Extra-Anatomic Stent (EAS) as a Salvage Procedure for Transplant Ureteric Stricture

American Journal of Transplantation 2014; XX: 1–4 Wiley Periodicals Inc.

C

Copyright 2014 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.12778

Case Report

Extra-Anatomic Stent (EAS) as a Salvage Procedure for Transplant Ureteric Stricture W. Tahir1, A. Hakeem1, A. White1, H. C. Irving2, S. N. Lloyd3 and N. Ahmad1,* 1

Division of Surgery, Department of Transplantation, St James’s University Hospital, Leeds, United Kingdom 2 Department of Radiology, St James’s University Hospital, Leeds, United Kingdom 3 Pyrah Department of Urology, St James’s University Hospital, Leeds, United Kingdom  Corresponding author: Niaz Ahmad, [email protected]

Ureteric stricture is the most common urological complication following renal transplantation. Management often involves endo-urological interventions and open surgery. The definitive treatment is surgical reconstruction to restore continuity. Where this is not possible or contra-indicated and a stent cannot be placed in the ureter, an extra-anatomic stent (EAS) could be used to bypass a complete ureteric obstruction. Using an existing nephrostomy tract, a percutaneous stent is placed in the kidney and is tunneled under the skin into the bladder establishing extraanatomical urinary drainage. We report the use of a novel EAS system in a patient with transplant ureteric stricture when antegrade stent placement or surgical reconstruction was not possible. Keywords: Extra-anatomic stent, reconstruction, ureteric stricture Abbreviations: EAS, extra-anatomic stent; IVC, inferior vena cava; USS, ultrasound scan Received 21 January 2014, revised 10 March 2014 and accepted for publication 01 April 2014

Introduction Ureteric stricture is the most common urological complication in a transplanted kidney (1). It has an incidence of around 2–5% and is most commonly due to ureteric ischemia (2,3). Three-fourths of all ureteric strictures occur either at the uretero-neocystostomy junction or in the distal ureteric segment, with the remaining involving longer segment or the entire length of the ureter (4). Ultrasound guided percutaneous nephrostomy is recommended to

decompress and protect the transplanted kidney. Contrast studies confirm the diagnosis and location of the stricture, following which an antegrade stent can be placed across the stricture prior to definitive management. For a small segment, distal stricture balloon dilatation has been reported with a modest success rate but the re-stricture usually recurs due to persistent ischemia (5). Surgical reconstruction options include ureteric re-implantation, Boari flap reconstruction (tubulization of a bladder flap), the use of native ureter (uretero-ureterostomy or ureteropyelostomy) or a small bowel conduit (6). These procedures are frequently associated with complications including failure to complete the procedure and risk of graft loss (7). Another consideration is long-term nephrostomy drainage. We report a case in which both antegrade stenting and attempted surgical reconstruction failed and an extraanatomic stent (EAS) was inserted to salvage the transplanted kidney.

Case Report A 65-year-old male with end-stage renal failure secondary to chronic glomerulonephritis, received a second renal transplant from a 50-year-old female donation after brain death donor. The donor right kidney had a single renal artery with Carrel’s patch and three renal veins on an inferior vena cava (IVC) conduit. The implantation was performed in the left iliac fossa on to the external iliac vessels. Donor IVC was used as a conduit for venous anastomosis. The ureter was implanted to the bladder using an onlay technique over a double-J stent. The kidney had primary function. A week posttransplant, graft dysfunction required an ultrasound scan (USS), which confirmed marked hydronephrosis. Percutaneous nephrostomy was performed to decompress the transplant kidney and the ureteric stent was removed to encourage urinary drainage via the uretero-neocystostomy. Subsequent antegrade contrast studies confirmed a long-segment ureteric stricture involving the distal two-thirds of the transplant ureter (Figure 1a). Attempted antegrade stenting proved unsuccessful and thus definitive surgical reconstruction was planned. At surgical exploration, 18 days posttransplant, dissection was difficult with extensive granulation and scarring making tissue planes unidentifiable. It was considered that continued dissection may 1

