Ø The most common surgical urology complications include urine leakage, ureteral obstruction, and lymphocele (fluid collection between the urinary bladder and the kidney allograft). The rates of urological complications range from 2.5% to 30.0% of all recipients.
Ø A high index of suspicion is needed to identify the complications as the symptoms and signs may be masked because of the immunosuppressive drugs and the analgesics used.
Extraperitoneal Urine Leak Post Kidney Transplantation
A high volume of clear drain fluid may indicate the possibility of extraperitoneal urine leak. Ultrasonography, CT scan or MRI, and fluid biochemistry further aid diagnosis. If drain fluid creatinine and potassium values are not dissimilar from the serum values, then the possibilities of lymphocele or seroma are higher. However, if they are significantly higher than the serum values, or are values that are incompatible with life, then it is a urine leak or urinoma.
Different ureteroneocystostomy techniques, including the Lich-Grégoir, Politano–Leadbetter, and U-stitch techniques, have an impact on development of urine leak. The Lich-Grégoir technique has a significantly lower incidence of urinary leakage compared to the Politano– Leadbetter procedure
Haemorrhage
If the drain is haemorrhagic, with accompanying factors like tachycardia, anaemia, local swelling over the graft, or if bleeding is a possibility, ultrasonography, CT scan, or MRI may be used to identify haematoma, necessitating an emergency re exploration. risk factors include recipient obesity, use of antiplatelet agents, and anticoagulation.
Urinary Fistula
Urinary fistula occurs in 2–5% of kidney transplantations, and may lead to significant morbidity, graft loss, and mortality. There is an 8% risk of mortality associated with urinary fistula. Ureteral ischaemia and necrosis and technical problems associated with the transplant procedure are important causes of urinary fistula development
Perinephric Abscess
Perinephric abscesses are uncommon complications post kidney transplantation. They usually present in the early post-transplant period (in the first few week’s post-transplant). The causes include pyelonephritis, infection of lymphocele, haematoma, or urinoma Aspiration of the collection and performing microscopy and culture of the aspirate may further help the diagnosis.
Lymphocele and Seroma
A collection of lymph in the perigraft area is called a lymphocele. Lymphoceles occur in 1-20% of kidney transplant operations, occur from as early as 2 weeks to as late as 5 years’ post-transplant. Usually they are small and asymptomatic, and such lymphoceles require no intervention.
Urine Leak and Urinoma
Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of cases. Urine leaks post kidney transplantation may manifest as free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma)
The different clinical presentations could be early extraperitoneal high-volume leak; early extraperitoneal small leak, defined by a persistent low urine output through drains, associated with low urine output, graft site swelling, and; late leak (1–2 weeks after kidney transplant), which may be caused by ureter necrosis or early removal of double J stent (<3–6 weeks); and intra-abdominal leak, which presents with an acute abdomen.
Compare drain creatinine and potassium levels with serum creatinine and potassium levels is a key for diagnosis
Preventive measures: importance of the golden triangle
Ø Urine leak usually occurs because of technical errors in the ureteroneocystostomy technique, the method of graft ureter implantation in the recipient’s urinary bladder, or because of the transplanted ureter’s compromised vascularity, which is caused by vessel damage during the harvest of the donor kidney.
Ø Presence of multiple renal arteries is also a risk factor for development of urological complications post kidney transplantation.
Ø During harvesting of the donor kidney, gentle handling of the ureter at the time of ureteral dissection is crucial to prevent urine leak post kidney transplantation.
Level 5
Naglaa Abdalla
2 years ago
There are different techniques are used to achieve ureterovesical anastomosis in kidney
transplantation. The most popular methods include the Lich–Grégoir, Politano-Leadbetter, and U-stitch techniques. Meta-analyses performed by Alberts et al showed that the Lich–Grégoir technique is significantly associated with a lower incidence of urinary leakage compared to the Politano-Leadbetter technique.
The analyses also showed significantly fewer incidences of hematuria with the Lich–Grégoir method than both the Politano-Leadbetter and U-stitch techniques. In order to prevent reflux during voiding, the ureterovesical anastomosis must be tension-free and protected by at least a 1 cm submucosal tunnel. Differential Diagnosis of urine leak: Hemorrhage:
Clinical features of anemia, hemorrhagic drain and local swelling over the graft.
Risk factors include; recipient obesity, use of anti-platelet and aspirin therapy. Urinary Fistula:
This occurs in 2–5% of kidney transplantations, and may lead to significant morbidity, graft loss, and mortality. Ureteral ischemia and necrosis and technical problems associated with the transplant procedure are important causes of urinary fistula
development. The risk factors include; younger recipient age (aged <10 years), uretero-ureteric anastomosis, use of high-dose steroids in immunosuppression, number of renal arteries, and bladder problems.
Management include; ureteral ligature and nephrostomy, ureteroureterostomy,
pyeloureterostomy, ureteroneocystostomy, percutaneous nephrostomy and ureteral stenting, and prolonged vesical drainage. Perinephric Abscess:
Uncommon complications post kidney transplantation.The causes include; pyelonephritis, infection of lymphocele, hematoma, or urinoma. The
drained fluid is purulent, with accompanying symptoms and signs (fever, swelling, and
tenderness over the graft).
Aspiration of the collection and performing microscopy and culture of the
aspirate may further help the diagnosis. Lymphocele and Seroma
A collection of lymph in the perigraft area is called a lymphocele. Lymphoceles may
present with features of compression symptoms including retention of urine, decreased urine output, elevated serum creatinine, thrombosis of iliac vein, and limb odema. The drainage fluid is clear with creatinine and potassium values are not much different from the serum values,
Treatment include; aspiration (nearly 100% chances of recurrence), percutaneous drainage (50% success rate), drainage by laparoscopic method, or open
marsupialisation.
Urine Leak and Urinoma:
It is an early post-operative complication after kidney transplantation.Clinically could be as free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma).
Presentation also could be either low or high volume urine leak, low urine output, graft swelling and pain. The fluid creatinine and potassium are high and incompatible with life.
Low-volume leak at the anastomotic site can be
managed conservatively by performing maximum decompression. Antegrade pyelogram to identify the site of the leak is helpful. Placing a Foley catheter and ureteral stent performing a nephrostomy are the techniques used for decompression. Surgical
re-exploration and re-implanting the transplant ureter becomes necessary if conservative
measures for stopping low-volume urine leak fail, or if there is a high-volume drain.
Prevention of these complications need gentle handling of the donor ureter at the time
of ureteral dissection is to prevent urine leak post kidney transplantation. An adequate peri-urethral tissue in the ‘golden triangle’ must be carefully preserved.
Investigations
The following investigations are helpful in evaluating extraperitoneal urine leak post
kidney transplantation, and to rule out differential diagnoses.
1- Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
2- Use ultrasonography to identify and define the perinephric collection and dilatation of thepelvicalyceal system.
3- Doppler ultrasonography.
4- CT or MRI scans.
5- An intravenous pyelogram.
6- Focal tracer scintigraphy uses
mercaptoacetyltriglycine or technetium 99.
7- Retrograde cystography.
> Antegrade pyelogram .
Radwa Ellisy
2 years ago
Introduction:
The early few days post-transplant are the most important ones. Careful monitoring for the patients` dynamics, laboratory investigations and rain output is crucial to identify complications early and prompt management. One of the early complication is urine leak, it occurs in 1.2-8.9 % post transplant.
Urological complication: occur in 2.5-30% of opertaion
1- uine leak: It occurs less with Lich–Grégoir operation
– presented by local signs: pain, tender graft but may be masked by analgesia and immunosupreeant
– investigations: drain creatinine and potassium more than serum levels
– ultrasonography and doppler: perinephric collection +/- dilatation of the pelvicalyceal system and perfusion defects
– CT or MRI scans confirm the perinephric collection and pelvicalyceal dilatation
– scintigraphy by mercaptoacetyltriglycine or technetium 99 and antegrade pyelogram for localization for site of anastomosis but the latter appropriate in case of delayed graft function
– management: by decompression by UB catheter, drain +/- antegrade stenting, but in case of high drain output exploration may be the solution
differentiating from hematoma (drain colour, fall in Hgb +/- hemodynamic instability), lymphocele (occurs later on 2-6 weeks, painless), and perinephric abcess (later on and with normal creatnine and potassium content similar to serum)
2- Complications caused by the length of the transplanted ureter: long ureter may lead to kinking and obstruction while a short ureter may interfere with tension-free anastomosis.
3- Atrophic bladder or dysfunctional bladder may result in bladder perforation or anastomotic dehiscence
4- Leak from distal calyx due to poor blood supply
5- Vigorous dissection for the ureter may lead to ischemia and urine leak distally.
level of evidence: 5
Nazik Mahmoud
2 years ago
This study concern about surgical complications post kidney transplant,mainly the urine leak. The symptoms vary between pain at the graft site, fever and fluid collection around the graft . The differential diagnosis can be lymhocyle , hematoma or abscess. Urine leak could be due to ischemia to the ureter or problem in the implantation technique, diagnosis can be made by ultrasound or radioisotope scan then fluid aspiration and analysis for creatinine and potassium
treament is conservative with antigrade stenting to the ureter
It is level 5 evidence
Rehab Fahmy
2 years ago
Introduction
Urological complications after kidney transplantation includes : Hemorrahge ,extraperitoneal urinary leak which usually occurs early post kidney transplantation and lymphocoele which usually occurs within 2-6 weeks after Kidney transplantation .Urinary leak is one of the early post transplant complications , incidence in studies from 1999 to 2000:1.5-6%, incidence is less in case of using Lich-Grégoir technique of construction of ureterovesical anastomosis. Occurs also in case of multiple renal arteries
Aims :
Aim :to illustrate clinical presentation , investigations and evidence based management differential diagnosis of urinary leak post kidney transplant through case presentation .
Presentation:
local :graft pain, tenderness, swelling over the graft)
+ systemic :fever, tachycardia, hypotension, and tachypnoea
Signs may be masked because of immunosuppression and analgesics.
+ high drain output.
It can come as:
Early extraperitoneal small leak : persistent low urine output through drains +low urine output, graft site swelling, and pain (imaging with contrast> urinoma.
late leak :1-2 wks after transplantation: caused by ureter necrosis or early removal of double J stent (<3-6 weeks)
Intra-abdominal leak>comes with acute abdomen.
DD: -Hemorrahge: hemorrhagic drain ,anemia, tachycardia) -Perinephricabscess: purulent drained fluid + fever and selling ,tenderness over the graft. -Urinaryfistula: especially in young recepients <10 yrs. Or received high dose steroids in induction , ureteral ischemia and necrosis. -Lymphoceleandseroma : 2 day- 5years after transplant + decrease urine output + increase serum creatinine + lower limb edema + iliac thrombosis. Investigations: 1- Compare urinary creatinine and potassium with serum creatinine and potassium. 2- Ultrasound US and Doppler to identify collection and perfusion 3- CT .MRI 4 -IV pyelogram 5- Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 :cannot be done in case of delayed graft function or uretral stasis 6- Retrograde cystography : to exclude bladder dehiscence. Evidence base management:
Maximum decompression :insert foley scatheter , uretral stent and nephrostomy
Once urinary leak stopped : foleyscatheter and nephrostomy can be removed but uretral stent kept for 4-6 weeks.
If infected collection ,uretral obstruction or extrinsic uretral compression>urgent percutaneous drainage
Surgical decompression and ureteral reimplantation if conservative measures fail. Outcomes of post transplant urinary leak : – Buggs et al, 2019:
increase rate of read missions, prolong hospitalization ,increase rate of delayed graft function and lower rate of graft survival. – Car also rt al, 2019:
Delayed graft survival ,prolong hospitalization – Pilot et al,2012:
Increase rate of delayed graft function, episodes of rejection, No impact on patient or graft survival.
Conclusion
1- High index of suspicion to identify post transplant urinary leak because of immunosuppression and analgesic masking of symptoms and signs 2- Lich-Grégoir technique has a significantly lower incidence of urinary leak age compared to the Politano-Lead better procedure. 3- Delicate dissection and implantation of ureter to preserve adventitia.
REFERENCES:-
Identifying Early Extra peritoneal High-Volume Urine Leak Post Kidney Transplantation,B Churchill et al, EMJ. 2021; DOI/10.33590/emj/20-00213.-Buggs Jet al. Repair of ureteral leaks post-kidney transplantation. Am Surg.2019; 85/8):e380-2.
Carvalho JA et al. Surgical complications in kidney transplantation: an overview ofa Portuguese reference center. Transplant Proc.2019;51(5):1590-6.
Pillot Pet al. Risk factors for surgical complications after renal transplantation and impact on patient and graft survival. Transplant Proc. 2012;44(9):2803-8.
Alaa eddin salamah
2 years ago
DDx of high urine leak includes:
1-
Hemorrhage
2- Urine
leak
3-
Lymphocele or Seroma
4- Urinary
Fistula
5-
Perinephric Abscess
Clinical Presentation
of Urine Leak
Variable
signs and symptoms may present in urine leak patients, they may overlap with
the other differential diagnosis and may be masked by the general condition of
the patient and the immunosuppressive medications; so, high index of suspicion
is needed together with the proper investigations to diagnose such cases. These
signs and symptoms, include:
•Local
symptoms like swelling and tenderness over the graft
•Systemic
manifestations including: tachycardia, fever, hypotension and tachypnea
•Increase
drain output with yellow urinary smelling fluid is the hallmark of urine leak
in these patients.
Some
preventive measures can be used to minimize the risk of urological
complications associated with urine leak, these measures include:
•Proper
ureter length to prevent kinking and allow water tight tension free anastomosis
•Fixation
of ureter to bladder wall
Fine dissection of ureter and proper handling to prevent necrosis and preserve periureteral tissue in the golden triangle
Several
investigations showed that patients’ with history of urine leak have prolonged
hospital stay, readmissions, delayed graft function and lower graft survival.
•Urological
complications are not uncommon post kidney transplantation
•High
index of suspicion is needed to detect these complications to preserve the
graft function
•Ultrasonography
is a non-invasive, bedside technique that help early diagnosis of such
complications
•Lich-Gregoir
procedure for ureteral reimplantation is associated with less risk of urinary
leak than Politano-Leadbetter
•Prevention
of the complications with proper surgical techniques is better than treatment
Evidence Level is V
Hamdy Hegazy
2 years ago
Urine leak can occur in 1.2-8.9% in early period of post renal transplantation.
Types of urine leak: low volume extra-peritoneal, high volume extra-peritoneal and intra-peritoneal.
Risk factors of urine leak: 1- Long ureter: increases the chance of kinking, and ischaemia. 2- Short ureter: leads to tense uretero-vesical anastomosis. 3- Ureteric damage during dissection. 4- Ligation or thrombosis of lower polar artery leading to proximal leak. 5- Bladder disorders like atrophic bladder or bladder dysfunction.
Diagnosis of urine leak: Urine leak usually presents clinically by: Fever, abdominal pain, graft tenderness, local swelling over the graft, urine leakage from the wound and hemodynamic instability. Clinical examination of drained fluid (colour and odour). Diagnostic aspiration of collected fluid and checking Creatinine and potassium level in the fluid. In case of urine collection, Creatinine and Potassium levels are very high compared to serum levels. Fluid should be sent fot culture to rule out infection and abscess formation. Imaging: using USS, CT or IV pyelogram and Focal tracer scintigraphy. Retrograde cystoscopy and antegrade pyelogram to identify site of leak. Differential Diagnosis: includes hematoma, seroma, lymphocele and perinephric abscess. Prevention of urine leak: 1- Ureteric stenting. 2- Technique of uretero-vesical anastomosis: Lisch-Gregoir is associated with lower incidence of complications. 3- Gentle dissection of donor ureter and preservation of peri-ureteral tissues in the golden triangle. Treatment of Urinary Leak: 1- Conservative measures: by urinary catheterization or percutaneous nephrostomy. 2- Antegrade or retrograde JJ stenting. 3- Surgical repair if high volume leak, needs resection andre-implanatation. What is the level of evidence provided by this article? Level V
Ahmed Omran
2 years ago
Urine leak following kidney transplantation is one of the early surgical complications with incidence range of 0.6-30 and can be manifested by abdominal pain, graft tenderness, fever, hypotension &increased drain flow of clear fluid,. USS evaluation early post-operative to assess the characteristics of collections which should be differentiated from hematoma, abscess, lymphocele, obstruction; and to proceed for biochemical analysis of the fluid for creatinine and potassium levels which can help to differentiate urine leak from lymphocele or hematoma.
Several predisposing factors are associated with increased risk of urine leak including black male recipients& type of surgical anastomosis.
Different surgical techniques were used for vesicoureteral anastomosis and as per evidence Lich–Grégoir, is better than Politano-Lead better,
and U-stitch techniques in order.
Low urine leak, usually treated with Foleys catheter insertion to relieve the pressure on the anastomosis site and to give chance for healing, if complicated with hydro nephrosis then nephrostomy and antegrade DJ stent insertion would be preferred if not previously done. The high-volume leak usually requires surgical intervention and reimplantation of the residual healthy tissue.
Level 5 narrative review
Dalia Ali
2 years ago
The clinical team is extremely vigilant in monitoring parameters that could indicate graft dysfunction, graft rejection, delayed graft function, post-operative complications, drug levels (especially tacrolimus or cyclosporine level), infection, and the general wellbeing of the kidney transplant recipient (KTR) and donor.
Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of these operations. Low-volume leaks may subside with conservative management and provided there is no distal obstruction. If not resolved, or if it is large-volume urine leak, surgical exploration and correction may be needed.
The most common surgical urology complications include urine leakage, ureteral obstruction, and lymphocele (fluid collection between the urinary bladder and the kidney allograft). The rates of urological complications range from 2.5% to 30.0% of all recipients.
Routine prophylactic intraoperative stenting of the ureter in kidney transplant recipients mitigates the effects of ureteric complications but does not reduce the incidence of these complications. The stents are generally well tolerated, but when longer stents are used (stent length: ≥20 cm), or if used for longer periods (>6 weeks), they may result in stent-related complications including infection, migration, and encrustation.
Signs and Symptoms
Varied symptoms can occur as a result of kidney transplant, including local (graft pain and tenderness, and local swelling over the graft)10 and systemic (fever, tachycardia, hypotension, and tachypnoea).10 Signs may be masked because of immunosuppression and analgesics. A high index of suspicion is warranted in a patient with high drain output
Investigations
Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
ultrasonography to identify and define the perinephric collection and dilatation of the pelvicalyceal system.
Doppler ultrasonography can be used to identify defects in perfusion.
CT or MRI scans are a useful tool to identify and define the perinephric collection and pelvicalyceal dilatation.
An intravenous pyelogram may be helpful to identify location of the leak.
Retrograde cystography helps clinicians to look for urinary bladder dehiscence.
Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak. This can be done in delayed graft function scenarios too. Pelvicalyceal dilatation makes it easier to do this procedure.
DIFFERENTIAL DIAGNOSIS AND CLINICAL REASONING
1-Hemorrhage
If the drain is haemorrhagic, with accompanying factors like tachycardia, anaemia, local swelling over the graft, or if bleeding is a possibility, ultrasonography, CT scan, or MRI may be used to identify haematoma, necessitating an emergency re-exploration.
2-Urinary Fistula
Urinary fistula occurs in 2–5% of kidney transplantations, and may lead to significant morbidity, graft loss, and mortality;30,31 there is an 8% risk of mortality associated with urinary f istula.30 Ureteral ischaemia and necrosis and technical problems associated with the transplant procedure are important causes of urinary fistula development
3-Perinephric Abscess
Perinephric abscesses are uncommon complications post kidney transplantation. They usually present in the early post-transplant period (in the first few week’s post-transplant). The causes include pyelonephritis, infection of lymphocele, haematoma, or urinoma. If the drained fluid is purulent, with accompanying symptoms and signs (fever, swelling, and tenderness over the graft), ultrasonography, CT scan, or MRI may aid the diagnosis of perinephric abscess.
4-Lymphocele and Seroma
A collection of lymph in the perigraft area is called a lymphocele. Lymphoceles occur in 1-20% of kidney transplant operations. Lymphocele may occur from as early as 2 weeks to as late as 5 years post-transplant. Usually they are small and asymptomatic, and such lymphoceles require no intervention.33 Lymphoceles may present with features of compression symptoms including retention of urine, decreased urine output, elevated serum creatinine, thrombosis of iliac vein, and limb oedema.
5-Urine Leak and Urinoma Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of cases.33 Urine leaks post kidney transplantation may manifest as free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma).
Different clinical presentations of urine leak
The different clinical presentations could be early extraperitoneal high-volume leak; early extraperitoneal small leak, defined by a persistent low urine output through drains, associated with low urine output, graft site swelling, and pain (imaging with contrast may help identify urinoma); late leak (1–2 weeks after kidney transplant), which may be caused by ureter necrosis or early removal of double J stent (<3–6 weeks); and intra-abdominal leak, which presents with an acute abdomen.
Evidence-based management plan in extraperitoneal urine leak
Low-volume leak at the anastomotic site can be managed conservatively by performing maximum decompression. Ante-grade pyelogram to identify the site of the leak is helpful. Placing a Foley catheter and ureteral stent performing a nephrostomy are the techniques used for decompression.Once the urine leak stops, the Foley catheter and nephrostomy tube can be removed; however, the ureteral stent is only removed after a period of 4–6 weeks. After conservative management, the patient is carefully followed-up. If the fluid collections become infected, or cause ureteral obstruction and extrinsic compression on the ureter, then urgent percutaneous drainage is required. Surgical re-exploration and reimplanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain
Preventive measures:
importance of the golden triangle Urine leak usually occurs because of technical errors in the ureteroneocystostomy technique, the method of graft ureter implantation in the recipient’s urinary bladder, or because of the transplanted ureter’s compromised vascularity, which is caused by vessel damage during the harvest of the donor kidney.Presence of multiple renal arteries is also a risk factor for development of urological complications post kidney transplantation.
An adequate periurethral tissue in the ‘golden triangle’ must be carefully preserved the ‘golden triangle’ is bound by the lower border of the junction between the renal vein and the inferior vena cava on the right, lower pole of the kidney on the left and the gonadal vein. Important factors that help to prevent major urological complications include delicate dissection of the ureter during donor nephrectomy to preserve adventitia; fat and blood supply of the ureter; short ureter length; and fixation of the adventitia, fat, and blood supply of the ureter to the bladder wall to prevent kinking or twisting.
Outcome of extraperitoneal urine leak: short-term and long-term effects on graft function and survival
Surgical complications can cause graft loss post kidney transplantation.Several studies have shown that urological complications post kidney transplant may lead to prolonged hospitalisation and reduced graft survival
conducted a retrospective cohort study of consecutive adult kidney transplant recipients and identified 36 cases of urine leak out of 1,308 cases. These investigators found that the patients with urine leak had a statistically significant longer length of hospital stay, more readmissions, more delayed graft function, and lower rates of graft survival. In another observational cross-sectional study of 3,102 kidney transplant patients, Carvalho et al. found that surgical complications occurred in 527 (17.0%) patients and urinary complications in 184 (5.9%). The most common complications observed were ureteral obstruction (in 85 patients; 2.7%) and urinary f istula (in 72 patients; 2.3%). They observed that surgical complications after kidney transplants lead to prolonged hospitalisation and decreased graft survival.
CONCLUSION
Different ureteroneocystostomy techniques, including the Lich-Grégoir, Politano–Leadbetter, and U-stitch techniques, have an impact on development of urine leak. The Lich-Grégoir technique has a significantly lower incidence of urinary leakage compared to the PolitanoLeadbetter procedure.
Technical errors in ureteroneocystostomy techniques or compromised vascularity of the transplanted ureter, caused by damage of the vessels during harvesting the donor kidney, are usually responsible for urine leak. Presence of multiple renal arteries is also a risk factor for development of urological complications post kidney transplantation.
A high index of suspicion is needed to identify the complications as the symptoms and signs may be masked because of the immunosuppressive drugs and the analgesics used. The colour of the drained fluid (haemorrhagic, clear, or purulent) and odour (uriniferous or foul) may indicate the development of a urological complication. If drain fluid is clear and the creatinine and potassium values are not much different from the serum values, then the possibilities of lymphocele or seroma are higher.
Extraperitoneal low-volume urine leak may be managed conservatively. Conservative management includes Foley catheterisation, nephrostomy, and placement of an antegrade ureteric stent. If conservative management fails, or if there is extraperitoneal high-volume leak, then surgical exploration and correction may become necessary. The ischaemic or necrosed part of the ureter needs to be removed, followed by reimplantation of the ureter. Development of urine leak may be associated with significant longer length of hospital stay, more readmissions, more delayed graft function, and lower rates of graft survival. If conservative management is used to manage the urine leak, prolonged followup may be necessary
level 5
Mu'taz Saleh
2 years ago
Introduction Most of post transplantation complication surgical and non surgical presented with approximately similar presentation , graft dysfunction could be rejection , vascular or urological complication . The first step in evaluating post renal transplantation graft dysfunction is to rule out surgical causes either vascular or urological causes before dealing with medical causes such as rejection , recurrence of primary disease .. Etc (5) In this poster we will discuss the common causes of urological complication
Causes : 1- Urinoma or urine leak : incidence 1.2 – 8.9%,may occurs early ( within 1st week ) or late ( 1-2 weeks after transplantation ) presented with urine output through drains , graft site swelling , pain and may associated with decrease urine out put (1) 2- Lymphocele and Seroma : incidence 1 – 20% , collection of lymph in the perigraft area , may occur early within 2 weeks or late up to 5 years . Most of time they are small size with no symptoms and in this case l require no intervention. (1) Some times present with compression symptoms such as urine retention, decreased urine output high creatinine level , venous thrombosis in iliac vein, and lower limb swelling (1) 3- Perinephric Abscess : uncommon , occurs early in the 1st few weeks , presented with systemic manifestation ( fever , malaise , general weakness ) and local signs ( swelling and pain over the graft associated with purulent discharge from the drain ) (1) 4- Hemorrhage : uncommon , risk factor including high BMI , antiplatelet, and anticoagulation usage . presented with bloody drainage , could be also associated with shok signs such as ( low BP , high HR ) , and pain in the site of surgery . (1) 5- Urinary Fistula : incidence 2–5% post kidney transplantation , and could cause significant morbidity, graft loss, and mortality . Caused by ureteral ischemia necrosis and technical problems . The risk factors associated with development of urinary fistula include younger recipient age (aged <10 years), uretero-ureteric anastomosis, use of high-dose steroids in immunosuppression, multiple renal arteries, and bladder problems (1)
Clinical Manifestation
• Urinoma can be present with different symptoms such as graft pain , tenderness and swelling . When the fluid become infected systemic symptoms may presents ( fever , tachycardia tachypnea and hypotension )
• Symptoms may be masked by immunosuppressant or analgesia
• So carful assessment is mandatory when high drain out put is present
•Our patient is day two post renal transplantation presented with sever pain , low grad fever , and increase extra peritoneal leak from the drain so on the top of the differentials is urinoma
•To differentiate between the previous causes : – Compare the level of creatinine and potassium in serum and drain fluid.
–imaging study ; ultrasonography , Doppler ultrasonography , CT or MRI scans , intravenous pyelogram , Focal tracer scintigraphy Retrograde cystography Antegrade pyelogram
Mangment
•Low-volume leak managed conservatively by performing maximum decompression
1.– Foley catheter : can be removed once urine leak stopped .
2.– Ureteral stent : removed after a period of 4–6 weeks .
3.– Nephrostomy : can be removed once urine leak stopped .
• When the fluid become infected or cause urethral obstruction and extrinsic compression urgent percutaneous drainage is required Re implantation of the transplanted ureter and other surgical intervention may be needed if conservative measures fail to mange small urine leak, or in case of high volume drain
Conclusion 1- Urological complications, post renal transplantation is not uncommon especially urine leaks and seroma . 2- The Lich-Gregoir ureteroneocystostomy technique and prophylactic DJ stenting (ureteral stenting ) , associated with decrease the incidence of urological complications. 3- Most of urological complication caused by excessive dissection of golden triangle ( confined by ureter , kidney and renal artery ) so injury to this triangle can cause ureter necrosis 3- The first line management of this complications is conservative management by urinary decompression. 4- If conservative management Failed, surgical intervention is may be needed required, especially in case of major leaks or necrosis in ureters. 5- despite urological complications associated with significant morbidity and mortality, its has an excellent prognosis if diagnosed early and treated in good way .
Summary
Urine leak after kidney transplantation is one of the early surgical complications with a variable incidence range of 0.6-30 and can be presented with abdominal pain, graft tenderness, fever, hypotension, and increased drain flow of more clear fluid, USS surveillance early post-operative to assess the nature of collections which need to be differentiated from hematoma, abscess, lymphocele, obstruction in addition to the biochemical analysis of the fluid for creatinine level and potassium which can further help to differentiate urine leak from lymphocele or hematoma
Many risk factors are associated with increased risk of urine leak including black male recipients, type of surgical anastomosis
Different surgical techniques were used for vesicoureteral anastomosis and as per evidence Lich–Grégoir, is better than Politano-Lead better,
and U-stitch techniques
Low urine leak, usually managed by Foleys catheter insertion to relieve the pressure on the anastomosis site and allowed for healing, if it’s complicated with hydronephrosis then nephrostomy and antegrade DJ stent insertion would be preferred if not done before. The high-volume leak usually needs surgical intervention and reimplantation of the remaining healthy tissue
What is the level of evidence provided by this article?
Level 5 narrative review
Mohammed Sobair
2 years ago
INTRODUCTION:
Urine leak is an early post-operative complication after kidney transplantation and occurs
in 1.2–8.9%.
This article discusses the identification of extra peritoneal urinary leak in a KTR in the
post-operative period, as well as the clinical clues.
URETEROVESICAL ANASTOMOSIS AND A COMPARISON OF ASSOCIATED
COMPLICATIONS:
The most popular methods include the Lich–Grégoir, Politano-Leadbetter, and U-stitch
techniques.
Meta-analyses performed by Alberts et al. showed that the Lich–Grégoir technique is
significantly associated with a lower incidence of urinary leakage compared to the
Politano-Leadbetter technique.
UROLOGICAL COMPLICATIONS DURING THE POST-OPERATIVE PERIOD IN
KIDNEY TRANSPLANT RECIPIENTS:
Common surgical urology complications include urine leakage, ureteral obstruction, and
lymphocele.
Long ureter is liable to kinking and obstruction.
Atrophic bladder or dysfunctional bladder.
Proximal calyceal leak may occur because of lower pole artery complications
(thrombosed, ligated, not reconstructed).
Damage to the ureter during dissection may result in ureteric ischemia, necrosis, and
distal leak.
Signs and Symptoms:
Local (graft pain and tenderness, and local swelling over the graft)
Systemic (fever, tachycardia, hypotension, and tachypnea).
Investigation:
Compare drain creatinine and potassium levels with serum creatinine and potassium
levels.
Use ultrasonography.
Doppler ultrasonography.
CT or MRI.
An intravenous pyelogram
.
Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the
location of the leak.
Retrograde cystography
Ante grade pyelogram.
DIFFERENTIAL DIAGNOSIS:
1-Haemorrhage.
2-Urinary Fistula.
3-Perinephric Abscess.
4-Lymphocele and Seroma.
Urine Leak and Urinoma:
Urine leak occurs early in 1.2–8.9% of cases.
Urine leaks post kidney transplantation may manifest:
As free fluid (urine ascites),
Extravasation in local tissues,
Or may be encapsulated (urinoma).
Different clinical presentations of urine leak:
Early:
Extra peritoneal high-volume leak.
Extra peritoneal small leak, defined by a persistent low urine output through drains,
associated with low urine output, graft site swelling, and pain.
Late leak (1–2 weeks after kidney transplant), which may be caused by ureter necrosis
or early removal of double J stent.
Evidence-based management plan in extra peritoneal urine leak:
Managed conservatively:
Low-volume leak at the anastomotic site can be by performing maximum
decompression.
Placing a Foley catheter and ureteral stent performing a nephrostomy are the
techniques used for decompression.
Percutaneous drainage:
if the fluid collections become infected, or cause ureteral obstruction and extrinsic
compression on the ureter, then urgent percutaneous drainage is required.
Surgical re-exploration and reimplanting the transplant ureter becomes necessary if
conservative measures for stopping low-volume urine leak fail, or if there is a high-
volume drain.
Preventive measures: importance of the golden triangle:
Per urethral tissue in the ‘golden triangle’ must be carefully preserved.
Outcome of extra peritoneal urine leak:
Short-term and long-term effects on graft function and survival surgical complications
can cause graft loss post kidney transplantation.
CONCLUSION:
Different ureteroneocystostomy techniques, including the Lich-Grégoir, Politano–
Leadbetter, and U-stitch techniques, have an impact on development of urine leak.
The Lich-Grégoir technique has a significantly lower incidence of urinary leakage
compared to the Politano– Leadbetter procedure.
What is the level of evidence provided by this article?
level of evidence V.
Asmaa Khudhur
2 years ago
Please summarise this article
Identifying Early Extraperitoneal High-Volume Urine Leak Post Kidney Transplantation Introduction :
Parameters indicate graft function,graft rejection ,DGF,post-operative complications,drug levels,infection must be monitored carefully by transplant team .
Urine leak occurs early in 1.2-8.9% of operations .
It’s either low-volume or large -volume leak.
URETEROVESICAL ANASTOMOSIS technique:
Lich-Gregoir technique associated with lower incidence of urinary leakage . Also fewer incidence of hematuria , with fewer urological complications than the other two techniques.
Politano-leadbetter technique.
U-stitch technique.
Whichever technique are used , it must be tension-free and protected by at least 1 cm submucosal tunnel.
UROLOGICAL COMPLICATIONS DURING THE POST-OPERATIVE PERIOD IN KIDNEY TRANSPLANT RECIPIENTS
1-urine leakage
2-ureteral obstruction
3-lymphocele
4-long ureter liable to kinking or obstruction.
5-short ureter not appropriate for achieving tension-free anastomosis.
6-bladder perforation or anastomoses dehiscence in case of bladder dysfunction in the recipients.
7-lower pole artery complications.
8-ureteric ischemia, necrosis and distal leak after damage to ureter during dissection.
Signs and Symptoms
Symptoms
Local :
graft pain , tenderness,local swelling over graft
Systemic :
Fever, tachycardia, hypotension and tachypnoea .
Signs masked by immunosuppressant and analgesics.
Investigations:
1-Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
2-Use ultrasonography to identify any collections and dilatation of pcs.
3-Doppler ultrasonography can be used to identify defects in perfusion.
4-CT or MRI scans are a useful tool to identify and define the perinephric collection and pelvicalyceal dilatation.
5-An intravenous pyelogram may be helpful to identify location of the leak.
6-Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak.
7-Retrograde cystography helps clinicians to look for urinary bladder dehiscence.
8-Antegrade pyelogram testing through
a nephrostomy may accurately identify
the location of the leak.
DIFFERENTIAL DIAGNOSIS AND CLINICAL REASONING
Haemorrhage
It is not a common complication after KT . Risk factors include: recipient obesity, use of antiplatelat agents , and anticoagulation .
It occurs when the drain is haemorrhagic associated with tachycardia , anemia , local swelling over the graft.
Diagnosed by US , CT scan or MRI .
Urinary Fistula
Occur in 2-5%, can lead to morbidity, mortality and graft loss.
Caused by ureteral ischemia and necrosis, technical problems.
Risk factors include younger recipient age and uretero-ureteric anastomoses, use of high dose steroid or IS, bladder problems and number of renal arteries.
Perinephric Abscess:
Uncommon complications, occur early post transplantation.
Causes include pyelonephritis , infection of lymphocele ,haematoma , urinoma.
Diagnosed by US , CT , or MRI.
Aspiration and doing microscopy and culture may help the diagnosis.
Lymphocele and Seroma:
Occurs in 1-20% of KT.from as early as 2 weeks to 5 years post transplant.
Present with features of compression. Occurs because of technical failures or use of sirolimus.
The fluid is clear . Diagnosed by US ,CT scan and MRI, and fluid biochemistry.treatment options include aspiration, percutaneaus drainage , laparoscopic drainage or open marsupialisation.
Urine Leak and Urinoma:
Occurs early , in 1.2-8.9% of cases. It’s either free fluid, extravasating in local tissues or encapsulated (urinoma).
