5. A 65-years-old renal transplant recipient stopped passing urine immediately after removing the ureteric stent. This was associated with rising in s Cr. USS showed moderate hydronephrosis. The antegrade pyelogram is shown below.
- What is your diagnosis?
- How to manage this patient?
The clinical history of anuria and associated hydronephrosis after removal of the ureteral catheter is highly suggestive of obstruction.
I would do an image exam with tomography to show that there are no extrinsic factors for ureteral compression. If this hypothesis is ruled out, we could program the implantation of a new double-J catheter or a surgical approach to create a new ureter implant.
hydronephrosis with ureteric obstruction.
IV antibiotic.
Refer urologist for stenting KIV nephrostomy tube,
close monitoring renal profile
ureteric obstruction complicated by hydronephrosis
Ø Common causes of urinary obstruction include catheter blockage, blood clots, extrinsic ureteric compression, ureteral stricture, stones, and prostatic hyperplasia. Low-grade obstruction in the early postoperative period may be a result of ureteral edema with vigorous diuresis and usually resolves. Obstruction is usually manifested by impairment of graft function and increasing hydronephrosis. It may be painless because of the absence of innervation to the transplanted kidney.
Ø Placement of an antegrade nephrostomy tube can rapidly reduce obstruction while serving as a conduit for an antegrade nephrostogram to help confirm the diagnosis.
Ø Minor ureteric obstruction may resolve with proximal diversion and stenting. Ureteric strictures shorter than 2 cm can be treated endoscopically with a laser or cutting blade, balloon dilation, and stenting.
Ø Ureteric strictures longer than 2 cm require excision and reimplantation
Ureter if obstruction after kidney transplant
could be caused by either intrinsic ,extrinsic causes
Intrinsic causes:edema ,clots
Extrinsic causes:obstruction by lymphocyte ,urinoma
others like:Ischaemia,Kinking,Previously unrecognized PUJ obstruction,Misplacement of
ureteric anastomosis
management:
Determine the level of obstruction
relieve the obstruction by DJ stent
treat the cause
The antigrade pylogram shows hydronephrosis with upper-uretric hydroureter , moslth suggested the presence of lower uretric obstruction and the diagnosis of obstructive uropathy.
Causes can be either external like compression by hematoma or lymphocele , or internsic like clott , calculi, tumor or adhesion.
Management is by urgent relief of the obstruction by PCN and doing nephrogram to localize the sit of obstruction. Restenting my be required with urosurgery consultation if need exploration and uretric reimplantation.
Diagnosis:
Lower ureteric obstruction/stricture with moderate hydroureteronephrosis
Management:
1.Diagnosis
Post-transplant obstructive uropathy with hydroureter and hydronephrosis.
causes in table 1
Kumar S, Ameli-Renani S, Hakim A, Jeon JH, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol. 2014 Dec;87(1044):20140169
Management
once diagnosed, urinary diversion must be undertaken to minimize kidney damage through:
1.Percutaneous nephrostomy insertion.
2.If failed, surgical management is indicated.
Options includes ureteroneocystostomy with excision of stenotic segment and re-implantation.
Kumar S, Ameli-Renani S, Hakim A, Jeon JH, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol. 2014 Dec;87(1044):20140169
What is your diagnosis?
Likely post-transplant obstructive uropathy as is evident of anuria after stent removal and imaging showing grossly dilated pelvicalyceal system and ureter. This can be because of intrinsic (clot,calculi)or extrinsic (hematoma)compression. Other factors which can cause this include: kinking ,ischemia or improper anastomosis of ureter.
How to manage this patient?
First step will be to relieve the obstruction with the help of PCN followed by nephrostogram to localize site of obstruction, then treatment of the cause. Re-stenting may be required. If all above measures failed, then surgical revision procedures like uretroneocystestomy & re-implantation maybe required.
REFERENCE:
1- S Kumar et al, Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol. December 2014; 87(1044
What is your diagnosis?
How to manage this patient?
· Urinary diversion must be undertaken promptly to minimize kidney damage and it is best achieved by percutaneous nephrostomy insertion. Although retrograde stent insertion may be used, this can be technically challenging, as the ureteric anastomosis is routinely performed along the anterolateral bladder wall, making it difficult to access and manipulate with an endoscopic approach.
· Once renal function has improved, definitive treatment of the ureteric obstruction is undertaken. Start with percutaneous balloon dilatation if technically feasible, followed by temporary antegrade ureteric stent placement. If the stenosis recurs after stent removal, surgical revision or long-term ureteric stenting is advocated.
· Continuing surveillance of renal function after stent removal is important as a rising serum creatinine level and/or diminishing urine output may indicate recurrent ureteric stenosis, which warrants surgical ureteric reconstruction. If this is not technically possible, for example owing to a long length of stricture or poor patient health, an antegrade ureteric stent is reinserted and a policy of long-term ureteric stenting instituted, with plastic or metal stents.
· Surgical intervention is indicated if minimally invasive procedures fail. Options include ureteroneocystostomy with excision of the stenotic segment and reimplantation, ureteroureterostomy using the recipient ipsilateral ureter (pyeloureterostomy between the donor renal pelvis and recipient ureter), or utilization of a Boari flap. This involves bladder flap substitution of the distal ureter.
Kumar S, Ameli-Renani S, Hakim A, Jeon JH, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol. 2014 Dec;87(1044):20140169. doi: 10.1259/bjr.20140169. Epub 2014 Oct 6. PMID: 25284426; PMCID: PMC4243200.
