases of herniation following repair of posterior urethral strictures. Both patients underwent transpubic bulboprostatic urethral anastomosis and omentoplasty, which resulted in a perineal hernia in one and a pubic hernia in the other.

Schistosomiasis and Renal Transplantation

Schistosomiasis was discovered in 4 recipients and 12 donors during evaluation for 67 consecutive live related renal transplants. All participants with schistosomiasis were treated with anti-schistosomal chemotherapy preoperatively. No complications were seen in the 4 recipients, including 2 with schistosomal-induced calcifications of the bladder. One donor returned to an endemic area and became reinfected with slight progression of distal ureteral dilatation. Cystoscopy with biopsy is more sensitive in the detection of infection than ultrasonography, excretory urography or urinalysis but structural changes are assessed by excretory urography. Although schistosomiasis is not an absolute contraindication for renal transplantation, potential live kidney donors with proved anatomical changes in the urinary tract should be excluded.

Recovery of Function in a Solitary Kidney After Intra-Terial Thrombolytic Therapy

Renal artery thromboembolism is a rare event that most often occurs in patients with cardiac dysrhythmias. Surgical thromboembolectomy is risky and medical therapy with intra-arterial thrombolytic agents has become increasingly popular. Although successful clot dissolution has been well documented, renal function often is not recovered. We describe a patient with anuria from thromboembolism to a solitary kidney, treated with low dose intra-arterial streptokinase infusion. There were no adverse effects from therapy and renal function returned to a point where dialysis was no longer required. A review of the literature is included with special attention to various protocols for infusion. Early diagnosis and prompt initiation of therapy may result in clinically significant recovery of renal function.

Experience with Parallel Incision Extravesical Ureteroneocystostomy in Renal Transplantation

A total of 43 consecutive renal transplant patients underwent extravesical ureteroneocystostomy via a parallel incision. The only urological complication (ureteral obstruction from a blood clot) did not appear to be related to this recently described technique. There were no instances of urinary leakage, extrinsic ureteral obstruction or reflux. This simplified technique of ureteroneocystostomy seems well suited to the special challenges presented by renal transplant patients.

Bilateral Ureteral Stricture from Polyarteritis Nodosa

A case of bilateral, asynchronous ureteral stricture from polyarteritis nodosa is described. Two cases of unilateral ureteral stricture from polyarteritis nodosa have been reported previously. Ureteral obstruction not associated with retroperitoneal fibrosis is rare with polyarteritis nodosa.

Clam-shell technique for right renal vein extension in cadaver kidney transplantation.

Abstract A clam-shell technique for right renal vein extension was used successfully in a cadaver kidney transplant.