Evidence-based management plan in extraperitoneal urine leak:
Conservative treatment for low-volume leak by maximum decompression.foley catheter and ureteral stent performing a nephrostomy used for decompression. Surgical re-exploration is necessary if conservative measures fail or if there is high-volume drain .
Preventive measures: importance of the golden triangle:
gentle handling of the ureter at the time of ureteral dissection is crucial to prevent urine leak post kidney transplantation. An adequate periurethral tissue in the ‘golden triangle’ must be carefully preserved.
Outcome of extraperitoneal urine leak: short-term and long-term effects on graft function and survival:
Graft loss , prolonged hospitalization, reduced graft function , ureteral obstruction, urinary fistula.
What is the level of evidence provided by this article?
Level V
Wael Jebur
2 years ago
Urine leak Post kidney transplantation:
Its the most common surgical complication, that might arise early 1-2 days, or later, after 7 days.
Early urine leaking is predominantly secondary to surgical defaults, like suture breakdown. late urine leak is usually due to ischemic necrosis of the the ureter. Early Urine Leak:
3 types of ureterovesical anastomosis are commonly implicated in kidney transplantation.
The most commonly associated with urine leak is U stitch.
Ureteric stent insertion:
Ureteric stent falter severity of post operative surgical complications, however, its falling short of preventing it.
Complications linked to stent usage:
1) When stent is linger than 20 cm..
2) Keeping stent for more than 6 weeks.
It might be resultant in migration, infection and encrustation. Conditions predisposed to surgical complications:
1) Long ureter, as its liable to kinking and obstruction and lower segment ischemia, owing to jeopardized blood supply coming from peri-ureteric tissues.
2)Short ureter: might demonstrate tension suturing uretero-cystostomy.
3) Bladder dysfunction, bearing risk of perforation and suture delicenses.
4)lower calyceal leak , predisposed to by trauma or ligation of lower pole artery.
5) dissection’s of ureter . High drain output:
Post operatively, increased fluid draining ,is come encounter. Which could be urine leak, hemorrhage, serum, lymph and pus based on nature of fluid and time of onset post operatively.
In order to ascertain nature of drained fluid, in addition to its apparent appearance and circumstance’s. thereof, Simultaneous analysis of drained fluid and serum for potassium and creatinine would give a major clue on its nature.
US study would differentiate between abscess and urinoma as its featuring hypoechoic vs hyperechoic cystic lesion.
Isotope scan is crucial in reflecting the site, extent and vastness of urine leak.
CT and MRI are helpful in identifying the extent of the collection.
Retrograde cystography is implied to show urine leak site.
Antegrade pyelo-uretero-cystogrm is modality of choice to diagnose the ureteric leak. Treatment:
maximum decompression of urinary system is the key to overcome urine leak, with nephrostomy, urethral catheter and antegrade ureteric stent.
High volume and failure of conservative measures is an indication for surgical exploration.
CARLOS TADEU LEONIDIO
2 years ago
Please summarise this article
The rates of urological complications range from 2.5% to 30.0% of all recipients, so the post-transplant period is quite critical. Regarding surgery, the main possible complications are: haemorrhage, extraperitoneal urine leak, and lymphocele, the first two being related to the most recent postoperative period and lymphocele usually present 2–6 weeks after transplantation. This paper discusses how to identify high-volume extraperitoneal urine leaks in the early post kidney transplant period and considers the differential diagnoses. The rates of urological complications range from 2.5% to 30.0% of all recipients. Other urologic complications include:
– Complications caused by the length of the transplanted ureter.
– Atrophic bladder or dysfunctional bladder in the recipient may result in bladder perforation or anastomotic dehiscence
– Proximal calyceal leak
– Damage to the ureter during dissection may result in ureteric ischaemia, necrosis, and distal leak
In kidney transplant there’s some techniques of ureterovesical anastomosis, but three are most important: Lich–Grégoir, Politano-Leadbetter, and U-stitch. The investigators concluded that the Lich-Grégoir technique results in fewer urological complications than the other two.
Varied symptoms can occur as a result of kidney transplant, including local (graft pain and tenderness, and local swelling over the graft) and systemic (fever, tachycardia, hypotension, and tachypnoea). For investigation, we can count on several tests:
– Compare drain creatinine and potassium levels with serum creatinine and potassium levels
– Use ultrasonography to identify and define the perinephric collection and dilatation of the pelvicalyceal system
– Doppler ultrasonography can be used to identify defects in perfusion
– CT or MRI scans are a useful tool to identify and define the perinephric collection and pelvicalyceal dilatation
– An intravenous pyelogram may be helpful to identify location of the leak
– Retrograde cystography helps clinicians to look for urinary bladder dehiscence
– Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak
URINE LEAK
Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of these operations. Low-volume leaks may subside with conservative management and provided there is no distal obstruction, may manifest as free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma).
The different clinical presentations could be:
– Early extraperitoneal high-volume leak;
– Early extraperitoneal small leak, defined by a persistent low urine output through drains, associated with low urine output, graft site swelling, and pain (imaging with contrast may help identify urinoma);
– Late leak (1–2 weeks after kidney transplant), which may be caused by ureter necrosis or early removal of double J stent (< 3-6 weeks);
– Intra-abdominal leak, which presents with an acute abdomen
Low-volume leak at the anastomotic site can be managed conservatively with Foley catheterisation, nephrostomy, and placement of an antegrade ureteric stent. If the fluid collections become infected, or cause ureteral obstruction and extrinsic compression on the ureter, then urgent percutaneous drainage is required. Once the urine leak stops, the Foley catheter and nephrostomy tube can be removed; however, the ureteral stent is only removed after a period of 4–6 weeks. If conservative management fails, or if there is extraperitoneal high-volume leak, then surgical exploration and correction may become necessary
DIFERENTIAL DIAGNOSIS
– Haemorrage: it is not a common complication for kidney transplantation, because bleeding usually stops spontaneously. If there is tachycardia, anemia, local swelling over the graft, ultrasonography, CT scan, or MRI are necessary to rule out haemorrage. And if confirmed, emergency surgical intervention.
– Urinary fistula: occurs in 2–5% of kidney transplantations, and may lead to significant morbidity, graft loss, and mortality. Ureteral ischaemia and necrosis and technical problems associated with the transplant procedure are important causes of urinary fistula development. Urinary fistulas may be managed by different techniques including ureteral ligature and nephrostomy, ureteroureterostomy, pyeloureterostomy, ureteroneocystostomy, percutaneous nephrostomy and ureteral stenting, and prolonged vesical drainage
– Perinephric abscesso: uncommon complications post kidney transplantation. If the drained fluid is purulent, with accompanying symptoms and signs (fever, swelling, and tenderness over the graft), ultrasonography, CT scan, or MRI may aid the diagnosis of perinephric abscesso.
– Lymphocele and Seroma: A collection of lymph in the perigraft area is called a lymphocele and occur in 1-20% of kidney transplant operations, from as early as 2 weeks to as late as 5 years post-transplant, your drainage fluid is clear. Ultrasonography, CT scan, or MRI, and fluid biochemistry further aid diagnosis. If drain fluid creatinine and potassium values are not much different from the serum values, then the possibilities of lymphocele or seroma are higher. Treatment options include aspiration (nearly 100% chances of recurrence), percutaneous drainage (50% success rate), drainage by laparoscopic method, or open marsupialisation.
What is the level of evidence provided by this article?
Your evidence is level 05.
Manal Malik
2 years ago
IDENTIFYING EARLY EXTRAPERITONEAL HIGH-VOLUME URINE LEAK POST KIDNEY TRANSPLANTATIONIntroduction:
Urine leak is an early postoperative complication after kidney transplantation and occurs in 1.2-8.9% of these operations.
This article discusses the identification of extraperitoneal urinary leaks in kidney transplantation in the post-operative period and rules out another differential diagnosis.
Ureterovesical anastomosis and a comparison of associated complications
Meta-analysis performed by Alberts et al showed that the lich-Gregior tech requirement is significantly associated with a lower incidence of urinary leakage compared to the politeam needs a better technique to prevent reflux during voiding the ureterovesical anastomosis must be tension free and protected by at least a 1cm submucosal tunnel.
Initial management is a urethral catheter as well as nephrostomy or placing a retrograde ureteric stent
The drain is left in situ
If all fail surgical exploration to reimplant the transplant ureter
Other surgical complications include:
· Kicking and obstruction of the ureter.
· Atrophic bladder results in perforation or anastomotic dehiscence
· Proximal calyceal leak
· Damage to the ureter during dissection may result in ureteric ischemia, necrosis, and distal leak
Symptoms and signs:
Local graft pain or swelling
Systematic symptoms such as fever and tachycardia
Signs masked because of immunosuppression investigation
The following testing can poleat differential diagnosis
Drain creatinine and potassium levels, compared with serum creatinine and potassium levels.
Ultrasonography doppler ultrasonography to detect any defect in perfusion
CT or MRI scans are useful tools to identify perinephric collection and pelvicalyceal dilatation.
An intravenous pyelogram detects the location of the leak.
Focal tracer scintigraphy (==) technetium 99 identifies the location of the leak
Retrograde cystography for urinary bladder dehiscence.
Anterograde pyelogram in delayed graft function to identify the location of the leak.
Identifying extra-peritoneal urine leak post kidney transplantation.
A high volume of clear drain fluid may indicate possible extra-peritoneal
Ultrasonography, CT scan or MRI, and fluid biochemistry aid the diagnosis, and urinoma can be diagnosed by U/S and nuclear scan.
Differential diagnosis:
v Haemorrhage:
Drain is hemorrhagically associated with tachycardia and anaemia.
CT, and MRI will identify hematoma and emergency exploration
v Urinary fistula:
Occur in 2-5% of kidney transplantation. Important cause is ischemia and necrosis
Technical problems
Risk factors:
v Perinephric abscess:
Uncommon complication
The cause is pyelonephritis, infection of lymphocele, hematoma or urinoma
Drain fluid is purulent with signs of infection
Ultrasonography, CT, and MRI aid in the diagnosis
Confirm the diagnosis by aspiration of the collection and performing microscopic culture of the aspirate may help in the diagnosis.
v Lymphocele and seroma:
Occur in 1-20% of the kidney transplant operation
Occur from 2 weeks up to 5 years post-transplant
Prevent by causing symptoms
Drain fluid clear
Diagnosis by ultrasonography
CT or MRI treatment
Aspiration: percutaneous drainage
Drainage by laparoscopic drainage of lymphocele.
v Urine leak and urinoma:
Occur in 1.2-8.9% of cases
Clinical presentation of urine leak:
Early extraperitoneal high-volume leak with low urine output
Late leak 1-2 weeks present with acute abdomen
Management of urine leak: maximum decompression by placing a foley catheter and urethral stent and nephrostomy
If fluid collection becomes infected or causes obstruction urgent placement as drainage is required
Surgical exploration and reimplantation of the transplant ureter if conservative increase fluid or high volume drain.
Prevention measures:
During having resting of the donor kidney gentle handling of the ureter at the time of urethral dissection to prevent urine leak post-kidney transplantation
Peri-urethral tissue in the golden triangle must be carefully preserved.
The outcome of an extraperitoneal leak
Surgical complications can cause graft loss post-kidney and also can lead to prolonged hospitalization and reduced graft survival.
Conclusion:
Different level cystotomy techniques including the Lich-Gregoir, Politano-lead better, and – stitch techniques have an impact on the development of urine leak
The Lich-Gregoir technique has a significantly low incidence of urinary leakage compared to the Politano lead better procedure.
evidence is level 5
rindhabibgmail-com
2 years ago
In this article it was discussed to identify the post operative complication post-transplantation. the most common complications included urinary leak, ureteral obstruction, lymphocele, stent related complication, ureteric ischemia, bladder complication.
These complication can be diagnosed by fluid color, sonography, fluid and blood sample comparison.
Small leak can be managed by just observation, if not settled then can be managed surgically.
Hinda Hassan
2 years ago
1. Please summarise this article
There are many surgical complications that can occur in the early post-transplant period. These include haemorrhage, extraperitoneal urine leak, lymphocele, ureter kinking and obstruction, bladder perforation or anastomotic dehiscence , proximal calyceal leak , ureteric ischaemia, necrosis, and distal leak.
Symptoms of urine leakage are fever, pain over the graft, and fluid leakage from the wound. These could be masked due to immunosuppression and analgesics which would necessitate high index of suspicion espically in patient with high drain output. Management is through decompression of the urinary system through leaving the drain and inserting a urethral catheter, nephrostomy tube or placing an antegrade ureteric stent. If no improvement with all these or the drain is of large amount, then surgical exploration is needed to reimplant the transplant ureter.
Investigations include comparing the creatinine and potassium components of the serum and the drain.
Ultrasound, CT or MRI will help in detection of perinephric collection and pelvicalyceal system dilatation. Other imaging modalities include intravenous pyelogram, scintigraphy, retrograde cystography and antegrade pyelogram.
If the creatinine and potassium contents of the drain fluid are similar to the serum values, then the possibilities of lymphocele or seroma are higher. otherwise it is a urine leak or urinoma.
Differential diagnoses include:
Haemorrhage If the drain is bloody and is associated with Hb drop in patients with bleeding risk. This can be assessed by ultrasonography, CT scan, or MRI.
Urinary Fistula due to ureteral ischaemia and necrosis or procedure technical problems are commoner in recipientaged <10 years, uretero-ureteric anastomosis, use of high-dose steroids, number of renal arteries and bladder problems.
Perinephric abscesses due to pyelonephritis, infection of lymphocele, haematoma, or urinoma. This is suspected when the drain is purulent in the presence of fever, swelling, and tenderness over the graft.
Lymphocele may present with features of compression symptoms including retention of urine, decreased urine output, elevated serum creatinine, thrombosis of iliac vein, and limb oedema. What is the level of evidence provided by this article? 5
Abdullah Raoof
2 years ago
Q1- Please summarise this article
Abstract
The common post transplant surgical complications are hematoma , extraperitoneal urine leak –urinoma , and lymphocele. The first two develp early in postoperative period but the last one ( lymphocele ) may occur from 14 – 42 day post op . Although not diagnostic the volme and colour of the drain may give us an idea about the underlying cause . biochemical analysis of the drained fluid is helpful .
Multiple ureteroneocystostomy procedures available , including the Lich–Grégoir , Politano–Leadbetter , and U-stitch techniques, with different complication rate regarding urinoma and hematuria .
INTRODUCTION
Post operatively patient should be monitored for graft dysfunction, graft rejection, delayed graft function, post-operative complications, drug levels infection, and the general wellbeing.
Urine leak is ocur in 1.2–8.9% of patients in the early post operative period. Low volume leake can be treated conservatively while the large volume one may need exploration . URETEROVESICAL ANASTOMOSIS AND A COMPARISON OF ASSOCIATED COMPLICATIONS.
There is three most common technique for uretrovesical anastomosis Lich–Grégoir, Politano Leadbetter, and U-stitch techniques. Meta-analyses performed by Alberts et al. showed that the
Lich–Grégoir technique is significantly associated with a lower incidence of urinary leakage and hematuria compared to the two other technique .
Whichever technique is used, the anastomosis must be tension-free and at least a 1 cm submucosal tunnel .
UROLOGICAL COMPLICATIONS DURING THE POST-OPERATIVE PERIOD IN KIDNEY TRANSPLANT RECIPIENTS
The most common surgical complications post operatively are urine leakage, ureteral obstruction, and lymphocele which is occur in 2.5% to 30.0% of patients.
Clinically present as a fever, graft pain , and fluid leakage from the wound.
Routine prophylactic intraoperative ureter stenting mitigates but does not reduce the incidence of these complications.
The stents are generally well tolerated, but complication occur when long length: ≥20 cm , or longer periods (>6 weeks), is used . the complications including infection, migration, and encrustation.
The management include decompression of the urinary system by inserting a urethral catheter, nephrostomy or placing an antegrade ureteric stent. The drain is left in situ.
If no response or if large-volume extravasation occurs, surgical exploration to reimplant the ureter.
Other urological complications include:9,10
1) Complications caused by the length of the transplanted ureter.
a. A long ureter – kinking and obstruction and ischaemia .
2) A short ureter may not be appropriate for achieving tension-free anastomosis.
3) Atrophic bladder or dysfunctional bladder : bladder perforation or anastomotic dehiscence.
4) Proximal calyceal leak may occur because of lower pole artery complications (thrombosed, ligated, not reconstructed).
5) Damage to the ureter – ureteric ischaemia, necrosis, and distal leak.
The underlying cause can be expected by drain fluid colour (clear, haemorrhagic, or purulent) and
odour (uriniferous or foul) . Signs and Symptoms
symptoms may including local (graft pain and tenderness, and local swelling over the graft)
and systemic (fever, tachycardia, hypotension, and tachypnoea). Although these Signs may be masked by immunosuppression and analgesics. high drain output is alarming sign.
Investigations
For extraperitoneal urine leak
1) Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
2) ultrasonography for perinephric collection and dilatation of the pelvicalyceal system.
3) Doppler ultrasonography to detect perfusion defect .
4) CT or MRI scans for perinephric collection and pelvicalyceal dilatation.
5) An intravenous pyelogram to localize the leak .
6) Focal tracer scintigraphy to localize the leak .
7) Retrograde cystography – for urinary bladder dehiscence.
8) Antegrade pyelogram through a nephrostomy for localization of the leak.
Identifying Extraperitoneal Urine Leak Post Kidney Transplantation
A high volume of clear drain fluid may indicate the possibility of extraperitoneal urine leak.
Ultrasonography, CT scan or MRI, and fluid biochemistry .
If drain fluid creatinine and potassium values are similar to the serum values, then the diagnosis is lymphocele or seroma . but if they are significantly higher than the serum values, or are values that are incompatible with life, then it
is a urine leak or urinoma.
DIFFERENTIAL DIAGNOSIS AND
CLINICAL REASONING
Haemorrhage
Is suspected If the drain is haemorrhagic, with tachycardia, anaemia, local swelling over the graft, or if bleeding is a possibility, ultrasonography, CT scan, or MRI may be used to identify haematoma, treated by emergency re-exploration.
The risk factors include recipient obesity, use of antiplatelet agents, and anticoagulation.
Other features a falling haematocrit level bu serial measures , hypotension, tachycardia, and pain in the flank or lower quadrant.
Surgical exploration is usually not required unless the needs pure red blood cell transfusion repeatedly, or if there is haemodynamic instability or compression of the kidney by haematoma.
Urinary Fistula
occurs in 2–5% of kidney transplantations, associated with significant morbidity, graft loss, and mortality of 8% .
causes : Ureteral ischaemia and necrosis and technical problems associated with the procedure .
Risk factors include :
· (aged <10 years),
· uretero-uretericanastomosis,
· use of high-dose steroids in immunosuppression,
· number of renal arteries,
· bladder problems.
·
Early management is important which include :
· Ureteral ligature and nephrostomy,
· ureteroureterostomy,
· pyeloureterostomy,
· ureteroneocystostomy,
· percutaneous nephrostomy and ureteral stenting,
· prolonged vesical drainage.
Perinephric Abscess
It is uncommon complications. It is occur within early few post operative weeks .
Caused by pyelonephritis, infection of lymphocele, haematoma, or urinoma.
Presented as : drained fluid is purulent, fever, swelling, and tenderness over the graft .
diagnosis : ultrasonography, CT scan, or MRI. Aspiration for microscopy and culture .
Lymphocele and Seroma
Is collection of lymph in the perigraft area occurring in 1-20% of operation. Can occur from 14 days to years after transplantation .
clinical features include retention of urine, reduced urine output, graft , thrombosis of iliac vein, and limb oedema.
sirolimus use is a risk factor . the aspirate is a clear fluid .
diagnosis : Ultrasonography, CT scan, or MRI, and fluid creatinine and potassium which are should be similar to that of serum .
Treatment
1. aspiration with very high recurrence rate .
2. percutaneous drainage ( half of them recurs ),
3. laparoscopic technique . is treatment of choice
4. open marsupialisation. Preferred if there is wound complication of small collection near vital structures .
if it is continued , sclerosants like povidone iodine, fibrin glue, and doxycycline, tetracycline, ethanol, bleomycin. Periureteral fibrosis is a risk factor .
Urine Leak and Urinoma
It is an early post operative complication occurring in 1.2-8.9% of transplantation . It present as free fluid (urine ascites), extravasation in local tissues, or encapsulated (urinoma).
Different clinical presentations of
urine leak
The different clinical presentations could be
· early extraperitoneal high-volume leak;
· early extraperitoneal small leak, characterized by a continuous small urine output through drains, low urine output, graft site swelling, and pain diagnosed by contrast imaging
· late leak occuring 7-14 days post op. caused by ureter necrosis or early stent removal (<3–6 weeks).
· intra-abdominal leak, usually manifested as acute abdomen.
Evidence-based management plan in extraperitoneal urine leak
Low-volume leak treated conservatively by maximum decompression which can be achieved by Foley catheter , ureteral stent , and a nephrostomy. Diagnosed by Antegrade pyelogram.
With improvement when the leak is stoped above measures can be removed but the uretric stent should be kept for 3-6 weeks .
Percutaneous drainage is indicated in case of infection ,obstruction by extrinsic uretric compression .
Surgical re-exploration and reimplanting is indicated in case of failure of conservative treatment or if there is a high volume drain.
Outcome of extraperitoneal urine leak: short-term and long-term effects on graft function and survival
Post op Surgical complications can increase hospital stay increase graft loss.
In astudy by Buggs et al. found that urine leak associated with prolonged hospitalization , high rate of readmission, delayed graft function , reduced graft survival .
another study by Carvalho et al. overall complications are (17.0%) but urinary complications (5.9%).
ureteral obstruction was present in 2.7%( the most common ) and urinary fistula (in 2.3%). These complication causes increased hospital stay , and reduces graft survival .
Q2- What is the level of evidence provided by this article?
Level v
MICHAEL Farag
2 years ago
What is the level of evidence provided by this article?
Level V
Introduction
Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of these operations. This article discusses the identification of extraperitoneal urinary leak
in a KTR in the post-operative period, as well as the clinical clues that help to rule out the differential diagnoses.
The impact of ureterovesical anastomosis on the outcome
Meta-analyses performed by Alberts et al.2 showed that the Lich–Grégoir technique is significantly associated with a lower incidence of urinary leakage compared to the Politano-Leadbetter technique.Whichever technique is used, in order to prevent reflux during
voiding, the ureterovesical anastomosis must be tension-free and protected by at least a 1 cm
submucosal tunnel
Urological complications during the post-operative period in kidney transplant recipients
The most common surgical urology complications include urine leakage, ureteral obstruction,
and lymphocele (fluid collection between the urinary bladder and the kidney allograft)
Routine prophylactic intraoperative stenting of the ureter in kidney transplant recipients
mitigates the effects of ureteric complications but does not reduce the incidence of these
complications.The stents are generally well tolerated, but when longer stents are used (stent
length: ≥20 cm), or if used for longer periods (>6 weeks), they may result in stent-related complications including infection, migration, and encrustation.
The initial step in urine leak management is to maximally decompress the urinary system. This is achieved by inserting a urethral catheter, as well as performing a nephrostomy or placing an antegrade ureteric stent. The drain is left in situ. If this technique fails, or if large-volume extravasation occurs, surgical exploration to reimplant the transplant ureter becomes necessary.
Other urological complications include:
– A long ureter is liable to kinking and obstruction as a result of ischaemia because the vascularity of the transplant ureter depends on renal vessels supplying through periureteric tissue, unlike the native ureter which has a segmental blood supply.
– A short ureter may not be appropriate for achieving tension-free anastomosis.
– Atrophic bladder or dysfunctional bladder in the recipient may result in bladder perforation or anastomotic dehiscence.
– Proximal calyceal leak may occur because of lower pole artery complications (thrombosed, ligated, not reconstructed).
– Damage to the ureter during dissection may result in ureteric ischaemia, necrosis, and
distal leak.
Investigations extraperitoneal urine leak post kidney transplantation
– Compare drain creatinine and potassium levels with serum creatinine and potassium levels. – Use ultrasonography to identify and define the perinephric collection and dilatation of the
pelvicalyceal system. – Doppler ultrasonography can be used to identify defects in perfusion. – CT or MRI scans are a useful tool to identify and define the perinephric collection and
pelvicalyceal dilatation. – An intravenous pyelogram may be helpful to identify location of the leak. – Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak. This technique is not useful if there is delayed graft function
or ureteral stasis. – Retrograde cystography helps clinicians to look for urinary bladder dehiscence. – Antegrade pyelogram testing through a nephrostomy may accurately identify
the location of the leak. This can be done in delayed graft function scenarios too.
Evidence-based management plan in extraperitoneal urine leak
– Low-volume leak at the anastomotic site can be managed conservatively by performing maximum decompression
– Antegrade pyelogram to identify the site of the leak is helpful.
– Placing a Foley catheter and ureteral stent performing a nephrostomy are the techniques used for decompression.
– Surgical re-exploration and reimplanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain
Jamila Elamouri
2 years ago
Summary:
Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9%. Low-volume leaks may subside with conservative management if no distal obstruction present. If not resolved, or if it is large-volume surgical exploration and correction may be needed. Ureterovesical anastomosis and a comparison of associated complications:
Techniques used for ureterovesical anastomosis in kidney transplantation are many and the most popular methods are the Lich-Gregoir, Politano-Leadbetter, and U-stitch techniques. Lich-Gregoir technique is significantly associated with a lower incidence of urinary leakage and haematuria as compared with other techniques. Whatever the technique used, the anastomosis must be tension-free and protected by at least a 1 cm submucosal tunnel. Urological complications during the post-operative period in kidney transplant recipients: 1- Urine leakage 2- Ureteral obstruction 3- Lymphocele.
The rate of urological complications is about 2.5% to 30%
Urinary leakage, the patient may have fever, pain over the graft, and fluid leakage from the wound.
Routine prophylactic intraoperative stenting of the ureter reduces the effect of ureteric complications but not the incidence. If used for long period, it can cause infection, migration, and encrustation.
Management of urinary leakage:
1- Decompress the urinary system is the first, most important step. Done by urethral catheter insertion and nephrostomy or replacing an antegrade ureteric stent. The drain is left in situ.
2- Surgical exploration to reimplant the transplant ureter in case of large volume extravasation or fails of the other techniques.
4- Longer ureter leads to Kinking and obstruction as a result of ischemia 5- Atrophic bladder or dysfunctional bladder in the recipient may result in bladder perforation or anastomotic dehiscence. 6- Proximal calyceal leak may occur because of lower pole artery complications (thrombosed, ligated, not reconstructed) 7- Damage to the ureter during dissection may result in ureteric ischemia, necrosis, and distal leak. Drained fluid colour and odour can identify the type of complication. Signs and symptoms:
Graft pain and tenderness
Local swelling over the graft
Systemic symptoms as fever, tachycardia, hypotension, and tachycardia.
High index of suspicion is warranted in patient with high drain output. Investigations
1- Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
2- Use ultrasonography.
3- Doppler ultrasonography.
4- CT or MRI scans.
5- An intravenous pyelogram may be helpful to identify location of the leak.
6- Focal tracer scintigraphy (mercaptoacetyltriglycine or technetium 99)
7- Retrograde cystography (diagnose urinary bladder dehiscence).
8- Antegrade pyelogram through nephrostomy. Identifying extraperitoneal urine leake post kidney transplantation.
High volume clear drain should rise the suspicion of urine leak. If the creatinine and potassium levels are similar in the drain fluid to that of the serum, then the collection is most likely lymphocele or seroma. While if the values are significantly higher than the serum values, or are values that are incompatible with life, then it is a urine leak or urinoma.
Differential diagnosis and clinical reasoning 1- Haemorrhage: it is rare, if it occurs t is usually from vessels in the graft hilum that is nt ligated or from small retroperitoneal vessels.
Risk factors: obesity, antiplatelet agents and anticoagulion.
Haemorrhagic drain, local swelling over the graft.
U/S, CT scan or MRI may be used to identify the hematoma.
May need emergency re-exploration. 2- Urinary Fistula
Causes:
a- ureteral ischemia and necrosis.
b- Technical problems associated with the transplant procedure.
Risk factors:
v Younger recipient age < 10 years
v Uretero-ureteric anastomosis
v High dose steroids
v Number of renal arteries
v Bladder problems
Management:
a- Ureteral ligature and nephrostomy
b- Ureteroureterostomy
c- Pyeloureterostomy
d- Ureteroneocystostomy
e- Percutaneous nephrostomy
f- ureteral stenting
g- prolonged vesical drainage.
3- Perinephric abscess:
It is uncommon, occur in the first week post-transplant. Can be caused by pyelonephritis, infected lymphocele, haematoma, or urinoma. It causes purulent drain and systemic symptoms of sepsis.
U/S, CT scan or MRI help diagnosis
Aspiration with culture and microscopic analysis of the drain needed.
4- Lymphocele and seroma
Lymphatic fluid collection in the perigraft area. It can occur as early as 2 weeks to as late as 5 years post-transplant.
Small lymphocele asymptomatic need no intervention.
Lymphocele may cause urinary retention, decreased urine output, elevated serum creatinine, thrombosis of the iliac vein, and limb oedema.
Treatment options:
1- Aspiration 100% recurrence rate
2- Percutaneous drainage 50% success rate
3- Laproscopic drainage is the method of choice
4- Open drain in patient with wound complication or if the lymphocele is adjacent to vital renal structures as vessel, ureter to avoid risk of injury to them or if the lymphocele is lateral to renal allograft.
5- Continuous drain with sclerosants agents which carry risk of periureteral fibrosis.
5-Urinary leak and urinoma
Occurs early post-transplant, may manifest as free fluid, (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma).
Clinical presentations:
a- Early extraperitoneal high-volume leak
b- Early extraperitoneal small leak
Defined with a low urine through drains, with low urine output, graft site swelling and pain
c- Late leak 1-2 weeks after transplant related to ureter necrosis or early removal of double J stent (3-6 weeks)
d- Intra-abdominal leak present with acute abdomen
Evidence-based management plan in extraperitoneal urine leak
Conservative with maximum decompression if low-volume leak at the anastomosis site.
Foley catheter, ureteral stent, nephrostomy are decompression methods.
Antegrade pyelogram to determine site of leak
Ureteral stent should be only removed after 4 – 6 weeks if urine leak stop.
Surgical re-exploration and reimplanting the transplant ureter in case of infected collection, ureteral obstructed and extrinsic compression if percutaneous drainage is failed.
Prevention:
Gentle handling of the ureter during donor nephrectomy with suitable length
Outcome of extraperitoneal urine leak: short-term and long-term effects on graft function and survival
Surgical complications can cause graft loss, prolonged hospitalization and reduce graft survival.
Conclusion:
High index of suspicion is needed to diagnose post-operative complications. Drained fluid colour and odours help in diagnosis. Drain biochemistry (Cr and K) compared with serum to differentiate between urine and others. Image study as U/S, CT scan and MRI can help diagnosis
Level 5
Huda Saadeddin
2 years ago
Surgical re-exploration and reimplanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain.
level V
Tahani Ashmaig
2 years ago
♧Introduction: ▪︎Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of these operations. ▪︎Low-volume leaks may subside with conservative management and provided there is no distal obstruction. If not resolved, or if it is large-volume urine leak, surgical exploration andcorrection may be needed. ▪︎The most popular methods of ureterovesical anastomosis in kidney transplantation include the Lich–Grégoir, Politano-Leadbetter, and U-stitch techniques. ▪︎Studies showed tat Lich–Grégoir technique is signifcantly associated with a lower incidence of urinary leakage and haematuria compared to the Politano-Leadbetter technique. ♧Surgical urology complications: 1. Urine leakage (the patient may have a fever, pain over the graft, and fluid leakage from the wound) 2. Ureteral obstruction, 3. Lymphocele. 4. Stent-related complications (infection, migration & encrustation). 5. Complications caused by the length of the transplanted ureter (eg: kinking, obstruction and anastomosis) 6. Atrophic or dys- functional bladder may result in bladder perforation or anastomotic dehiscence. 7.Proximal calyceal leak 8. Damage to the ureter Note : Urological complications in the post-operative period can be identifed by the drained fluid’s colour (clear, haemorrhagic, or purulent) and odour (uriniferous or foul). If there is a delayed graft function, a urinary leak can be detected only after the urine output increases. Management urine leak: 1. Inserting a urethral catheter, as well as performing a nephrostomy or placing an antegrade ureteric stent. The drain is left in situ. 2- If this technique fails, or if large-volume extravasation occurs, surgical exploration to reimplant the transplant ureter Urological complications during the post-operative periods: Signs and Symptoms ▪︎A high index of suspicion is warranted in a patient with high drain output. Investigations ▪︎To evaluate extraperitoneal urine leak and to rule out differential diagnoses: 1. Compare drain crand K levels with s. cr & K levels. 2. US to identify and defne the perinephric collection and dilatation of the pelvicalyceal system. 3. Doppler US can be used to identify defects in perfusion. 4. CT or MRI scans to identify and define the perinephric collection and pelvicalyceal dilatation. 5. An intravenous pyelogram may be helpful to identify location of the leak. 6. Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak. 7. Retrograde cystography helps clinicians to look for urinary bladder dehiscence. 8. Antegrade pyelogram testing through a nephrostomy to identify the location of the leak. Urine Leak and Urinoma ▪︎Urine leak is an early post- operative complication ▪︎May manifest as free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma). Different clinical presentations of urine leak i. Early extraperitoneal high-volume leak ii. Early extraperitoneal small leak ( a persistent low urine output through drains, associated with low urine output, graft site swelling, & pain (imaging with contrast may help identify urinoma) iii. Late leak (may be caused by ureter necrosis or early removal of double J stent (<3–6 weeks). iv. Intra-abdominal leak, which presents with an acute abdomen. Evidence-based management plan in extraperitoneal urine leak ▪︎Low-volume leak at the anastomotic site can be managed conservatively by performing maximum decompression by placing a Foley catheter , ureteral stent and performing a nephrostomy ▪︎Follow-up; If the fluid collections become infected, or cause ureteral obstruction and extrinsic compression on the ureter, then urgent percutaneous drainage is required. ▪︎Surgical re-exploration and reimplanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain. ▪︎Preventive measures: An adequate periurethral tissue in the ‘golden triangle’ must be carefully preserved: the ‘golden triangle’ is bound by the lower border of the junction between the renal vein and the inferior vena cava on the right, lower pole of the kidney on the left and the gonadal vein. delicate dissection of the ureter during donor nephrectomy to preserve adventitia; fat and blood supply of the ureter; short ureter length; and fxation of the adventitia, fat, and blood supply of the ureter to the bladder wall to prevent kinking or twisting.
Outcome ofextraperitoneal urine leak: ___________ ▪︎Short-term and long-term effects on graft function and survival ▪︎Significant longer length of hospital stay, more readmissions, more delayed graft function, and lower rates of graft survival.
Identifying Extraperitoneal Urine Leak Post Kidney Transplantation
1. High volume of clear drain fluid. 2. US, CT scan or MRI features. 3. Significantly higher values of creatinine and potassium in the drain fluid (which is also seen in urinoma. The later can will easily be picked up on an US or nuclear scan. 4. Antegrade pyelogram, cystogram, or scintigraphy may be required to identify the cause and to localise the leak. DIfferential diagnosis: A. Haemorrhage in which: 1. The drain is haemorrhagic 2, There is tachycardia, anaemia, local swelling over the graft, or if bleeding is a possibility, ▪︎Can be confirmed by: US, CT scan, or MRI and surgical re-exploration may be required. B. Urinary Fistula ▪︎May lead to significant morbidity, graft loss, and mortality. ▪︎The risk factors include younger recipient age (aged <10 years), uretero-ureteric anastomosis, use of high-dose steroids in immunosuppression, number of renal arteries, and bladder problems. ▪︎Managed by different techniques including ureteral ligature and nephrostomy, ureteroureterostomy, pyeloureterostomy, ureteroneocystostomy, percutaneous nephrostomy and ureteral stenting, and prolonged vesical drainage. C. Perinephric Abscess ▪︎Uncommon and usually present in the early post-transplant period ▪︎The causes include pyelonephritis, infection of lymphocele, haematoma, or urinoma. ▪︎The drained fluid is purulent, with fever, swelling, and tenderness over the graft. US, CT scan, or MRI & aspiration of the collection and performing microscopy and culture of the aspirate may further help the diagnosis. D. Lymphocele & Seroma ▪︎A collection of lymph in the perigraft area ▪︎May occur from as early as 2 weeks to as late as 5 years post-transplant. ▪︎They can present with features of compression symptoms ▪︎In lymphocele and seroma, the drainage fluid is clear. Ultrasonography, CT scan, or MRI, and fluid biochemistry further aid diagnosis. ▪︎ The drain fluid creatinine and potassium values are not much different from the serum values, ▪︎Treatment options include aspiration, percutaneous drainage, drainage by laparoscopic method (the method of choice, or open marsupialization (preferred over laparoscopic technique in patients with wound complications and in a small lymphocele adjacent to vital renal structures, Continuous drainage may be used together with the application of sclerosants like povidone iodine, fbrin glue, and doxycycline, tetracycline, ethanol, bleomycin. Periureteral fbrosis is a risk if sclerosing agents are used.