Q1- What is your diagnosis?
There is hydro-nephrosis and hydro ureter with absent contrast in lower part of ureter suggesting lower uretric obstruction.
Q2- How to manage this patient?
The uretric obstruction could be result from:
1) Intrinsic obstruction: edema, Clot, Tumor, Calculi.
2) Extrinsic compression: Lymphocele, Abscess, Hematoma.
3) Others: Ischemia, Kinking, Previously unrecognized PUJ obstruction,Misplacement of ureteric anastomosis.
This patient need immediate relieve of obstruction by nephrodtomy. Then the cause of obstruction should be searched for and treated acordinglly.
This patient may need replacement of stent or even reimplantation of ureter according to underlying cause.
REFERENCE:
1) Kumar S, Ameli- Renani S, Hakim A, Jeon JH, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radio. 2014 Dec;87(1044).
What is your diagnosis?
Hydronephrosis and upper hydro-ureter, absent contrast in the lower ureter points to lower ureteric blockage which could be related to hematoma or lymphocele (external compression) or intra-luminal block by clots or adhesion, or lastly ischaemia or ureter.
This clinical scenario points to distal ureteric blockage after removal of ureteric stent that is mostly related to blood clots or adhesions.
How to manage this patient?
Percutaneous nephrostomy to relieve the blockage
JJ stenting should be done later after improvement of renal functions.
Management of the cause of obstruction.
Urology surgeon review for further surgical procedures if needed like re-implantation of the ureter.
Ureteric obstruction which may be due to intraluminal clots, intraluminal stricture or ureteric ischemia.
immediate relief of obstruction by percutaneous nephrostomy and urinary diversion then Antegrade ureteric DJ stenting should be done later once the creatinine normalizes.
Then the cause of this obstruction should be analyzed. Ultrasound will help in evaluating any source of extrinsic compression like lymphocele or hematoma. If present, they should be managed (evacuation of hematoma, laparoscopic fenestration of lymphocele).
Ureteric stricture is initially treated with balloon dilatation and stent insertion Surgical excision of the stenosed segment and re-implantation of ureter may be required if the conservative measure fails
The patient most probably has graft ureteric obstruction due to ureteric ischemia and necrosis, stricture or blood clot.
Management: percutaneous nephrostomy; Ultrasound guided to relieve the obstruction
Ureteroscopy for reinsertion of stent and removal of the blood clot if it is there.
Kumar S, Ameli- Renani S, Hakim A, Jeon JH, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radio. 2014 Dec;87(1044).
This antegrade pyelogram shows hydronephrosis and ureteral tapering that indicates ureteral stenosis which would be extrinsic (due to lymphocele, hematoma or abscess), intrinsic (due to edema, clot, tumor or calculi) or other causes such as ureteral ischemia.
First, urinary diversion by percutaneous nephrostomy and then balloon dilation and ureteric stent placement. Prophylactic antibiotics are used to prevent infection. Resolving the etiology of stenosis such as lymphocele is appropriate. Finally, excision and then ureteral reimplantation might be necessary.
Kumar S, Ameli-Renani S, Hakim A, Jeon JH, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol. 2014 Dec;87(1044):20140169.
The patient has graft ureteric obstruction, may be due to ureteric ischemia and necrosis, stricture or blood clot.
Management:
Ultrasound guided percutaneous nephrostomy to relive the obstruction
Ureteroscopy for stent reinsertion and removal of the blood clot if present.
Kumar S, Ameli-Renani S, Hakim A, Jeon JH, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol. 2014 Dec;87(1044):20140169.
What is your diagnosis?
hydronephrosis of renal graft due to Ureteral obstruction.
incidence of ureteral obstruction secondary to stenosis range in from 1% to 6.5% .
Ischemia is the most common cause of ureteral stenosis usually occurred with a long ureter and double artery. Preservation of lower pole accessory arteries and periureteral tissue of the donor allograft is essential to avoid ischemic insult to the ureter.
Delayed stenosis is often due to recurrent infection, rejection, BK virus or external compression by lymphocele, hematoma .
Rarely, obstruction from a ureteral stone or blood clot which must be differentiated from luminal narrowing.
diagnosis and management :
-Initially, ureteral stenosis may present with new-onset or worsening hydronephrosis.
This may or may not be associated with decreased urine output and reduced glomerular filtration rate.
– initial management of stenosis can be done with percutaneous antegrade pyelography and nephrostomy tube placement .
– A Whitaker test can be used to confirm obstruction prior to nephrostomy tube placement.
-Other diagnostic modalities include voiding cystourethrography in a refluxing system, renography, or retrograde pyelography.
-Open repair is considered the gold standard for ureteral stenosis as it provides more durable treatment.
-When the gold standard open repair cannot be safely performed
minimally invasive techniques include antegrade or retrograde balloon dilatation, electrocautery ureterotomy, and holmium:yttrium-aluminum-garnet (YAG) laser ureterotomy for strictures with a length of 10 mm or less .
– combined balloon dilation with holmium:YAG laser who report success rates of 75%.
–Third line management options include chronic ureteral stenting, percutaneous transplant nephrostomy tube, or placement of a subcutaneous pyelovesical bypass graft . These methods are reserved for patients who have failed open surgical repair, are too high risk for open surgery, or have recalcitrant ureteral strictures despite endoscopic treatments.
