Diagnosis & management of Post transplant hydronephrosis.pptx

Diagnosis & management of Post transplant hydronephrosis

1. Post Transplant Hydronephrosis Dr Ambuj Jain Ref : Campbell Urology12th edition

2. Post Transplant Hydronephrosis Ureteric complications have an incidence of approx 7 -10 % following renal transplant Ureteric obstructions leading to Post transplant HDN present early or late and account for 3 % of complications Early : more prevalent, within 3 months Late : less prevalent, after 3 months Ref : Campbell Urology12th edition

3. Post Tranplant HDN Early Ureteral Obstruction (<3months) Late Ureteral Obstruction (>3months) Technical error during ureteroneocystostomy Stones Forgoing ureteral stent Ureteral strictures Anastomosis edema Lymphocele Redundant ureter Fibrosis related to immunosuppresant medications Extrinsic compression Ref : Campbell Urology12th edition Page-1937

4. THE ENIGMA “ Low grade pelvicalyceal dilatation of a denervated system can be a normal post-transplant finding and therefore a source of a dilemma when found” It usually occurs with vigorous diuresis and edema The incidence of post-transplant hydronephrosis is 5.4 % out of which only 2.7% is true obstructive hydronephrosis . Taneja complications of urologic surgery 5 th Edition, Shaveen K et al, 2022 Post Tranplant HDN

5. Hydronephrosis can occur without obstruction in setting of prior obstruction Long standing UPJ obstruction in donor Reflux Loss of renal cortex as in Chronic Allograft Nephropathy Post Tranplant HDN Peter J Morris Kidney Transplant 7 th Edition, Page 466

6. Stuart J Knechtle , Lorna P. Marson , Peter J Morris, Kidney Transplantation - Principles and Practice 8th Edition Post Tranplant HDN Extraluminal Intrinsic Intraluminal Lymphocele Ureteric ischemia & stenosis Renal stone Compression by s permatic cord BK virus ureteritis Fungal ball Urinoma Vesicoureteric reflux Sloughed renal papillae Haematoma Refluxing Anastomosis Blood Clots Bladder Outlet Obstruction Foreign body (Forgotten stent)

7. Asymptomatic mostly Progressive decline in renal function Decreased urine output Hydronephrosis on USG screening The classic symptoms of ureteral obstruction of pain and colic are absent due to denervation of the renal allograft. Presentation Campbell Urology12th edition, page 1936

8. Advanced donor age > 65 years Delayed graft function Multiple arteries in graft BK virus ureteritis Increased cold ischemia time Ureteric kink Risk Factors Kumar S et al, 2014 ; Peter J Morris Kidney Transplantation 7 th Edition page 466

9. Graft ureter is supplied from lower polar arterial branches only which are end arteries therefore the distal segment of the ureter is prone to ischemia Loss of blood supply > Ischemia > leaks/obstruction Chintala D S et al 2015 Blood supply of graft ureter

10. More than 1750 transplants till now Mostly Live Donor transplants Lap Donor nephrectomy (total laproscopic approach) Recipient through open approach Ureteroneocystostomy by Lich Gregoir extravesical technique Prophylactic stenting for 3 wks, cathetrization for 5 days Overall incidence of ureteric complications leading to HDN is 2.11% At our institute

11. EXTRA VESICAL URETERONEOCYSTOSTOMY ( Lich-Gregoir ) Antirefluxing Easier technique Faster Less leak rate Lesser complications Ref : https://pubmed.ncbi.nlm.nih.gov/20620446/Ureteroneocystostomy_techniques_transplant Ureteroneocystostomy techniques

12. Other ureteroneocystostomy techniques like Leadbetter-Politano intravesical can also be considered Ref : https://pubmed.ncbi.nlm.nih.gov/20620446/Ureteroneocystostomy_techniques_transplant Ureteroneocystostomy techniques