♧Conclusion: ▪︎Differentureteroneocystostomy techniques, including the Lich-Grégoir, Politano–Leadbetter, & U-stitch techniques, have an impact on development of urine leak. ▪︎ The Lich-Grégoir technique has a signifcantly lower incidence of urinary leakage compared to the Politano– Leadbetter procedure.
▪︎Level of evidence: V
Theepa Mariamutu
2 years ago
Identifying Early Extraperitoneal High volume urine leak post KT- evidence 5
Incidence of urine leak is about 1.2-8.9% of KTR.
Lich- Gregoir showed significant lower incidences of urinary leakage, heamaturia, but any method must be tension free and protected by at least a 1 cm submucosal tunnel.
The most common surgical urology complications included urine leakage, urethral obstruction,and lymphocele
Stents longer than 20 cm or if used longer than 6 weeks, may end up stent related complications
Common complications
Caused by length of transplanted ureter- long , prone for kinking and obstruction as a result of ischaemia because of vascularity: if short ureter may not be appropriate for tension free anastomosis
Atrophic bladder or dysfunctional bladder – result in bladder perforation or anastomotic dehiscence
Damaged to ureter during dissection – end up in ureteric ischaemia, necrosis and distal leak
Signs of Urine leak
Graft pain
Tenderness
Local swelling
Fever
Tachycardia
Hypotension
Tachypnoea
Investigations
Compare drain creatinine and potassium levels with serum creatinine and potassium levels.- If drain fluid creatinine and potassium values are not dissimilar from the serum values, then the possibilities of lymphocele or seroma are higher. However, if they are significantly higher than the serum values, or are values that are incompatible with life, then it is a urine leak or urinoma.
Use ultrasonography to identify and define the perinephric collection and dilatation of the pelvicalyceal system.
Doppler ultrasonography can be used to identify defects in perfusion.
CT or MRI scans are a useful tool to identify and define the perinephric collection and pelvicalyceal dilatation.
An intravenous pyelogram may be helpful to identify location of the leak.
Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak. This technique is not useful if there is delayed graft function or ureteral stasis.
Retrograde cystography helps clinicians to look for urinary bladder dehiscence.
Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak. This can be done in delayed graft function scenarios too. Pelvicalyceal dilatation makes it easier to do this procedure.
Management
Low volume leak- managed by maximum decompression
Antegrade pyelogram to identify the leak
Foley catheter and urethral stent performing nephrostomy – decompression
If the fluid becomes infected or causing ureteric obstruction or extrinsic compression on the ureter – urgent percutaneous drainage
If conservative measures failed – surgical re-exploration and reimplantation of the ureter should be done
Preventive measures
Urine leak happens due to technical errors, method of graft ureter implantation or compromised vascularity
Gentle handling of the ureter at the time of ureteral dessection is important
An adequate periurethral tissue in-golden triangle’ – bound by the lower border of the junction between the renal vein and the inferior vena cava on the right, lower pole of the kidney on the left and the gonadal vein.
Last edited 2 years ago by Theepa Mariamutu
Assafi Mohammed
2 years ago
Summary of the article DENTIFYING EARLY EXTRAPERITONEAL HIGH-VOLUME URINE LEAK POST KIDNEY TRANSPLANTATION
This review article discusses the identification of extraperitoneal urinary leak and it’s differentials in a KTR in the post-operative period. Urology complications in the early post-transplant period A. The most common complications: 1. Urine leakage; the patient may have a fever, pain over the graft, and fluid leakage from the wound. Initially; should be managed with: · Inserting a urethral catheter. · Performing a nephrostomy or placing an antegrade ureteric stent. · Surgical exploration to reimplant the transplant ureter becomes necessary; a. If the above failed to decompress the urinary system. b. if there’s large-volume extravasation. 2. Ureteral obstruction; ureteric stenting mitigates the sequelae but doesn’t reduce the incidence. Stent’s use for more than 6 weeks may cause stent-related complications: · Infection. · Migration. · Encrustation. 3. Lymphocele; fluid collection between the urinary bladder and the kidney allograft. B. Other urological complications: 1. Complications related to the length of the transplanted ureter: a. A Long ureter is liable to kinking and obstruction as a result of ischaemia. b. A short ureter may not be appropriate for achieving tension-free anastomosis. 2. Atrophic bladder or dysfunctional bladder in the recipient may result in bladder perforation or anastomotic dehiscence. 3. Proximal calyceal leak may occur because of lower pole artery complications (thrombosed, ligated, not reconstructed). 4. Damage to the ureter during dissection may result in ureteric ischaemia, necrosis, and distal leak.
Identification of Urological complications in the post-operative period: 1. Signs and symptoms may be masked because of immunosuppression and analgesics; a. Local: graft pain and tenderness, and local swelling over the graft. b. Systemic: fever, tachycardia, hypotension, and tachypnoea. 2. A high index of suspicion is warranted in a patient with high drain output. If there is a delayed graft function, a urinary leak can be detected only after the urine output increases. 3. The drained fluid’s colour (clear, haemorrhagic, or purulent) and odour (uriniferous or foul). 4. Investigations: the following are helpful in evaluating extraperitoneal urine leak post kidney transplantation, and to rule out differential diagnoses: a. Compare drain creatinine and potassium levels with serum creatinine and potassium levels. b. Ultrasonography to identify and define the perinephric collection and dilatation of the pelvicalyceal system. c. Doppler ultrasonography can be used to identify defects in perfusion. d. CT or MRI scans are a useful tool to identify and define the perinephric collection and pelvicalyceal dilatation. e. An intravenous pyelogram may be helpful to identify location of the leak. f. Focal tracer scintigraphy uses mercapto-acetyl-triglycine or technetium 99 to identify the location of the leak. This technique is not useful if there is delayed graft function or ureteral stasis. g. Retrograde cystography helps clinicians to look for urinary bladder dehiscence. h. Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak. This can be done in delayed graft function scenarios too. Pelvicalyceal dilatation makes it easier to do this procedure. Identifying extraperitoneal urine leak post-kidney transplantation
Clues to identify urine leakage from other differentials: a. A high volume of clear drain fluid. b. If drain fluid creatinine and potassium values are significantly higher than the serum values, or are values that are incompatible with life, then it is a urine leak or urinoma. c. If drain fluid creatinine and potassium values are not dissimilar from the serum values, then the possibilities of lymphocele or seroma are higher. d. Ultrasonography, CT scan or MRI, and fluid biochemistry further aid diagnosis. e. Antegrade pyelogram, cystogram, or scintigraphy may be required to identify the cause and to localise the leak. Urine Leak and Urinoma a) Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of cases. b) Manifestation:
· as free fluid (urine ascites).
· extravasation in local tissues.
· may be encapsulated (urinoma). c) The different clinical presentations could be: 1. Early extraperitoneal high-volume leak 2. Early extraperitoneal small leak: defined by a persistent low urine output through drains, associated with low urine output, graft site swelling, and pain (imaging with contrast may help identify urinoma). 3. Late leak (1–2 weeks after kidney transplant), which may be caused by ureter necrosis or early removal of double J stent (<3–6 weeks). 4. Intra-abdominal leak: presents with an acute abdomen. d) Evidence-based management plan in extraperitoneal urine leak 1. Low-volume leak at the anastomotic site: · can be managed conservatively by performing maximum decompression. · Antegrade pyelogram to identify the site of the leak is helpful. Placing a Foley catheter and ureteral stent performing a nephrostomy are the techniques used for decompression. · Once the urine leak stops, the Foley catheter and nephrostomy tube can be removed(the ureteral stent is only removed after a period of 4–6 weeks). 2. After conservative management and carefull follow up; · Urgent percutaneous drainage is required; if the fluid collections become infected, or cause ureteral obstruction and extrinsic compression on the ureter. · Surgical re-exploration and reimplanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain. e) Preventive measures: 1. During harvesting of the donor kidney, gentle handling of the ureter at the time of ureteral dissection is crucial to prevent urine leak post kidney transplantation. 2. An adequate periurethral tissue in the ‘golden triangle’ must be carefully preserved. 3. Important factors that help to prevent major urological complications include: · delicate dissection of the ureter during donor nephrectomy to preserve adventitia. · delicate dissection of the fat and blood supply of the ureter. · short ureter length. · fixation of the adventitia, fat, and blood supply of the ureter to the bladder wall to prevent kinking or twisting. f) Outcome of extraperitoneal urine leak: short-term and long-term effects on graft function and survival. · Prolonged hospitalisation and reduced graft survival. · More readmissions, more delayed graft function. What is the level of evidence provided by this article?
This is a narrative review article
Level of evidence grade 5.
Mohamed Saad
2 years ago
Identifying Early Extra-peritoneal High-Volume Urine Leak Post Kidney Transplantation. Introduction.
Urine leak is one of the early post-operative complication after kidney transplantation and occurs in 1.2–8.9% and according to its volume, compression manifestation and affecting graft function, our plan of management is considered.
Usually, small volume urine leak is resolved by conservative management.
Urinary leak is considered when creatinine and potassium are significantly higher than the serum values, or are values that are incompatible with life, Urinoma will easily be picked up on an ultrasound scan or nuclear scan . Antegrade pyelogram, cystogram, or scintigraphy may be required to identify the cause and to localize the leak URETEROVESICAL ANASTOMOSIS AND A COMPARISON OF ASSOCIATED COMPLICATIONS . Lich–Grégoir technique is significantly associated with a lower incidence of urinary leakage, hematuria and all postoperative complication comparing to other methods. The most common surgical urology complications include urine leakage, ureteral obstruction, and lymphocele, other complication as kinking of long ureter, atrophic or dysfunctional bladder and ureteric ischemia which manifested by graft pain, tenderness, and local swelling over the graft) and systemic (fever, tachycardia, hypotension, and tachypnea). Urinary leak and other complications should be investigated by: –Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
-USG/Doppler.
-CT or MRI scans are a useful tool to identify and define the perinephric collection .
-Intravenous pyelogram and tracer scintigraphy .
-Retrograde cystography and antegrade pyelogram testing .
DIFFERENTIAL DIAGNOSIS:
Hemorrhage:
Manifested by tachycardia, anemia , pain over the graft, not commonly presented, may need exploration but mainly conservative treatment.
Urinary Fistula.
Associated sometimes with graft loss and mortality,
Urinary fistulas may be managed by different techniques including ureteral ligature and nephrostomy, ureteroureterostomy, pyeloureterostomy, ureteroneocystostomy, percutaneous nephrostomy and ureteral stenting, and prolonged vesical drainage.
Perinephric Abscess.
Systemic manifestation of infection and purulent drain from aspiration with positive culture with USG needed for diagnosis.
Lymphocele and Seroma.
Occur in 1-20% of kidney transplant operations,
occur from as early as 2 weeks to as late as 5 years post-transplant, mainly it is due to seal perivascular lymphatic channels incised during operation some studies showed relation between sirolimus and lymphocele, treated by drainage either by laparoscopic method, or open marsupialization.
Urine Leak and Urinoma.
May be free fluid or urinoma (encapsulated), occur early post kidney transplant, high volume leak is defined by a persistent low urine output through drains, associated with low urine output, graft site swelling, and pain over the graft.
Start treatment conservatively by urinary catheter and ureteral stent performing a nephrostomy if not resolved open surgery required to re-implant ureter again.
Studies shown that there is significant longer length of hospital stay, more readmissions, more delayed graft function, and lower rates of graft survival. Conclusion:
The Lich-Grégoir technique has a significantly lower incidence of urinary leakage compared to others.
Comparing chemistries value from the drain with serum values to detect urinoma, start with conservative treatment if failed surgical intervention is a must ,surgical complications affecting graft survival.
Level of evidence: V.
Ghalia sawaf
2 years ago
Urine leak is an early post-operative complication
occurs in 1.2–8.9% of these operations.
URETEROVESICAL ANASTOMOSIS AND A COMPARISON OF ASSOCIATED COMPLICATIONS
• The most popular methods include the Lich–Grégoir, Politano-Leadbetter, and U-stitch techniques.
• Lich–Grégoir technique is significantly associated with a lower incidence of urinary leakage and hematuria compared to the Politano- technique.
• in order to prevent reflux during voiding, the ureterovesical anastomosis must be tension-free and protected by at least a 1 cm submucosal tunnel.
UROLOGICAL COMPLICATIONS DURING THE POST-OPERATIVE PERIOD IN KIDNEY TRANSPLANT RECIPIENTS
The most common surgical urology complications include
• urine leakage,
• ureteral obstruction,
• lymphocele
1- Urine leakage
The rates of urological complications range from 2.5% to 30.0%
fever, pain over the graft, and fluid leakage from the wound
Routine prophylactic intraoperative stenting
• The stents are generally well tolerated,
• longer stents (stent length: ≥20 cm), or longer periods (>6 weeks), may result in stent-related
• complications including infection, migration, and encrustation.
The initial step in urine leak management
1. inserting a urethral catheter,
2. nephrostomy or placing an antegrade ureteric stent.
3. The drain is left in situ.
4. If this technique fails, or if large-volume extravasation occurs, surgical exploration to reimplant the transplant ureter becomes necessary.
Other complications
2- kinking and obstruction
caused by the length of the transplanted ureter.
3- A short ureter
4- Atrophic bladder or dysfunctional bladder in the recipient
5- Proximal calyceal leak may occur because of lower pole artery complications (thrombosed, ligated, not reconstructed)
6- Damage to the ureter during dissection may result in ureteric ischaemia, necrosis, and distal leak.
Urology complications can be identified by
• drained fluid’s colour and odour
• If there is a delayed graft function, a urinary leak can be detected only after the urine output increases.
Signs and Symptoms
• local (graft pain and tenderness, and local swelling over the graft)
• systemic (fever, tachycardia, hypotension, and tachypnoea).
Investigations
1. Compare drain creatinine and potassium levels with serum creatinine and potassium levels
2. Use US to identify and define the perinephric collection and dilatation of the pelvicalyceal system.
3. Doppler ultrasonography can be used to identify defects in perfusion
4. CT or MRI scans are a useful tool to identify and define the perinephric collection and pelvicalyceal dilatation.
5. An intravenous pyelogram may be helpful to identify location of the leak.
6. Focal tracer scintigraphy to identify the location of the leak.
7. This technique is not useful if there is delayed graft function or ureteral stasis.
8. Retrograde cystography helps clinicians to look for urinary bladder dehiscence.
9. Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak. This can be done in delayed graft function scenarios too.
Identifying Extraperitoneal Urine Leak Post Kidney Transplantation
1- Ultrasonography, CT scan or MRI, and fluid biochemistry further aid diagnosis.
2- If drain fluid creatinine and potassium values are not dissimilar from the serum values, then the possibilities of lymphocele or seroma are higher.
3- If they are significantly higher than the serum values, or are values that are incompatible with life, then it is a urine leak or urinoma.
4- Urinoma will easily be picked up on an ultrasound scan or nuclear scan
5- Antegrade pyelogram, cystogram, or scintigraphy may be required to identify the cause and to localise the leak
DIFFERENTIAL DIAGNOSIS AND CLINICAL REASONING
Haemorrhage
• If the drain is haemorrhagic,
• ultrasonography, CT scan, or MRI may be used to identify haematoma,
• is not a common complication after kidney transplantation.
• If it occurs, it is usually from the vessels in the graft hilum that are not ligated, or from small, severed retroperitoneal vessels.
• risk factors include
1. recipient obesity,
2. use of antiplatelet agents,
3. anticoagulation.
Surgical exploration is usually not required because bleeding usually stops spontaneously.
, if the patient needs pure red blood cell transfusion repeatedly, or if there is haemodynamic instability or compression of the kidney by haematoma, surgical re-exploration may be required.
Urinary fistula
occurs in 2–5% ,
may lead to significant morbidity, graft loss, and mortality
The risk factors;
1. Ureteral ischaemia and necrosis and technical problems associated
2. younger recipient age (aged <10 years),
3. uretero-ureteric anastomosis
4. use of high-dose steroids
5. number of renal arteries
6. bladder problems
Early intervention helps to prevent graft loss and reduces mortality.
Management
1. ureteral ligature and nephrostomy,
2. ureteroureterostomy,
3. pyeloureterostomy,
4. ureteroneocystostomy,
5. percutaneous nephrostomy and ureteral stenting, and prolonged vesical drainage
Perinephric abscesses
• are uncommon complications
• usually early post-transplant period (in the first few week’s post-transplant).
• The causes include pyelonephritis, infection of lymphocele, haematoma, or urinoma.
• If the drained fluid is purulent, with accompanying symptoms and signs (fever, swelling, and tenderness over the graft),
• ultrasonography, CT scan, or MRI
• Aspiration of the collection and performing microscopy and culture of the aspirate may further help the diagnosis.
Lymphocele and Seroma
in 1-20% of kidney transplant operations.
early as 2 weeks to as late as 5 years post-transplant.
Usually they are small and asymptomatic, and such lymphoceles require no intervention.
may present with features of compression symptoms including retention of urine, decreased urine output, elevated serum creatinine, thrombosis of iliac vein, and limb oedema.
Etiology
technical failures
lymph leakage from the hilum of the allograft itself
sirolimus use and occurrence of lymphoceles and seromas
Ultrasonography, CT scan, or MRI, and fluid biochemistry further aid diagnosis.
If drain fluid creatinine and potassium values are not much different from the serum values, then the possibilities of lymphocele or seroma are higher.
Treatment options
1. aspiration (100% chances of recurrence
2. percutaneous drainage (50% success rate),
3. drainage by laparoscopic method, or open marsupialisation.
Laparoscopic drainage is the method of choice for fpost-transplant lymphocele.
open drainage is preferred over laparoscopic technique in patients
with wound complications.
Or for small lymphocele adjacent to vital renal structures,
or lymphocele is lateral to the renal allograft,
Application of sclerosants like povidone iodine, fibrin glue, and doxycycline, tetracycline, ethanol, bleomycin
Urine Leak and Urinoma
early post-operative complication
1.2–8.9% of cases.
manifest as
(urine ascites), extravasation in local tissues, or may be encapsulated (urinoma)
Classification
1- Early extraperitoneal high-volume leak; or small leak,
• low urine output through drains,
• associated with low urine output,
• graft site swelling, and pain
2- late leak (1–2 weeks after kidney transplant),
• which may be caused by ureter necrosis
• or early removal of double J stent (<3–6 weeks);
3- intra-abdominal leak, which presents with an acute abdomen.
management plan
Low-volume leak; conservatively by performing maximum decompression
Antegrade pyelogram to identify the site of the leak is helpful.
Placing a Foley catheter
ureteral stent
performing a nephrostomy are the techniques used for decompression.
Preventive measures:
• During harvesting of the donor kidney, gentle handling of the ureter at the time of ureteral dissection
• An adequate periurethral tissue in the ‘golden triangle’ must be carefully preserved
• delicate dissection of the ureter during donor nephrectomy to preserve adventitia; fat and blood supply of the ureter;
• short ureter length; and fixation of the adventitia, fat, and blood supply of the ureter to the bladder wall to prevent kinking or twisting.49
Outcome of extraperitoneal urine leak:
prolonged hospitalisation and reduced graft survival
Level V
Mahmud Islam
2 years ago
This a good review, but the Level of evidence is 5.
Surgical complications are primarily observed in the first few days, but some may be as late as 6 weeks. opposite to hematoma and urine leak seen earlier post-transplantation, lymphocele may be as late as 2-6 weeks post-transplantation.
urinary leak, haemorrhage, perinephric abscess, urinoma, lymphocele or seroma may present a similar picture though some features will help differentiate among them. All may present with pain and delayed graft function, but haemorrhage may present with hypovolemia. sampling or drainage will help as the first tool of evaluation . gross appearance may give a clue. Laboratory investigations are also essential, significantly to differentiate urinary leaks from lymphocele or seroma. sample showing very high creatinine and/or potassium incompatible with life and serum samples favour urinoma/urine leak. Radiologic evaluation is also helpful in evaluating both the collection and source of the leak.
ultrasonography will help describe the collection and may differentiate haemorrhage. doppler USG helps define vasculature patency and leakage. Scintigraphic techniques with 99 Tch and MAG3 help in defining urine leakage but are not suitable in case of delayed graft function.
Prevention is the most critical measure to prevent such complications or at least minimize them. Leakage may be due to technical error or maybe due to the compromisation of ureter vascularity. adventitia preservation and at least 1 cm depth of ureter into the recipient’s bladder is essential. The ‘golden triangle, which is bound by the lower border of the junction between the renal vein and the inferior vena cava on the right, the lower pole of the kidney on the left and the gonadal vein needs to be protected. Periureteral fat tissue needs to be preserved. many techniques are used for uretreoneostomy but the Lich-Grégoir technique was found to be better than Politano–Leadbetter and U-stitch techniques in terms of leakage.
Not to forget, sometimes these complications may be masked clinically because of the immunocomprimsation and medications like analgesics and antipyretics. many studies showed different incidences of these complications, but primarily those of high numbers showed a modest number of urological complication
Ahmed Omran
2 years ago
Level of evidence :V
Identifying early extraperitoneal high volume urine leak post kidney transplantation
Abstract
Several surgical complications in early post transplant period include hemorrhage, extraperitoneal urine leak and lymphocele .Hemorrhage and extraperitoneal urine leak occur early but lymphocele occurs 2-6 weeks following transplantation. Colour and volume of the drain give some clue but are not enough for definite diagnosis of urine leak .So, biochemical analysis of drained fluid and ultrasonography are helpful .Different ureteroneocystostomy procedures have different complication rates. Surgical complications require proper management according to the condition.
Introduction:
Urine leak occurs in 1.2-8.9% early post operatively Low volume leaks without distal obstruction are managed first conservatively .If not responding or large volume ,surgical exploration with correction is indicated.
Ureterovesical anastomosis and comparison of associated complications:
Lich-Gregoir technique has lower incidence of urinary leak in comparison with Politano-Leadbetter one .Hematuria was found also of lower incidence in the same comparison and additionally if compared with U-stitch techneque.To prevent reflux during voiding ,tension free ureterovesical anastomosis is needed with with at least 1 cm submucosal tunnel protection.
Urological complications during postoperative period :
Urine leak, ureteral obstruction and lymphocele are the most common urological complications. ;ranging from 2.5-305.Urine leak is manifested by fever, pain over graft and oozing from the wound .Intraoperative ureteric stenting does not decrease incidence but mitigates effects of ureteric complications. Stents of 20 cm or more in length or of periods more than 6 weeks may be associated with infection ,migration and encrustation.
Management starts with maximal decompression by inserting urethral catheter and nephrostomy or antegrade ureteric stenting and drain left in situ. Surgical exploration with reimplantation of transplant ureter is indicated if that approach failed and in case of large -volume leak.
Other complications:
-Kinking and obstruction of long ureter due to ischemia.
-Bladder perforation or anastomotic dehiscence of atrophic or dysfunctional bladder.
-Lower pole artery complications leading to proximal calyceal leak.
-Dissection related ureteric damage leading to ischemia and distal leak.
Drain colour and odour can guide expectation of underlying cause.
DGF leads to delayed detection of urinary leak till urine output increases.
Signs and symptoms:
high suspicion index is needed
Local symptoms: graft pain ,swelling
Signs:
IS and analgesics can mask signs.
Local graft tenderness
Investigations:
-Drain and serum creatinine and potassium
-Ultrasonography
-Doppler us to detect perfusion defects
-CT and MRI imaging to detect perinephric collection and pelvicalyceal dilatation
-IV pyelogram to detect leak site
-Isotope scintigraphy to determine leak site ;not useful in case of DGF and ureteral stasis.
-Retrograde cystography for bladder dehiscence detection.
-Antegrade pyelogram using nephrostomy for leak site detection ;could be done with DGF and pelvicalyceal dilatation has facilatatory effect.
Identification of extraperitoneal urine leak post KT
Extraperitoneal leak is suspected with high volume of clear drain .
Significantly higher levels of drain fluid creatinine and potassium compared with serum detect urine leak or urinoma .Cause and site can be recognised by antegrade pyelogram, cystogram or scintigraphy.
Differential diagnosis and causes
Haemorrhage:
not common; risk factors are obesity, antiplatelets and anticoagulants.
Causes include non ligation of graft hilum vessels or from small severed retroperitoneal vessels.
Haemorrhagic drain is associated with tachycardia ,anaemia and swelling over graft .Identification of hematoma needs imaging with US ,CT ,or MRI.
Urinary fistula
Occurs in 2-5%,associated with high morbidity and mortality(8%) and graft loss
Risk factors
age less than 10 years ,uretero-ureteric anastomosis high dose steroids ,number of renal arteries and bladder issues.
Causes
ureteral ischemia and necrosis in addition to technical issues.
Perinephric abscess
uncommon ,occur early
manifested by purulent drain with fever ,swelling and tenderness over the graft
Causes
pyelonephritis, infection ,lymphocele hematoma and urinoma.
Diagnosis is aided by imaging .Aspiration with c/s support diagnosis.
Lymphocele and seroma
1-20%
occurs as early as 2 weeks or as late as 5 years post transplant.
Usually small and asymptomatic.
Causes
Failure to seal perivascular lymphatic channels
lymph leakage from the hilum
use of sirolimus
Clinical manifestations
large lymphoceles are associated with compression symptoms like urine retention ,less urine output ,increased creatinine ,iliac vein thrombosis and ll edema.
Drainage fluid is clear drain fluid creatinine and potassium are similar to serum
Imaging helps confirmation.
TREATMENT:
Aspiration ;100 % RECURRENCE
Percutaneous drainage;50% success
laparscopic drainage is the method of choice in case of wound complications ,open drainage is preferred and also when there is small lymphocele near to vital renal structures.
Sclerosants can be used with continuous drainage with risk of periureteral fibrosis.
Urine leak and urinoma
occurs early in 1.2-8.9%
Either free or encapsulated(urinoma)
Clinical presentation
Early; small or large associated with persistent low urine output ,graft site swelling and pain ;urinoma can be recognised by imaging
Late::1-2 weeks post KT caused by ureter necrosis or early removal of ureteric stent.
Intraabdominal leak manifested by acute abdomen
Management
Conservative treatment for small leaks
if fails surgical exploration ureteric reimplantation is required as in large volume leaks.
Prevention
Gentle ureteric handling
Preservation of golden triangle
Outcome
Urological complications lead to prolonged hospitalization .with more readmissions and DGF.
Ureteral obstruction and urinary fistula are common
Conclusion
Ureteroneocystomy using Lich-Gregoir technique has lowest incidence of urinary leak.
Urine leak has technical errors in ureteroneostomy and vascular damage as underlying causes.
Multiple renal vessels is a risk factor
High suspicion index is needed for diagnosis
Investigations involve biochemical testing and imaging
Low volume leak is treated mainly conservatively
High volume leak needs surgical intervention
Urine leak leads to prolonged hospitalization
Prolonged follow up is needed with conservative treatment implementation.
mai shawky
2 years ago
Club 1; identification of extraperitoneal urine leakage after KT
Summary:
· Post-transplant surgical complications as hemorrhage and urine leakage occur early post-operative, while lymphocele occurs late (2-6 weeks post-transplant).
· Different surgical techniques of uretro-vesical anastomosis include Lich–Grégoir, Politano-Leadbetter, and U-stitch technique.
· Lich–Grégoir technique is associated with lower incidence of urological complications as leakage and hematuria. In addition, tension free anastomosis and submucosal tunnel are essential to decrease the incidence of reflux.
· Urinary leakage is diagnosed based on clinical (color and odeur of the leaking fluid) and biochemical analysis of fluid creatinine.
· urine leakage is either generalized ascites or localized (capsulated) urinoma.
· Urinary leakageis presented clinically by fever, tender graft, fluid leakage from the wound, tachycardia and hypotension. high index of suspicion is essential to diagnose asymptomatic cases presented with high drain output.
· Small leakage just presented with low urine output, or large leak and acute abdomen.
· Small volume urine leakage can be resolved spontaneously, but large volume need exploration and surgical correction.
· Causes of urinary leakage:
o long ureter is liable to kinking and compromised vascularity and hence perforation and leakage.
o short ureter is liable to tension.
o lower calyceal leak due to lower pole artery stenosis or obstruction or failure of construction.
· Diagnosis based on:
o comparing serum and drain (creatinine and K), it is higher than that of the Darin and serum.
o Doppler to detect renal perfusion.
o US to detect perinephric collection and dilated pelvicalyceal system.
o CT and MRI may be more accurate tools for diagnosis.
o Identification of leakage site by IV pyelography or TC 99 scintigraphy (not useful in delayed graft function) or antegrade pyelogram through nephrostomy tube can be used in case of delayed graft function.
· If drain creatinine and K are higher than that of serum, so it is urine leakage or urinoma. If it is not dissimilar, it favors the diagnosis of seroma or lymphocele.
· Ureteric stenting decrease the symptoms but it does not decrease the incidence of urological complications. Long stent > 20 cm or prolonged than 6 weeks can cause infections or migration of the stent.
· Management of urinary leakage:
o Decompression by urinary cath or even nephrostomy is the only needed management if low volume leakage and their removal after resolution of collection.
o if large volume leakage , exploration and surgical correction through removal of the ischaemic or necrosed part of the ureter followed by reimplantation of the ureter.
· Hemorrhage:
o It not common, related to defective anastomosis of hilar vessels.
o Presented with hemoglobin drop and hemodynamic instability.
o Risk factors include use of antiplatelet and anti coagulants.
o usually stop without intervention. except if severe and required repeated RBC transfusion, exploration is needed.
· Ureteric fistula:
o associated with graft dysfunction, higher morbidity and mortality.
o increased incidence with increased doses of immunosupressives.
· perinephric abscess:
o infected hematoma, urinoma and lymphocele.
o presented with fever, tender graft and diagnosed with CT and MRI.
· lymphocele:
o Either asymptomatic or presented with compression manifestations.
o Increased risk with m TOR.
o Treatment includes aspiration (100% risk of recurrence, open drainage and the best is laparoscopic drainage).
o open drainage is preferred only in case of wound complications and small lymphocele adjacent to vital structures as (ureter or renal vessels).
o Use of sclerosant agents like povidone iodine, fibrin glue, and doxycycline, tetracycline, ethanol, bleomycin can be used in case of ureteric leakage.
· Prevention of urological complications:
o Preservation of the ‘golden triangle’ which is bound by the lower border of the junction between the renal vein and IVC on the right, lower pole of the kidney on the left and the gonadal vein.
o Delicate dissection of the ureter during donor nephrectomy to preserve adventitia; fat and blood supply of the ureter; adequate ureter length; and fixation of the adventitia, fat, and blood supply of the ureter to the bladder wall to prevent kinking or twisting.
· Prognosis of cases with urological complications:
o Lower graft survival and higher morbidity and mortality.
I like your emphasis on preserving the tissues, mentioned as ‘Golden Triangle’. I agree it is level 5 evidence. Ajay
Rihab Elidrisi
2 years ago
This is very informative article with a lot of information:
In generally the urine leak occurs in up to 9% post operative complication with a lot oaf morbidity .
urine leak is one of the important complication which can be suspected in case of active drain .
There is 3 teqnieque for ureteric anastomosis but the best one with less complications is the Lich–Grégoir: lower incidence of urinary leakage and hematuria. In cases of urine leak, the patient may have a fever, pain over the graft, and fluid leakage from the wound. – The stents are generally well tolerated, but when longer stents are used (stent length: ≥20 cm), or if used for longer periods (>6 weeks), they may result in stent-related complications including infection, migration, and encrustation. -Management is to maximally decompress the urinary system. This is achieved by inserting a urethral catheter, as well as performing a nephrostomy or placing an antegrade ureteric stent. The drain is left in situ. If this technique fails, or if large-volume extravasation occurs, surgical exploration to reimplant the transplant ureter becomes necessary. – A long ureter is liable to kinking and obstruction as a result of ischaemia . -Atrophic bladder or dysfunctional bladder in the recipient may result in bladder perforation or anastomotic dehiscence.
roximal calyceal leak may occur because of lower pole artery complications .
-Damage to the ureter during dissection may result in ureteric ischaemia, necrosis, and distal leak. Signs and Symptoms
Varied symptoms can occur as a result of kidney transplant, including local (graft pain and tenderness, and local swelling over the graft)
and systemic (fever, tachycardia, hypotension,
and tachypnoea).
– Signs may be masked because of immunosuppression and analgesics. Investigations
The following investigations are helpful in evaluating extraperitoneal urine leak post kidney transplantation, and to rule out differential diagnoses:
-Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
– U/S.
-Doppler ultrasonography can be used to identify defects in perfusion.
-CT or MRI scans .
-An intravenous pyelogram may be helpful to identify location of the leak.
– Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak.
-Retrograde cystography .
-Antegrade pyelogram testing . Identifying Extraperitoneal Urine Leak Post Kidney Transplantation
-If drain fluid creatinine and potassium values are not dissimilar
from the serum values, then the possibilities of lymphocele or seroma are higher. However, if they are significantly higher than the serum values, or are values that are incompatible with life, then it
is a urine leak or urinoma.
– Urinoma will easily be picked up on an ultrasound scan or nuclear scan
-Antegrade pyelogram, cystogram, or scintigraphy may be required to identify the cause and to localise the leak.
Hi Dr Rihab, I wish you could have emphasised on preserving the tissues, often mentioned as ‘Golden Triangle’. I agree it is level 5 evidence. Ajay
Hadeel Badawi
2 years ago
Surgical complications may occur in the early post-transplant period, including hemorrhage, extraperitoneal urine leak, and lymphocele.
Low-volume leaks may subside with conservative management. If not resolved, or if it is large-volume urine leak, surgical exploration andcorrection may be needed.
Ureterovesical anastomosis and a comparison of associated complications:
Multiple methods are available; the most popular methods include the -Lich–Grégoir: lower incidence of urinary leakage and hematuria. -Politano-Leadbetter -U-stitch techniques.
Urological complications during the postoperative period in KTR The rates of urological complications 2.5% to 30.0% of all recipients Routine intraoperative stenting of the ureter in kidney transplant recipients mitigates the effects of ureteric complications but does notreduce the incidence of these complications.
The stent may result in infection, migration, and encrustation.
Risk factors:
technical errors in the ureteroneocystostomy technique compromised vascularity due to vascular injury. Presence of multiple renal arteries.
Presentation:
-Require a high index of suspicion.
-May be asymptomatic because of IS and analgesics. -Local; graft pain and tenderness and local swelling over the graft. -Systemic; fever, tachycardia, hypotension, and tachypnoea.
Investigations
– Drain fluid analysis to be compared with serum creatinine and potassium;
if drained creat &K are significantly higher than the serum values, or value incompatible with life, then it is a urine leak or urinoma.
– The colour of the drained fluid (hemorrhagic,clear, or purulent) and odour (uriniferous or foul) may indicate the development of a urological complication – US; define the size, location and pressure effect. – Doppler ultrasonography; evaluate perfusion. – CT or MRI scans for detailed evaluation. – IVP; identify the location of the leak. – Nuclear scintigraphy; location of the leak, not valuable in DGF or ureteral stasis. – Retrograde cystography; look for UB dehiscence. – Antegrade pyelogram testing through a nephrostomy may accurately identify the leak’s location. This can be done in delayed graft function scenarios too.
Differential diagnosis: Hemorrhage; failure to ligate vessels in the graft hilum or from small, several retroperitoneal vessels. Require monitoring of Hg and Hct.