Hannah R. Choate, Laura A. Mihalko, Bevan T.Urologic complications in renal transplants.Transl Androl Urol. 2019 Apr; 8(2): 141–147.
the patient has rising creatinine due to obstructive uropathy could be a clot in the lumen, a twisted unilateral ureter, and also stricture or edema or ischemia, or ischemia. some time compression from fluid collection
ureteral complication occur 2 to 10% post kidney transplantation
first role UTI sends for culture and sensitivity
percutaneous nephrostomy insertion and retrograde stent
if no response surgical excision and reimplantation
references
0. Bhayani SB, Landman J, Slotoroff C, Figenshau RS. Transplant ureter stricture: Acuciseendoureterotomy and balloon dilation are effective. J Endourol 2003;17:19e22.
There is progressive decrease is seen in lower down of the nephrostogram, most probably there is stenosis (internal) causing obstruction and rising of creatinine.
I would go for PCN, CT imaging, once infection is ruled out will proceed for antegrade ballooning and reinsertion of DJ stent.
What is your diagnosis?
Ureteral obstruction associated with hydronephrosis
This complication occurs in 2% to 10% of renal transplant patients postoperatively, and usually occurs early post-transplant caused by internal obstruction (clot, edema, ischemia, and kink) or external causes (compression by lymphocele, hematoma, and tumor. Ureteric ischemia is the most common cause (around 90%) which usually occurred with a long ureter, double artery, and long ischemia time.
Management
Urinary diversion by percutaneous nephrostomy insertion. Retrograde endoscopic stenting can be done but this will be challenging since the ureter has abnormal anatomy.
Followed by one of the following
· Ureteric strictures shorter than 2 cm: Percutaneous balloon dilatation first is done if feasible, followed by an antegrade ureteric stent with or without endoscopic revision or long-term stenting of the ureter if needed.
· If the stricture is Longer than 2 cm (surgical excision and reimplantation). If the length of the ureter is compromised, uretero-pyelostomy using the ipsilateral native ureter or cysto-pyelostomy is a reasonable alternative
REFERANCES
1. Sandhu C, Patel U. Renal transplantation dysfunction: the role of interventional radiology. Clin Radiol 2002; 57: 772–83.
2. Duty BD, Conlin MJ, Fuchs EF, Barry JM. The current role of endourologic management of renal transplantation complications. Adv Urol 2013; 2013: 246520
Hydroureteronephrosis is secondary to ureteral obstruction.
It’s may contribute to graft dysfunction and rejection.
ureteral obstruction secondary to postoperative edema/ ischemia torsion or kink, extrinsic compression from hematoma or lymphocele.
Ureteral obstruction account 2% to 10% of renal transplant.
Management of megaureteral is interventional radiological with ballon dilatation of ureteric stricture with or without stent or surgical intervention by nephrostomy tube placement or double j stent at anastomoses ends of ureter and removed after one month. also surgical excision of the stenotic segment and reinmplantation.
Reference:
Haberal, Mehmet1; Boyvat, Fatih2; Akdur, Aydincan1; Kirnap, Mahir1; Ozcelik, Umit3; Karakayali, Feza Yarbug3:
Surgical Treatment for Ureteral Obstruction After Kidney Transplantation,
Transplantation: July 2018 – Volume 102 – Issue – p S630.
This is typical picture of kinced urter post removal of DJ stent.
This patient need urgnent cystcopy and Re onsertion of another DJ for at lest 3 month and re correction of urtrer insertion point.
What is your diagnosis?
There is obvious obstruction at ureteric level.
Causes can be intraluminal like clot or debri, stones.Luminal like stenosis at reimplantation site or due to ischemia, kinks. It can be extraluminal like external compression by collections etc.
How to manage this patient?
This has to be dealt with urgently. I will make sure patient is on antibiotics.
I will send full set of blood test including blood complete picture, renal function and electrolytes, clotting profile, drug levels.
Doppler scan to assess vessels
CT to assess the exact anatomy and any other collection
Consultation with IR team for urgent PCN , nephrostogram . . The urine from PCN should be sent for culture.
Once infection is ruled out he will need antegrade balloon dilatation of stricture site and JJ stenting. The success rate is around 50-70%.
If this fails then he will require revision of ureterooneocystostomy if adequate length is available.
Other options include use of native Ureter, Boari flap.
Kumar S, Ameli-Renani S, Hakim A, Jeon JH, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol. 2014 Dec;87(1044):20140169.
Ureteral obstruction occurs in 2% to 10% of renal transplant patients postoperatively, usually presenting within the first few weeks or the first year. Ureteric ischemia is the most common cause, accounting for around 90% of occurrences. The first option for treatment is interventional radiological methods. Percutaneous therapy of ureteral strictures consists of balloon dilatation with or without temporary stenting. If all of these methods are unsuccessful, surgical treatment should be applied.
Causes of obstruction in renal transplant patients
Risk factors
Intrinsic obstruction
Extrinsic compression
Others
>65 years old
More than two transplant arteries
Increased cold ischaemia time
Stentless anastomotic transplant
Oedema
Clot
Tumour
Calculi
Lymphocele
Abscess
Haematoma
Ischaemia
Kinking
Previously unrecognized PUJ obstruction
Misplacement of ureteric anastomosis
Once ureteric obstruction is confirmed or strongly suspected, urinary diversion must be undertaken promptly to minimize kidney damage. This is best achieved by percutaneous nephrostomy insertion. Although retrograde stent insertion may be used, this can be technically challenging, as the ureteric anastomosis is routinely performed along the anterolateral bladder wall, making it difficult to access and manipulate with an endoscopic approach.