Tahir et al

Figure 1: (a) Nephrostogram of the transplant kidney showing an ischemic type long-segment ureteric stricture. (b) Plain X-ray demonstrating the previously placed transplant stent (with lateral fenestration) and successfully placed extra-anatomic stent (without lateral fenestrations).

result in vascular injury and loss of the graft thus surgery was abandoned. Within 24 h following surgery, the patient sustained a nonST elevation myocardial infarction, which was medically managed, initially within intensive care. The patient’s renal function deteriorated transiently (creatinine [Cr] 2.5–3.4 mg/dL). Further attempt of antegrade stenting 9 days later was successful and the nephrostomy was removed. The patient was discharged home with a Cr of 2.3 mg/dL, but was readmitted 20 days later with deteriorating renal function (Cr 3.1 mg/dL). A USS demonstrated hydronephrotic kidney with suspected stent obstruction. Nephrostomy was performed to decompress the kidney, and this tract was subsequently converted to a tunneled EAS to bypass the ureteric stricture (Figure 1b). The nephrostomy tract was dilated with teflon dilators over a sensor guidewire. The cutaneous aspect of the tract was excised under local anesthesia. An 8F, 24 cm doublepigtail ureteric stent was inserted into the pelvis of the transplanted kidney (Boston ScientificTM, Hemel Hempstead, Herts, UK). This stent only has side holes within the pigtails (not the shaft), thus urine only drains via the lumen of the stent to avoid extravasation. The skin incision was extended to be 1 cm in size. The bladder was then distended with saline via a urethral catheter and ultrasound-guided puncture of the bladder was performed using a small skin incision and a trocar. Following this a subcutaneous extra-peritoneal tunnel was created from the region of the lower pole of the kidney to the anterior wall of the bladder using a short 12F peel-away sheath (CookTM, Hitchin, Hertfordshire, UK). The lower end of the 2

stent was then passed through the sheath and over a guidewire into the bladder. The skin incision was closed using absorbable subcuticular stitches. No immediate postoperative complications occurred and the patient was discharged 7 days later with a Cr of 2.0 mg/dL. The EAS was replaced 7 months postinsertion, so as to avoid the risk of encrustation and blockage. The procedure was performed under general anesthesia, although it can be done under local anesthetic as well. After a small skin incision over the most superficial point of the stent, a loop of stent was retrieved and after stent division a wire was passed into the kidney and the old proximal end of the old stent removed and fresh stent replaced. The lower end of the stent was then retrieved cystoscopically over a guidewire. The distal end of the new stent followed and its position checked cystoscopically and radiologically (Figure 2). At 1 year the patients Cr has stabilized to 2.6 mg/dL.

Discussions Ureteric strictures posttransplantation pose a significant surgical challenge. The risk is substantially greater when the placement of an antegrade stent is not feasible. Use of an EAS to drain the transplant kidney offers a minimally invasive, effective and socially acceptable way of managing such kidneys on a long-term basis. The use of an EAS to bypass uretero-vesical obstruction was first described in the 1960s in native kidneys (8). Thereafter various authors have described the use of such technique in patients with benign disease who have American Journal of Transplantation 2014; XX: 1–4

Extra-Anatomic Stent

diversion system in one renal transplant patient following ureteric stenosis. Follow-up period was 8 months and no complications were reported. In 1998, the same group reported three bypass procedures in renal transplant patients to treat ureteric stenosis (13). After a mean follow-up period of 32 months all grafts had good function without complications of encrustation or obstruction. With this type of stent, replacement is not intended. Andonian et al reported ‘‘artificial ureter’’ placement following failed endo-urological and surgical management of ureteric obstruction in two renal transplant patients (14). Graft function remained stable with no signs of obstruction following 12 and 15 months of follow-up. Olsburgh et al reported the use of a Detour permanent extra-anatomic subcutaneous stent in two renal transplant patients (15). The patients maintained good graft function at 6 and 12 months follow-up, with one patient suffering two episodes of urinary tract infection.