13. Although ureteral stenting at the time of transplant reduces the incidence of early stenosis , it has no effect on the rate of late ureteral stenosis . Advantages Disadvantages Reduction in ureteric complications 95% patients have unnecessary stent Urine leak easier to manage Increased risk of UTI Cost effective Risk of stent migration/encrustation No evidence for patient or graft survival benefit Patient discomfort from bladder spasms Prophylactic Ureteric Stenting

14. Recommended follow up visits Time after transplantation Freq. of visits First 30 days Twice weekly 2 nd month Weekly 3 rd month Fortnightly 4 th month onwards 3 Monthly At first month patient screened with USG & Doppler During these visits worsening creatinine or decrease in urine output prompts for further investigations Post Tranplant monitoring

15. USG : First radiologic test to pick up HDN Colour doppler study for optimal graft perfusion Investigations

16. Other Investigations CT/MRI Antegrade pyelogram DTPA/MAG 3 Investigations

17. MR Pyelography T2 weighted imaging is used Investigations

18. Percutaneous antegrade nephrostogram Antegrade pyelography is the preferred test when obstruction is strongly suspected. Kidney is easily accessible with a small spinal needle to inject contrast medium. Investigations

19. occurs in approximately 3% of transplant recipients Most common cause of HDN in transplant recipients Ureteric Stenosis

20. Management : Retrograde / Antegrade stenting Balloon dilatation of stenosed segment & stenting Re-exploration followed by Ureteroneocystostomy Ureteroureterostomy Boari’s flap Vesicopyelostomy Interpositioning of ileal segment Ureteric Stenosis

21. 48 years male, post renal transplant patient presented with HDN on routine screening MR pyelogram revealed ureteric narrowing Re-exploration done & transplant ureter anastomosed to native ureter ( Ureteroureterostomy ) Case study

22. 65yr male Post RAR patient Came with deranged RFT & HDN on USG Further evaluation with MR pyelogram revealed ureteric diverticula near VU junction Reexploration done diverticular ureteric segment excised, Boari’s flap raised and anastomosed to graft ureter Case study

23. 50yr male Post RAR patient Came with HDN Re-exploration revealed clot in transplant ureter Clot evacuated Case study

24. Source of calculus Calculus from native kidney De novo stone formation in recipient Forgotton DJ stent with encrustation Management : Conservative approach PCNL : since percutaneous access is easier in transplant kidney Renal Calculi

25. Encrusted Ureteric Stent Deposition of stone like material in upper ureter

26. Immediate Later Urinoma Abscess Lymph Lymphocele Hamatoma Post Transplant Collections Most fluid collections after renal transplantation are incidental findings on baseline ultrasound examinations and require no treatment

27. 3% transplants Mc site : Ureteroneocystostomy site Cause : Distal ureteric necrosis Technical errors Diagnosis confirmed by Drain fluid creatinine Radiologic investigations Prevention by Decompression of bladder via catheter Management : Retrograde stenting Re exploration & re do ureteroneocystostomy Urinoma

28. Diagnosis confirmed by Fall in Hb Fall in urine output Radiologic investigations Management : Re exploration & clot evacuation Haemostsis Haematoma

29. Seen in 0.6 to 33.9% recipients as per different studies Small : less than 3 cm Asymptomatic Resolve spontaneously Larger lymphocele : more than 3 cm Compresses ureter Produces HDN Lymphocele Campbell Urology12th edition

30. Management of Large / Symptomatic : Percutaneous drainage Fenestration procedure In recurrent/intractable lymphocele making a window into the peritoneum to allow the lymphocoele to drain Lymphocele

31. Not all post tranplant HDN are pathological, further evaluation is required before any intervention Most obstructive complications can be prevented by careful handling of ureter & proper techniques TAKE HOME MESSAGE

32. Preserve significant margin of periureteral tissue Anatomy of the golden triangle should be respected Lower-pole renal artery branches should be preserved Excess length of ureter should be trimmed Ref : Stuart J. Knechtle , Lorna P. Marson , Peter J Morris, Kidney Transplantation - Principles and Practice 8th Edition Preventing ureteric ischemia

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