Once renal function has improved, definitive treatment of the ureteric obstruction is undertaken.
percutaneous balloon dilatation if technically feasible, followed by temporary antegrade ureteric stent placement. If the stenosis recurs after stent removal, surgical revision or long-term ureteric stenting is advocated.
Options include ureteroneocystostomy with excision of the stenotic segment and reimplantation, ureteroureterostomy using the recipient ipsilateral ureter (pyeloureterostomy between the donor renal pelvis and recipient ureter).
What is your diagnosis?
Ureteric obstruction.
Could be the result of1:
· Peri-nephric fluid collection due to back pressure changes. Possible etiological factors are blood clot into ureteric lumen, lymphocele, urinoma and hematoma.
· Twist in long ureters and stricture or edema at anastomotic site are also well recognized facts. Distal ureter is the commonest site of ureteric stricture.
How to manage this patient?
1. In order to reduce the morbidity and mortality for this complication early and aggressive treatment is advocated2. Doppler ultrasound for the diagnosis or percutaneous nephrostomy for the radiological establishment of the blocked level as well as the first choice of treatment.
2. Urgent nephrostomy is required initially till exact location of exact cause with definitive treatment plan.
3. For ureteric strictures besides surgical exploration endo-urological techniques has also been evolved and adopted with favorable outcomes1. These include ureterotomy and balloon dilatation which has success rate of 70% and 51% respectively1.
References
1. Approach to urological complications early post renal transplant Akbar Mahmood Nephrology Department, Sultan Qaboos University Hospital, Muscat, Oman.
2. Vennarecci G, Tisone G, Pisani F, Fiore A, Alciati E, Iorio B, Casciani CU. Le ostruzioni ureterali nei pazienti con trapianto di rene [Ureteral obstruction in the kidney transplant patient]. Minerva Urol Nefrol. 1995 Jun;47(2):59-64. Italian. PMID: 8560350.
Diagnosis
Obstruction at the ureteral obstruction distally can be seen in this patient. Risk factors include the following :
Causes of intrinsic obstruction include edema, clotting, tumor or calculi. Causes of extrinsic obstruction include lymphocele, abscess or hematoma. Other possible causes include
Ureteric ischemia is a common cause. Distal ureter is involved since it is close to ureterovescial junction.
Investigation modalities include those used to assess hydronephrosis – Ultrasound, CT, MR urography and scintigraphy.
Ultrasound is sensitive but CT offers greater anatomic detail to assess extent of hydronephrosis and allows to pinpoint site of obstruction.
Management
References :
What is your diagnosis?
· There is distal ureteric obstruction complicated with reduced urine output and moderate hydro-nephrosis.
· Distal ureteric obstruction causes are classified as early vs late post transplantation:
Early causes:
1) Ischemic ureteric obstruction(> 90% of cases).
The distal ureter close to the uretero-vesical junction is invariably involved as this area is particularly vulnerable to ischemia owing to its anatomical location, being furthest from the renal artery.
To protect against ureteric ischemia, it is a routine practice to stent the ureter for the first 4–6 weeks after transplantation as ureteric ischemia typically presents early if a stent is not placed at the time of transplant surgery or after stent removal from the site of anastomosis
2) Intrinsic causes like edema, clots, ischemic ureteral slough near the vesico-ureteric junction
3) Extrinsic causes like ureteric compression by a hematoma ,lymphocele or ureteric kinking if the ureter is long
Late causes:
1) Malignant causes like bladder malignancy or malignant ureteric stricture
2) Ischemic fibrosis caused by a deficient vascular supply
3) Vasculitis in the context of an acute rejection episode
4) Vasoconstriction caused by immunosuppressant therapy, such as corticosteroids and calcineurin inhibitors
How to manage this patient?
Diagnosis:
There are several imaging modalities that can be used to diagnose and assess hydro nephrosis, including ultrasonography, CT, MR urography and scintigraphy.
Treatment:
·urinary diversion is done promptly to minimize kidney damage. This is done by percutaneous nephrostomy insertion(PCN).
Once renal function has improved, definitive treatment of the ureteric obstruction is done by percutaneous balloon dilatation if technically feasible, followed by temporary antegrade ureteric stent placement.
– If the stenosis recurs after stent removal, surgical revision and re-implant or long-term ureteric stenting is required.
References
Kumar S, Ameli-Renani S, Hakim A, Jeon JH, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol. 2014 Dec;87(1044)
>>ischemia , ureteric necrosis
>>trauma ,edema or clotting during removal of the stent
>>stricture during anastomosis
>> Retention due to BPH after catheter removal.
>> Inability to void due to bladder dysfunction: long-standing defunctionalized bladder, neuropathy due to DM.
>>PCN and antegrade stenting .
>>Retention due to Benign Prostatic Hyperplasia after Catheter Removal
– Try medical treatment (e.g. alpha adrenergic blockers) and trial voiding.
– Surgical treatment of BPH (e.g. TURP, TURIS, Laser): if medical treatment fails.
>> clean intermittent self catheterization (CIC) may be required if bladder dysfunction
>>surgical options i.e re-anastomosis of the ureter depending on the cause
(Bedeir Ali-El-Dein ;Acute Transplant Dysfunction: Surgical Causes , fellowship in clinical transplantation , 2022 )
Hydronephrosis with hydro ureter in upper part.