Figure 2: Schematic diagram of the detour extra-anatomic stent post replacement (Illustration by Paul Brown).

undergone failed conventional surgical treatment as well those with end-stage malignancies (9–11). These reports demonstrate the effectiveness of EAS with excellent longterm outcomes. This technique has been used in our institution for the last two decades for the management of obstructed native kidney, but had never been used to salvage a transplant kidney. There have been a handful of reported cases of the use of EAS in transplanted kidneys. To the authors’ knowledge, there have been 24 reported cases in the literature (Table 1). These procedures have always involved a permanent type of stent, which has required a much more invasive procedure than the one we have described here. Desgrandchamps et al (12) used a subcutaneous nephro-vesical

Burgos et al successfully used the Detour in three renal transplant patients after failed open surgery in high-risk surgical patients with poor graft function (16). After a mean follow-up of 32 months, two patients had patent stents and the third patient developed obstruction secondary to encrustation that required endoscopic laser lithotripsy. One patient developed urinary tract infection requiring prolonged antibiotic treatment. In 2010, Azhar et al reported using the Detour EAS as a salvage treatment in eight transplant patients with ureteric stenosis (17). Four patients had failed surgical intervention and in the remaining surgical intervention was not attempted due to high stricture location and/or high-risk surgery. Technical issues meant that the stent was dislodged in two patients but was repaired within 3 days. Two patients also experienced recurrent infections with one graft loss. Remaining patients had good graft function and outcomes after 19.4 months follow-up. Yazdani et al used the Detour in five kidney transplant patients with a mean follow-up of 11.3 months (18). One patient required re-operation for urinary leakage due to kinking of the tube.

Table 1: Reported cases of extra-anatomic stent in the management of transplant ureteric stricture Author

Cases (n)

Follow-up (months)

Complications

Desgrandchamps et al (12) Desgrandchamps et al (13) Andonian et al (14) Olsburgh et al (15) Burgos et al (16)

1 3 2 2 3

8 32 14 9 32

Azhar et al (17)

8

19

Yazdani et al (18)

5

11

Nil Nil Nil 1 patient with 2 episodes of UTI1 1 obstruction due to encrustation requiring lithotripsy 1 recurrent UTI requiring long-term antibiotics 2 early stent displacements, corrected 2 recurrent UTI requiring long-term antibiotics 1 graft loss 1 stent kinking requiring re-operation 1 developed symptom of urgency and frequency

1

UTI, urinary tract infection.

American Journal of Transplantation 2014; XX: 1–4

3

Tahir et al

One patient developed prolonged frequency and urgency and one patient developed asymptomatic bacteriuria, which existed before the surgery. No cases of tube infection or obstruction were encountered. First, the technique of EAS that we promote in our patient offers the advantage of direct access to the transplant renal pelvis via an existing percutaneous nephrostomy. Second, any length of ureteric stenosis can be dealt with and the procedure is performed under local anesthesia being considerably less invasive. EAS have also been shown to improve quality of life compared to the experience of failed surgery/previous drainage systems (10). Changing the stent is simple and could be done under local anesthesia over a guidewire requiring small skin incision. This is a simple technique requiring minimal experience. Cystoscopic management of the stent (change over a guidewire) may be difficult because of the soft tissue resistance of the subcutaneous tunnel. Risks of EAS include stent encrustation, stent kinking and infection (19). Mostly, these can be avoided by early stent change but this could be carried out on an annual basis indefinitely. Such annual stent change avoids the risk of colonization of organisms and frequent infections, thereby avoiding the need for long-term prophylactic antibiotics. The longest period that a patient with a nontransplant EAS survived with annual change of a Paterson-Forrester stent (CookTM) was 14 years before she died of other causes. Our patient had an acceptable graft function at 18 months postprocedure and no complications. The intention is to continue with long-term stent changes in the same fashion. The procedure offers an effective alternative in the management of transplant ureteric stricture but remains relatively unknown in the wider transplant community. An EAS should be considered to manage transplant ureteric stricture where, surgery is not feasible or carries a high-risk, an antegrade stent is not possible or graft function is poor. The technique of EAS is relatively easy to learn but given the paucity of the need for the procedure, we recommend, these should be performed in a specialist center with experience of EAS in native and transplant ureteric obstruction.