Urinary Fistula; resulted from ureteral ischemia and necrosis and technical problems associated with the transplant procedure
Perinephric Abscess:causes include pyelonephritis, infection of lymphocele, hematoma, or urinoma
Lymphocele and Seromaoccur because of technical failures to seal perivascular lymphatic channels incised during surgical exposure of the iliac vessels or because of lymph leakage from the hilum of the allograft itself.
Urine Leak and Urinoma
Management of extraperitoneal urinary leak: Low-volume leaks can be managed conservatively by performing maximum decompression by urethral catheter, performing a nephrostomy and placing an antegrade ureteric stent.
If the fluid collections become infected or cause ureteral obstruction and extrinsic compression on the ureter, then urgent percutaneous drainage is required.
If this technique fails, or if a high volume leak occurs, surgical exploration to re-implant the transplant ureter becomes necessary
Prevention: -Gentle handling of the ureter at the time of dissection -An adequate peri-urethral tissue in the ‘golden triangle’ must be carefully preserved.
– Short ureter length; and fixation to prevent kinking or twisting.
Outcome: short-term and long-term effects on graft function and survival
– Longer length of hospitalization. – More readmission. – More DGF. – Reduced graft survival
– Graft loss.
-Please summarise this article
-The first few days after kidney transplantation are the most critical in determining the fate of the graft and the recipient.
-Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of these operations. URETEROVESICAL ANASTOMOSIS AND A COMPARISON OF ASSOCIATED COMPLICATIONS
-TheLich–Grégoir technique is significantly associatedwith a lower incidence of urinary leakageand of haematuria compared to the Politano-Leadbetter technique. UROLOGICAL COMPLICATIONS DURING THE POST-OPERATIVE PERIOD IN KIDNEY TRANSPLANT RECIPIENTS
The most common surgical urology complications include urine leakage, ureteral obstruction, and lymphocele.
– In cases of urine leak, the patient may have a fever, pain over
the graft, and fluid leakage from the wound.
– The stents are generally well tolerated, but when longer stents are used (stent length: ≥20 cm), or if used for longer periods (>6 weeks), they may result in stent-related complications including infection, migration, and encrustation.
-Management is to maximally decompress the urinary system. This is achieved by inserting a urethral catheter, as well as performing a
nephrostomy or placing an antegrade ureteric stent. The drain is left in situ. If this technique fails, or if large-volume extravasation occurs, surgical exploration to reimplant the transplant ureter
becomes necessary.
– A long ureter is liable to kinking and obstruction as a result of
ischaemia .
-Atrophic bladder or dysfunctional bladder in the recipient may result in bladder perforation or anastomotic dehiscence.
-Proximal calyceal leak may occur because of lower pole artery complications .
-Damage to the ureter during dissection may result in ureteric ischaemia, necrosis, and distal leak. Signs and Symptoms
Varied symptoms can occur as a result of kidney transplant, including local (graft pain and tenderness, and local swelling over the graft)
and systemic (fever, tachycardia, hypotension,
and tachypnoea).
– Signs may be masked because of immunosuppression and analgesics. Investigations
The following investigations are helpful in evaluating extraperitoneal urine leak post kidney transplantation, and to rule out differential diagnoses:
-Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
– U/S.
-Doppler ultrasonography can be used to identify defects in perfusion.
-CT or MRI scans .
-An intravenous pyelogram may be helpful to identify location of the leak.
– Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak.
-Retrograde cystography .
-Antegrade pyelogram testing .
Identifying Extraperitoneal Urine Leak Post Kidney Transplantation
-If drain fluid creatinine and potassium values are not dissimilar
from the serum values, then the possibilities of lymphocele or seroma are higher. However, if they are significantly higher than the serum values, or are values that are incompatible with life, then it
is a urine leak or urinoma.
– Urinoma will easily be picked up on an ultrasound scan or nuclear scan
-Antegrade pyelogram, cystogram, or scintigraphy may be required to identify the cause and to localise the leak. DIFFERENTIAL DIAGNOSIS AND CLINICAL REASONING
Haemorrhage
Urinary Fistula
Perinephric Abscess
Lymphocele and Seroma Urine Leak and Urinoma
-Urine leaks post kidney transplantation may manifest as free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma). Different clinical presentations of urine leak
-It defined by a persistent low urine output through drains, associated
with low urine output, graft site swelling, pain , and intra-abdominal leak, which presents with an acute abdomen. Evidence-based management plan in extraperitoneal urine leak
-Low-volume leak at the anastomotic site can be managed conservatively by performing maximum decompression.
– If the fluid collections become infected, or cause ureteral obstruction and extrinsic compression on the ureter, then urgent
percutaneous drainage is required.
-Surgical re-exploration and reimplanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain. Preventive measures: importance of the golden triangle
-During harvesting of the donor kidney, gentle handling of the ureter at the time of ureteral dissection is crucial to prevent urine leak post kidney transplantation. An adequate periurethral tissue in the ‘golden triangle’ must be carefully preserved. Outcome of extraperitoneal urine leak:
-Surgical complications can cause graft loss post kidney transplantation.
-Surgical complications after kidney transplants lead to prolonged hospitalisation and decreased graft survival. What is the level of evidence provided by this article?
Level 5
This article describes early post transplant complications , especially urine leak.
In early pos transplant period it is very important to monitor graft functions and look for any complications. Urine leak may resent in different ways like high drain output , effect on graft functions , ileus or systemic signs of sepsis. So index of suspicion should be high. Multiple factors can lead to collection in extraperitoeal spaces and urine leak. Common factors can be catheter blockages, stent migration.
, technical issues with ureteric reimplantation, ischemia etc.
Techniques of Ureter reimplantation
These include-
Lich–Grégoir
Politano-Leadbetter
U-stitch
Lich–Grégoir is most commonly used with less chances of reflux and bleeding. Submucosal tunnel principle- Ureteric diameter to tunnel length- Ratio should be 1:5. Mucosa to mucosa stitch
Other complications
Urine leakage
Uureteral obstruction
Lymphocele.
Complications caused by the length of the transplanted ureter
Atrophic bladder or dysfunctional bladder
Proximal calyceal leak
Damage to the ureter
Presentation of Urine leak
It can present with fever, pain over the graft, and fluid leakage from the wound. The presentation can be masked by immune suppression.
Differential diagnosis
Urine leak
Haemorrhage
Lymphocele
Perinephric abcess
Seroma
Investigations
1- Compare drain creatinine and potassium levels with serum
2-Ultrasound scan
3- Doppler ultrasound
4-CT/MRI
5- MAG 3 renal Scan
6- Cystogram
7-Antegrade Nephrostogram
Management Principles.
Gentle dissection in Golden triangle
Identify and confirm urine leak
Put the urethral catheter
Leave the drain in
Antibiotic cover
Percutaneous nephrostomy
Antegrade JJ stenting if already not stented.
Anticholenergics
If urine leak does not settle then sometime exploration is required. Options include revision of ureteroneocystostomy, ileal ureter, Boari flap or use of native ureter
Urine leak is usually due to error in ureteric reimplantation or uereteric ischemia. Gentle dissection in Golden triangle and safegaurding periureteric tissue and vascularity.
The outcomes can be affected by urine leak. There can be an effect on graft function including delayed graft function and graft loss.
Summary:
Introduction:
The article is about the occurrence of urine leaks in patients that are post-transplant. Urine leaks may occur after a few days post-transplant. It is very important due to the fact that it can determine the outcome of the graft. The incidence of urine leaks is about 1.2-8.9%. A urine leak can be categorized into two groups one is a low-volume urine leak that can be managed conservatively and the other one is a large-volume leak that needs to be explored surgically to be corrected. The aim of the article was to discuss urine leaks in the post-operative period and their differential diagnosis.
There were some surgical techniques used that were used to see which one is associated with the most complications. Surgical techniques like:
1) LICH-GREGOIR, Politano-Leadbetter, and U-stitch techniques. The LICH-GREGOIR had less incidence of a urine leak, with less hematuria and fewer complications as it related to the other techniques.
Some of the surgical complications are:
1) Urine leakage
2) Ureteral obstruction
3) Lymphocele
4) Others are atrophic or dysfunctional bladder, proximal calyceal leak, and also damage to the ureter.
To diagnose the urine leak, investigations must be done. They can be:
1) A comparison of serum creatinine and potassium with drain creatinine and potassium
2) The next important one is ultrasound to see areas affected.
3) Doppler ultrasound or duplex ultrasound can be done to see renal perfusion, etc.
4) Intravenous pyelogram is needed to identify the origin of the leak
5) Retrograde cystography can be done
6) Antegrade pyelogram can be performed once the nephrostomy is placed to help to localize the urine leak.
7) CT and MRI can be done but it will not show where the urine leak is from but may give details about if there is the perinephric collection and pelvicalyceal dilatation.
Some of the differential diagnoses are:
1) Haemorrhage
2) Urinary fistula
3) Perinephric abscess
4) Lymphocele and seroma
5) Urine leak and urinoma:
Once the urine leak has been diagnosed, the aim is to manage to avoid or prevent the graft from functional or rejection, or failure. The management plan is:
1) low volume leak. This type is treated conservatively. A foley catheter or ureteral stent can be placed by performing a nephrostomy. It can be removed in about 4-6 weeks
2) High urine leak. This problem will need an intervention that is surgical to explore and reimplantation.
How to prevent leakage: the golden triangle importance?
The ureter must be handled gently at the time of ureteral dissection during the harvesting. This is important as it will prevent urine leakage
Periurethral tissue must be preserved as much as possible in the golden triangle.
In conclusion, surgical techniques are very important and as they relate to the different types the most important one with less complication is the LICH-GREGOIR.
If a leak is detected, depending on the volume if it is low or high volume, the low volume can be managed conservatively while the high volume must be managed surgically.
It must be noted that urine leaks can cause longer hospitalization stays and more readmission with possible graft-delayed function or possibly other complications like infection.
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
Hussam Juda
2 years ago
INTRODUCTION
· Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of these operations
· Low volume leak may improve without intervention
· Surgery indicated for large volume leak, or if low volume not resolved conservatively.
URETEROVESICAL ANASTOMOSIS AND A COMPARISON OF ASSOCIATED COMPLICATIONS
· Lich–Grégoir technique of ureterovesical anastomosis, associated with a lower incidence of urinary leakage
· also incidences of haematuria with the Lich–Grégoir method is less than other techniques
UROLOGICAL COMPLICATIONS DURING THE POST-OPERATIVE PERIOD IN KIDNEY TRANSPLANT RECIPIENTS
1. The most common surgical urology complications include urine leakage, ureteral obstruction, and lymphocele
· urine leak, induces fever, pain over the graft, and fluid leakage from the wound
· Intraoperative stenting of the ureter in kidney transplant recipients lessen the effects of ureteric complications but does not reduce the incidence of these complications
· Stent length>20 cm, or used for >6weeks, increases risk of infection, migration, and encrustation
· Leak treated with inserting a urethral catheter, and nephrostomy or placing an antegrade ureteric stent
2. Other urological complications include:
· A long ureter may cause kinking and obstruction due to ischaemia, and short ureter may not achieve tension-free anastomosis
· The recipient bladder atrophy or dysfunction, may cause perforation of bladder.
· Proximal calyceal leak may occur secondary to lower pole artery complications
· Damage to the ureter during dissection may cause ureteric ischaemia, necrosis, and distal leak
Investigations
· Compare drain creatinine and potassium levels with serum creatinine and potassium levels
· ultrasonography detects perinephric collection and dilatation of the pelvicalyceal system
· Perfusion defects detected with Doppler ultrasonography
· CT or MRI detect the perinephric collection and pelvicalyceal dilatation
· An intravenous pyelogram may be helpful to identify location of the leak
· Focal tracer scintigraphy can identify the location of the leak, but not useful if there is delayed graft function or ureteral stasis
· Retrograde cystography useful to diagnose urinary bladder dehiscence
· Antegrade pyelogram testing via a nephrostomy may accurately identify the location of the leak
Identifying Extraperitoneal Urine Leak Post Kidney Transplantation
· extraperitoneal urine leak should be suspected if the is high volume of clear drain fluid
· Ultrasonography, CT scan or MRI, and fluid biochemistry may support the diagnosis
· Antegrade pyelogram, cystogram, or scintigraphy may be required to identify the cause and to localise the leak
DIFFERENTIAL DIAGNOSIS AND CLINICAL REASONING
· Haemorrhage is not a common complication after kidney transplantation. If it occurs, it is usually from the vessels in the graft hilum that are not ligated, or from small, severed retroperitoneal vessels
· Urinary fistula occurs in 2–5% of kidney transplantations, and may lead to significant morbidity, graft loss, and mortality
· Perinephric abscesses uncommon, usually present in the first few weeks’ post-transplant
· Lymphoceles occur in 1-20% of kidney transplant operations and may occur from as early as 2 weeks to as late as 5 years post-transplant.
· Laparoscopic drainage is the method of choice for the treatment of post-transplant lymphocele. However, open drainage is preferred over laparoscopic technique in patients with wound complications
· Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of cases
Different clinical presentations of urine leak
· Early extraperitoneal high-volume leak;
· Early extraperitoneal small leak
· Late leak (1–2 weeks after transplant), due to ureter necrosis or early removal of double J stent
· intra-abdominal leak, which presents with an acute abdomen
Evidence-based management plan in extraperitoneal urine leak
· Low-volume leak at the anastomotic site: conservative
· Foley catheter and ureteral stent performing a nephrostomy for decompression
· Infected fluid collections or compression on the ureter: urgent percutaneous drainage
· Surgical re-exploration and reimplanting the transplant ureter if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain
Preventive measures: importance of the golden triangle
· Important factors that help to prevent major urological complications:
delicate dissection of the ureter during donor nephrectomy to preserve adventitia; fat and blood supply of the ureter; short ureter length; and fixation of the adventitia, fat, and blood supply of the ureter to the bladder wall to prevent kinking or twisting Outcome of extraperitoneal urine leak: short-term and long-term effects on graft function and survival: urological complications post kidney transplant may lead to prolonged hospitalisation and reduced graft survival
CONCLUSION
· The Lich-Grégoir technique has a significantly lower incidence of urinary leakage compared to the Politano– Leadbetter procedure
· Risk factors for urine leak: ureteroneocystostomy error, vascularity defect of the transplanted ureter
· multiple renal arteries is also a risk factor for development of urological complications post kidney transplantation
· The color of the drained fluid and odor may indicate the development of a urological complication
· Ultrasonography, CT, or MRI may help to arrive at a diagnosis. Doppler ultrasonography, contrast pyelogram, focal tracer scintigraphy can be useful
· If conservative treatment failed, surgical exploration and correction may become necessary
What is the level of evidence provided by this article?
Evidence 5
I like your emphasis on preserving the tissues, mentioned as ‘Golden Triangle’. I agree it is level 5 evidence. Ajay
Hussein Bagha baghahussein@yahoo.com
2 years ago
This article describes how to identify an extra-peritoneal leak post-transplantation and how to manage it
Introduction:
The number of kidney transplants are increasing worldwide due to its superior benefits over dialysis. However, graft dysfunction, especially in the early post-transplant period can affect the survival of the graft. Early graft dysfunction can be due to surgical complications or due to acute rejection.
Urological complication rates vary from 2.5%-30% and can include urinary leak, urinary fistula, lymphocyte, and ureteral obstruction.
Urine leak is an early post operative complication after kidney transplant and occurs in 1.2%-8.9% of surgeries.
Ureterovesical Anastomosis:
Many different techniques are used to achieve ureterovesical anastomoses in kidney transplantation. These include:
Lich-Gregoir method – Has the lowest incidence of urinary leakage and hematuria
Politano-Leadbetter method
U-stitch technique
The authors concluded that Lich-Gregoir technique is better as it results in fewer urological complications
Use of ureteric stents during kidney transplant helps to mitigate the effects of the ureteric complications but does not reduce the incidence of these complications. The stents are generally well tolerated but they can lead to infections and can migrate.
Signs and symptoms:
The signs and symptoms of a urinary leak are varied and quite non-specific. They include:
Fever
Pain and tenderness over graft site
Localized swelling over the graft
Tachycardia
Hypotension
Tachypnea
Investigations:
The following investigations are helpful in evaluating extraperitoneal urine leak post kidney transplantation:
Effluent creatinine and potassium levels compared to serum creatinine and potassium levels
Ultrasound – Helps to identify and define perinephric collections and dilatation of the pelvicalyceal system
Doppler US to rule out perfusion defects
MCUG – can help to detect bladder dehiscence
IV pyelogram – can help to identify the site of the clinic
CT scan/MRI – To identify and define perinephric collections
Focal tracer scintigraphy – Not useful if there is delayed graft function or ureteral stasis
Antegrade pyelogram
Differential Diagnosis
Hemorrhage
Urinary fistula
Perinephric abscess
Lymphocele and seroma
Management:
The initial management of a urinary leak is to decompress the bladder by inserting a urethral catheter as well as by inserting a nephrostomy tube of an antegrade stent. The stent should be left in situ for six weeks. If an infection develops, then exploratory laparotomy should be done. If the decompression fails, then re-anastomoses of the ureter to the bladder should be done
Conclusion:
Urologic complications post=kidney transplant are common. Urinary leak occurs 1.2%-8.9% of surgeries. It may be present with fever, graft tenderness and localized swelling over the graft. It can lead to graft dysfunction. The Lich-Gregoir technique for ureterovesical anastomoses had the least incidence of urological complications and hematuria. The management of a urine leak is to maximally decompress the bladder and put in a ureteric stent. If the site of leak does not heal then re-anastomes of the ureter to the bladder needs to be carried out.
Level of Evidence
It is level V evidence as it is a systemic review
This article discusses about early post transplant surgical complications, especially extraperitoneal high volume urine leaks.
INTRODUCTION
Initial few days post transplantation are quite critical and close monitoring is needed to anticipate graft dysfunction or post operative complications earliest.
urine leak is a early post-operative complication in kidney transplantation. Low volume leaks usually resolve spontaneously but if there is no resolution or leak volume is high, then surgical exploration is usually indicated. Techniques of ureterovesical anastomosis
Lich–Grégoir (associated with significantly lower incidence of urine leak, hematuria in comparison to other techniques as per meta analysis )
Politano-Leadbetter
U-stitch techniques
To prevent reflux during voiding, the ureterovesical anastomosis must
be tension-free and protected by at least a 1 cm submucosal tunnel.
Urological complications during post operative period
Urine leak
lymphocele
ureteral obstruction
Urine leak is usually associated with fever, pain over graft and fluid leak from the wound.
The first step in urine leak management is to decompress the urinary system by either:
inserting a urethral catheter
performing a nephrostomy
placing an antegrade ureteric stent.
If this technique fails or if large-volume extravasation occurs, surgical
exploration to reimplant the transplant ureter is the modality of choice.
Other urological complications
Long ureter causing kinking, obstruction and ureteric ischemia
Bladder perforation or anastomotic dehiscence in case of dysfunctional bladder
Ureteric damage during dissection causing ureteric ischemia and necrosis
Colour of the drained fluid can be quite helpful in guiding towards diagnosis.
Investigations:
Drain fluid creatinine and potassium vs that of serum
ultrasonography to identify and define the collection
Doppler USG to identify defects in perfusion
Ct / MRI scans
Reterograde cystography to look for bladder dehiscence
Antegrade pyelogram to assess the location of leaks
Differential diagnosis
Haemorrhage
Urinary fistula
Perinephric abscess
Lymphocele
Presentations of urine leak
Low urine output
Graft site swelling
Pain
Acute abdomen due to intraperitoneal leak
management of urine leak
decompression of leak by DJ stent / foleys catheter / Nephrostomy
Antegrade pyelogram to identify leak site
If fluid becomes infective then urgent percutaneous drainage is needed
Surgical re-exploration and re-implanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail.
Preventive measures: The golden triangle
Technical errors in urine leak
erroneous ureteroneocystostomy
erroneous graft ureter implantation in bladder
compromised vascularity of ureter
During harvesting of the donor kidney, gentle handling of the ureter at the time of ureteral dissection is crucial to prevent urine leak post kidney transplantation.
The ‘golden triangle’ is bound by the lower border of the junction
between the renal vein and the inferior vena cava on the right, lower pole of the kidney on the left and the gonadal vein. There should be adequate periurethral tissue in the ‘golden triangle’
#Please summarise this article
# The aim of the study:
To discusses the identification of extraperitoneal urinary leak in a KTR in the post operative period, as well as the clinical clues that help to rule out the differential diagnoses.
* Early post kidney transplantation are the most important period in determining the outcome of the recipient and graft survival.
*Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% .
*This leaks may be of low volume which subside with conservative management and provided there is no distal obstruction. If not resolved, or it is large-volume, surgical exploration and correction may be needed.
#The ureterovesical anastomosis techniques:
1) Lich–Grégoir technique
2) Politano-Leadbetter technique
3) U-stitch technique.
*Alberts et al. in meta-analyses showed that the Lich–Grégoir technique has a lower risk of urinary leakage and haematuria compared to other methods.
*To prevent reflux during voiding, the ureterovesical anastomosis must be tension-free and protected by at least a 1 cm submucosal tunnel.
# Urological complication during the post operative period in KT recipients
*Urine leakage
*Ureteral obstruction
*Lymphocele
* Stent-related complications (infection, migration, and encrustation)
* Kinking and obstruction of ureter
* Atrophic or dysfunctional bladder
* Proximal calyceal leak
* Damage to the ureter during dissection (ureteric ischaemia, necrosis, and distal leak)
# The incidence rates of urological complications range from 2.5% to 30.0% of all recipients.
# Signs and Symptoms
A)Local: (graft pain, tenderness and swelling over )
B)Systemic: (fever, tachycardia, hypotension, and tachypnoea).
*Signs may be masked because of immunosuppression and analgesics.
# Investigations
*Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
*Ultrasonography to identify the perinephric collection and dilatation of the pelvicalyceal system.
*Doppler ultrasonography to identify defects in perfusion.
*CT or MRI scans to identify the perinephric collection and pelvicalyceal dilatation.
*An intravenous pyelogram to identify location of the leak.
*Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak.
*Retrograde cystography for urinary bladder dehiscence.
*Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak.
# Differential diagnosis and clinica reasoning
***Haemorrhage:
*Not a common complication PKT.
* It is usually from the vessels in the graft hilum that are not ligated, or from small, severed retroperitoneal vessels, other risk factors recipient obesity, use of antiplatelet agents, and anticoagulation.
*The presentation are haemorrhagic drain, tachycardia, anaemia, local swelling over the graft, hypotension.
*Bleeding usually stops spontaneously. But, if there haemodynamic instability or compression of the kidney by haematoma, surgical re-exploration may be required.
***Urinary Fistula
*Occurs in 2–5% of KT.
*Result in significant morbidity, graft loss and mortality
* Ureteral ischaemia, necrosis and technical problems are most important causes.
* The risk factors include younger age, uretero-ureteric anastomosis, use of high-dose steroids in immunosuppression, number of renal arteries, and bladder problems.
*The management by different techniques including ureteral ligature and nephrostomy, ureteroureterostomy, pyeloureterostomy, ureteroneocystostomy, percutaneous nephrostomy and ureteral stenting, and prolonged vesical drainage.
***Perinephric Abscess
*Uncommon complications. present in the early PKT.
* The causes include pyelonephritis, infection of lymphocele, haematoma, or urinoma.
***Lymphocele and Seroma
*It is collection of lymph in the perigraft area. Occur in 1-20%.
*May occur from as early as 2 weeks to as late as 5 years PKT.
* Usually they are small and asymptomatic which require no intervention, but may present with features of compression symptoms (retention of urine, decreased urine output, elevated serum creatinine, thrombosis of iliac vein, and limb oedema).
*In lymphocele and seroma, the drainage fluid is clear and If drain fluid creatinine and potassium values are not much different from the serum values, then the possibilities of lymphocele or seroma are higher.
* Treatment options include aspiration (nearly 100% chances of recurrence), percutaneous drainage (50% success rate), drainage by laparoscopic method, or open marsupialisation.
*Laparoscopic drainage is better for the treatment of PT Lymphocele, while open drainage is preferred over laparoscopic in wound complications and small lymphocele adjacent to vital renal structures, which increases the risk of vessel or ureter injury.
***Urine Leak and Urinoma
*Early post-operative complication occurs in 1.2–8.9% of cases.
*Manifest as free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma).
# Different clinical presentations of urine leak
*Early extraperitoneal high-volume leak
*Early extraperitoneal small leak.
* late leak (1–2 weeks PKT)
*Intra-abdominal leak, which presents with an acute abdomen.
# Evidence-based management plan in extraperitoneal urine leak
*Low-volume leak at the anastomotic site can be managed conservatively by performing maximum decompression (by lacing a Foley catheter and ureteral stent performing a nephrostomy).
* Antegrade pyelogram to identify the site of the leak is helpful.
*If the fluid collections become infected, or cause ureteral obstruction and extrinsic compression on the ureter, then urgent percutaneous drainage is required.
* Surgical re-exploration and reimplanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain.
# Preventive measures: importance of the golden triangle
* During harvesting of the donor kidney, gentle handling of the ureter at the time of ureteral dissection is crucial to prevent urine leak PKT.
*An adequate periurethral tissue in the ‘golden triangle’ must be carefully preserved.
*Delicate dissection of the ureter during donor nephrectomy to preserve adventitia; fat and blood supply of the ureter; short ureter length; fixation of the adventitia, fat, and blood supply of the ureter to the bladder wall to prevent kinking or twisting.
# What is the level of evidence provided by this article?
* Level (5)
Hi Dr Amiri, I like your emphasis on preserving the tissues, mentioned as ‘Golden Triangle’. 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
Esraa Mohammed
2 years ago
*Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of these operations.
*Many different techniques are used to achieve ureterovesical anastomosis in kidney transplantation wiyh different outcome.
*The rates of urological complications range from 2.5% to 30.0% of all recipients.
The most common Are: 1-urine leakage 2-ureteral obstruction 3- lymphocele
*Other urological complications include:
-Complications caused by the length of the transplanted ureter.
-Atrophic bladder or dysfunctional
-Proximal calyceal leak
-Damage to the ureter during dissection
*Signs and Symptoms
–local (graft pain and tenderness, and local swelling over the graft) -systemic (fever, tachycardia, hypotension, tachypnoea)
Signs may be masked because of immunosuppression and analgesics.
A high index of suspicion is warranted in a patient with
high drain output
Investigations
1-Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
2- ultrasonography to define perinephric collection and dilatation of the pelvicalyceal system.
3-Doppler ultrasonography can be used to identify defects in perfusion.
4-CT or MRI scans are a useful tool to identify and define the perinephric collection and pelvicalyceal dilatation.
5-An intravenous pyelogram may be helpful to identify location of the leak.18
6-Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to
identify the location of the leak. This technique is not useful if there is delayed graft function or ureteral stasis.
7-Retrograde cystography helps clinicians to look for urinary bladder dehiscence.
8-Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak. This can be done in delayed graft function scenarios too.
Pelvicalyceal dilatation makes it easier to do
this procedure.26
DIFFERENTIAL DIAGNOSIS AND CLINICAL REASONING
>Haemorrhage
>Urinary Fistula
>Perinephric Abscess
>Lymphocele and Seroma
>Urine Leak and Urinoma
Evidence-based management plan in extraperitoneal urine leak
*Low-volume leak can be managed conservatively by performing maximum
decompression By Placing a Foley catheter and ureteral stent performing
a nephrostomy and the patient is carefully followed-up.
*If the fluid collections become infected, or cause ureteral obstruction and
extrinsic compression on the ureter, then urgent
percutaneous drainage is required.
*Surgical re-exploration and reimplanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain
Outcome of extraperitoneal urine leak:
short-term and long-term effects on graft
function and survival
Surgical complicationsmay lead to prolonged hospitalisation
and reduced graft survival
* the patients with urine leak had a statistically significant
longer length of hospital stay, more readmissions,
more delayed graft function, and lower rates
of graft survival.
● Urine leak is an early complication after kidney transplantation
● occurs in 1.2–8.9% of these
● Most techniques used to ureterovesical anastomosis in kidney transplantation include :
** the Lich–Grégoir
** Politano-Leadbetter
** U-stitch techniques
● Lich–Grégoir technique is associated with a lower urinary leakage and haematuria compared to the Politano-Leadbetter technique.
● The most common surgical urology complications include
** urine leakage
** ureteral obstruction
** lymphocele
● The rates of urological complications range from 2.5% to 30.0% of all recipients.
● urin leak manifest with a fever, tachycardia, hypotension, and tachypnoea
pain and swelling over the graft, and fluid leakage from the wound.
● in case of urin leak inserting a urethral catheter, as well as performing a nephrostomy or placing an antegrade ureteric stent.
● If this technique fails, surgical exploration to reimplant the transplant ureter becomes necessary.
● Other urological complications include:
** Ureter kinking and obstruction
** A short ureter may not be appropriate for achieving tension-free anastomosis.
** Atrophic or dysfunctional bladder may result in bladder perforation or anastomotic dehiscence.
** Proximal calyceal leak
** Ureteric ischaemia, necrosis, and distal leak.
● Drained fluid’s colour and odour important to assess urological complications
● Investigations includes comparsion drain creatinine and potassium levels with serum creatinine and potassium levels
● Urinoma will easily be picked up on an ultrasound scan or nuclear scan
Antegrade pyelogram, cystogram, or scintigraphy may be required to identify the cause and to localise the leak.
● If drain fluid creatinine and potassium values are similar to the serum values, then the possibilities of lymphocele or seroma are higher.
● DIFFERENTIAL DIAGNOSIS
** Haemorrhage
** Urinary Fistula
** Perinephric Abscess
** Lymphocele and Seroma
● Urological complications post kidney transplant may lead to prolonged hospitalisation and reduced graft survival
● Extraperitoneal low-volume urine leak may be managed conservatively by Foley catheterisation, nephrostomy, and placement of an antegrade ureteric stent. If conservative management fails, or if there is extraperitoneal high-volume leak,
then surgical exploration and correction may become necessary.
● Level 5
Dear Dr Huda, 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
Amit Sharma
2 years ago
Please summarise this article
Early post-transplant period is very crucial in determining the long-term graft and recipient outcomes. Urinary leak in early post-operative period is seen in 1.2-8.9% with the low-volume leaks requiring conservative management alone while the large-volume urinary leaks require surgical intervention.
The most common techniques used for ureterovesical anastomosis (which should be tension-free and with a submucosal tunnel of minimum 1 cm) include Lich-Gregoir (having lower incidences of hematuria and urine leak), Politano-Leadbetter, and U-stitch techniques.
Post-operative urologicalcomplications in kidney transplant, with a frequency of 2.5% to 30%, include urine leak, ureteral obstruction (due to kinking of long ureter or ischemic damage to ureter), and lymphocele. Prophylactic ureteric stenting can mitigate the effects of ureteric complications, but not the incidence of these complications. Stent use is associated with complications like infection, migration, encrustation etc.
Signs and symptoms of urine leak include fever, pain and swelling at the graft site, decreased urine output, and increased drain fluid. Late (1-2 weeks post-transplant) presentation is with acute abdomen features.
Investigations for evaluating urine leak include drain fluid creatinine and potassium (higher than serum values in case of urine leak), ultrasound (for perinephric collection and pelvicalyceal system dilatation), Doppler ultrasound (for perfusion defects), CT or MRI (if ultrasound is non-conclusive), IVP, antegrade pyelogram or scintigraphy for identifying location of leak, and retrograde cystography for urinary bladder dehiscence.
Differential diagnosis:
1) Hemorrhage: presents with bloody drain and hypotension, anemia, bleeding, hematoma on imaging. May require surgical exploration, if severe.
2) Urinary fistula: due to ureteral ischemia and necrosis, and needs surgical intervention.
3) Perinephric abscess: It happens due to infection of lymphocele, hematoma or urinoma, and requires aspiration and antibiotics.
4) Lymphocele and seroma: They have clear fluid with the fluid creatinine and potassium similar to that of serum. Aspiration is associated with recurrence. Laparoscopic drainage is treatment of choice.
Management of urine leak include decompression of the urinary system by urethral catheterization, nephrostomy or antegrade ureteric stenting for low-volume leaks, or exploration and ureteric reimplantation in large volume leak. Percutaneous drainage is required if the fluid collection compresses ureter or gets infected. The stent should be removed 4-6 weeks after stopping of the urinary leak.
Prevention: it can be achieved by avoiding technical errors including using Lich-Gregoir technique, meticulous dissection, and preserving periureteral tissue in the ‘golden triangle’.
Outcomes: Urine leak is associated with prolonged hospital stay, increased readmissions and delayed graft function, and reduced graft survival. Follow-up is required in case of conservative management.
What is the level of evidence provided by this article?
Dear Dr Amit I am not sure if MRi is a choice of imaging in patient with urine leak. I agree it is level 5 evidence. Ajay
KAMAL ELGORASHI
2 years ago
Summary of the Article; Perioperative area is vital in the success of the graft, which involve a close monitiring of all graft parameters. Drain fluid colour in the post operative period can make a remark for urological complication, (clear, hemorrhogic, or purulent). Post-operative concerns;
Post -surgical complication.
Graft dysfunction.
Graft rejection.
Drug immunosuppressant levels.
Infection.
General wellbeing of Donor and recipient.
Urological complications during the post-operative period in kidney transplant recipients; The most common;
Urine leakage.
Ureteral obstruction.
Lymphocele.
Urological complication ranging from 2.5-30% of all recipients. Manifestation of urine leak;
Fever.
Pain over the graft.
Fluid leakage from the wound.
So intraoperative prophylactic stenting to avoid such complication but does not affect the rate of occurrence. Stent are usually tolerated, but some complication may develop specially if stent was long >20 cm, or used for longer period. Stent related complication;
Infection.
Migration.
Encrustation.
Urological complication;
Complication related to the transplanted ureter length; as the longer ureter associated with kinking and obstruction, as a result of ischemia. And there is a tension anastomosis if the transplanted ureter is short.
Atrophic bladder or dysfunctional bladder, especially in chronic anuria associated dialysis, this may result in bladder perforation or anastomosis dehiscence.
Proximal calyceal leak ; occur because of lower pole artery complications, (thromboses, ligation, or not reconstructed).
Damage to the ureter during dissection may result in ischemia, necrosis, and distal leak.
Signs and Sympoms; Local;
Graft pain or tenderness.
swelling over the graft.
Systemic;
Fever.
Tachycardia.
Hypotension.
tachypnoea.
Signs some times masked because of immunosuppressant medication, analgesics and antibiotics. Investigation;
Comparison between drain, (Cr and K) to serum Cr and K.
US, to detect collection, dilatation of pelvicalyceal system.
Doppler US, for perfusion defects.
CT or MRI, for more sensitive, definite, detection, of collection or system dilatation.
An intravenous pyelogram, to identify location of the leak.
Focal tracer scintigraphy, to identify leak location.
Retrograde cystography, to identify bladder dehiscence.
Antegrade pyelogram testing through a nephrostomy, may accurately identify the location of the leak, especially in pelvicalyceal dilatation.
Identifying Extraperitoneal Urine leak, post kidney Tx; 1.High fluid volume, US-CT-MRI, fluid biochemistry, can help diagnosis. 2.The possibility of lymphocele or seroma, are higher if fluid Cr and K, are not dissimilar to serum Cr and K. 3.Urinoma or urinary leak are possible if fluid Cr and K are very high or incompatible with life. Differential diagnosis;
Hemorrhage; hemorrhagic drain, and signs of tachycardia, anemia, local swelling over the graft, or bleeding. Diagnosed by same measures. Treated by urgent exploration, if not controlled or spontaneous stopping, and itis not common but usually from vascular origin, or from recipients factors,(obesity, antiplatelet, or anticoagulant).
Urinary fistula; occur in 2-5% of KTs, can lead to significant morbidity, graft loss, and mortality. Ureteric ischemia, and necrosis associated with transplant procedure. risk factors are, younger recipients, uretero-ureteric anastomosis, high dose steroids, multiple renal arteries, and bladder problems.
Peri-nephric abscess; uncommon complication, usually in early KT period, drain fluid usually purulent, with signs of infection.
Lymphocele and seroma; collection of lymph in peri graft area, occur in 1-20% of KTs, occur as early as 2 weeks to as late as 5 years, usually asymptomatic, and need no intervention, may present as compression symptoms, and AKI, some association between sirolimus use and lymphocele and seromas. Treatment option include, drainage, percutaneous drainage, by laparoscopic (preferred) or open marsupialization.