Early obstruction is often related to ureteric ischaemia, a narrow anti-reflux tunnel at the ureterovesical anastomosis or external compression by a lymphocoele or haematoma.
Errors in surgical technique are also a recognized cause. A long ureter increases the risk of early obstruction, as it is more prone to ischaemia and liable to kinking, presenting as intermittent obstruction
The aetiology of late ureteral stricture is less well defined. It may be owing to ischaemic fibrosis caused by a deficient vascular supply, vasculitis in the context of an acute rejection episode or vasoconstriction caused by immunosuppressant therapy, such as corticosteroids and calcineurin inhibitors. In comparison, ureteric tumours and ureterolithiasis, which are common causes of ureteric obstruction in non-transplant patients, are infrequent in the transplant ureteric stenosis setting.
Once ureteric obstruction is confirmed or strongly suspected, urinary diversion must be undertaken promptly to minimize kidney damage. This is best achieved by percutaneous nephrostomy insertion. Although retrograde stent insertion may be used, this can be technically challenging, as the ureteric anastomosis is routinely performed along the anterolateral bladder wall, making it difficult to access and manipulate with an endoscopic approach.
Once renal function has improved, definitive treatment of the ureteric obstruction is undertaken. Our practice is to carry out percutaneous balloon dilatation if technically feasible, followed by temporary antegrade ureteric stent placement. If the stenosis recurs after stent removal, surgical revision or long-term ureteric stenting is advocated.
Percutaneous nephrostomy insertion poses a risk of bleeding, which should be minimized by ensuring an adequate platelet and haemoglobin count and coagulation time.
Ref:
Ureteral obstruction following renal transplantation: causes, diagnosis and managementS Kumar, S Ameli-Renani, A Hakim, J H Jeon,S Shrivastava, and U Patel.Br J Radiol. December 2014; 87(1044): 20140169.
The antegrade pyelogram showed moderate hydronephrosis and upper hydroureter with distal obstruction of lower part of the ureter
Causes :
A- Intrinsic :
Oedema
Clot
Calculi
B-Extrinsic
Lymphocele
Abscess
Haematoma
C- Others :
Ischaemia
Kinking
Stricture
Investigations :
A- ultrasonography : is the perfect first-line for confirming hydronephrosis, excluding periureteric collections, and assuring proper transplant perfusion
B- CT : better anatomical information and identify the site of obstruction and clarify the origin and severity of hydronephrosis
C-MRU : Same advantage of CT but without risk of Ionized radiation
D- 99mTc mercaptotriglycylglycine (MAG3) scintigraphy :
is helpful in excluding alternative reasons of decreased renal function, such as acute tubular necrosis, rejection, and medication toxicity, in addition to providing information on renal excretory function
TTT :
1- First step : percutaneous nephrostomy and once renal function has improved, definitive treatment of the ureteric obstruction is undertaken.
2- An initial nephrostogram identifies the site and extent of the ureteral obstruction, along with exclusion of any leak from the collecting system
Treatment according to the cause :
Ureteric stricture :
if mild >> dilatation with ureteric stent insertion
severe >> ureteroneocystostomy with excision of the stenotic segment and reimplantation or ureteroureterostomy using the recipient ipsilateral ureter
Stone : Extraction with ureteric stent insertion
Extrinsic :
Lymphocele :
Percutaneous aspiration or Laparoscopic fenestration or Open surgical drainage
Abcess : Drainage with Antibiotic treatment
REFERENCES
Patel U, Hussain FF. Percutaneous nephrostomy of nondilated renal collecting systems with fluoroscopic guidance: technique and results. Radiology 2004; 233: 226–33.
Lojanapiwat B, Mital D, Fallon L, Koolpe H, Raja R, Badosa F, et al. Management of ureteral stenosis after renal transplantation. J Am Coll Surg 1994; 179: 21–4.
Duty BD, Conlin MJ, Fuchs EF, Barry JM. The current role of endourologic management of renal transplantation complications. Adv Urol 2013; 2013: 246520. doi:
The antegrade pyelogram show sever hydronephrosis with hydroureter indicating distal ureteric obstruction
Ureteric ischaemia is the most common cause accounting for around 90% of cases.The distal ureter close to the ureterovesical junction is invariably involved as this area is particularly vulnerable to ischaemia owing to its anatomical location, being furthest from the renal artery.
The proximal ureter is supplied by small branches from the main renal artery, but this can be variable. Indeed, it is now routine practice for the ureter to be stented for the first 4–6 weeks after transplantation as added protection since ureteric ischaemia typically presents early if a stent is not placed at the time of transplant surgery or following stent removal from the site of anastomosis.
Causes of ureteric obstruction may be classified as early (<3 months) or late (>3 months) post transplantion.
Once ureteric obstruction is confirmed or strongly suspected, urinary diversion must be undertaken promptly to minimize kidney damage. This is best achieved by percutaneous nephrostomy insertion.
Although retrograde stent insertion may be used, this can be technically challenging, as the ureteric anastomosis is routinely performed along the anterolateral bladder wall, making it difficult to access and manipulate with an endoscopic approach.
Once renal function has improved, definitive treatment of the ureteric obstruction is undertaken. percutaneous balloon dilatation can be done if technically feasible, followed by temporary antegrade ureteric stent placement. If the stenosis recurs after stent removal, surgical revision or long-term ureteric stenting is advocated.