Disclosure The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

4

References 1. Emiroglu R, Karakayall H, Sevmis S, Akkoc H, Bilgin N, Haberal M. Urological complications in 1275 consecutive renal transplantations. Elsevier Sci 2001; 33: 2016–2017. 2. Giessing M. Transplant ureter stricture following renal transplantation: Surgical options. Transplantation Proc 2011; 43: 383–386. 3. Shoskes DA, Hanbury D, Cranston D, Morris PJ. Urological complications in 1000 consecutive renal transplant recipients. J Urol 1995: 18–21. 4. Gibbons WS, Barry JM, Hefty TR. Complications following unstented parallel incision extravesical ureteroneocystostomy in 1000 kidney transplants. J Urol 1992; 148: 38–40. 5. Lojanapiwat B, Mital D, Fallon L, et al. Management of ureteral stenosis after renal transplantation. J Am Coll Surg 1994; 179: 21–24. 6. Fontana I, Bertocchi M, Rossi AM, et al. Late ureteral stenosis after kidney transplantation: A single-center experience. Transplant Proc 2010; 42: 1174–1175. 7. Kashi SH, Lodge JP, Giles GR, Irving HC. Ureteric complications of renal transplantation. Br J Urol 1992; 70: 139–143. 8. Marberger M. Prosthetic nephrovesical bypass. Eur Urol 2006; 50: 879–883. 9. Minhas S, Irving HC, Lloyd SN, Eardley I, Browning AJ, Joyce AD. Extra-anatomic stents in ureteric obstruction: Experience and complications. BJU Int 1999; 84: 762–764. 10. Lloyd SN, Tirokonda P, Biyani CS, Wah TM, Irving HC. The detour extra-anatomic stent—A permanent solution for benign and malignant ureteric obstruction? Eur Urol 2007; 52: 193–198. 11. Desgrandchamps F, Cussenot O, Meria P, Cortesse A, Teillac P, Le Duc A. Subcutaneous urinary diversions for palliative treatment of pelvic malignancies. J Urol 1995; 154: 367–370. 12. Desgrandchamps F, Cussenot O, Bassi S, et al. Percutaneous extraanatomic nephrovesical diversion: Preliminary report. J Endourol 1993; 7: 323–326. 13. Desgrandchamps F, Paulhac P, Fornairon S, et al. Artificial ureteral replacement for ureteral necrosis after renal transplantation: Report of 3 cases. J Urol 1998; 159: 1830–1832. 14. Andonian S, Zorn KC, Paraskevas S, Anidjar M. Artificial ureters in renal transplantation. Urology 2005; 66: 1109. 15. Olsburgh J, Dorling A, Tait P, Williams G. Extra-anatomic stents for transplant ureteric stenosis. Br J Radiol 2007; 80: 216–218. 16. Burgos FJ, Bueno G, Gonzalez R, Vazquez JJ, Diez-Nicolas V, Marcen R. Endourologic implants to treat complex ureteral stenosis after kidney transplantation. Transplant Proc 2009; 41: 2427–2429. 17. Azhar RA, Hassanain M, Aljiffry M, et al. Successful salvage of kidney allografts threatened by ureteral stricture using pyelovesical bypass. Am J Transplant 2010; 10: 1414–1419. 18. Yazdani M, Gharaati MR, Zargham M. Subcutaneous nephrovesical bypass in kidney transplanted patients. IJOTM 2010; 3: 121– 124. 19. Jurczok A, Loertzer H, Wagner S, Fornara P. Subcutaneous nephrovesical and nephrocutaneous bypass: Palliative approach to ureteral obstruction caused by pelvic malignancy. Gynecol Obstet Invest 2005; 59: 144–148.

American Journal of Transplantation 2014; XX: 1–4