Urine leak and Urinoma; Occur in early post Tx period, 1.2-8.9% of cases. Like free fluid, extravasated or loculated.
Different ureteric leak clinical presentation;
Early extraperitoneal high volume leak.
Early extraperitoneal small volume leak.
manifested by urine from the drain, reduce UOP, graft side swelling, and pain. Intra-abdominal leak may present as an acute abdomen.
Evidence based management plan in extraperitoneal urine leak;
Low- volume leak, managed conservatively.
Placing of folly catheter, and ureteral stenting used for decompression, and removed when the leak is stoped, with carefull followup.
If fluid infected, or cause ureteral obstruction, then urgent percutaneous drainage is required. Re-explaoration and re-implantation if conservative measurement failed.
Golden triangle; Bounded by the lower border of the junction between the renal vein and the IVC on the right, lower pole of the kidney in the left side, and the gonadal vein.
The peri-urethral tissue must be carefully preserved ( the golden triangle). Care to be taken to prevent complication; delicate dissection, to prevent adventitia, fat and blood supply, short ureter length, fixation of the adventitia, fat, and blood supply of the ureter to the bladder wall to prevent kinking or twisting. Outcome of the extraperitoneal urine leak, short and long-term on graft function and survival;
Buggs et al.; a Retrospective cohort study for 36 urine leak out off 1,308 KTs, found that, patient with urine leak had a lower long of hospital stay, more readmission, more DGF, and lower rate of graft survival.
Carvalho et al.; Observational cross-sectional study; in 3102 recipients, found that, most common complication is the ureteral obstruction, in 85 patients, urinary fistula in 72 patients, and assocaiated with longer hospitalisation and decreased graft survival.
Conclusion;
Different ureteroneocystostomy techniques, (Lich-Gregoir, Politano-Leadbetter, and U-stitch), have an impact on ureteric leak.
Damage of the vassels during harvesting the donor kidney usually lead to the ureteric leak.
Multiples arteries also considered as a risk factor of ureteric leak.
Ureteric leak associated with longer hospital stay, DGF, and reduce graft survival.
Dear Dr Kamal, I am not sure if MRi is a choice of imaging in patient with urine leak. I like your emphasis on preserving the tissues, mentioned as ‘Golden Triangle’. I agree it is level 5 evidence. Ajay
thank you Prof; Ajay
MRI i found it on my search, it may be an other option if the issue is beyond than urine leak or lymphocele.
Thank you.
Mohammad Alshaikh
2 years ago
Please summarise this article Urinary complications after kidney transplantations are – Urinary leak /urinoma – 1.2-8.9% – complications caused by the length of the transplanted ureter, proximal calyceal leak may occur because of lower pole artery complications,or distal due to ureteric ischaemia, necrosis, or anastomosis dehiscence due atrophic dysfunctional bladder. – Ureteral obstruction – Lymphocele-incidence 1-20% depends on how gentle the kidney harvested, occurs 2 weeks – 5 years post transplant, usually asymptomatic but can produce obstructive symptoms – Haemorrhage– drop hematocrit, hemodynamic instability me be the presentation usually early post transplant. – Urinary fistula- incidence 2–5% associated with 8% mortality, and high risk for graft loss. – Perinephric abscesses – fever, swelling, tenderness over the graft.
Investigations to differentiate: – Compare drain creatinine and potassium levels with serum creatinine and potassium levels, if both are high to levels incompatible with life support diagnosis of urine leak. – Ultrasonography to identify and define the perinephric collection and dilatation of the pelvicalyceal system. – Doppler ultrasonography can be used to identify defects in perfusion. – CT or MRI scans are a useful tool to identify and define the perinephric collection and pelvicalyceal dilatation. – An intravenous pyelogram may be helpful to identify location of the leak. – Focal tracer scintigraphy used to identify the location of the leak. This technique is not useful if there is delayed graft function or ureteral stasis. – Retrograde cystography helps clinicians to look for urinary bladder dehiscence. – Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak.
Surgical procedures and their outcomes: – Lich-Gregoir has the lowest risk of urinary leak, and less hematoma. – Politano–Leadbetter – U-stitch techniques Risk factors for urine leak are : compromised ureter vascularity ,may be damaged while harvesting the kidney, multiple renal arteries, adequate periurethral tissue in the Golden triangle must be preserved. Outcome of urine leak The urinary leak was associated with longer hospital stay, more readmissions , more delayed graft function, but conflicting results on graft survival but most of the studies identified lower graft survival with urine leak.
Conclusion: Urine leak is the commonest urological complication post kidney transplant the clinician should be aware off, and how to differentiate. Using Lich-Gregior technique decrease the risk of this complication significantly, with better knowing the Golden triangle when implanting the ureter to the bladder, and excellent handling of the kidney while harvesting all decrease the risk of complications. Urine leak associated with long hospital stay and decreased graft survival.
What is the level of evidence provided by this article? Review article – level of evidence V.
Dear Dr Muhammad, I am not sure if MRi is a choice of imaging in patient with urine leak. I like your emphasis on preserving the tissues, mentioned as ‘Golden Triangle’. Y I agree it is level 5 evidence. Ajay
abosaeed mohamed
2 years ago
This article discusses the occurrence of urine leak in post kidney transplant recipients. incidence is up to 8.9%. if low volume urine leak , can be managed conservatively , but large volume urine leak , surgical exploration & correction may be needed .
Regarding the anastomosis, the article here concluded that Lich-Grégoir technique results in fewer urological complications than the other two ureterovesical anastomosis procedures & the anastomosis should be tension free to avoid reflux during voiding.
Pt can present with local symptoms (graft pain and tenderness, and local swelling over the graft) and systemic symptoms (fever, tachycardia, hypotension, and tachypnoea). Signs may be masked because of immunosuppression and analgesics. A high index of suspicion is warranted in a patient with high drain output.
main differential diagnosis include Haemorrhage , Urinary Fistula , Perinephric Abscess , Lymphocele and Seroma .
investigations:
> Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
> Use ultrasonography to identify and define the perinephric collection and dilatation of the pelvicalyceal system.
> Doppler ultrasonography can be used to identify defects in perfusion.
> CT or MRI scans are a useful tool to identify and define the perinephric collection and pelvicalyceal dilatation.
> An intravenous pyelogram may be helpful to identify location of the leak.
> Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak. This technique is not useful if there is delayed graft function or ureteral stasis.
> Retrograde cystography to look for urinary bladder dehiscence.
> Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak. This can be done in delayed graft function scenarios too. Pelvicalyceal dilatation makes it easier to do this procedure.
– A high volume of clear drain fluid may indicate the possibility of extraperitoneal urine leak. Ultrasonography, CT scan or MRI, and fluid biochemistry further aid diagnosis. If drain fluid creatinine and potassium values are not dissimilar from the serum values, then the possibilities of lymphocele or seroma are higher. However, if they are significantly higher than the serum values, or are values that are incompatible with life, then it is a urine leak or urinoma. Urinoma will easily be picked up on an ultrasound scan or nuclear scan. Antegrade pyelogram, cystogram, or scintigraphy may be required to identify the cause and to localise the leak
– Important factors that help to prevent major urological complications include delicate dissection of the ureter during donor nephrectomy to preserve adventitia; fat and blood supply of the ureter; short ureter length; and fixation of the adventitia, fat, and blood supply of the ureter to the bladder wall to prevent kinking or twisting.
– urine leak had a statistically significant longer length of hospital stay, more readmissions, more delayed graft function, and lower rates of graft survival.
level of evidence >>narrative review , level 5 of evidence
Dear Dr Mohamed, I am not sure if MRi is a choice of imaging in patient with urine leak. I like your emphasis on preserving the tissues, but you did not mention it as ‘Golden Triangle’. Your headings and sub-headings should be in bold or underline. That will make it easy to read. I agree it is level 5 evidence. Ajay
Last edited 2 years ago by Ajay Kumar Sharma
Mohammed Abdallah
2 years ago
Please summarise this article
INTRODUCTION
The first few days after kidney transplantation are the most critical in determining the fate of the graft and the recipient
Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9%
The aim of this article is to discuss urinary leak in in the post-operative period and the differential diagnoses
URETEROVESICAL ANASTOMOSIS AND A COMPARISON OF ASSOCIATED COMPLICATIONS
Techniques for ureterovesical anastomosis include Lich–Grégoir, Politano-Leadbetter, and U-stitch techniques
Lich–Grégoir technique is significantly associated with a lower incidence of urinary leakage compared to the Politano-Leadbetter technique (Alberts et al. meta-analyses study)
Significantly fewer incidences of haematuria with the Lich–Grégoir method than both the Politano-Leadbetter and U-stitch techniques, regardless of ureteral stenting
Lich-Grégoir technique results in fewer urological complications than the other two ureterovesical anastomosis procedures
UROLOGICAL COMPLICATIONS DURING THE POST-OPERATIVE PERIOD IN KIDNEY TRANSPLANT RECIPIENTS
Common surgical urology complications include urine leakage, ureteral obstruction, and lymphocele
Other urological complications include long ureter, atrophic or dysfunctional bladder, proximal calyceal leak and damage to the ureter during dissection
Investigations
Compare drain creatinine and K levels with serum creatinine and K
USS to for perinephric collection and dilatation of the pelvicalyceal system
Doppler USS for perfusion defects
CT or MRI for perinephric collection and pelvicalyceal dilatation
An intravenous pyelogram may be helpful to identify location of the leak
Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak. This technique is not useful if there is DGF or ureteral stasis
Retrograde cystography for urinary bladder dehiscence
Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak. This can be done in DGF
Identifying Extraperitoneal Urine Leak Post Kidney Transplantation
A high volume of clear drain fluid
USS, CT scan or MRI, and fluid biochemistry (urinary leak or urinoma if drain fluid creatinine and K is significantly higher than the serum, and lymphocle if the same)
Antegrade pyelogram, cystogram, or scintigraphy
DIFFERENTIAL DIAGNOSIS AND CLINICAL REASONING
Haemorrhage
Tachycardia, anaemia, graft swelling and haemorrhagic drain
USS, CT scan, or MRI
Surgical re-exploration
Not common and usually from the vessels in the graft hilum that are not ligated, or from small, severed retroperitoneal vessels
Risk factors include recipient obesity, use of antiplatelet agents, and anticoagulation
Urinary Fistula
Occurs in 2–5% of kidney transplant and may lead to significant morbidity, graft loss, and mortality
Causes are ureteral ischaemia and necrosis and technical problems
Risk factors include younger recipient age (aged <10 years), uretero-ureteric anastomosis, use of high-dose steroids in immunosuppression, number of renal arteries, and bladder problems
Management techniques are ureteral ligature and nephrostomy, ureteroureterostomy, pyeloureterostomy, ureteroneocystostomy, percutaneous nephrostomy and ureteral stenting, and prolonged vesical drainage
Perinephric Abscess
Early post-transplant (in the first few weeks’ post-transplant)
Causes include pyelonephritis, infected lymphocele, haematoma, or urinoma
Fever, swelling, and tenderness over the graft and purulent drained fluid
USS, CT scan, or MRI
Aspiration of the collection and performing microscopy and culture of the aspirate
Lymphocele and Seroma
Occur in 1-20% of kidney transplant (2 weeks -5 years)
Small and asymptomatic, no intervension
Compression symptoms are retention of urine, decreased urine output, elevated serum creatinine, thrombosis of iliac vein, and limb oedema
Risk factors are technical problems, lymph leakage from the hilum of the allograft itself, and sirolimus use
Drainage fluid is clear
USS, CT scan, or MRI, and fluid biochemistry (drain fluid creatinine and K values are the same of serum)
Treatment options:
1. aspiration (nearly 100% chances of recurrence)
2. percutaneous drainage (50% success rate)
3. Laparoscopic drainage (preferred method)
4. open drainage (if wound complications a small lymphocele adjacent to vital renal structures, which increases the risk of vessel or ureter injury)
5. Continuous drainage with sclerosants like povidone iodine, fibrin glue, and doxycycline, tetracycline, ethanol, bleomycin (risk of periureteral fibrosis)
Urine Leak and Urinoma
Occurs early and in 1.2–8.9% of cases
Urine leaks may be free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma)
Different clinical presentations of urine leak
1. Early extraperitoneal high-volume leak
2. Early extraperitoneal small leak
3. Late leak (1–2 weeks after kidney transplant). caused by ureter necrosis or early removal of double J stent (<3–6 weeks)
4. Intra-abdominal leak (presents with an acute abdomen)
Evidence-based management plan in extraperitoneal urine leak
Low-volume leak at the anastomotic site: conservatively with maximum decompression (Foley catheter and ureteral stent). The ureteral stent is only removed after 4–6 weeks
Urgent percutaneous drainage if the fluid collections become infected, or cause ureteral obstruction and extrinsic compression on the ureter
Surgical re-exploration and reimplanting the transplant ureter if conservative measures fail, or if there is a high-volume drain
Preventive measures: importance of the golden triangle
Gentle handling of the ureter at the time of ureteral dissection during harvesting of the donor kidney is crucial to prevent urine leak post kidney transplantation
An adequate periurethral tissue in the ‘golden triangle’ must be carefully preserved
Outcome of extraperitoneal urine leak: short-term and long-term effects on graft function and survival
Longer length of hospital stay, more readmissions, more delayed graft function, and lower rates of graft survival
CONCLUSION
Technical errors (the Lich-Grégoir technique has a significantly lower incidence of urinary leakage compared to the Politano– Leadbetter procedure) and presence of multiple renal arteries are important risk factors for development of urological complications post kidney transplantation
A high index of suspicion is needed to identify the complications as the symptoms and signs may be masked by the immunosuppressive drugs and the analgesics used
Low-volume leak is managed conservatively with maximum decompression and if conservative management fails, or if there is extraperitoneal high-volume leak, then surgical exploration and correction may become necessary
Urine leak may be associated with significant longer length of hospital stay, more readmissions, more delayed graft function, and lower rates of graft survival
What is the level of evidence provided by this article?
Level 5 (narrative study)
Dear Dr Mohamed, I am not sure if MRi is a choice of imaging in patient with urine leak. I like your emphasis on preserving the tissues, mentioning as ‘Golden Triangle’. I agree it is level 5 evidence. Ajay
Mohamed Mohamed
2 years ago
1. Please summarise this article Introduction Urine leak usually present early post KTX & occurs in 1.2–8.9% of transplants.
This paper discusses the identification of high-volume extra–peritoneal urine leaks in the early post KTX period as well as its differential diagnoses & impact on both patient & graft outcome. Techniques of ureterovesical anastomosis 1. Lich–Grégoir technique:
Lower incidence of urinary leakage compared to other techniques
Fewer incidences of haematuria 2. Politano-Leadbetter technique 3. U-stitch technique
The anastomoses must be tension-free & protected by a 1 cm submucosal tunnel in order to prevent reflux during voiding. The most common surgical urology complications include:
1. Urine leakage
2. Ureteral obstruction
3. Lymphocele
4. Kinking of a long ureter
5. Atrophic bladder or dysfunctional bladder (may lead to perforation or dehiscence).
6. Proximal calyceal leak
7. Damage to the ureter during dissection may result in ureteric ischaemia, necrosis, & distal leak Signs & Symptoms
Fever
Pain over the graft
Fluid leakage from the wound
Stent-related complications (longer stents or if left for >6 weeks): infection, migration, & encrustation. Investigations
1. Compare creatinine & potassium levels in the drain with that of serum: both are higher in the drain versus serum in case of leak or urinoma. 2. USS to identify & define perinephric collection & pelvicalyceal system dilatation.
3. Doppler USS to identify defects in perfusion. 4. CT or MRI can identify & define the perinephric collection & pelvicalyceal dilatation. 5. IV pyelogram may identify location of the leak. 6. Focal tracer scintigraphy used to identify the location of the leak; however, it is not useful if there is DGF or ureteral stasis. 7. Retrograde cystography to look for urinary bladder dehiscence.
8. Antegrade pyelogram testing through a nephrostomy: accurately identify the location of the leak. Differential diagnosis
1. Haemorrhage:
Usually not common
Presents withtachycardia, anaemia, or local swelling over the graft.
Recipient obesity, antiplatelet use, & anti-coagulation are risk factors.
2. Urinary fistula
Occurs in 2–5% of KTXs.
Causes significant morbidity, graft loss, & mortality.
Caused by ureteral ischaemia & necrosis & technical problems associated with the TX operation.
Risk factors include:
Younger recipient age (<10 yrs)
Uretero-ureteric anastomosis
Use of high-dose steroids.
Number of renal arteries
Bladder problems.
3. Perinephric Abscess
Uncommon
Present early post-TX
Causes include:
Pyelonephritis
Infection of lymphocele, haematoma, or urinoma.
Symptoms & signs: fever, swelling, & tenderness. Diagnosed: USS, CT scan, or MRI.
4. Lymphocele & Seroma
Lymphoceles occur in 1-20% of cases & may occur as early as 2 weeks up to 5 years post-TX.
Present with pressure symptoms: retention of urine, decreased UOP, high creatinine, thrombosis of iliac vein, & limb oedema.
5. Urine Leak & Urinoma
Occurs in 1.2–8.9% of cases.
Presents early post-operatively after KTX.
ManifestS as free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma). Management plan
Low-volume leak: treated conservatively by maximum decompression (placing a Foley catheter or ureteral stent performing a nephrostomy).
Surgical re-exploration & reimplantation of TX ureter if conservative measures fail, or if there is a high-volume drain. Preventive measures:
Avoidance of errors in anastomosis techniques.
Gentle handling of the ureter at the time of ureteral dissection.
An adequate periuretral tissue must be preserved in the ‘golden triangle’(bound by the lower border of the junction between the renal vein & the IVC on the right, lower pole of the kidney on the left & the gonadal vein).
Impact of urological complications post KTX on duration of hospitalisation & graft survival: 1.Buggs et al., 2019: Total number: 1,308 Number of patients urine leak 36(2.75%) Observations: prolonged hospitalization,increased DGF & lower graft survival. 2. Carvalho et al., 2019: Total number: 3,102 Number of patients urinary complications 184 (5.93%) Observations: prolonged hospitalization & lower graft survival. 3.van Roijen et al., 2001: Total number: 695 Number of patients required revision of vesico-ureteral anastomoses 42 (6.04%) Observations: no effect on long-term graft survival by a surgically treated urological complication within 1-year post-TX 4.Pillot et al.,2012 Total number: 200 Number of patients urinary complications 49 (24.50%), 66 surgical complications in 49 patients, with the majority being urological complications Observations: Increased incidence of DGF & graft rejection episodes among patients with surgical complications. No impact on patient or graft survival 5.Kaskarelis et al.,2008 Total number: 21 Number of patients urinary complications: 21 (9 urinary leak, 6 ureteric obstruction, & 6 with obstruction preceded by leak) Observations: No impact on patient and graft survival ////////////////////////////////////// 2. What is the level of evidence provided by this article? Level V
Dear Dr Mohamed, I am not sure if MRi is a choice of imaging in patient with urine leak.
I like your emphasis on preserving the tissues, mentioning as ‘Golden Triangle’. I agree it is level 5 evidence. Ajay
Huda Al-Taee
2 years ago
Summary:
Urological complications during the postoperative period in kidney transplant recipients:
The most common:
urine leakage, ureteral obstruction, and lymphocele.
Other:
Complications caused by the length of the transplanted ureter. A long ureter is liable to kink and obstruction. A short ureter may not be appropriate for achieving tension-free anastomosis.
Atrophic bladder or dysfunctional bladder in the recipient may result in bladder perforation or anastomotic dehiscence.
Proximal calyceal leak may occur because of lower pole artery complications (thrombosed, ligated, not reconstructed).
Signs and Symptoms:
local (graft pain and tenderness and local swelling over the graft).
systemic (fever, tachycardia, hypotension, and tachypnoea).
Investigations:
Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
Use ultrasonography to identify and define the perinephric collection and dilatation of the pelvicalyceal system.
Doppler ultrasonography can be used to detect defects in perfusion.
CT or MRI scans to define the perinephric collection and pelvicalyceal dilatation.
An intravenous pyelogram may be helpful in case of a urine leak.
Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak.
Retrograde cystography helps look for urinary bladder dehiscence.
Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak.
DDX and Clinical Reasoning:
Haemorrhage:
the drain is haemorrhagic.
tachycardia, anaemia, local swelling over the graft.
CT scan or MRI is useful.
risk factors include recipient obesity, use of antiplatelet agents, and anticoagulation.
Surgical exploration is usually not required because bleeding usually stops spontaneously.
pure red blood cell transfusion repeatedly.
surgical re-exploration if there is haemodynamic instability or compression of the kidney by haematoma.
Urinary Fistula:
Occurs in 2–5% of kidney transplantations.
May lead to significant morbidity, graft loss, and mortality.
Causes: Ureteral ischaemia and necrosis and technical problems associated with the transplant procedure.
The risk factors: younger recipient age (aged <10 years), uretero-ureteric anastomosis, use of high-dose steroids in immunosuppression, number of renal arteries, and bladder problems.
Managed by different techniques including ureteral ligature and nephrostomy, ureteroureterostomy, pyeloureterostomy, ureteroneocystostomy, percutaneous nephrostomy and ureteral stenting, and prolonged vesical drainage
Perinephric Abscess:
usually present in the early post-transplant period.
causes include pyelonephritis, infection of lymphocele, haematoma, or urinoma.
ultrasonography, CT scan, or MRI may aid in the diagnosis of a perinephric abscess.
Aspiration of the collection and performing microscopy and culture of the aspirate may further help the diagnosis.
Lymphocele and Seroma:
occur in 1-20% of kidney transplant operations.
y occur from as early as 2 weeks to as late as 5 years post-transplant.
Can be small and asymptomatic and require no intervention.
may present with features of compression symptoms.
Ultrasonography, CT scan, or MRI, and fluid biochemistry further aid diagnosis.
Treatment options include aspiration (nearly 100% chances of recurrence), percutaneous drainage (50% success rate), drainage by laparoscopic method, or open marsupialisation.
Urine Leak and Urinoma:
an early postoperative complication.
occurs in 1.2–8.9% of cases.
may manifest as free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma).
Different clinical presentations of urine leak:
early extraperitoneal high-volume leak.
early extraperitoneal small leak.
late leak (1–2 weeks after kidney transplant).
intra-abdominal leak.
Evidence-based management plan in extraperitoneal urine leak:
Low-volume leak at the anastomotic site can be managed conservatively by performing maximum decompression( Placing a Foley catheter and ureteral stent performing a nephrostomy).
Antegrade pyelogram to identify the site of the leak is helpful.
urgent percutaneous drainage is required in cases of fluid collections becoming infected or causing ureteral obstruction and extrinsic compression on the ureter.
Surgical re-exploration and reimplanting of the transplant ureter is necessary if conservative measures fail, or if there is a high-volume drain.
Preventive measures: importance of the golden triangle:
gentle handling of the ureter at the time of ureteral dissection is crucial to prevent urine leak post-kidney transplantation.
adequate periurethral tissue in the ‘golden triangle’ must be carefully preserved.
delicate dissection of the ureter during donor nephrectomy to preserve adventitia; fat and blood supply of the ureter; short ureter length; and fixation of the adventitia, fat, and blood supply of the ureter to the bladder wall to prevent kinking or twisting.
Hi Dr Huda, I am not sure if MRi is a choice of imaging in patient with urine leak. I like your emphasis on preserving the tissues, mentioning as ‘Golden Triangle’. I agree it is level 5 evidence. Ajay
The first few days after kidney transplantation are the most critical in determining the fate of the graft and the recipient
Urine leak is an early postoperative complication after kidney transplantation and occurs in 1.2–8.9% of these operations
Low-volume leaks may subside with conservative management
large-volume urine leak, surgical exploration, and correction may be needed
URETEROVESICAL ANASTOMOSIS AND A COMPARISON OF ASSOCIATED COMPLICATIONS
Many different techniques are used to achieve ureterovesical anastomosis in kidney transplantation.The most popular methods include the following:
Lich–Grégoir, Politano-Leadbetter, and U-stitch techniques
Lich–Grégoir technique is significantly associated with a lower incidence of urinary leakage and also showed significantly fewer incidences of haematuria and fewer urological complications
UROLOGICAL COMPLICATIONS DURING THE POSTOPERATIVE PERIOD IN KIDNEY TRANSPLANT RECIPIENTS
The most common surgical urology complications include :
1-urine leakage
2- ureteral obstruction
3- lymphocele (fluid collection between the urinary bladder and the kidney allograft).
4 -Complications caused by the length of the transplanted ureter A long ureter is liable to kink and obstruction. A short ureter may not be appropriate for achieving tension-free anastomosis.
5-Atrophic bladder or dysfunctional bladder in the recipient may result in bladder perforation or anastomotic dehiscence
6-Proximal calyceal leak may occur because of lower pole artery complications (thrombosed, ligated, not reconstructed). In addition, damage to the ureter during dissection may result in ureteric ischemia, necrosis, and distal leak.
The drained fluid’s color can identify
7-Urological complications in the postoperative period.
Signs and Symptoms
(graft pain and tenderness, local swelling over the graft, and systemic (fever, tachycardia, hypotension, and tachypnoea). Signs because of immunosuppression and analgesics. A high index of suspicion is warranted in a patient with a high drain output
Investigations:
Ø Compare drain creatinine and potassium levels with serum creatinine and potassium levels
Ø ultrasonography to identify and define the perinephric collection and dilatation of the pelvicalyceal system
Ø Doppler ultrasonography can be used to identify perfusion defects.
Ø CT or MRI scans
Ø An intravenous pyelogram.
Ø Focal tracer scintigraphy
Ø Retrograde cystography
Ø Antegrade pyelogram
Identifying Extra peritoneal Urine Leak Post Kidney Transplantation
A high volume of clear drain fluid may indicate the possibility of an extraperitoneal urine leak: ultrasonography, CT scan, or MRI and fluid biochemistry.
Ante-grade pyelo gram, cysto gram, or scintigraphy may be required to identify the cause and to localize the leak.
DIFFERENTIAL DIAGNOSIS AND CLINICAL REASONING:
Hemorrhage.
Urinary Fistula.
Perinephric Abscess.
Lymphocele and Seroma.
Urine Leak and Urinoma. Different clinical presentations of urine leak:
The different clinical presentations could be early extraperitoneal high-volume leak; early extraperitoneal small leak, defined by a persistent low urine output through drains, associated with low urine output, graft site swelling, and pain (imaging with contrast may help identify urinoma); late leak (1–2 weeks after kidney transplant), which may be caused by ureter necrosis or early removal of double J stent (<3–6 weeks); and intra-abdominal leak, which presents with an acute abdomen.
CONCLUSION
Different ureteroneocystostomy techniques, including the Lich-Grégoir, Politano–Leadbetter, and U-stitch techniques, impact the development of urine leaks.
The Lich-Grégoir technique has a significantly lower incidence of urinary leakage than the Politano– Leadbetter procedure.
Hi Dr Allam, I am not sure if MRi is a choice of imaging in patient with urine leak. I wish you could have emphasised on preserving the tissues, mentioning as ‘Golden Triangle’. I agree it is level 5 evidence. Ajay
Sherif Yusuf
2 years ago
Urinary leak is not uncommon complication occurring in 1.2–8.9% usually in early post operative period
Urinary leak is classified into
Low volume extra-peritoneal leak
High volume extra-peritoneal leak
Intra-peritoneal leak
Clinical presentation
Fever
Hemodynamic instability
Abdominal pain, graft tenderness and acute abdomen in case of intraperitoenal leak
Local swelling over the graft
Urinary leakage from the wound
The diagnosis may be delayed till urine output increase in case of DGF, and the systemic manifestation can be masked due to immunosuppression, so it needs high index of suspicion
Risk factors for urinary leak
Long ureter which is liable to kinking, ischemia induced obstruction since the blood supply of the transplant ureter is from the periureteric tissue
Short ureter with subsequent tense ureterovesical anastomosis
Damage of the ureter during dissection, with subsequent ischemia
Ligation or thrombosis of lower polar artery may lead to proximal leak
Bladder disorders including atrophic bladder and bladder dysfunction can vcasue asasmotic leak or even dehiscence
Diagnosis
Clinical by examination of the drained fluid including the color and odor
Diagnostic aspiration with measurement of creatinine and potassium in the drained fluid, if it is comparable to the serum the diagnosis is either lymphocele or seroma, while if they are much higher than the serum, the diagnosis is urinaoma, moreover microscopy (RBCS, WBCS) is important to exclude abscess transformation
US is used for assessment of fluid collection, dilatation of pelvicalecyal system and Doppler examination for assessment of perfusion of the graft and RI
CT or MRI for better assessment of the size, site, contents of collection and pelvicalecyal system dilatation
IV pyelogram and focal tracer scintigraphy are useful in identification of the site of the leak but are not recommended to be done in case of DGF
Retrograde cystography asses anastomotic leak and urinary bladder dehiscence.
Antegrade pyelogram through PCN can identify the site of leak even in patients with DGF, but the patient should have hydronephrosis
Differential diagnosis
Hematoma/haemorrahge
Seroma
Lymphocele
Perinephric Abscess
Prevention
Ureteric stenting is routinely performed intraoperative and left for 4-6 weeks after transplantation, although intraoperative stenting improve the overall effects of ureteric complications, but it does not reduce the incidence of complications and is associated with adverse effects if it is ≥ 20 cm or used for > 6 weeks including infection, migration or encrustation.
Ureterovesical anastomosis can be performed using many techniques; the most commonly used are Lich–Grégoir, Politano-Leadbetter, and U-stitch techniques. Lich–Grégoir is associated with lower incidence of complications including urinary leak and hematuria compared to the other 2 procedures.
Ureterovesical anastomosis should not be tense and protected by submucosal tunnel of ≥ 1 cm to preserve good vascular supply
Gentile dissection of the donor ureter
Preservation of the periuretral tissues in the golden triangle which lies between the lower border of the junction IVC and RV, lower pole of the kidney and gonadal veins
Treatment of urinary leak
A- Conservative measures
Urinary system decompression, by Urinary catheterization, which reduce intra-vesical pressure so can control small anastomotic leak and urinary diversion through image guided percutaneous nephrostomy insertion (if there is pelvicalyceal system dilatation). All should be removed once the leak heal (in low volume leak) or repair is done (in high volume leak)
Antegrade or less commonly retrograde douple j stenting if not placed at the time of transplantation and should be kept in place for 4-6 weeks
Close follow up is required for assessment of response and monitoring of complications
B- Surgical repair
Indicated in high volume urinary leak or if conservative measures fail in low volume leak
In the form of resection of the damaged ureter and re-implantation again either in the urinary bladder or sometimes to the native ureter if the remaining transplant ureter is short
What is the level of evidence provided by this article?
Hi Dr Yusuf,
I am not sure if MRi is a choice of imaging in patient with urine leak.
I like emphasis on preserving the tissues, mentioning as ‘Golden Triangle’.
You mention ‘less commonly retrograde douple j stenting’. This is would be tricky to do, even most expert urologists struggle to do retrograde stenting. We, in Liverpool, have never used this in the management of a patient with urine leak.
Ajay
Ø The most common surgical urology complications include urine leakage, ureteral obstruction, and lymphocele (fluid collection between the urinary bladder and the kidney allograft). The rates of urological complications range from 2.5% to 30.0% of all recipients.
Ø A high index of suspicion is needed to identify the complications as the symptoms and signs may be masked because of the immunosuppressive drugs and the analgesics used.
Extraperitoneal Urine Leak Post Kidney Transplantation
A high volume of clear drain fluid may indicate the possibility of extraperitoneal urine leak. Ultrasonography, CT scan or MRI, and fluid biochemistry further aid diagnosis. If drain fluid creatinine and potassium values are not dissimilar from the serum values, then the possibilities of lymphocele or seroma are higher. However, if they are significantly higher than the serum values, or are values that are incompatible with life, then it is a urine leak or urinoma.
Different ureteroneocystostomy techniques, including the Lich-Grégoir, Politano–Leadbetter, and U-stitch techniques, have an impact on development of urine leak. The Lich-Grégoir technique has a significantly lower incidence of urinary leakage compared to the Politano– Leadbetter procedure
Haemorrhage
If the drain is haemorrhagic, with accompanying factors like tachycardia, anaemia, local swelling over the graft, or if bleeding is a possibility, ultrasonography, CT scan, or MRI may be used to identify haematoma, necessitating an emergency re exploration. risk factors include recipient obesity, use of antiplatelet agents, and anticoagulation.
Urinary Fistula
Urinary fistula occurs in 2–5% of kidney transplantations, and may lead to significant morbidity, graft loss, and mortality. There is an 8% risk of mortality associated with urinary fistula. Ureteral ischaemia and necrosis and technical problems associated with the transplant procedure are important causes of urinary fistula development
Perinephric Abscess
Perinephric abscesses are uncommon complications post kidney transplantation. They usually present in the early post-transplant period (in the first few week’s post-transplant). The causes include pyelonephritis, infection of lymphocele, haematoma, or urinoma Aspiration of the collection and performing microscopy and culture of the aspirate may further help the diagnosis.
Lymphocele and Seroma
A collection of lymph in the perigraft area is called a lymphocele. Lymphoceles occur in 1-20% of kidney transplant operations, occur from as early as 2 weeks to as late as 5 years’ post-transplant. Usually they are small and asymptomatic, and such lymphoceles require no intervention.
Urine Leak and Urinoma
Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of cases. Urine leaks post kidney transplantation may manifest as free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma)
The different clinical presentations could be early extraperitoneal high-volume leak; early extraperitoneal small leak, defined by a persistent low urine output through drains, associated with low urine output, graft site swelling, and; late leak (1–2 weeks after kidney transplant), which may be caused by ureter necrosis or early removal of double J stent (<3–6 weeks); and intra-abdominal leak, which presents with an acute abdomen.
Compare drain creatinine and potassium levels with serum creatinine and potassium levels is a key for diagnosis
Preventive measures: importance of the golden triangle
Ø Urine leak usually occurs because of technical errors in the ureteroneocystostomy technique, the method of graft ureter implantation in the recipient’s urinary bladder, or because of the transplanted ureter’s compromised vascularity, which is caused by vessel damage during the harvest of the donor kidney.
Ø Presence of multiple renal arteries is also a risk factor for development of urological complications post kidney transplantation.
Ø During harvesting of the donor kidney, gentle handling of the ureter at the time of ureteral dissection is crucial to prevent urine leak post kidney transplantation.
Level 5
There are different techniques are used to achieve ureterovesical anastomosis in kidney
transplantation. The most popular methods include the Lich–Grégoir, Politano-Leadbetter, and U-stitch techniques. Meta-analyses performed by Alberts et al showed that the Lich–Grégoir technique is significantly associated with a lower incidence of urinary leakage compared to the Politano-Leadbetter technique.
The analyses also showed significantly fewer incidences of hematuria with the Lich–Grégoir method than both the Politano-Leadbetter and U-stitch techniques. In order to prevent reflux during voiding, the ureterovesical anastomosis must be tension-free and protected by at least a 1 cm submucosal tunnel.
Differential Diagnosis of urine leak:
Hemorrhage:
Clinical features of anemia, hemorrhagic drain and local swelling over the graft.
Risk factors include; recipient obesity, use of anti-platelet and aspirin therapy.
Urinary Fistula:
This occurs in 2–5% of kidney transplantations, and may lead to significant morbidity, graft loss, and mortality. Ureteral ischemia and necrosis and technical problems associated with the transplant procedure are important causes of urinary fistula
development. The risk factors include; younger recipient age (aged <10 years), uretero-ureteric anastomosis, use of high-dose steroids in immunosuppression, number of renal arteries, and bladder problems.
Management include; ureteral ligature and nephrostomy, ureteroureterostomy,
pyeloureterostomy, ureteroneocystostomy, percutaneous nephrostomy and ureteral stenting, and prolonged vesical drainage.
Perinephric Abscess:
Uncommon complications post kidney transplantation.The causes include; pyelonephritis, infection of lymphocele, hematoma, or urinoma. The
drained fluid is purulent, with accompanying symptoms and signs (fever, swelling, and
tenderness over the graft).
Aspiration of the collection and performing microscopy and culture of the
aspirate may further help the diagnosis.