Percutaneous nephrostomy insertion poses a risk of bleeding, which should be minimized by ensuring an adequate platelet and haemoglobin count and coagulation time.7,8 We consider a platelet count of >80,000 × 109 per litre, a haemoglobin of >8 g dl−1 and an international normalized ratio of <1.5 to be acceptable. Urine is tested for infection, and use of prophylactic antibiotics is directed by local policy. Imaging should be reviewed for anatomical consideration and procedure planning, to reduce the risk of injury to bowel, peritoneum and adjacent vessels.
Reference
Ureteral obstruction following renal transplantation: causes, diagnosis and management
1S KUMAR, BSc (Hons), 2S AMELI-RENANI, MB BS, FRCR, 1A HAKIM, BSc (Hons), 1J H JEON, BSc (Hons), 3S SHRIVASTAVA, PhD, MRCP and 2U PATEL, MRCP, FRCR
2014 The Authors. Published by the British Institute of Radiology
The antegrade pyelogram of the transplant kidney showed hydronephrosis and upper hydroureter with absence of contrast in the lower part of ureter. This could be due to distal ureteric obstruction.
Cause Includes:
Management
References
-The antegrade pyelogram shows hydronephrosis and distal ureteric obstruction.
Could be either
· Intrinsic obstruction due to oedema , clot ,tumor , calculi
· Extrinsic compression due to lymphocele, abscess ,haematoma
· Others as Ischaemia ,Kinking ,Previously unrecognized pelviurteric junction obstruction ,misplacement of ureteric anastomosis
Ureteric ischaemia is the most common cause representing 90% .
The distal ureter close to the ureterovesical junction is invariably involved as this area is vulnerable to ischaemia owing to its anatomical location, being furthest from the renal artery.
-Ultrasonography is the first-line investigation, other investigations includes CT, MR urography and scintigraphy.
Surgical urinary diversion must be done rapidly to minimize kidney damage by percutaneous nephrostomy insertion which carries bleeding risk therefore platelete , Hb, coagulation profile must be checked before the procedure.
Although retrograde stent insertion may be used, this can be technically challenging, as the ureteric anastomosis is routinely performed along the anterolateral bladder wall, rendering accessibility and manipulation with an endoscopic approach difficult.
When renal function improves , definitive treatment of the ureteric obstruction is carried out .
Percutaneous balloon dilatation if technically possible, followed by temporary antegrade ureteric stent placement. If the stenosis recurs after stent removal, surgical revision or long-term ureteric stenting is adviced.
Surgical intervention can be needed including ureteroneocystostomy with excision of the stenotic segment and reimplantation.
Urine is tested for infection, and prophylactic antibiotics will be neede. Imaging should be reviewed for anatomical consideration and procedure planning, to reduce the risk of injury to bowel, peritoneum and adjacent vessels.
Reference
Kumar S, Ameli-Renani S, Hakim A, Jeon JH, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol. 2014 Dec;87(1044):20140169.
I agree it is level 5 evidence.Your headings and sub-headings should be in bold or underline. That will make it easy to read.
Ajay
What is your diagnosis?
Urinary tract obstruction immediately after removal of stenting with high serum creatinine and ultrasound showed hydronephosis (exclude peri-transplant fluid collection)
The antegrade nephrostogram showing complete obstruction of the ureter (distal part)
Causes of obstruction in renal transplant patients:
Intrinsic obstruction (oedema, clot, tumour, calculi, stricture)
Extrinsic compression (lymphocele, abscess, haematoma)
Others (Ischaemia, Kinking, Previously unrecognized PUJ obstruction, misplacement of ureteric anastomosis)
Ureteric ischaemia is the most common cause (90% of cases). The distal ureter is particularly vulnerable to ischaemia owing to its anatomical location, being furthest from the renal artery
How to manage this patient?
Immediate placement of an antegrade nephrostomy tube to relief obstruction (risk of bleeding). Adequate platelet, haemoglobin and coagulation time are required
Doppler ultrasound/renal scan for flow and to exclude peri-transplant fluid collection
Other imaging modalities are CT, MR urography and scintigraphy
Prophylactic antibiotics
Temporary antegrade ureteric stent placement (4-6 weeks)
Treat the underlying cause of obsrtuction
Minor ureteric obstruction may resolve with proximal diversion and stenting
Ureteric strictures: shorter than 2 cm (endoscopically with a laser or cutting blade, balloon dilation, and stenting). Longer than 2 cm (excision and reimplantation). If the length of the ureter is compromised, ureteropyelostomy using the ipsilateral native ureter or cystopyelostomy is a reasonable alternative
Extrinsic ureteric compression can be treated with external drainage of the lymphocele, hematoma, or urinoma
References
1. Kumar S, Ameli-Renani S, Hakim A, Jeon JH, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol. 2014 Dec;87(1044):20140169. doi: 10.1259/bjr.20140169. Epub 2014 Oct 6. PMID: 25284426; PMCID: PMC4243200.
2. Gabriel M. Danovitch. Handbook of Kidney Transplantation. Sixth edition, 2017
I like your approach, Dr Abdallah.
The antegrade pyelogram of the transplant kidney shows hydronephrosis and upper hydroureter with absence of contrast in the lower part of ureter, suggesting distal ureteric obstruction.
It could be due to extrinsic compression like hematoma or lymphocele, or due to intrinsic cause like clot or stenosis of ureter (1).