Lymphocele and Seroma
A collection of lymph in the perigraft area is called a lymphocele. Lymphoceles may
present with features of compression symptoms including retention of urine, decreased urine output, elevated serum creatinine, thrombosis of iliac vein, and limb odema. The drainage fluid is clear with creatinine and potassium values are not much different from the serum values,
Treatment include; aspiration (nearly 100% chances of recurrence), percutaneous drainage (50% success rate), drainage by laparoscopic method, or open
marsupialisation.
Urine Leak and Urinoma:
It is an early post-operative complication after kidney transplantation.Clinically could be as free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma).
Presentation also could be either low or high volume urine leak, low urine output, graft swelling and pain. The fluid creatinine and potassium are high and incompatible with life.
Low-volume leak at the anastomotic site can be
managed conservatively by performing maximum decompression. Antegrade pyelogram to identify the site of the leak is helpful. Placing a Foley catheter and ureteral stent performing a nephrostomy are the techniques used for decompression. Surgical
re-exploration and re-implanting the transplant ureter becomes necessary if conservative
measures for stopping low-volume urine leak fail, or if there is a high-volume drain.
Prevention of these complications need gentle handling of the donor ureter at the time
of ureteral dissection is to prevent urine leak post kidney transplantation. An adequate peri-urethral tissue in the ‘golden triangle’ must be carefully preserved.
Investigations
The following investigations are helpful in evaluating extraperitoneal urine leak post
kidney transplantation, and to rule out differential diagnoses.
1- Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
2- Use ultrasonography to identify and define the perinephric collection and dilatation of thepelvicalyceal system.
3- Doppler ultrasonography.
4- CT or MRI scans.
5- An intravenous pyelogram.
6- Focal tracer scintigraphy uses
mercaptoacetyltriglycine or technetium 99.
7- Retrograde cystography.
> Antegrade pyelogram .
Introduction:
The early few days post-transplant are the most important ones. Careful monitoring for the patients` dynamics, laboratory investigations and rain output is crucial to identify complications early and prompt management. One of the early complication is urine leak, it occurs in 1.2-8.9 % post transplant.
Urological complication: occur in 2.5-30% of opertaion
1- uine leak: It occurs less with Lich–Grégoir operation
– presented by local signs: pain, tender graft but may be masked by analgesia and immunosupreeant
– investigations: drain creatinine and potassium more than serum levels
– ultrasonography and doppler: perinephric collection +/- dilatation of the pelvicalyceal system and perfusion defects
– CT or MRI scans confirm the perinephric collection and pelvicalyceal dilatation
– scintigraphy by mercaptoacetyltriglycine or technetium 99 and antegrade pyelogram for localization for site of anastomosis but the latter appropriate in case of delayed graft function
– management: by decompression by UB catheter, drain +/- antegrade stenting, but in case of high drain output exploration may be the solution
differentiating from hematoma (drain colour, fall in Hgb +/- hemodynamic instability), lymphocele (occurs later on 2-6 weeks, painless), and perinephric abcess (later on and with normal creatnine and potassium content similar to serum)
2- Complications caused by the length of the transplanted ureter: long ureter may lead to kinking and obstruction while a short ureter may interfere with tension-free anastomosis.
3- Atrophic bladder or dysfunctional bladder may result in bladder perforation or anastomotic dehiscence
4- Leak from distal calyx due to poor blood supply
5- Vigorous dissection for the ureter may lead to ischemia and urine leak distally.
level of evidence: 5
This study concern about surgical complications post kidney transplant,mainly the urine leak. The symptoms vary between pain at the graft site, fever and fluid collection around the graft . The differential diagnosis can be lymhocyle , hematoma or abscess. Urine leak could be due to ischemia to the ureter or problem in the implantation technique, diagnosis can be made by ultrasound or radioisotope scan then fluid aspiration and analysis for creatinine and potassium
treament is conservative with antigrade stenting to the ureter
It is level 5 evidence
Introduction
Urological complications after kidney transplantation includes : Hemorrahge ,extraperitoneal urinary leak which usually occurs early post kidney transplantation and lymphocoele which usually occurs within 2-6 weeks after Kidney transplantation .Urinary leak is one of the early post transplant complications , incidence in studies from 1999 to 2000:1.5-6%, incidence is less in case of using Lich-Grégoir technique of construction of ureterovesical anastomosis. Occurs also in case of multiple renal arteries
Aims :
Aim :to illustrate clinical presentation , investigations and evidence based management differential diagnosis of urinary leak post kidney transplant through case presentation .
Presentation:
local :graft pain, tenderness, swelling over the graft)
+ systemic :fever, tachycardia, hypotension, and tachypnoea
Signs may be masked because of immunosuppression and analgesics.
+ high drain output.
It can come as:
Early extraperitoneal small leak : persistent low urine output through drains +low urine output, graft site swelling, and pain (imaging with contrast> urinoma.
late leak :1-2 wks after transplantation: caused by ureter necrosis or early removal of double J stent (<3-6 weeks)
Intra-abdominal leak>comes with acute abdomen.
DD:
-Hemorrahge: hemorrhagic drain ,anemia, tachycardia)
-Perinephric abscess: purulent drained fluid + fever and selling ,tenderness over the graft.
-Urinary fistula: especially in young recepients <10 yrs. Or received high dose steroids in induction , ureteral ischemia and necrosis.
-Lymphocele and seroma : 2 day- 5years after transplant + decrease urine output + increase serum creatinine + lower limb edema + iliac thrombosis.
Investigations:
1- Compare urinary creatinine and potassium with serum creatinine and potassium.
2- Ultrasound US and Doppler to identify collection and perfusion
3- CT .MRI
4 -IV pyelogram
5- Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 :cannot be done in case of delayed graft function or uretral stasis
6- Retrograde cystography : to exclude bladder dehiscence.
Evidence base management:
Maximum decompression :insert foley scatheter , uretral stent and nephrostomy
Once urinary leak stopped : foleyscatheter and nephrostomy can be removed but uretral stent kept for 4-6 weeks.
If infected collection ,uretral obstruction or extrinsic uretral compression>urgent percutaneous drainage
Surgical decompression and ureteral reimplantation if conservative measures fail.
Outcomes of post
transplant urinary leak :
– Buggs et al, 2019:
increase rate of read missions, prolong hospitalization ,increase rate of delayed graft function and lower rate of graft survival.
– Car also rt al, 2019:
Delayed graft survival ,prolong hospitalization
– Pilot et al,2012:
Increase rate of delayed graft function, episodes of rejection, No impact on patient or graft survival.
Conclusion
1- High index of suspicion to identify post transplant urinary leak because of immunosuppression and analgesic masking of symptoms and signs
2- Lich-Grégoir technique has a significantly lower incidence of urinary leak age compared to the Politano-Lead better procedure.
3- Delicate dissection and implantation of ureter to preserve adventitia.
REFERENCES:-
Identifying Early Extra peritoneal High-Volume Urine Leak Post Kidney Transplantation,B Churchill et al, EMJ. 2021; DOI/10.33590/emj/20-00213.-Buggs Jet al. Repair of ureteral leaks post-kidney transplantation. Am Surg.2019; 85/8):e380-2.
Carvalho JA et al. Surgical complications in kidney transplantation: an overview ofa Portuguese reference center. Transplant Proc.2019;51(5):1590-6.
Pillot Pet al. Risk factors for surgical complications after renal transplantation and impact on patient and graft survival. Transplant Proc. 2012;44(9):2803-8.
DDx of high urine leak includes:
1-
Hemorrhage
2- Urine
leak
3-
Lymphocele or Seroma
4- Urinary
Fistula
5-
Perinephric Abscess
Clinical Presentation
of Urine Leak
Variable
signs and symptoms may present in urine leak patients, they may overlap with
the other differential diagnosis and may be masked by the general condition of
the patient and the immunosuppressive medications; so, high index of suspicion
is needed together with the proper investigations to diagnose such cases. These
signs and symptoms, include:
•Local
symptoms like swelling and tenderness over the graft
•Systemic
manifestations including: tachycardia, fever, hypotension and tachypnea
•Increase
drain output with yellow urinary smelling fluid is the hallmark of urine leak
in these patients.
Some
preventive measures can be used to minimize the risk of urological
complications associated with urine leak, these measures include:
•Proper
ureter length to prevent kinking and allow water tight tension free anastomosis
•Fixation
of ureter to bladder wall
Fine
dissection of ureter and proper handling to prevent necrosis and preserve
periureteral tissue in the golden triangle
Several
investigations showed that patients’ with history of urine leak have prolonged
hospital stay, readmissions, delayed graft function and lower graft survival.
•Urological
complications are not uncommon post kidney transplantation
•High
index of suspicion is needed to detect these complications to preserve the
graft function
•Ultrasonography
is a non-invasive, bedside technique that help early diagnosis of such
complications
•Lich-Gregoir
procedure for ureteral reimplantation is associated with less risk of urinary
leak than Politano-Leadbetter
•Prevention
of the complications with proper surgical techniques is better than treatment
Evidence
Level is V
Urine leak can occur in 1.2-8.9% in early period of post renal transplantation.
Types of urine leak: low volume extra-peritoneal, high volume extra-peritoneal and intra-peritoneal.
Risk factors of urine leak:
1- Long ureter: increases the chance of kinking, and ischaemia.
2- Short ureter: leads to tense uretero-vesical anastomosis.
3- Ureteric damage during dissection.
4- Ligation or thrombosis of lower polar artery leading to proximal leak.
5- Bladder disorders like atrophic bladder or bladder dysfunction.
Diagnosis of urine leak:
Urine leak usually presents clinically by: Fever, abdominal pain, graft tenderness, local swelling over the graft, urine leakage from the wound and hemodynamic instability.
Clinical examination of drained fluid (colour and odour).
Diagnostic aspiration of collected fluid and checking Creatinine and potassium level in the fluid. In case of urine collection, Creatinine and Potassium levels are very high compared to serum levels. Fluid should be sent fot culture to rule out infection and abscess formation.
Imaging: using USS, CT or IV pyelogram and Focal tracer scintigraphy.
Retrograde cystoscopy and antegrade pyelogram to identify site of leak.
Differential Diagnosis: includes hematoma, seroma, lymphocele and perinephric abscess.
Prevention of urine leak:
1- Ureteric stenting.
2- Technique of uretero-vesical anastomosis: Lisch-Gregoir is associated with lower incidence of complications.
3- Gentle dissection of donor ureter and preservation of peri-ureteral tissues in the golden triangle.
Treatment of Urinary Leak:
1- Conservative measures: by urinary catheterization or percutaneous nephrostomy.
2- Antegrade or retrograde JJ stenting.
3- Surgical repair if high volume leak, needs resection andre-implanatation.
What is the level of evidence provided by this article?
Level V
Urine leak following kidney transplantation is one of the early surgical complications with incidence range of 0.6-30 and can be manifested by abdominal pain, graft tenderness, fever, hypotension &increased drain flow of clear fluid,. USS evaluation early post-operative to assess the characteristics of collections which should be differentiated from hematoma, abscess, lymphocele, obstruction; and to proceed for biochemical analysis of the fluid for creatinine and potassium levels which can help to differentiate urine leak from lymphocele or hematoma.
Several predisposing factors are associated with increased risk of urine leak including black male recipients& type of surgical anastomosis.
Different surgical techniques were used for vesicoureteral anastomosis and as per evidence Lich–Grégoir, is better than Politano-Lead better,
and U-stitch techniques in order.
Low urine leak, usually treated with Foleys catheter insertion to relieve the pressure on the anastomosis site and to give chance for healing, if complicated with hydro nephrosis then nephrostomy and antegrade DJ stent insertion would be preferred if not previously done. The high-volume leak usually requires surgical intervention and reimplantation of the residual healthy tissue.
Level 5 narrative review
The clinical team is extremely vigilant in monitoring parameters that could indicate graft dysfunction, graft rejection, delayed graft function, post-operative complications, drug levels (especially tacrolimus or cyclosporine level), infection, and the general wellbeing of the kidney transplant recipient (KTR) and donor.
Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of these operations. Low-volume leaks may subside with conservative management and provided there is no distal obstruction. If not resolved, or if it is large-volume urine leak, surgical exploration and correction may be needed.
The most common surgical urology complications include urine leakage, ureteral obstruction, and lymphocele (fluid collection between the urinary bladder and the kidney allograft). The rates of urological complications range from 2.5% to 30.0% of all recipients.
Routine prophylactic intraoperative stenting of the ureter in kidney transplant recipients mitigates the effects of ureteric complications but does not reduce the incidence of these complications. The stents are generally well tolerated, but when longer stents are used (stent length: ≥20 cm), or if used for longer periods (>6 weeks), they may result in stent-related complications including infection, migration, and encrustation.
Signs and Symptoms
Varied symptoms can occur as a result of kidney transplant, including local (graft pain and tenderness, and local swelling over the graft)10 and systemic (fever, tachycardia, hypotension, and tachypnoea).10 Signs may be masked because of immunosuppression and analgesics. A high index of suspicion is warranted in a patient with high drain output
Investigations
Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
ultrasonography to identify and define the perinephric collection and dilatation of the pelvicalyceal system.
Doppler ultrasonography can be used to identify defects in perfusion.
CT or MRI scans are a useful tool to identify and define the perinephric collection and pelvicalyceal dilatation.
An intravenous pyelogram may be helpful to identify location of the leak.
Retrograde cystography helps clinicians to look for urinary bladder dehiscence.
Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak. This can be done in delayed graft function scenarios too. Pelvicalyceal dilatation makes it easier to do this procedure.
DIFFERENTIAL DIAGNOSIS AND CLINICAL REASONING
1-Hemorrhage
If the drain is haemorrhagic, with accompanying factors like tachycardia, anaemia, local swelling over the graft, or if bleeding is a possibility, ultrasonography, CT scan, or MRI may be used to identify haematoma, necessitating an emergency re-exploration.
2-Urinary Fistula
Urinary fistula occurs in 2–5% of kidney transplantations, and may lead to significant morbidity, graft loss, and mortality;30,31 there is an 8% risk of mortality associated with urinary f istula.30 Ureteral ischaemia and necrosis and technical problems associated with the transplant procedure are important causes of urinary fistula development
3-Perinephric Abscess
Perinephric abscesses are uncommon complications post kidney transplantation. They usually present in the early post-transplant period (in the first few week’s post-transplant). The causes include pyelonephritis, infection of lymphocele, haematoma, or urinoma. If the drained fluid is purulent, with accompanying symptoms and signs (fever, swelling, and tenderness over the graft), ultrasonography, CT scan, or MRI may aid the diagnosis of perinephric abscess.
4-Lymphocele and Seroma
A collection of lymph in the perigraft area is called a lymphocele. Lymphoceles occur in 1-20% of kidney transplant operations. Lymphocele may occur from as early as 2 weeks to as late as 5 years post-transplant. Usually they are small and asymptomatic, and such lymphoceles require no intervention.33 Lymphoceles may present with features of compression symptoms including retention of urine, decreased urine output, elevated serum creatinine, thrombosis of iliac vein, and limb oedema.
5-Urine Leak and Urinoma Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of cases.33 Urine leaks post kidney transplantation may manifest as free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma).
Different clinical presentations of urine leak
The different clinical presentations could be early extraperitoneal high-volume leak; early extraperitoneal small leak, defined by a persistent low urine output through drains, associated with low urine output, graft site swelling, and pain (imaging with contrast may help identify urinoma); late leak (1–2 weeks after kidney transplant), which may be caused by ureter necrosis or early removal of double J stent (<3–6 weeks); and intra-abdominal leak, which presents with an acute abdomen.
Evidence-based management plan in extraperitoneal urine leak
Low-volume leak at the anastomotic site can be managed conservatively by performing maximum decompression. Ante-grade pyelogram to identify the site of the leak is helpful. Placing a Foley catheter and ureteral stent performing a nephrostomy are the techniques used for decompression.Once the urine leak stops, the Foley catheter and nephrostomy tube can be removed; however, the ureteral stent is only removed after a period of 4–6 weeks. After conservative management, the patient is carefully followed-up. If the fluid collections become infected, or cause ureteral obstruction and extrinsic compression on the ureter, then urgent percutaneous drainage is required. Surgical re-exploration and reimplanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain
Preventive measures:
importance of the golden triangle Urine leak usually occurs because of technical errors in the ureteroneocystostomy technique, the method of graft ureter implantation in the recipient’s urinary bladder, or because of the transplanted ureter’s compromised vascularity, which is caused by vessel damage during the harvest of the donor kidney.Presence of multiple renal arteries is also a risk factor for development of urological complications post kidney transplantation.
An adequate periurethral tissue in the ‘golden triangle’ must be carefully preserved the ‘golden triangle’ is bound by the lower border of the junction between the renal vein and the inferior vena cava on the right, lower pole of the kidney on the left and the gonadal vein. Important factors that help to prevent major urological complications include delicate dissection of the ureter during donor nephrectomy to preserve adventitia; fat and blood supply of the ureter; short ureter length; and fixation of the adventitia, fat, and blood supply of the ureter to the bladder wall to prevent kinking or twisting.
Outcome of extraperitoneal urine leak: short-term and long-term effects on graft function and survival
Surgical complications can cause graft loss post kidney transplantation.Several studies have shown that urological complications post kidney transplant may lead to prolonged hospitalisation and reduced graft survival
conducted a retrospective cohort study of consecutive adult kidney transplant recipients and identified 36 cases of urine leak out of 1,308 cases. These investigators found that the patients with urine leak had a statistically significant longer length of hospital stay, more readmissions, more delayed graft function, and lower rates of graft survival. In another observational cross-sectional study of 3,102 kidney transplant patients, Carvalho et al. found that surgical complications occurred in 527 (17.0%) patients and urinary complications in 184 (5.9%). The most common complications observed were ureteral obstruction (in 85 patients; 2.7%) and urinary f istula (in 72 patients; 2.3%). They observed that surgical complications after kidney transplants lead to prolonged hospitalisation and decreased graft survival.
CONCLUSION
Different ureteroneocystostomy techniques, including the Lich-Grégoir, Politano–Leadbetter, and U-stitch techniques, have an impact on development of urine leak. The Lich-Grégoir technique has a significantly lower incidence of urinary leakage compared to the PolitanoLeadbetter procedure.
Technical errors in ureteroneocystostomy techniques or compromised vascularity of the transplanted ureter, caused by damage of the vessels during harvesting the donor kidney, are usually responsible for urine leak. Presence of multiple renal arteries is also a risk factor for development of urological complications post kidney transplantation.
A high index of suspicion is needed to identify the complications as the symptoms and signs may be masked because of the immunosuppressive drugs and the analgesics used. The colour of the drained fluid (haemorrhagic, clear, or purulent) and odour (uriniferous or foul) may indicate the development of a urological complication. If drain fluid is clear and the creatinine and potassium values are not much different from the serum values, then the possibilities of lymphocele or seroma are higher.
Extraperitoneal low-volume urine leak may be managed conservatively. Conservative management includes Foley catheterisation, nephrostomy, and placement of an antegrade ureteric stent. If conservative management fails, or if there is extraperitoneal high-volume leak, then surgical exploration and correction may become necessary. The ischaemic or necrosed part of the ureter needs to be removed, followed by reimplantation of the ureter. Development of urine leak may be associated with significant longer length of hospital stay, more readmissions, more delayed graft function, and lower rates of graft survival. If conservative management is used to manage the urine leak, prolonged followup may be necessary
level 5
Introduction
Most of post transplantation complication surgical and non surgical presented with approximately similar presentation , graft dysfunction could be rejection , vascular or urological complication .
The first step in evaluating post renal transplantation graft dysfunction is to rule out surgical causes either vascular or urological causes before dealing with medical causes such as rejection , recurrence of primary disease .. Etc (5)
In this poster we will discuss the common causes of urological complication
Causes :
1- Urinoma or urine leak : incidence 1.2 – 8.9%,may occurs early ( within 1st week ) or late ( 1-2 weeks after transplantation ) presented with urine output through drains , graft site swelling , pain and may associated with decrease urine out put (1)
2- Lymphocele and Seroma : incidence 1 – 20% , collection of lymph in the perigraft area , may occur early within 2 weeks or late up to 5 years .
Most of time they are small size with no symptoms and in this case l require no intervention. (1)
Some times present with compression symptoms such as urine retention, decreased urine output high creatinine level , venous thrombosis in iliac vein, and lower limb swelling (1)
3- Perinephric Abscess : uncommon , occurs early in the 1st few weeks , presented with systemic manifestation ( fever , malaise , general weakness ) and local signs ( swelling and pain over the graft associated with purulent discharge from the drain ) (1)
4- Hemorrhage : uncommon , risk factor including high BMI , antiplatelet, and anticoagulation usage . presented with bloody drainage , could be also associated with shok signs such as ( low BP , high HR ) , and pain in the site of surgery . (1)
5- Urinary Fistula : incidence 2–5% post kidney transplantation , and could cause significant morbidity, graft loss, and mortality .
Caused by ureteral ischemia necrosis and technical problems .
The risk factors associated with development of urinary fistula include younger recipient age (aged <10 years), uretero-ureteric anastomosis, use of high-dose steroids in immunosuppression, multiple renal arteries, and bladder problems (1)
Clinical Manifestation
• Urinoma can be present with different symptoms such as graft pain , tenderness and swelling . When the fluid become infected systemic symptoms may presents ( fever , tachycardia tachypnea and hypotension )
• Symptoms may be masked by immunosuppressant or analgesia
• So carful assessment is mandatory when high drain out put is present
•Our patient is day two post renal transplantation presented with sever pain , low grad fever , and increase extra peritoneal leak from the drain so on the top of the differentials is urinoma
•To differentiate between the previous causes :
– Compare the level of creatinine and potassium in serum and drain fluid.
–imaging study ; ultrasonography , Doppler ultrasonography , CT or MRI scans , intravenous pyelogram , Focal tracer scintigraphy Retrograde cystography Antegrade pyelogram
Mangment
•Low-volume leak managed conservatively by performing maximum decompression
1.– Foley catheter : can be removed once urine leak stopped .
2.– Ureteral stent : removed after a period of 4–6 weeks .
3.– Nephrostomy : can be removed once urine leak stopped .
• When the fluid become infected or cause urethral obstruction and extrinsic compression urgent percutaneous drainage is required
Re implantation of the transplanted ureter and other surgical intervention may be needed if conservative measures fail to mange small urine leak, or in case of high volume drain
Conclusion
1- Urological complications, post renal transplantation is not uncommon especially urine leaks and seroma .
2- The Lich-Gregoir ureteroneocystostomy technique and prophylactic DJ stenting (ureteral stenting ) , associated with decrease the incidence of urological complications.
3- Most of urological complication caused by excessive dissection of golden triangle ( confined by ureter , kidney and renal artery ) so injury to this triangle can cause ureter necrosis
3- The first line management of this complications is conservative management by urinary decompression.
4- If conservative management Failed, surgical intervention is may be needed required, especially in case of major leaks or necrosis in ureters.
5- despite urological complications associated with significant morbidity and mortality, its has an excellent prognosis if diagnosed early and treated in good way .
Level 5
Summary
Urine leak after kidney transplantation is one of the early surgical complications with a variable incidence range of 0.6-30 and can be presented with abdominal pain, graft tenderness, fever, hypotension, and increased drain flow of more clear fluid, USS surveillance early post-operative to assess the nature of collections which need to be differentiated from hematoma, abscess, lymphocele, obstruction in addition to the biochemical analysis of the fluid for creatinine level and potassium which can further help to differentiate urine leak from lymphocele or hematoma
Many risk factors are associated with increased risk of urine leak including black male recipients, type of surgical anastomosis
Different surgical techniques were used for vesicoureteral anastomosis and as per evidence Lich–Grégoir, is better than Politano-Lead better,
and U-stitch techniques
Low urine leak, usually managed by Foleys catheter insertion to relieve the pressure on the anastomosis site and allowed for healing, if it’s complicated with hydronephrosis then nephrostomy and antegrade DJ stent insertion would be preferred if not done before. The high-volume leak usually needs surgical intervention and reimplantation of the remaining healthy tissue
What is the level of evidence provided by this article?
Level 5 narrative review
INTRODUCTION:
Urine leak is an early post-operative complication after kidney transplantation and occurs
in 1.2–8.9%.
This article discusses the identification of extra peritoneal urinary leak in a KTR in the
post-operative period, as well as the clinical clues.
URETEROVESICAL ANASTOMOSIS AND A COMPARISON OF ASSOCIATED
COMPLICATIONS:
The most popular methods include the Lich–Grégoir, Politano-Leadbetter, and U-stitch
techniques.
Meta-analyses performed by Alberts et al. showed that the Lich–Grégoir technique is
significantly associated with a lower incidence of urinary leakage compared to the
Politano-Leadbetter technique.
UROLOGICAL COMPLICATIONS DURING THE POST-OPERATIVE PERIOD IN
KIDNEY TRANSPLANT RECIPIENTS:
Common surgical urology complications include urine leakage, ureteral obstruction, and
lymphocele.
Long ureter is liable to kinking and obstruction.
Atrophic bladder or dysfunctional bladder.
Proximal calyceal leak may occur because of lower pole artery complications
(thrombosed, ligated, not reconstructed).
Damage to the ureter during dissection may result in ureteric ischemia, necrosis, and
distal leak.
Signs and Symptoms:
Local (graft pain and tenderness, and local swelling over the graft)
Systemic (fever, tachycardia, hypotension, and tachypnea).
Investigation:
Compare drain creatinine and potassium levels with serum creatinine and potassium
levels.
Use ultrasonography.
Doppler ultrasonography.
CT or MRI.
An intravenous pyelogram
.
Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the
location of the leak.
Retrograde cystography
Ante grade pyelogram.
DIFFERENTIAL DIAGNOSIS:
1-Haemorrhage.
2-Urinary Fistula.
3-Perinephric Abscess.
4-Lymphocele and Seroma.
Urine Leak and Urinoma:
Urine leak occurs early in 1.2–8.9% of cases.
Urine leaks post kidney transplantation may manifest:
As free fluid (urine ascites),
Extravasation in local tissues,
Or may be encapsulated (urinoma).
Different clinical presentations of urine leak:
Early:
Extra peritoneal high-volume leak.
Extra peritoneal small leak, defined by a persistent low urine output through drains,
associated with low urine output, graft site swelling, and pain.
Late leak (1–2 weeks after kidney transplant), which may be caused by ureter necrosis
or early removal of double J stent.
Evidence-based management plan in extra peritoneal urine leak:
Managed conservatively:
Low-volume leak at the anastomotic site can be by performing maximum
decompression.
Placing a Foley catheter and ureteral stent performing a nephrostomy are the
techniques used for decompression.
Percutaneous drainage:
if the fluid collections become infected, or cause ureteral obstruction and extrinsic
compression on the ureter, then urgent percutaneous drainage is required.
Surgical re-exploration and reimplanting the transplant ureter becomes necessary if
conservative measures for stopping low-volume urine leak fail, or if there is a high-
volume drain.
Preventive measures: importance of the golden triangle:
Per urethral tissue in the ‘golden triangle’ must be carefully preserved.
Outcome of extra peritoneal urine leak:
Short-term and long-term effects on graft function and survival surgical complications
can cause graft loss post kidney transplantation.
CONCLUSION:
Different ureteroneocystostomy techniques, including the Lich-Grégoir, Politano–
Leadbetter, and U-stitch techniques, have an impact on development of urine leak.
The Lich-Grégoir technique has a significantly lower incidence of urinary leakage
compared to the Politano– Leadbetter procedure.
level of evidence V.
Please summarise this article
Identifying Early Extraperitoneal High-Volume Urine Leak Post Kidney Transplantation
Introduction :
Parameters indicate graft function,graft rejection ,DGF,post-operative complications,drug levels,infection must be monitored carefully by transplant team .
Urine leak occurs early in 1.2-8.9% of operations .
It’s either low-volume or large -volume leak.
URETEROVESICAL ANASTOMOSIS technique:
Lich-Gregoir technique associated with lower incidence of urinary leakage . Also fewer incidence of hematuria , with fewer urological complications than the other two techniques.
Politano-leadbetter technique.
U-stitch technique.
Whichever technique are used , it must be tension-free and protected by at least 1 cm submucosal tunnel.
UROLOGICAL COMPLICATIONS DURING THE POST-OPERATIVE PERIOD IN KIDNEY TRANSPLANT RECIPIENTS
1-urine leakage
2-ureteral obstruction
3-lymphocele
4-long ureter liable to kinking or obstruction.
5-short ureter not appropriate for achieving tension-free anastomosis.
6-bladder perforation or anastomoses dehiscence in case of bladder dysfunction in the recipients.
7-lower pole artery complications.
8-ureteric ischemia, necrosis and distal leak after damage to ureter during dissection.
Signs and Symptoms
Symptoms
Local :
graft pain , tenderness,local swelling over graft
Systemic :
Fever, tachycardia, hypotension and tachypnoea .
Signs masked by immunosuppressant and analgesics.
Investigations:
1-Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
2-Use ultrasonography to identify any collections and dilatation of pcs.
3-Doppler ultrasonography can be used to identify defects in perfusion.
4-CT or MRI scans are a useful tool to identify and define the perinephric collection and pelvicalyceal dilatation.
5-An intravenous pyelogram may be helpful to identify location of the leak.
6-Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak.
7-Retrograde cystography helps clinicians to look for urinary bladder dehiscence.
8-Antegrade pyelogram testing through
a nephrostomy may accurately identify
the location of the leak.
DIFFERENTIAL DIAGNOSIS AND CLINICAL REASONING
Haemorrhage
It is not a common complication after KT . Risk factors include: recipient obesity, use of antiplatelat agents , and anticoagulation .
It occurs when the drain is haemorrhagic associated with tachycardia , anemia , local swelling over the graft.
Diagnosed by US , CT scan or MRI .
Urinary Fistula
Occur in 2-5%, can lead to morbidity, mortality and graft loss.
Caused by ureteral ischemia and necrosis, technical problems.
Risk factors include younger recipient age and uretero-ureteric anastomoses, use of high dose steroid or IS, bladder problems and number of renal arteries.
Perinephric Abscess:
Uncommon complications, occur early post transplantation.
Causes include pyelonephritis , infection of lymphocele ,haematoma , urinoma.
Diagnosed by US , CT , or MRI.
Aspiration and doing microscopy and culture may help the diagnosis.
Lymphocele and Seroma:
Occurs in 1-20% of KT.from as early as 2 weeks to 5 years post transplant.
Present with features of compression. Occurs because of technical failures or use of sirolimus.
The fluid is clear . Diagnosed by US ,CT scan and MRI, and fluid biochemistry.treatment options include aspiration, percutaneaus drainage , laparoscopic drainage or open marsupialisation.
Urine Leak and Urinoma:
Occurs early , in 1.2-8.9% of cases. It’s either free fluid, extravasating in local tissues or encapsulated (urinoma).
Evidence-based management plan in extraperitoneal urine leak:
Conservative treatment for low-volume leak by maximum decompression.foley catheter and ureteral stent performing a nephrostomy used for decompression. Surgical re-exploration is necessary if conservative measures fail or if there is high-volume drain .
Preventive measures: importance of the golden triangle:
gentle handling of the ureter at the time of ureteral dissection is crucial to prevent urine leak post kidney transplantation. An adequate periurethral tissue in the ‘golden triangle’ must be carefully preserved.
Outcome of extraperitoneal urine leak: short-term and long-term effects on graft function and survival:
Graft loss , prolonged hospitalization, reduced graft function , ureteral obstruction, urinary fistula.
What is the level of evidence provided by this article?
Level V
Urine leak Post kidney transplantation:
Its the most common surgical complication, that might arise early 1-2 days, or later, after 7 days.
Early urine leaking is predominantly secondary to surgical defaults, like suture breakdown. late urine leak is usually due to ischemic necrosis of the the ureter.
Early Urine Leak:
3 types of ureterovesical anastomosis are commonly implicated in kidney transplantation.
The most commonly associated with urine leak is U stitch.
Ureteric stent insertion:
Ureteric stent falter severity of post operative surgical complications, however, its falling short of preventing it.
Complications linked to stent usage:
1) When stent is linger than 20 cm..
2) Keeping stent for more than 6 weeks.
It might be resultant in migration, infection and encrustation.
Conditions predisposed to surgical complications:
1) Long ureter, as its liable to kinking and obstruction and lower segment ischemia, owing to jeopardized blood supply coming from peri-ureteric tissues.
2)Short ureter: might demonstrate tension suturing uretero-cystostomy.
3) Bladder dysfunction, bearing risk of perforation and suture delicenses.
4)lower calyceal leak , predisposed to by trauma or ligation of lower pole artery.
5) dissection’s of ureter .
High drain output:
Post operatively, increased fluid draining ,is come encounter. Which could be urine leak, hemorrhage, serum, lymph and pus based on nature of fluid and time of onset post operatively.
In order to ascertain nature of drained fluid, in addition to its apparent appearance and circumstance’s. thereof, Simultaneous analysis of drained fluid and serum for potassium and creatinine would give a major clue on its nature.
US study would differentiate between abscess and urinoma as its featuring hypoechoic vs hyperechoic cystic lesion.
Isotope scan is crucial in reflecting the site, extent and vastness of urine leak.
CT and MRI are helpful in identifying the extent of the collection.
Retrograde cystography is implied to show urine leak site.
Antegrade pyelo-uretero-cystogrm is modality of choice to diagnose the ureteric leak.
Treatment:
maximum decompression of urinary system is the key to overcome urine leak, with nephrostomy, urethral catheter and antegrade ureteric stent.
High volume and failure of conservative measures is an indication for surgical exploration.
The rates of urological complications range from 2.5% to 30.0% of all recipients, so the post-transplant period is quite critical. Regarding surgery, the main possible complications are: haemorrhage, extraperitoneal urine leak, and lymphocele, the first two being related to the most recent postoperative period and lymphocele usually present 2–6 weeks after transplantation. This paper discusses how to identify high-volume extraperitoneal urine leaks in the early post kidney transplant period and considers the differential diagnoses. The rates of urological complications range from 2.5% to 30.0% of all recipients. Other urologic complications include:
– Complications caused by the length of the transplanted ureter.
– Atrophic bladder or dysfunctional bladder in the recipient may result in bladder perforation or anastomotic dehiscence
– Proximal calyceal leak
– Damage to the ureter during dissection may result in ureteric ischaemia, necrosis, and distal leak
In kidney transplant there’s some techniques of ureterovesical anastomosis, but three are most important: Lich–Grégoir, Politano-Leadbetter, and U-stitch. The investigators concluded that the Lich-Grégoir technique results in fewer urological complications than the other two.
Varied symptoms can occur as a result of kidney transplant, including local (graft pain and tenderness, and local swelling over the graft) and systemic (fever, tachycardia, hypotension, and tachypnoea). For investigation, we can count on several tests:
– Compare drain creatinine and potassium levels with serum creatinine and potassium levels
– Use ultrasonography to identify and define the perinephric collection and dilatation of the pelvicalyceal system
– Doppler ultrasonography can be used to identify defects in perfusion
– CT or MRI scans are a useful tool to identify and define the perinephric collection and pelvicalyceal dilatation
– An intravenous pyelogram may be helpful to identify location of the leak
– Retrograde cystography helps clinicians to look for urinary bladder dehiscence
– Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak
URINE LEAK
Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of these operations. Low-volume leaks may subside with conservative management and provided there is no distal obstruction, may manifest as free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma).
The different clinical presentations could be:
– Early extraperitoneal high-volume leak;
– Early extraperitoneal small leak, defined by a persistent low urine output through drains, associated with low urine output, graft site swelling, and pain (imaging with contrast may help identify urinoma);
– Late leak (1–2 weeks after kidney transplant), which may be caused by ureter necrosis or early removal of double J stent (< 3-6 weeks);
– Intra-abdominal leak, which presents with an acute abdomen
Low-volume leak at the anastomotic site can be managed conservatively with Foley catheterisation, nephrostomy, and placement of an antegrade ureteric stent. If the fluid collections become infected, or cause ureteral obstruction and extrinsic compression on the ureter, then urgent percutaneous drainage is required. Once the urine leak stops, the Foley catheter and nephrostomy tube can be removed; however, the ureteral stent is only removed after a period of 4–6 weeks. If conservative management fails, or if there is extraperitoneal high-volume leak, then surgical exploration and correction may become necessary
DIFERENTIAL DIAGNOSIS
– Haemorrage: it is not a common complication for kidney transplantation, because bleeding usually stops spontaneously. If there is tachycardia, anemia, local swelling over the graft, ultrasonography, CT scan, or MRI are necessary to rule out haemorrage. And if confirmed, emergency surgical intervention.