First and foremost, relief of obstruction by percutaneous nephrostomy and urinary diversion should be done (1). Antegrade ureteric DJ stenting should be done later once the creatinine normalizes.
Then the cause of this obstruction should be analyzed. Ultrasound will help in evaluating any source of extrinsic compression like lymphocele or hematoma. If present, they should be managed (evacuation of hematoma, laparoscopic fenestration of lymphocele).
Ureteric stricture is initially treated with balloon dilatation and stent insertion (1). Surgical excision of the stenosed segment and re-implantation of ureter may be required if the conservative measure fails (1).
References:
1) Kumar S, Ameli-Renani S, Hakim A, Jeon JH, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol. 2014 Dec;87(1044):20140169. doi: 10.1259/bjr.20140169. Epub 2014 Oct 6. PMID: 25284426; PMCID: PMC4243200.
Thank you
Diagnosis: distal ureteric obstruction
Management:
-Initial: relief of obstruction by PCN
-Latter: re stenting or re implant of ureter
Too short a reply. We need references as well.
1. The antegrade pyelogram shows tapered end of ureter indicating distal ureteric obstruction, mostly due to ischemic event or poor technical uretrovesical anastomosis.
2. The managemnt is immediate PCN to relieve the obstruction and hydronephrotic changes to preserve the graft then antegrade ureteric stenting.
_ close follow up of urine output, graft function and any evidence of obstruction after removal of stent that may indicate need for re-anastmosis (uretrouretrostomy ) or reimplantation (uretroneocystostomy).
I like your brief reply. We need references as well.
5. A 65-years-old renal transplant recipient stopped passing urine immediately after removing the ureteric stent. This was associated with rising in s Cr. USS showed moderate hydronephrosis. The antegrade pyelogram is shown below.
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How to manage this patient?
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Refernce
I like your approach, Dr Wadi
Thanks alot Prof.Sharma
What is your diagnosis?
Distal transplanted ureteric obstruction
How to manage this patient?
-Percutaneous nephrostomy insertion. Once renal function has improved, definitive treatment of the ureteric obstruction is undertaken→percutaneous balloon dilatation if technically feasible, followed by temporary antegrade ureteric stent placement.
-If the stenosis recurs after stent removal, surgical revision or long-term ureteric stenting is advocated.
Reference:
S Kumar et al. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol. December 2014; 87(1044): 20140169.
Yes, Dr Reem.
A 65-year-old post-transplant anuria post ureteric stent removal. Ultrasound showed moderate hydronephrosis.
The likely diagnosis is distal ureteric obstruction causing hydroureteronephrosis post-stent removal.
The incidence of ureteric complication post-transplant is about 7-10 %. The complications can occur during the first 3 months after the surgery. Ureteric obstruction can be classified as early or late. Early is less than 3 months and late is greater than 3 months.
The management is to alleviate the cause of the obstruction by:
1) Performing or placing a percutaneous nephrostomy and performing a nephrogram.
2) Can place a stent
3) If all the above fail, then surgical intervention can be done for correction.
It must be noted that if there is hydronephrosis but the creatinine is normal no intervention is required but if the creatinine is abnormal. One can perform a ureteric reconstruction. If after performing the ureteric reconstruction and the creatinine is abnormal then the surgeon has to redo the procedure to correct the ureteric problem. If after the first ureteric reconstruction has normal creatinine, then observation alone with ultrasounds follow-ups is needed.
References:
Bhattacharjya, S., Journal of medicine and public health report (2022). Post renal transplant hydronephrosis- obstructive or – a longitudinal single center study. https://Doi.Org/10.38207/JCMPHR/2022/JAN03010415
What is your diagnosis?
Distal Ureteric obestruction
May be due to :
Intrinsic causes : clots , calculi
Extrinsic causes : compression by abscess hematoma , lymphocele
others : ischemia , kinking
How to manage this patient?
Rapid intervention to relieve obstruction by neprostomy tube ( PCN)
After improving renal chemistry DJ may be reinserted
If obestruction is recurrent then surgical intervention
Reference:
S Kumar et al. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol. December 2014; 87(1044): 20140169.
Short and sweet
I like your reference, Dr Marius Badal. This is published by my dear friend and a superb academic transplant Surgeon from Adelaide, Dr Shantanu Bhattacharjye.
Severe graft hydronephrosis with hydro-ureter upper part
urologist consultation urgently
urgent nephrostomy for decompression to save the graft, and nephrogram to identify the site of obstruction and its extension.
DJ insertion
surgical reimplantation if the ischemic ureter no improved with dilatation
Short and sweet. We need references as well.
There is ureteric obstruction causing hydronephrosis and upper hydroureter.
Need nephrostomy tube insertion to preserve the transplanted kidney , cystescopy with re-insertion of the stent.
open surgery with re-implantation of the ureter may be needed.
Short and sweet. We need references as well
This is a severe hydronephrosis with ureteric obstruction
Causes of obstruction in renal transplant patients:
1. Intrinsic obstruction: Edema, Clot, Tumor, Calculi
2. Extrinsic compression: Lymphocele, Abscess, Hematoma
3. Others: Ischemia, Kinking, Previous PUJ, Misplacement of ureteric anastomosis
· After improvement of kidney function post nephrostomy, percutaneous balloon dilatation , followed by temporary antegrade ureteric stent placement.
· If the stenosis recurs after stent removal, surgical revision or long-term ureteric stenting is adviced.
Ureteral obstruction following renal transplantation: causes, diagnosis and management
S KUMAR, BSc (Hons), S AMELI-RENANI, MB BS, FRCR, A HAKIM, BSc (Hons), J H JEON, BSc (Hons), S SHRIVASTAVA, PhD, MRCP and U PATEL, MRCP, FRCR
Short and sweet.
*The antegrade pyelogram showed: Picture of hydrouretero-nephrosis after stent removal indicate lower ureteric obstruction which may be due to ischemic ureteric obstruction or ureteral kinking or even intraluminal clots.
*Management with : Percutaneous nephrostomy and antegrade stenting with or without balloon dilation but, for longer time if no improvement then may need open surgery
re-implantation.
Short and sweet. We need references as well
The pyelogram shows obstruction of the ureter. As my colleagues shared. edema or ischemic injury is the most probable cause, but this may be reflex anuria, a rare complication that may be seen after the removal of the DJ stent, even with short stenting. There are some rare case reports regarding that. This can be either due to intrarenal or ureteral spasms.
To differentiate other causes, we may need cystoscopy and resenting. emergent nephrostomy is crucial. According to cause, operation and revision of ureterosystostomy may be needed
Short and sweet. We need references as well
Distal ureteric obstruction with backpressure hydroureteronephrosis likely after stent removal indicates distal obstruction.
How to manage this patient?
ischemic ureteric obstruction accounts for > 90% of the cases and usually occur in the first 3 months (1).
The causes of distal ureteric obstruction could be acute <3 monthsspost-Txx –
1. Intrinsic (blood clots, edema, poor reimplantation, ischemic ureteral slough near the ureteric-vesicle junction
2. Extrinsic (ureteral kinking( longer ureter ),hematoma, large lymphocele )
late post-transplant ureteric obstruction should exclude malignancies like UB malignancy or malignant-ureteric stricture
Management
References
1.Kumar S, Ameli-Renani S, Hakim A, Jeon JH, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol. 2014 Dec;87(1044):20140169.
Many thanks Dr Saja.
What is your diagnosis?
How to manage this patient?
The index case has acute graft dysfunction decrease in urine output immediately after stent removal, and the pyelogram showed moderate hydronephrosis. All these findings are suggestive of ureteric obstruction.
Causes of obstruction in renal transplant patients
Intrinsic obstruction; edema, intraluminal clot, intraluminal calculi, stenosis
Extrinsic compression; Lymphocele, Hematoma and Abscess
Others: Kinking, Previously unrecognized PUJ obstruction, Misplacement of ureteric anastomosis
Ureteric stricture caused by ischemia fibrosis caused by a deficient vascular supply, vasculitis in the context of an acute rejection episode or vasoconstriction caused by IS. In general, ureteric ischemia presents early with urine leaks.
Management:
-Renal US initial screening test.
-CT offers greater anatomical detail to elucidate the cause and extent of hydronephrosis, in addition to pinpointing the site of obstruction
-MR urography can be used in selected cases and offers similar advantages to CT without the risk of ionizing radiation.
-Urinary diversion must be undertaken promptly to minimize kidney damage
-Percutaneous nephrostomy PCN insertion carries a risk for bleeding and infection.
-Retrograde stent insertion may be used,
-Surgical intervention is indicated if minimally invasive procedures fail; ureteroneocystostomy with excision of the stenotic segment and reimplantation, ureteroureterostomy using the recipient ipsilateral ureter (pyeloureterostomy between the donor renal pelvis and recipient ureter), or utilization of flap
References:
Kumar S, Ameli-Renani S, Hakim A, Jeon JH, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol. 2014;87(1044):20140169. doi:10.1259/bjr.20140169
Yes, Dr Hadeel.
What is your diagnosis?
This is a case of acute anuria after ureteric stent removal from the graft kidney. Above image shows grossly dilated pelvicalyceal system dilation along with dilated ureter with no dye in bladder
This is likely obstruction at VUJ of graft kidney ureter.
How to manage this patient?
Acutely the patient will require re-stenting to relieve obstruction and avoid post renal AKI.
Stent will have to be kept for prolonged period and even then if VUJO doesn’t resolve then patient will require ureteric re implant.
Yes Dr Saini, I appreciate your approach
Urinary Obstruction
Common causes of urinary obstruction include;
catheter blockage, blood clots, extrinsic ureteric compression, ureteral stricture, stones, and prostatic hyperplasia (In males)
Low-grade obstruction in the early postoperative period may be a result of ureteral edema with vigorous diuresis and usually resolves.
Obstruction is usually manifested by impairment of graft function and increasing hydronephrosis
Placement of an antegrade nephrostomy tube can rapidly reduce obstruction while serving as a conduit for an antegrade nephrostogram to help confirm the diagnosis.
Ureteric strictures shorter than 2 cm can be treated endoscopically with a
laser or cutting blade, balloon dilation, and stenting
Ureteric strictures longer than 2 cm require excision and reimplantation.
Handbook of
Kidney
Transplantation
Edited by
Gabriel M. Danovitch, MD
Medical Director, Kidney and Pancreas Transplant Program
Ronald Reagan Medical Center at UCLA
John J. Kuiper Chair of Nephrology and Renal Transplantation
Distinguished Professor of Medicine
David Geffen School of Medicine at UCLA
Los Angeles, California
Yes Dr Esraa, I appreciate your approach