– Urinary fistula: occurs in 2–5% of kidney transplantations, and may lead to significant morbidity, graft loss, and mortality. Ureteral ischaemia and necrosis and technical problems associated with the transplant procedure are important causes of urinary fistula development. Urinary fistulas may be managed by different techniques including ureteral ligature and nephrostomy, ureteroureterostomy, pyeloureterostomy, ureteroneocystostomy, percutaneous nephrostomy and ureteral stenting, and prolonged vesical drainage
– Perinephric abscesso: uncommon complications post kidney transplantation. If the drained fluid is purulent, with accompanying symptoms and signs (fever, swelling, and tenderness over the graft), ultrasonography, CT scan, or MRI may aid the diagnosis of perinephric abscesso.
– Lymphocele and Seroma: A collection of lymph in the perigraft area is called a lymphocele and occur in 1-20% of kidney transplant operations, from as early as 2 weeks to as late as 5 years post-transplant, your drainage fluid is clear. Ultrasonography, CT scan, or MRI, and fluid biochemistry further aid diagnosis. If drain fluid creatinine and potassium values are not much different from the serum values, then the possibilities of lymphocele or seroma are higher. Treatment options include aspiration (nearly 100% chances of recurrence), percutaneous drainage (50% success rate), drainage by laparoscopic method, or open marsupialisation.
Your evidence is level 05.
IDENTIFYING EARLY EXTRAPERITONEAL HIGH-VOLUME URINE LEAK POST KIDNEY TRANSPLANTATIONIntroduction:
Urine leak is an early postoperative complication after kidney transplantation and occurs in 1.2-8.9% of these operations.
This article discusses the identification of extraperitoneal urinary leaks in kidney transplantation in the post-operative period and rules out another differential diagnosis.
Ureterovesical anastomosis and a comparison of associated complications
Meta-analysis performed by Alberts et al showed that the lich-Gregior tech requirement is significantly associated with a lower incidence of urinary leakage compared to the politeam needs a better technique to prevent reflux during voiding the ureterovesical anastomosis must be tension free and protected by at least a 1cm submucosal tunnel.
Initial management is a urethral catheter as well as nephrostomy or placing a retrograde ureteric stent
The drain is left in situ
If all fail surgical exploration to reimplant the transplant ureter
Other surgical complications include:
· Kicking and obstruction of the ureter.
· Atrophic bladder results in perforation or anastomotic dehiscence
· Proximal calyceal leak
· Damage to the ureter during dissection may result in ureteric ischemia, necrosis, and distal leak
Symptoms and signs:
Local graft pain or swelling
Systematic symptoms such as fever and tachycardia
Signs masked because of immunosuppression investigation
The following testing can poleat differential diagnosis
Drain creatinine and potassium levels, compared with serum creatinine and potassium levels.
Ultrasonography doppler ultrasonography to detect any defect in perfusion
CT or MRI scans are useful tools to identify perinephric collection and pelvicalyceal dilatation.
An intravenous pyelogram detects the location of the leak.
Focal tracer scintigraphy (==) technetium 99 identifies the location of the leak
Retrograde cystography for urinary bladder dehiscence.
Anterograde pyelogram in delayed graft function to identify the location of the leak.
Identifying extra-peritoneal urine leak post kidney transplantation.
A high volume of clear drain fluid may indicate possible extra-peritoneal
Ultrasonography, CT scan or MRI, and fluid biochemistry aid the diagnosis, and urinoma can be diagnosed by U/S and nuclear scan.
Differential diagnosis:
v Haemorrhage:
Drain is hemorrhagically associated with tachycardia and anaemia.
CT, and MRI will identify hematoma and emergency exploration
v Urinary fistula:
Occur in 2-5% of kidney transplantation. Important cause is ischemia and necrosis
Technical problems
Risk factors:
v Perinephric abscess:
Uncommon complication
The cause is pyelonephritis, infection of lymphocele, hematoma or urinoma
Drain fluid is purulent with signs of infection
Ultrasonography, CT, and MRI aid in the diagnosis
Confirm the diagnosis by aspiration of the collection and performing microscopic culture of the aspirate may help in the diagnosis.
v Lymphocele and seroma:
Occur in 1-20% of the kidney transplant operation
Occur from 2 weeks up to 5 years post-transplant
Prevent by causing symptoms
Drain fluid clear
Diagnosis by ultrasonography
CT or MRI treatment
Aspiration: percutaneous drainage
Drainage by laparoscopic drainage of lymphocele.
v Urine leak and urinoma:
Occur in 1.2-8.9% of cases
Clinical presentation of urine leak:
Early extraperitoneal high-volume leak with low urine output
Late leak 1-2 weeks present with acute abdomen
Management of urine leak: maximum decompression by placing a foley catheter and urethral stent and nephrostomy
If fluid collection becomes infected or causes obstruction urgent placement as drainage is required
Surgical exploration and reimplantation of the transplant ureter if conservative increase fluid or high volume drain.
Prevention measures:
During having resting of the donor kidney gentle handling of the ureter at the time of urethral dissection to prevent urine leak post-kidney transplantation
Peri-urethral tissue in the golden triangle must be carefully preserved.
The outcome of an extraperitoneal leak
Surgical complications can cause graft loss post-kidney and also can lead to prolonged hospitalization and reduced graft survival.
Conclusion:
Different level cystotomy techniques including the Lich-Gregoir, Politano-lead better, and – stitch techniques have an impact on the development of urine leak
The Lich-Gregoir technique has a significantly low incidence of urinary leakage compared to the Politano lead better procedure.
evidence is level 5
In this article it was discussed to identify the post operative complication post-transplantation. the most common complications included urinary leak, ureteral obstruction, lymphocele, stent related complication, ureteric ischemia, bladder complication.
These complication can be diagnosed by fluid color, sonography, fluid and blood sample comparison.
Small leak can be managed by just observation, if not settled then can be managed surgically.
1. Please summarise this article
There are many surgical complications that can occur in the early post-transplant period. These include haemorrhage, extraperitoneal urine leak, lymphocele, ureter kinking and obstruction, bladder perforation or anastomotic dehiscence , proximal calyceal leak , ureteric ischaemia, necrosis, and distal leak.
Symptoms of urine leakage are fever, pain over the graft, and fluid leakage from the wound. These could be masked due to immunosuppression and analgesics which would necessitate high index of suspicion espically in patient with high drain output. Management is through decompression of the urinary system through leaving the drain and inserting a urethral catheter, nephrostomy tube or placing an antegrade ureteric stent. If no improvement with all these or the drain is of large amount, then surgical exploration is needed to reimplant the transplant ureter.
Investigations include comparing the creatinine and potassium components of the serum and the drain.
Ultrasound, CT or MRI will help in detection of perinephric collection and pelvicalyceal system dilatation. Other imaging modalities include intravenous pyelogram, scintigraphy, retrograde cystography and antegrade pyelogram.
If the creatinine and potassium contents of the drain fluid are similar to the serum values, then the possibilities of lymphocele or seroma are higher. otherwise it is a urine leak or urinoma.
Differential diagnoses include:
Haemorrhage If the drain is bloody and is associated with Hb drop in patients with bleeding risk. This can be assessed by ultrasonography, CT scan, or MRI.
Urinary Fistula due to ureteral ischaemia and necrosis or procedure technical problems are commoner in recipientaged <10 years, uretero-ureteric anastomosis, use of high-dose steroids, number of renal arteries and bladder problems.
Perinephric abscesses due to pyelonephritis, infection of lymphocele, haematoma, or urinoma. This is suspected when the drain is purulent in the presence of fever, swelling, and tenderness over the graft.
Lymphocele may present with features of compression symptoms including retention of urine, decreased urine output, elevated serum creatinine, thrombosis of iliac vein, and limb oedema.
What is the level of evidence provided by this article?
5
Q1- Please summarise this article
Abstract
The common post transplant surgical complications are hematoma , extraperitoneal urine leak –urinoma , and lymphocele. The first two develp early in postoperative period but the last one ( lymphocele ) may occur from 14 – 42 day post op . Although not diagnostic the volme and colour of the drain may give us an idea about the underlying cause . biochemical analysis of the drained fluid is helpful .
Multiple ureteroneocystostomy procedures available , including the Lich–Grégoir , Politano–Leadbetter , and U-stitch techniques, with different complication rate regarding urinoma and hematuria .
INTRODUCTION
Post operatively patient should be monitored for graft dysfunction, graft rejection, delayed graft function, post-operative complications, drug levels infection, and the general wellbeing.
Urine leak is ocur in 1.2–8.9% of patients in the early post operative period. Low volume leake can be treated conservatively while the large volume one may need exploration .
URETEROVESICAL ANASTOMOSIS AND A COMPARISON OF ASSOCIATED COMPLICATIONS.
There is three most common technique for uretrovesical anastomosis Lich–Grégoir, Politano Leadbetter, and U-stitch techniques. Meta-analyses performed by Alberts et al. showed that the
Lich–Grégoir technique is significantly associated with a lower incidence of urinary leakage and hematuria compared to the two other technique .
Whichever technique is used, the anastomosis must be tension-free and at least a 1 cm submucosal tunnel .
UROLOGICAL COMPLICATIONS DURING THE POST-OPERATIVE PERIOD IN KIDNEY TRANSPLANT RECIPIENTS
The most common surgical complications post operatively are urine leakage, ureteral obstruction, and lymphocele which is occur in 2.5% to 30.0% of patients.
Clinically present as a fever, graft pain , and fluid leakage from the wound.
Routine prophylactic intraoperative ureter stenting mitigates but does not reduce the incidence of these complications.
The stents are generally well tolerated, but complication occur when long length: ≥20 cm , or longer periods (>6 weeks), is used . the complications including infection, migration, and encrustation.
The management include decompression of the urinary system by inserting a urethral catheter, nephrostomy or placing an antegrade ureteric stent. The drain is left in situ.
If no response or if large-volume extravasation occurs, surgical exploration to reimplant the ureter.
Other urological complications include:9,10
1) Complications caused by the length of the transplanted ureter.
a. A long ureter – kinking and obstruction and ischaemia .
2) A short ureter may not be appropriate for achieving tension-free anastomosis.
3) Atrophic bladder or dysfunctional bladder : bladder perforation or anastomotic dehiscence.
4) Proximal calyceal leak may occur because of lower pole artery complications (thrombosed, ligated, not reconstructed).
5) Damage to the ureter – ureteric ischaemia, necrosis, and distal leak.
The underlying cause can be expected by drain fluid colour (clear, haemorrhagic, or purulent) and
odour (uriniferous or foul) .
Signs and Symptoms
symptoms may including local (graft pain and tenderness, and local swelling over the graft)
and systemic (fever, tachycardia, hypotension, and tachypnoea). Although these Signs may be masked by immunosuppression and analgesics. high drain output is alarming sign.
Investigations
For extraperitoneal urine leak
1) Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
2) ultrasonography for perinephric collection and dilatation of the pelvicalyceal system.
3) Doppler ultrasonography to detect perfusion defect .
4) CT or MRI scans for perinephric collection and pelvicalyceal dilatation.
5) An intravenous pyelogram to localize the leak .
6) Focal tracer scintigraphy to localize the leak .
7) Retrograde cystography – for urinary bladder dehiscence.
8) Antegrade pyelogram through a nephrostomy for localization of the leak.
Identifying Extraperitoneal Urine Leak Post Kidney Transplantation
A high volume of clear drain fluid may indicate the possibility of extraperitoneal urine leak.
Ultrasonography, CT scan or MRI, and fluid biochemistry .
If drain fluid creatinine and potassium values are similar to the serum values, then the diagnosis is lymphocele or seroma . but if they are significantly higher than the serum values, or are values that are incompatible with life, then it
is a urine leak or urinoma.
DIFFERENTIAL DIAGNOSIS AND
CLINICAL REASONING
Haemorrhage
Is suspected If the drain is haemorrhagic, with tachycardia, anaemia, local swelling over the graft, or if bleeding is a possibility, ultrasonography, CT scan, or MRI may be used to identify haematoma, treated by emergency re-exploration.
The risk factors include recipient obesity, use of antiplatelet agents, and anticoagulation.
Other features a falling haematocrit level bu serial measures , hypotension, tachycardia, and pain in the flank or lower quadrant.
Surgical exploration is usually not required unless the needs pure red blood cell transfusion repeatedly, or if there is haemodynamic instability or compression of the kidney by haematoma.
Urinary Fistula
occurs in 2–5% of kidney transplantations, associated with significant morbidity, graft loss, and mortality of 8% .
causes : Ureteral ischaemia and necrosis and technical problems associated with the procedure .
Risk factors include :
· (aged <10 years),
· uretero-uretericanastomosis,
· use of high-dose steroids in immunosuppression,
· number of renal arteries,
· bladder problems.
·
Early management is important which include :
· Ureteral ligature and nephrostomy,
· ureteroureterostomy,
· pyeloureterostomy,
· ureteroneocystostomy,
· percutaneous nephrostomy and ureteral stenting,
· prolonged vesical drainage.
Perinephric Abscess
It is uncommon complications. It is occur within early few post operative weeks .
Caused by pyelonephritis, infection of lymphocele, haematoma, or urinoma.
Presented as : drained fluid is purulent, fever, swelling, and tenderness over the graft .
diagnosis : ultrasonography, CT scan, or MRI. Aspiration for microscopy and culture .
Lymphocele and Seroma
Is collection of lymph in the perigraft area occurring in 1-20% of operation. Can occur from 14 days to years after transplantation .
clinical features include retention of urine, reduced urine output, graft , thrombosis of iliac vein, and limb oedema.
sirolimus use is a risk factor . the aspirate is a clear fluid .
diagnosis : Ultrasonography, CT scan, or MRI, and fluid creatinine and potassium which are should be similar to that of serum .
Treatment
1. aspiration with very high recurrence rate .
2. percutaneous drainage ( half of them recurs ),
3. laparoscopic technique . is treatment of choice
4. open marsupialisation. Preferred if there is wound complication of small collection near vital structures .
if it is continued , sclerosants like povidone iodine, fibrin glue, and doxycycline, tetracycline, ethanol, bleomycin. Periureteral fibrosis is a risk factor .
Urine Leak and Urinoma
It is an early post operative complication occurring in 1.2-8.9% of transplantation . It present as free fluid (urine ascites), extravasation in local tissues, or encapsulated (urinoma).
Different clinical presentations of
urine leak
The different clinical presentations could be
· early extraperitoneal high-volume leak;
· early extraperitoneal small leak, characterized by a continuous small urine output through drains, low urine output, graft site swelling, and pain diagnosed by contrast imaging
· late leak occuring 7-14 days post op. caused by ureter necrosis or early stent removal (<3–6 weeks).
· intra-abdominal leak, usually manifested as acute abdomen.
Evidence-based management plan in extraperitoneal urine leak
Low-volume leak treated conservatively by maximum decompression which can be achieved by Foley catheter , ureteral stent , and a nephrostomy. Diagnosed by Antegrade pyelogram.
With improvement when the leak is stoped above measures can be removed but the uretric stent should be kept for 3-6 weeks .
Percutaneous drainage is indicated in case of infection ,obstruction by extrinsic uretric compression .
Surgical re-exploration and reimplanting is indicated in case of failure of conservative treatment or if there is a high volume drain.
Outcome of extraperitoneal urine leak: short-term and long-term effects on graft function and survival
Post op Surgical complications can increase hospital stay increase graft loss.
In astudy by Buggs et al. found that urine leak associated with prolonged hospitalization , high rate of readmission, delayed graft function , reduced graft survival .
another study by Carvalho et al. overall complications are (17.0%) but urinary complications (5.9%).
ureteral obstruction was present in 2.7%( the most common ) and urinary fistula (in 2.3%). These complication causes increased hospital stay , and reduces graft survival .
Q2- What is the level of evidence provided by this article?
Level v
What is the level of evidence provided by this article?
Level V
Introduction
Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of these operations. This article discusses the identification of extraperitoneal urinary leak
in a KTR in the post-operative period, as well as the clinical clues that help to rule out the differential diagnoses.
The impact of ureterovesical anastomosis on the outcome
Meta-analyses performed by Alberts et al.2 showed that the Lich–Grégoir technique is significantly associated with a lower incidence of urinary leakage compared to the Politano-Leadbetter technique. Whichever technique is used, in order to prevent reflux during
voiding, the ureterovesical anastomosis must be tension-free and protected by at least a 1 cm
submucosal tunnel
Urological complications during the post-operative period in kidney transplant recipients
The most common surgical urology complications include urine leakage, ureteral obstruction,
and lymphocele (fluid collection between the urinary bladder and the kidney allograft)
Routine prophylactic intraoperative stenting of the ureter in kidney transplant recipients
mitigates the effects of ureteric complications but does not reduce the incidence of these
complications. The stents are generally well tolerated, but when longer stents are used (stent
length: ≥20 cm), or if used for longer periods (>6 weeks), they may result in stent-related complications including infection, migration, and encrustation.
The initial step in urine leak management is to maximally decompress the urinary system. This is achieved by inserting a urethral catheter, as well as performing a nephrostomy or placing an antegrade ureteric stent. The drain is left in situ. If this technique fails, or if large-volume extravasation occurs, surgical exploration to reimplant the transplant ureter becomes necessary.
Other urological complications include:
– A long ureter is liable to kinking and obstruction as a result of ischaemia because the vascularity of the transplant ureter depends on renal vessels supplying through periureteric tissue, unlike the native ureter which has a segmental blood supply.
– A short ureter may not be appropriate for achieving tension-free anastomosis.
– Atrophic bladder or dysfunctional bladder in the recipient may result in bladder perforation or anastomotic dehiscence.
– Proximal calyceal leak may occur because of lower pole artery complications (thrombosed, ligated, not reconstructed).
– Damage to the ureter during dissection may result in ureteric ischaemia, necrosis, and
distal leak.
Investigations extraperitoneal urine leak post kidney transplantation
– Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
– Use ultrasonography to identify and define the perinephric collection and dilatation of the
pelvicalyceal system.
– Doppler ultrasonography can be used to identify defects in perfusion.
– CT or MRI scans are a useful tool to identify and define the perinephric collection and
pelvicalyceal dilatation.
– An intravenous pyelogram may be helpful to identify location of the leak.
– Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak. This technique is not useful if there is delayed graft function
or ureteral stasis.
– Retrograde cystography helps clinicians to look for urinary bladder dehiscence.
– Antegrade pyelogram testing through a nephrostomy may accurately identify
the location of the leak. This can be done in delayed graft function scenarios too.
Evidence-based management plan in extraperitoneal urine leak
– Low-volume leak at the anastomotic site can be managed conservatively by performing maximum decompression
– Antegrade pyelogram to identify the site of the leak is helpful.
– Placing a Foley catheter and ureteral stent performing a nephrostomy are the techniques used for decompression.
– Surgical re-exploration and reimplanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain
Summary:
Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9%. Low-volume leaks may subside with conservative management if no distal obstruction present. If not resolved, or if it is large-volume surgical exploration and correction may be needed.
Ureterovesical anastomosis and a comparison of associated complications:
Techniques used for ureterovesical anastomosis in kidney transplantation are many and the most popular methods are the Lich-Gregoir, Politano-Leadbetter, and U-stitch techniques. Lich-Gregoir technique is significantly associated with a lower incidence of urinary leakage and haematuria as compared with other techniques. Whatever the technique used, the anastomosis must be tension-free and protected by at least a 1 cm submucosal tunnel.
Urological complications during the post-operative period in kidney transplant recipients:
1- Urine leakage
2- Ureteral obstruction
3- Lymphocele.
The rate of urological complications is about 2.5% to 30%
Urinary leakage, the patient may have fever, pain over the graft, and fluid leakage from the wound.
Routine prophylactic intraoperative stenting of the ureter reduces the effect of ureteric complications but not the incidence. If used for long period, it can cause infection, migration, and encrustation.
Management of urinary leakage:
1- Decompress the urinary system is the first, most important step. Done by urethral catheter insertion and nephrostomy or replacing an antegrade ureteric stent. The drain is left in situ.
2- Surgical exploration to reimplant the transplant ureter in case of large volume extravasation or fails of the other techniques.
4- Longer ureter leads to Kinking and obstruction as a result of ischemia
5- Atrophic bladder or dysfunctional bladder in the recipient may result in bladder perforation or anastomotic dehiscence.
6- Proximal calyceal leak may occur because of lower pole artery complications (thrombosed, ligated, not reconstructed)
7- Damage to the ureter during dissection may result in ureteric ischemia, necrosis, and distal leak.
Drained fluid colour and odour can identify the type of complication.
Signs and symptoms:
Graft pain and tenderness
Local swelling over the graft
Systemic symptoms as fever, tachycardia, hypotension, and tachycardia.
High index of suspicion is warranted in patient with high drain output.
Investigations
1- Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
2- Use ultrasonography.
3- Doppler ultrasonography.
4- CT or MRI scans.
5- An intravenous pyelogram may be helpful to identify location of the leak.
6- Focal tracer scintigraphy (mercaptoacetyltriglycine or technetium 99)
7- Retrograde cystography (diagnose urinary bladder dehiscence).
8- Antegrade pyelogram through nephrostomy.
Identifying extraperitoneal urine leake post kidney transplantation.
High volume clear drain should rise the suspicion of urine leak. If the creatinine and potassium levels are similar in the drain fluid to that of the serum, then the collection is most likely lymphocele or seroma. While if the values are significantly higher than the serum values, or are values that are incompatible with life, then it is a urine leak or urinoma.
Differential diagnosis and clinical reasoning
1- Haemorrhage: it is rare, if it occurs t is usually from vessels in the graft hilum that is nt ligated or from small retroperitoneal vessels.
Risk factors: obesity, antiplatelet agents and anticoagulion.
Haemorrhagic drain, local swelling over the graft.
U/S, CT scan or MRI may be used to identify the hematoma.
May need emergency re-exploration.
2- Urinary Fistula
Causes:
a- ureteral ischemia and necrosis.
b- Technical problems associated with the transplant procedure.
Risk factors:
v Younger recipient age < 10 years
v Uretero-ureteric anastomosis
v High dose steroids
v Number of renal arteries
v Bladder problems
Management:
a- Ureteral ligature and nephrostomy
b- Ureteroureterostomy
c- Pyeloureterostomy
d- Ureteroneocystostomy
e- Percutaneous nephrostomy
f- ureteral stenting
g- prolonged vesical drainage.
3- Perinephric abscess:
It is uncommon, occur in the first week post-transplant. Can be caused by pyelonephritis, infected lymphocele, haematoma, or urinoma. It causes purulent drain and systemic symptoms of sepsis.
U/S, CT scan or MRI help diagnosis
Aspiration with culture and microscopic analysis of the drain needed.
4- Lymphocele and seroma
Lymphatic fluid collection in the perigraft area. It can occur as early as 2 weeks to as late as 5 years post-transplant.
Small lymphocele asymptomatic need no intervention.
Lymphocele may cause urinary retention, decreased urine output, elevated serum creatinine, thrombosis of the iliac vein, and limb oedema.
Treatment options:
1- Aspiration 100% recurrence rate
2- Percutaneous drainage 50% success rate
3- Laproscopic drainage is the method of choice
4- Open drain in patient with wound complication or if the lymphocele is adjacent to vital renal structures as vessel, ureter to avoid risk of injury to them or if the lymphocele is lateral to renal allograft.
5- Continuous drain with sclerosants agents which carry risk of periureteral fibrosis.
5-Urinary leak and urinoma
Occurs early post-transplant, may manifest as free fluid, (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma).
Clinical presentations:
a- Early extraperitoneal high-volume leak
b- Early extraperitoneal small leak
Defined with a low urine through drains, with low urine output, graft site swelling and pain
c- Late leak 1-2 weeks after transplant related to ureter necrosis or early removal of double J stent (3-6 weeks)
d- Intra-abdominal leak present with acute abdomen
Evidence-based management plan in extraperitoneal urine leak
Conservative with maximum decompression if low-volume leak at the anastomosis site.
Foley catheter, ureteral stent, nephrostomy are decompression methods.
Antegrade pyelogram to determine site of leak
Ureteral stent should be only removed after 4 – 6 weeks if urine leak stop.
Surgical re-exploration and reimplanting the transplant ureter in case of infected collection, ureteral obstructed and extrinsic compression if percutaneous drainage is failed.
Prevention:
Gentle handling of the ureter during donor nephrectomy with suitable length
Outcome of extraperitoneal urine leak:
short-term and long-term effects on graft function and survival
Surgical complications can cause graft loss, prolonged hospitalization and reduce graft survival.
Conclusion:
High index of suspicion is needed to diagnose post-operative complications. Drained fluid colour and odours help in diagnosis. Drain biochemistry (Cr and K) compared with serum to differentiate between urine and others. Image study as U/S, CT scan and MRI can help diagnosis
Level 5
Surgical re-exploration and reimplanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain.
level V
♧Introduction:
▪︎Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of these operations.
▪︎Low-volume leaks may subside with conservative management and provided there is no distal obstruction. If not resolved, or if it is large-volume urine leak, surgical exploration and correction may be needed.
▪︎The most popular methods of ureterovesical anastomosis in kidney transplantation include the Lich–Grégoir, Politano-Leadbetter, and U-stitch techniques.
▪︎Studies showed tat Lich–Grégoir technique is signifcantly associated with a lower incidence of urinary leakage and haematuria compared to the Politano-Leadbetter technique.
♧Surgical urology complications:
1. Urine leakage (the patient may have a fever, pain over the graft, and fluid leakage from the wound)
2. Ureteral obstruction,
3. Lymphocele.
4. Stent-related complications (infection, migration & encrustation).
5. Complications caused by the length of the transplanted ureter (eg: kinking, obstruction and anastomosis)
6. Atrophic or dys- functional bladder may result in bladder perforation or anastomotic dehiscence.
7. Proximal calyceal leak
8. Damage to the ureter
Note :
Urological complications in the post-operative period can be identifed by the drained fluid’s colour (clear, haemorrhagic, or purulent) and odour (uriniferous or foul). If there is a delayed graft function, a urinary leak can be detected only after the urine output increases.
Management urine leak:
1. Inserting a urethral catheter, as well as performing a nephrostomy or placing an antegrade ureteric stent. The drain is left in situ.
2- If this technique fails, or if large-volume extravasation occurs, surgical exploration to reimplant the transplant ureter
Urological complications during the post-operative periods:
Signs and Symptoms
▪︎A high index of suspicion is warranted in a patient with high drain output.
Investigations
▪︎To evaluate extraperitoneal urine leak and to rule out differential diagnoses:
1. Compare drain crand K levels with s. cr & K levels.
2. US to identify and defne the perinephric collection and dilatation of the
pelvicalyceal system.
3. Doppler US can be used to identify defects in perfusion.
4. CT or MRI scans to identify and define the perinephric collection and
pelvicalyceal dilatation.
5. An intravenous pyelogram may be helpful to identify location of the leak.
6. Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak.
7. Retrograde cystography helps clinicians to look for urinary bladder dehiscence.
8. Antegrade pyelogram testing through a nephrostomy to identify the location of the leak.
Urine Leak and Urinoma
▪︎Urine leak is an early post- operative complication
▪︎May manifest as free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma).
Different clinical presentations of urine leak
i. Early extraperitoneal high-volume leak
ii. Early extraperitoneal small leak ( a persistent low urine output through drains, associated with low urine output, graft site swelling, & pain (imaging with contrast may help identify urinoma)
iii. Late leak (may be caused by ureter necrosis or early removal of double J stent (<3–6 weeks).
iv. Intra-abdominal leak, which presents with an acute abdomen.
Evidence-based management plan in extraperitoneal urine leak
▪︎Low-volume leak at the anastomotic site can be managed conservatively by performing maximum decompression by placing a Foley catheter , ureteral stent and performing a nephrostomy
▪︎Follow-up; If the fluid collections become infected, or cause ureteral obstruction and extrinsic compression on the ureter, then urgent percutaneous drainage is required.
▪︎Surgical re-exploration and reimplanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail,
or if there is a high-volume drain.
▪︎Preventive measures:
An adequate periurethral tissue in the ‘golden triangle’ must be carefully preserved: the ‘golden triangle’ is bound by the lower border of the junction between the renal vein and the inferior vena cava on the right, lower pole of the kidney on the left and the gonadal vein.
delicate dissection of the ureter during donor nephrectomy to preserve adventitia; fat and blood supply of the ureter;
short ureter length; and fxation of the adventitia, fat, and blood supply of the ureter to the bladder wall to
prevent kinking or twisting.
Outcome ofextraperitoneal urine leak:
___________
▪︎Short-term and long-term effects on graft function and survival
▪︎Significant longer length of hospital stay, more readmissions, more delayed graft function, and lower rates of graft survival.
Identifying Extraperitoneal Urine Leak Post Kidney Transplantation
1. High volume of clear drain fluid.
2. US, CT scan or MRI features.
3. Significantly higher values of creatinine and potassium in the drain fluid (which is also seen in urinoma. The later can will easily be picked up on an US or nuclear scan.
4. Antegrade pyelogram, cystogram, or scintigraphy may be required to identify the cause and to localise the leak.
DIfferential diagnosis:
A. Haemorrhage in which:
1. The drain is haemorrhagic
2, There is tachycardia, anaemia, local swelling over the graft, or if bleeding is a possibility,
▪︎Can be confirmed by: US, CT scan, or MRI and surgical re-exploration may be required.
B. Urinary Fistula
▪︎May lead to significant morbidity, graft loss, and mortality.
▪︎The risk factors include younger recipient age (aged <10 years), uretero-ureteric anastomosis, use of high-dose steroids in immunosuppression, number of renal arteries, and bladder problems.
▪︎Managed by different techniques including ureteral ligature and nephrostomy, ureteroureterostomy, pyeloureterostomy, ureteroneocystostomy, percutaneous nephrostomy and ureteral stenting, and prolonged vesical drainage.
C. Perinephric Abscess
▪︎Uncommon and usually present in the early post-transplant period
▪︎The causes include pyelonephritis, infection of lymphocele, haematoma, or urinoma.
▪︎The drained fluid is purulent, with fever, swelling, and tenderness over the graft.
US, CT scan, or MRI & aspiration of the collection and performing microscopy and culture of the aspirate may further help the diagnosis.
D. Lymphocele & Seroma
▪︎A collection of lymph in the perigraft area
▪︎May occur from as early as 2 weeks to as late as 5 years post-transplant.
▪︎They can present with features of compression symptoms
▪︎In lymphocele and seroma, the drainage fluid is clear. Ultrasonography, CT scan, or MRI, and fluid biochemistry further aid diagnosis.
▪︎ The drain fluid creatinine and potassium values are not much different from the serum values,
▪︎Treatment options include aspiration, percutaneous drainage, drainage by laparoscopic method (the method of choice, or open marsupialization (preferred over laparoscopic technique in patients with wound complications and in a small lymphocele adjacent to vital renal structures, Continuous drainage may be used
together with the application of sclerosants like povidone iodine, fbrin glue, and doxycycline,
tetracycline, ethanol, bleomycin. Periureteral
fbrosis is a risk if sclerosing agents are used.
♧Conclusion:
▪︎Differentureteroneocystostomy techniques, including the Lich-Grégoir, Politano–Leadbetter, & U-stitch techniques, have an impact on development of urine leak.
▪︎ The Lich-Grégoir
technique has a signifcantly lower incidence of urinary leakage compared to the Politano– Leadbetter procedure.
▪︎Level of evidence: V
Identifying Early Extraperitoneal High volume urine leak post KT- evidence 5
Incidence of urine leak is about 1.2-8.9% of KTR.
Lich- Gregoir showed significant lower incidences of urinary leakage, heamaturia, but any method must be tension free and protected by at least a 1 cm submucosal tunnel.
The most common surgical urology complications included urine leakage, urethral obstruction,and lymphocele
Stents longer than 20 cm or if used longer than 6 weeks, may end up stent related complications
Common complications
Caused by length of transplanted ureter- long , prone for kinking and obstruction as a result of ischaemia because of vascularity: if short ureter may not be appropriate for tension free anastomosis
Atrophic bladder or dysfunctional bladder – result in bladder perforation or anastomotic dehiscence
Damaged to ureter during dissection – end up in ureteric ischaemia, necrosis and distal leak
Signs of Urine leak
Graft pain
Tenderness
Local swelling
Fever
Tachycardia
Hypotension
Tachypnoea
Investigations
Compare drain creatinine and potassium levels with serum creatinine and potassium levels.- If drain fluid creatinine and potassium values are not dissimilar from the serum values, then the possibilities of lymphocele or seroma are higher. However, if they are significantly higher than the serum values, or are values that are incompatible with life, then it is a urine leak or urinoma.
Use ultrasonography to identify and define the perinephric collection and dilatation of the pelvicalyceal system.
Doppler ultrasonography can be used to identify defects in perfusion.
CT or MRI scans are a useful tool to identify and define the perinephric collection and pelvicalyceal dilatation.
An intravenous pyelogram may be helpful to identify location of the leak.
Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak. This technique is not useful if there is delayed graft function or ureteral stasis.
Retrograde cystography helps clinicians to look for urinary bladder dehiscence.
Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak. This can be done in delayed graft function scenarios too. Pelvicalyceal dilatation makes it easier to do this procedure.
Management
Low volume leak- managed by maximum decompression
Antegrade pyelogram to identify the leak
Foley catheter and urethral stent performing nephrostomy – decompression
If the fluid becomes infected or causing ureteric obstruction or extrinsic compression on the ureter – urgent percutaneous drainage
If conservative measures failed – surgical re-exploration and reimplantation of the ureter should be done
Preventive measures
Urine leak happens due to technical errors, method of graft ureter implantation or compromised vascularity
Gentle handling of the ureter at the time of ureteral dessection is important
An adequate periurethral tissue in-golden triangle’ – bound by the lower border of the junction between the renal vein and the inferior vena cava on the right, lower pole of the kidney on the left and the gonadal vein.
Summary of the article
DENTIFYING EARLY EXTRAPERITONEAL HIGH-VOLUME URINE LEAK POST KIDNEY TRANSPLANTATION
This review article discusses the identification of extraperitoneal urinary leak and it’s differentials in a KTR in the post-operative period.
Urology complications in the early post-transplant period
A. The most common complications:
1. Urine leakage; the patient may have a fever, pain over the graft, and fluid leakage from the wound. Initially; should be managed with:
· Inserting a urethral catheter.
· Performing a nephrostomy or placing an antegrade ureteric stent.
· Surgical exploration to reimplant the transplant ureter becomes necessary;
a. If the above failed to decompress the urinary system.
b. if there’s large-volume extravasation.
2. Ureteral obstruction; ureteric stenting mitigates the sequelae but doesn’t reduce the incidence. Stent’s use for more than 6 weeks may cause stent-related complications:
· Infection.
· Migration.
· Encrustation.
3. Lymphocele; fluid collection between the urinary bladder and the kidney allograft.
B. Other urological complications:
1. Complications related to the length of the transplanted ureter:
a. A Long ureter is liable to kinking and obstruction as a result of ischaemia.
b. A short ureter may not be appropriate for achieving tension-free anastomosis.
2. Atrophic bladder or dysfunctional bladder in the recipient may result in bladder perforation or anastomotic dehiscence.
3. Proximal calyceal leak may occur because of lower pole artery complications (thrombosed, ligated, not reconstructed).
4. Damage to the ureter during dissection may result in ureteric ischaemia, necrosis, and distal leak.
Identification of Urological complications in the post-operative period:
1. Signs and symptoms may be masked because of immunosuppression and analgesics;
a. Local: graft pain and tenderness, and local swelling over the graft.
b. Systemic: fever, tachycardia, hypotension, and tachypnoea.
2. A high index of suspicion is warranted in a patient with high drain output. If there is a delayed graft function, a urinary leak can be detected only after the urine output increases.
3. The drained fluid’s colour (clear, haemorrhagic, or purulent) and odour (uriniferous or foul).
4. Investigations: the following are helpful in evaluating extraperitoneal urine leak post kidney transplantation, and to rule out differential diagnoses:
a. Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
b. Ultrasonography to identify and define the perinephric collection and dilatation of the pelvicalyceal system.
c. Doppler ultrasonography can be used to identify defects in perfusion.
d. CT or MRI scans are a useful tool to identify and define the perinephric collection and pelvicalyceal dilatation.
e. An intravenous pyelogram may be helpful to identify location of the leak.
f. Focal tracer scintigraphy uses mercapto-acetyl-triglycine or technetium 99 to identify the location of the leak. This technique is not useful if there is delayed graft function or ureteral stasis.
g. Retrograde cystography helps clinicians to look for urinary bladder dehiscence.
h. Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak. This can be done in delayed graft function scenarios too. Pelvicalyceal dilatation makes it easier to do this procedure.
Identifying extraperitoneal urine leak post-kidney transplantation
Clues to identify urine leakage from other differentials:
a. A high volume of clear drain fluid.
b. If drain fluid creatinine and potassium values are significantly higher than the serum values, or are values that are incompatible with life, then it is a urine leak or urinoma.
c. If drain fluid creatinine and potassium values are not dissimilar from the serum values, then the possibilities of lymphocele or seroma are higher.
d. Ultrasonography, CT scan or MRI, and fluid biochemistry further aid diagnosis.
e. Antegrade pyelogram, cystogram, or scintigraphy may be required to identify the cause and to localise the leak.
Urine Leak and Urinoma
a) Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of cases.
b) Manifestation:
· as free fluid (urine ascites).
· extravasation in local tissues.
· may be encapsulated (urinoma).
c) The different clinical presentations could be:
1. Early extraperitoneal high-volume leak
2. Early extraperitoneal small leak: defined by a persistent low urine output through drains, associated with low urine output, graft site swelling, and pain (imaging with contrast may help identify urinoma).
3. Late leak (1–2 weeks after kidney transplant), which may be caused by ureter necrosis or early removal of double J stent (<3–6 weeks).
4. Intra-abdominal leak: presents with an acute abdomen.
d) Evidence-based management plan in extraperitoneal urine leak
1. Low-volume leak at the anastomotic site:
· can be managed conservatively by performing maximum decompression.
· Antegrade pyelogram to identify the site of the leak is helpful. Placing a Foley catheter and ureteral stent performing a nephrostomy are the techniques used for decompression.
· Once the urine leak stops, the Foley catheter and nephrostomy tube can be removed(the ureteral stent is only removed after a period of 4–6 weeks).
2. After conservative management and carefull follow up;
· Urgent percutaneous drainage is required; if the fluid collections become infected, or cause ureteral obstruction and extrinsic compression on the ureter.
· Surgical re-exploration and reimplanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain.
e) Preventive measures:
1. During harvesting of the donor kidney, gentle handling of the ureter at the time of ureteral dissection is crucial to prevent urine leak post kidney transplantation.
2. An adequate periurethral tissue in the ‘golden triangle’ must be carefully preserved.
3. Important factors that help to prevent major urological complications include:
· delicate dissection of the ureter during donor nephrectomy to preserve adventitia.
· delicate dissection of the fat and blood supply of the ureter.
· short ureter length.
· fixation of the adventitia, fat, and blood supply of the ureter to the bladder wall to prevent kinking or twisting.
f) Outcome of extraperitoneal urine leak: short-term and long-term effects on graft function and survival.
· Prolonged hospitalisation and reduced graft survival.
· More readmissions, more delayed graft function.
What is the level of evidence provided by this article?
This is a narrative review article
Level of evidence grade 5.
Identifying Early Extra-peritoneal High-Volume Urine Leak Post Kidney Transplantation.
Introduction.
Urine leak is one of the early post-operative complication after kidney transplantation and occurs in 1.2–8.9% and according to its volume, compression manifestation and affecting graft function, our plan of management is considered.
Usually, small volume urine leak is resolved by conservative management.
Urinary leak is considered when creatinine and potassium are significantly higher than the serum values, or are values that are incompatible with life, Urinoma will easily be picked up on an ultrasound scan or nuclear scan . Antegrade pyelogram, cystogram, or scintigraphy may be required to identify the cause and to localize the leak
URETEROVESICAL ANASTOMOSIS AND A COMPARISON OF ASSOCIATED COMPLICATIONS .
Lich–Grégoir technique is significantly associated with a lower incidence of urinary leakage, hematuria and all postoperative complication comparing to other methods.
The most common surgical urology complications include urine leakage, ureteral obstruction, and lymphocele, other complication as kinking of long ureter, atrophic or dysfunctional bladder and ureteric ischemia which manifested by
graft pain, tenderness, and local swelling over the graft) and systemic (fever, tachycardia, hypotension, and tachypnea).
Urinary leak and other complications should be investigated by:
–Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
-USG/Doppler.
-CT or MRI scans are a useful tool to identify and define the perinephric collection .
-Intravenous pyelogram and tracer scintigraphy .
-Retrograde cystography and antegrade pyelogram testing .
DIFFERENTIAL DIAGNOSIS:
Hemorrhage:
Manifested by tachycardia, anemia , pain over the graft, not commonly presented, may need exploration but mainly conservative treatment.
Urinary Fistula.
Associated sometimes with graft loss and mortality,
Urinary fistulas may be managed by different techniques including ureteral ligature and nephrostomy, ureteroureterostomy, pyeloureterostomy, ureteroneocystostomy, percutaneous nephrostomy and ureteral stenting, and prolonged vesical drainage.
Perinephric Abscess.
Systemic manifestation of infection and purulent drain from aspiration with positive culture with USG needed for diagnosis.
Lymphocele and Seroma.
Occur in 1-20% of kidney transplant operations,
occur from as early as 2 weeks to as late as 5 years post-transplant, mainly it is due to seal perivascular lymphatic channels incised during operation some studies showed relation between sirolimus and lymphocele, treated by drainage either by laparoscopic method, or open marsupialization.
Urine Leak and Urinoma.
May be free fluid or urinoma (encapsulated), occur early post kidney transplant, high volume leak is defined by a persistent low urine output through drains, associated with low urine output, graft site swelling, and pain over the graft.
Start treatment conservatively by urinary catheter and ureteral stent performing a nephrostomy if not resolved open surgery required to re-implant ureter again.
Studies shown that there is significant longer length of hospital stay, more readmissions, more delayed graft function, and lower rates of graft survival.
Conclusion:
The Lich-Grégoir technique has a significantly lower incidence of urinary leakage compared to others.
Comparing chemistries value from the drain with serum values to detect urinoma, start with conservative treatment if failed surgical intervention is a must ,surgical complications affecting graft survival.
Level of evidence: V.
Urine leak is an early post-operative complication
occurs in 1.2–8.9% of these operations.
URETEROVESICAL ANASTOMOSIS AND A COMPARISON OF ASSOCIATED COMPLICATIONS
• The most popular methods include the Lich–Grégoir, Politano-Leadbetter, and U-stitch techniques.
• Lich–Grégoir technique is significantly associated with a lower incidence of urinary leakage and hematuria compared to the Politano- technique.
• in order to prevent reflux during voiding, the ureterovesical anastomosis must be tension-free and protected by at least a 1 cm submucosal tunnel.
UROLOGICAL COMPLICATIONS DURING THE POST-OPERATIVE PERIOD IN KIDNEY TRANSPLANT RECIPIENTS
The most common surgical urology complications include
• urine leakage,
• ureteral obstruction,
• lymphocele
1- Urine leakage
The rates of urological complications range from 2.5% to 30.0%
fever, pain over the graft, and fluid leakage from the wound
Routine prophylactic intraoperative stenting
• The stents are generally well tolerated,
• longer stents (stent length: ≥20 cm), or longer periods (>6 weeks), may result in stent-related
• complications including infection, migration, and encrustation.
The initial step in urine leak management
1. inserting a urethral catheter,
2. nephrostomy or placing an antegrade ureteric stent.
3. The drain is left in situ.
4. If this technique fails, or if large-volume extravasation occurs, surgical exploration to reimplant the transplant ureter becomes necessary.
Other complications
2- kinking and obstruction
caused by the length of the transplanted ureter.
3- A short ureter
4- Atrophic bladder or dysfunctional bladder in the recipient
5- Proximal calyceal leak may occur because of lower pole artery complications (thrombosed, ligated, not reconstructed)
6- Damage to the ureter during dissection may result in ureteric ischaemia, necrosis, and distal leak.
Urology complications can be identified by
• drained fluid’s colour and odour
• If there is a delayed graft function, a urinary leak can be detected only after the urine output increases.
Signs and Symptoms
• local (graft pain and tenderness, and local swelling over the graft)
• systemic (fever, tachycardia, hypotension, and tachypnoea).
Investigations
1. Compare drain creatinine and potassium levels with serum creatinine and potassium levels
2. Use US to identify and define the perinephric collection and dilatation of the pelvicalyceal system.
3. Doppler ultrasonography can be used to identify defects in perfusion
4. CT or MRI scans are a useful tool to identify and define the perinephric collection and pelvicalyceal dilatation.
5. An intravenous pyelogram may be helpful to identify location of the leak.
6. Focal tracer scintigraphy to identify the location of the leak.
7. This technique is not useful if there is delayed graft function or ureteral stasis.
8. Retrograde cystography helps clinicians to look for urinary bladder dehiscence.
9. Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak. This can be done in delayed graft function scenarios too.
Identifying Extraperitoneal Urine Leak Post Kidney Transplantation
1- Ultrasonography, CT scan or MRI, and fluid biochemistry further aid diagnosis.
2- If drain fluid creatinine and potassium values are not dissimilar from the serum values, then the possibilities of lymphocele or seroma are higher.
3- If they are significantly higher than the serum values, or are values that are incompatible with life, then it is a urine leak or urinoma.
4- Urinoma will easily be picked up on an ultrasound scan or nuclear scan
5- Antegrade pyelogram, cystogram, or scintigraphy may be required to identify the cause and to localise the leak
DIFFERENTIAL DIAGNOSIS AND CLINICAL REASONING
Haemorrhage
• If the drain is haemorrhagic,
• ultrasonography, CT scan, or MRI may be used to identify haematoma,
• is not a common complication after kidney transplantation.
• If it occurs, it is usually from the vessels in the graft hilum that are not ligated, or from small, severed retroperitoneal vessels.
• risk factors include
1. recipient obesity,
2. use of antiplatelet agents,
3. anticoagulation.
Surgical exploration is usually not required because bleeding usually stops spontaneously.
, if the patient needs pure red blood cell transfusion repeatedly, or if there is haemodynamic instability or compression of the kidney by haematoma, surgical re-exploration may be required.
Urinary fistula
occurs in 2–5% ,
may lead to significant morbidity, graft loss, and mortality
The risk factors;
1. Ureteral ischaemia and necrosis and technical problems associated
2. younger recipient age (aged <10 years),
3. uretero-ureteric anastomosis
4. use of high-dose steroids
5. number of renal arteries
6. bladder problems
Early intervention helps to prevent graft loss and reduces mortality.
Management
1. ureteral ligature and nephrostomy,
2. ureteroureterostomy,
3. pyeloureterostomy,
4. ureteroneocystostomy,
5. percutaneous nephrostomy and ureteral stenting, and prolonged vesical drainage
Perinephric abscesses
• are uncommon complications
• usually early post-transplant period (in the first few week’s post-transplant).
• The causes include pyelonephritis, infection of lymphocele, haematoma, or urinoma.
• If the drained fluid is purulent, with accompanying symptoms and signs (fever, swelling, and tenderness over the graft),
• ultrasonography, CT scan, or MRI
• Aspiration of the collection and performing microscopy and culture of the aspirate may further help the diagnosis.
Lymphocele and Seroma
in 1-20% of kidney transplant operations.
early as 2 weeks to as late as 5 years post-transplant.
Usually they are small and asymptomatic, and such lymphoceles require no intervention.
may present with features of compression symptoms including retention of urine, decreased urine output, elevated serum creatinine, thrombosis of iliac vein, and limb oedema.
Etiology
Ultrasonography, CT scan, or MRI, and fluid biochemistry further aid diagnosis.
If drain fluid creatinine and potassium values are not much different from the serum values, then the possibilities of lymphocele or seroma are higher.
Treatment options
1. aspiration (100% chances of recurrence
2. percutaneous drainage (50% success rate),
3. drainage by laparoscopic method, or open marsupialisation.
Laparoscopic drainage is the method of choice for fpost-transplant lymphocele.
open drainage is preferred over laparoscopic technique in patients
Application of sclerosants like povidone iodine, fibrin glue, and doxycycline, tetracycline, ethanol, bleomycin
Urine Leak and Urinoma
early post-operative complication
1.2–8.9% of cases.
manifest as
(urine ascites), extravasation in local tissues, or may be encapsulated (urinoma)
Classification
1- Early extraperitoneal high-volume leak; or small leak,
• low urine output through drains,
• associated with low urine output,
• graft site swelling, and pain
2- late leak (1–2 weeks after kidney transplant),
• which may be caused by ureter necrosis
• or early removal of double J stent (<3–6 weeks);
3- intra-abdominal leak, which presents with an acute abdomen.
management plan
Preventive measures:
• During harvesting of the donor kidney, gentle handling of the ureter at the time of ureteral dissection
• An adequate periurethral tissue in the ‘golden triangle’ must be carefully preserved
• delicate dissection of the ureter during donor nephrectomy to preserve adventitia; fat and blood supply of the ureter;
• short ureter length; and fixation of the adventitia, fat, and blood supply of the ureter to the bladder wall to prevent kinking or twisting.49
Outcome of extraperitoneal urine leak:
prolonged hospitalisation and reduced graft survival
Level V
This a good review, but the Level of evidence is 5.
Surgical complications are primarily observed in the first few days, but some may be as late as 6 weeks. opposite to hematoma and urine leak seen earlier post-transplantation, lymphocele may be as late as 2-6 weeks post-transplantation.
urinary leak, haemorrhage, perinephric abscess, urinoma, lymphocele or seroma may present a similar picture though some features will help differentiate among them. All may present with pain and delayed graft function, but haemorrhage may present with hypovolemia. sampling or drainage will help as the first tool of evaluation . gross appearance may give a clue. Laboratory investigations are also essential, significantly to differentiate urinary leaks from lymphocele or seroma. sample showing very high creatinine and/or potassium incompatible with life and serum samples favour urinoma/urine leak. Radiologic evaluation is also helpful in evaluating both the collection and source of the leak.
ultrasonography will help describe the collection and may differentiate haemorrhage. doppler USG helps define vasculature patency and leakage. Scintigraphic techniques with 99 Tch and MAG3 help in defining urine leakage but are not suitable in case of delayed graft function.
Prevention is the most critical measure to prevent such complications or at least minimize them. Leakage may be due to technical error or maybe due to the compromisation of ureter vascularity. adventitia preservation and at least 1 cm depth of ureter into the recipient’s bladder is essential. The ‘golden triangle, which is bound by the lower border of the junction between the renal vein and the inferior vena cava on the right, the lower pole of the kidney on the left and the gonadal vein needs to be protected. Periureteral fat tissue needs to be preserved. many techniques are used for uretreoneostomy but the Lich-Grégoir technique was found to be better than Politano–Leadbetter and U-stitch techniques in terms of leakage.
Not to forget, sometimes these complications may be masked clinically because of the immunocomprimsation and medications like analgesics and antipyretics. many studies showed different incidences of these complications, but primarily those of high numbers showed a modest number of urological complication
Level of evidence :V
Identifying early extraperitoneal high volume urine leak post kidney transplantation
Abstract
Several surgical complications in early post transplant period include hemorrhage, extraperitoneal urine leak and lymphocele .Hemorrhage and extraperitoneal urine leak occur early but lymphocele occurs 2-6 weeks following transplantation. Colour and volume of the drain give some clue but are not enough for definite diagnosis of urine leak .So, biochemical analysis of drained fluid and ultrasonography are helpful .Different ureteroneocystostomy procedures have different complication rates. Surgical complications require proper management according to the condition.
Introduction:
Urine leak occurs in 1.2-8.9% early post operatively Low volume leaks without distal obstruction are managed first conservatively .If not responding or large volume ,surgical exploration with correction is indicated.
Ureterovesical anastomosis and comparison of associated complications:
Lich-Gregoir technique has lower incidence of urinary leak in comparison with Politano-Leadbetter one .Hematuria was found also of lower incidence in the same comparison and additionally if compared with U-stitch techneque.To prevent reflux during voiding ,tension free ureterovesical anastomosis is needed with with at least 1 cm submucosal tunnel protection.
Urological complications during postoperative period :
Urine leak, ureteral obstruction and lymphocele are the most common urological complications. ;ranging from 2.5-305.Urine leak is manifested by fever, pain over graft and oozing from the wound .Intraoperative ureteric stenting does not decrease incidence but mitigates effects of ureteric complications. Stents of 20 cm or more in length or of periods more than 6 weeks may be associated with infection ,migration and encrustation.
Management starts with maximal decompression by inserting urethral catheter and nephrostomy or antegrade ureteric stenting and drain left in situ. Surgical exploration with reimplantation of transplant ureter is indicated if that approach failed and in case of large -volume leak.
Other complications:
-Kinking and obstruction of long ureter due to ischemia.
-Bladder perforation or anastomotic dehiscence of atrophic or dysfunctional bladder.
-Lower pole artery complications leading to proximal calyceal leak.
-Dissection related ureteric damage leading to ischemia and distal leak.
Drain colour and odour can guide expectation of underlying cause.
DGF leads to delayed detection of urinary leak till urine output increases.
Signs and symptoms:
high suspicion index is needed
Local symptoms: graft pain ,swelling
Signs:
IS and analgesics can mask signs.
Local graft tenderness
Investigations:
-Drain and serum creatinine and potassium
-Ultrasonography
-Doppler us to detect perfusion defects
-CT and MRI imaging to detect perinephric collection and pelvicalyceal dilatation
-IV pyelogram to detect leak site
-Isotope scintigraphy to determine leak site ;not useful in case of DGF and ureteral stasis.
-Retrograde cystography for bladder dehiscence detection.
-Antegrade pyelogram using nephrostomy for leak site detection ;could be done with DGF and pelvicalyceal dilatation has facilatatory effect.
Identification of extraperitoneal urine leak post KT
Extraperitoneal leak is suspected with high volume of clear drain .
Significantly higher levels of drain fluid creatinine and potassium compared with serum detect urine leak or urinoma .Cause and site can be recognised by antegrade pyelogram, cystogram or scintigraphy.
Differential diagnosis and causes
Haemorrhage:
not common; risk factors are obesity, antiplatelets and anticoagulants.
Causes include non ligation of graft hilum vessels or from small severed retroperitoneal vessels.
Haemorrhagic drain is associated with tachycardia ,anaemia and swelling over graft .Identification of hematoma needs imaging with US ,CT ,or MRI.
Urinary fistula
Occurs in 2-5%,associated with high morbidity and mortality(8%) and graft loss
Risk factors
age less than 10 years ,uretero-ureteric anastomosis high dose steroids ,number of renal arteries and bladder issues.
Causes
ureteral ischemia and necrosis in addition to technical issues.
Perinephric abscess
uncommon ,occur early
manifested by purulent drain with fever ,swelling and tenderness over the graft
Causes
pyelonephritis, infection ,lymphocele hematoma and urinoma.
Diagnosis is aided by imaging .Aspiration with c/s support diagnosis.
Lymphocele and seroma
1-20%
occurs as early as 2 weeks or as late as 5 years post transplant.
Usually small and asymptomatic.
Causes
Failure to seal perivascular lymphatic channels
lymph leakage from the hilum
use of sirolimus
Clinical manifestations
large lymphoceles are associated with compression symptoms like urine retention ,less urine output ,increased creatinine ,iliac vein thrombosis and ll edema.
Drainage fluid is clear drain fluid creatinine and potassium are similar to serum
Imaging helps confirmation.
TREATMENT:
Aspiration ;100 % RECURRENCE
Percutaneous drainage;50% success
laparscopic drainage is the method of choice in case of wound complications ,open drainage is preferred and also when there is small lymphocele near to vital renal structures.
Sclerosants can be used with continuous drainage with risk of periureteral fibrosis.
Urine leak and urinoma
occurs early in 1.2-8.9%
Either free or encapsulated(urinoma)
Clinical presentation
Early; small or large associated with persistent low urine output ,graft site swelling and pain ;urinoma can be recognised by imaging
Late::1-2 weeks post KT caused by ureter necrosis or early removal of ureteric stent.
Intraabdominal leak manifested by acute abdomen
Management
Conservative treatment for small leaks
if fails surgical exploration ureteric reimplantation is required as in large volume leaks.
Prevention
Gentle ureteric handling
Preservation of golden triangle
Outcome
Urological complications lead to prolonged hospitalization .with more readmissions and DGF.
Ureteral obstruction and urinary fistula are common
Conclusion
Ureteroneocystomy using Lich-Gregoir technique has lowest incidence of urinary leak.
Urine leak has technical errors in ureteroneostomy and vascular damage as underlying causes.
Multiple renal vessels is a risk factor
High suspicion index is needed for diagnosis
Investigations involve biochemical testing and imaging
Low volume leak is treated mainly conservatively
High volume leak needs surgical intervention
Urine leak leads to prolonged hospitalization
Prolonged follow up is needed with conservative treatment implementation.
Club 1; identification of extraperitoneal urine leakage after KT
Summary:
· Post-transplant surgical complications as hemorrhage and urine leakage occur early post-operative, while lymphocele occurs late (2-6 weeks post-transplant).
· Different surgical techniques of uretro-vesical anastomosis include Lich–Grégoir, Politano-Leadbetter, and U-stitch technique.
· Lich–Grégoir technique is associated with lower incidence of urological complications as leakage and hematuria. In addition, tension free anastomosis and submucosal tunnel are essential to decrease the incidence of reflux.
· Urinary leakage is diagnosed based on clinical (color and odeur of the leaking fluid) and biochemical analysis of fluid creatinine.
· urine leakage is either generalized ascites or localized (capsulated) urinoma.
· Urinary leakage is presented clinically by fever, tender graft, fluid leakage from the wound, tachycardia and hypotension. high index of suspicion is essential to diagnose asymptomatic cases presented with high drain output.
· Small leakage just presented with low urine output, or large leak and acute abdomen.
· Small volume urine leakage can be resolved spontaneously, but large volume need exploration and surgical correction.
· Causes of urinary leakage:
o long ureter is liable to kinking and compromised vascularity and hence perforation and leakage.
o short ureter is liable to tension.
o lower calyceal leak due to lower pole artery stenosis or obstruction or failure of construction.
· Diagnosis based on:
o comparing serum and drain (creatinine and K), it is higher than that of the Darin and serum.
o Doppler to detect renal perfusion.
o US to detect perinephric collection and dilated pelvicalyceal system.
o CT and MRI may be more accurate tools for diagnosis.
o Identification of leakage site by IV pyelography or TC 99 scintigraphy (not useful in delayed graft function) or antegrade pyelogram through nephrostomy tube can be used in case of delayed graft function.
· If drain creatinine and K are higher than that of serum, so it is urine leakage or urinoma. If it is not dissimilar, it favors the diagnosis of seroma or lymphocele.
· Ureteric stenting decrease the symptoms but it does not decrease the incidence of urological complications. Long stent > 20 cm or prolonged than 6 weeks can cause infections or migration of the stent.
· Management of urinary leakage:
o Decompression by urinary cath or even nephrostomy is the only needed management if low volume leakage and their removal after resolution of collection.
o if large volume leakage , exploration and surgical correction through removal of the ischaemic or necrosed part of the ureter followed by reimplantation of the ureter.
· Hemorrhage:
o It not common, related to defective anastomosis of hilar vessels.
o Presented with hemoglobin drop and hemodynamic instability.
o Risk factors include use of antiplatelet and anti coagulants.
o usually stop without intervention. except if severe and required repeated RBC transfusion, exploration is needed.
· Ureteric fistula:
o associated with graft dysfunction, higher morbidity and mortality.
o increased incidence with increased doses of immunosupressives.
· perinephric abscess:
o infected hematoma, urinoma and lymphocele.
o presented with fever, tender graft and diagnosed with CT and MRI.
· lymphocele:
o Either asymptomatic or presented with compression manifestations.
o Increased risk with m TOR.
o Treatment includes aspiration (100% risk of recurrence, open drainage and the best is laparoscopic drainage).
o open drainage is preferred only in case of wound complications and small lymphocele adjacent to vital structures as (ureter or renal vessels).
o Use of sclerosant agents like povidone iodine, fibrin glue, and doxycycline, tetracycline, ethanol, bleomycin can be used in case of ureteric leakage.
· Prevention of urological complications:
o Preservation of the ‘golden triangle’ which is bound by the lower border of the junction between the renal vein and IVC on the right, lower pole of the kidney on the left and the gonadal vein.
o Delicate dissection of the ureter during donor nephrectomy to preserve adventitia; fat and blood supply of the ureter; adequate ureter length; and fixation of the adventitia, fat, and blood supply of the ureter to the bladder wall to prevent kinking or twisting.
· Prognosis of cases with urological complications:
o Lower graft survival and higher morbidity and mortality.
o increased risk of DGF and hospitalization.
Level of evidence: narrative review (level V)
I like your emphasis on preserving the tissues, mentioned as ‘Golden Triangle’.
I agree it is level 5 evidence.
Ajay
This is very informative article with a lot of information:
In generally the urine leak occurs in up to 9% post operative complication with a lot oaf morbidity .
urine leak is one of the important complication which can be suspected in case of active drain .
There is 3 teqnieque for ureteric anastomosis but the best one with less complications is the Lich–Grégoir: lower incidence of urinary leakage and hematuria.
In cases of urine leak, the patient may have a fever, pain over
the graft, and fluid leakage from the wound.
– The stents are generally well tolerated, but when longer stents are used (stent length: ≥20 cm), or if used for longer periods (>6 weeks), they may result in stent-related complications including infection, migration, and encrustation.
-Management is to maximally decompress the urinary system. This is achieved by inserting a urethral catheter, as well as performing a
nephrostomy or placing an antegrade ureteric stent. The drain is left in situ. If this technique fails, or if large-volume extravasation occurs, surgical exploration to reimplant the transplant ureter
becomes necessary.
– A long ureter is liable to kinking and obstruction as a result of
ischaemia .
-Atrophic bladder or dysfunctional bladder in the recipient may result in bladder perforation or anastomotic dehiscence.
roximal calyceal leak may occur because of lower pole artery complications .
-Damage to the ureter during dissection may result in ureteric ischaemia, necrosis, and distal leak.
Signs and Symptoms
Varied symptoms can occur as a result of kidney transplant, including local (graft pain and tenderness, and local swelling over the graft)
and systemic (fever, tachycardia, hypotension,
and tachypnoea).
– Signs may be masked because of immunosuppression and analgesics.
Investigations
The following investigations are helpful in evaluating extraperitoneal urine leak post kidney transplantation, and to rule out differential diagnoses:
-Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
– U/S.
-Doppler ultrasonography can be used to identify defects in perfusion.
-CT or MRI scans .
-An intravenous pyelogram may be helpful to identify location of the leak.
– Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak.
-Retrograde cystography .
-Antegrade pyelogram testing .
Identifying Extraperitoneal Urine Leak Post Kidney Transplantation
-If drain fluid creatinine and potassium values are not dissimilar
from the serum values, then the possibilities of lymphocele or seroma are higher. However, if they are significantly higher than the serum values, or are values that are incompatible with life, then it
is a urine leak or urinoma.
– Urinoma will easily be picked up on an ultrasound scan or nuclear scan
-Antegrade pyelogram, cystogram, or scintigraphy may be required to identify the cause and to localise the leak.
Hi Dr Rihab,
I wish you could have emphasised on preserving the tissues, often mentioned as ‘Golden Triangle’.
I agree it is level 5 evidence.
Ajay
Surgical complications may occur in the early post-transplant period, including hemorrhage, extraperitoneal urine leak, and lymphocele.
Low-volume leaks may subside with conservative management. If not resolved, or if it is large-volume urine leak, surgical exploration and correction may be needed.
Ureterovesical anastomosis and a comparison of associated complications:
Multiple methods are available; the most popular methods include the
-Lich–Grégoir: lower incidence of urinary leakage and hematuria.
-Politano-Leadbetter
-U-stitch techniques.
Urological complications during the postoperative period in KTR
The rates of urological complications 2.5% to 30.0% of all recipients
Routine intraoperative stenting of the ureter in kidney transplant recipients mitigates the effects of ureteric complications but does not reduce the incidence of these complications.
The stent may result in infection, migration, and encrustation.
Risk factors:
technical errors in the ureteroneocystostomy technique compromised vascularity due to vascular injury. Presence of multiple renal arteries.
Presentation:
-Require a high index of suspicion.
-May be asymptomatic because of IS and analgesics.
-Local; graft pain and tenderness and local swelling over the graft.
-Systemic; fever, tachycardia, hypotension, and tachypnoea.
Investigations
– Drain fluid analysis to be compared with serum creatinine and potassium;
if drained creat &K are significantly higher than the serum values, or value incompatible with life, then it is a urine leak or urinoma.
– The colour of the drained fluid (hemorrhagic,clear, or purulent) and odour (uriniferous or foul) may indicate the development of a urological complication
– US; define the size, location and pressure effect.
– Doppler ultrasonography; evaluate perfusion.
– CT or MRI scans for detailed evaluation.
– IVP; identify the location of the leak.
– Nuclear scintigraphy; location of the leak, not valuable in DGF or ureteral stasis.
– Retrograde cystography; look for UB dehiscence.
– Antegrade pyelogram testing through a nephrostomy may accurately identify the leak’s location. This can be done in delayed graft function scenarios too.
Differential diagnosis:
Hemorrhage; failure to ligate vessels in the graft hilum or from small, several retroperitoneal vessels. Require monitoring of Hg and Hct.
Urinary Fistula; resulted from ureteral ischemia and necrosis and technical problems associated with the transplant procedure
Perinephric Abscess: causes include pyelonephritis, infection of lymphocele, hematoma, or urinoma
Lymphocele and Seroma occur because of technical failures to seal perivascular lymphatic channels incised during surgical exposure of the iliac vessels or because of lymph leakage from the hilum of the allograft itself.
Urine Leak and Urinoma
Management of extraperitoneal urinary leak:
Low-volume leaks can be managed conservatively by performing maximum decompression by urethral catheter, performing a nephrostomy and placing an antegrade ureteric stent.
If the fluid collections become infected or cause ureteral obstruction and extrinsic compression on the ureter, then urgent percutaneous drainage is required.
If this technique fails, or if a high volume leak occurs, surgical exploration to re-implant the transplant ureter becomes necessary
Prevention:
-Gentle handling of the ureter at the time of dissection
-An adequate peri-urethral tissue in the ‘golden triangle’ must be carefully preserved.
– Short ureter length; and fixation to prevent kinking or twisting.
Outcome: short-term and long-term effects on graft function and survival
– Longer length of hospitalization.
– More readmission.
– More DGF.
– Reduced graft survival
– Graft loss.
Level of evidence: 5 narrative review.
I agree it is level 5 evidence.
Ajay
-Please summarise this article
-The first few days after kidney transplantation are the most critical in determining the fate of the graft and the recipient.
-Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of these operations.
URETEROVESICAL ANASTOMOSIS AND A COMPARISON OF
ASSOCIATED COMPLICATIONS
-The Lich–Grégoir technique is significantly associated with a lower incidence of urinary leakage and of haematuria compared to the Politano-Leadbetter technique.
UROLOGICAL COMPLICATIONS DURING THE POST-OPERATIVE PERIOD IN KIDNEY TRANSPLANT RECIPIENTS
The most common surgical urology complications include urine leakage, ureteral obstruction, and lymphocele.
– In cases of urine leak, the patient may have a fever, pain over
the graft, and fluid leakage from the wound.
– The stents are generally well tolerated, but when longer stents are used (stent length: ≥20 cm), or if used for longer periods (>6 weeks), they may result in stent-related complications including infection, migration, and encrustation.
-Management is to maximally decompress the urinary system. This is achieved by inserting a urethral catheter, as well as performing a
nephrostomy or placing an antegrade ureteric stent. The drain is left in situ. If this technique fails, or if large-volume extravasation occurs, surgical exploration to reimplant the transplant ureter
becomes necessary.
– A long ureter is liable to kinking and obstruction as a result of
ischaemia .
-Atrophic bladder or dysfunctional bladder in the recipient may result in bladder perforation or anastomotic dehiscence.
-Proximal calyceal leak may occur because of lower pole artery complications .
-Damage to the ureter during dissection may result in ureteric ischaemia, necrosis, and distal leak.
Signs and Symptoms
Varied symptoms can occur as a result of kidney transplant, including local (graft pain and tenderness, and local swelling over the graft)
and systemic (fever, tachycardia, hypotension,
and tachypnoea).
– Signs may be masked because of immunosuppression and analgesics.
Investigations
The following investigations are helpful in evaluating extraperitoneal urine leak post kidney transplantation, and to rule out differential diagnoses:
-Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
– U/S.
-Doppler ultrasonography can be used to identify defects in perfusion.
-CT or MRI scans .
-An intravenous pyelogram may be helpful to identify location of the leak.
– Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak.
-Retrograde cystography .
-Antegrade pyelogram testing .
Identifying Extraperitoneal Urine Leak Post Kidney Transplantation
-If drain fluid creatinine and potassium values are not dissimilar
from the serum values, then the possibilities of lymphocele or seroma are higher. However, if they are significantly higher than the serum values, or are values that are incompatible with life, then it
is a urine leak or urinoma.
– Urinoma will easily be picked up on an ultrasound scan or nuclear scan
-Antegrade pyelogram, cystogram, or scintigraphy may be required to identify the cause and to localise the leak.
DIFFERENTIAL DIAGNOSIS AND CLINICAL REASONING
Haemorrhage
Urinary Fistula
Perinephric Abscess
Lymphocele and Seroma
Urine Leak and Urinoma
-Urine leaks post kidney transplantation may manifest as free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma).
Different clinical presentations of urine leak
-It defined by a persistent low urine output through drains, associated
with low urine output, graft site swelling, pain , and intra-abdominal leak, which presents with an acute abdomen.
Evidence-based management plan in extraperitoneal urine leak
-Low-volume leak at the anastomotic site can be managed conservatively by performing maximum decompression.
– If the fluid collections become infected, or cause ureteral obstruction and extrinsic compression on the ureter, then urgent
percutaneous drainage is required.
-Surgical re-exploration and reimplanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain.
Preventive measures: importance of the golden triangle
-During harvesting of the donor kidney, gentle handling of the ureter at the time of ureteral dissection is crucial to prevent urine leak post kidney transplantation. An adequate periurethral tissue in the ‘golden triangle’ must be carefully preserved.
Outcome of extraperitoneal urine leak:
-Surgical complications can cause graft loss post kidney transplantation.
-Surgical complications after kidney transplants lead to prolonged hospitalisation and decreased graft survival.
What is the level of evidence provided by this article?
Level 5
Thank you
Please summarise this article
This article describes early post transplant complications , especially urine leak.
In early pos transplant period it is very important to monitor graft functions and look for any complications. Urine leak may resent in different ways like high drain output , effect on graft functions , ileus or systemic signs of sepsis. So index of suspicion should be high. Multiple factors can lead to collection in extraperitoeal spaces and urine leak. Common factors can be catheter blockages, stent migration.
, technical issues with ureteric reimplantation, ischemia etc.
Techniques of Ureter reimplantation
These include-
Lich–Grégoir
Politano-Leadbetter
U-stitch
Lich–Grégoir is most commonly used with less chances of reflux and bleeding. Submucosal tunnel principle- Ureteric diameter to tunnel length- Ratio should be 1:5. Mucosa to mucosa stitch
Other complications
Urine leakage
Uureteral obstruction
Lymphocele.
Complications caused by the length of the transplanted ureter
Atrophic bladder or dysfunctional bladder
Proximal calyceal leak
Damage to the ureter
Presentation of Urine leak
It can present with fever, pain over the graft, and fluid leakage from the wound. The presentation can be masked by immune suppression.
Differential diagnosis
Urine leak
Haemorrhage
Lymphocele
Perinephric abcess
Seroma
Investigations
1- Compare drain creatinine and potassium levels with serum
2-Ultrasound scan
3- Doppler ultrasound
4-CT/MRI
5- MAG 3 renal Scan
6- Cystogram
7-Antegrade Nephrostogram
Management Principles.
Gentle dissection in Golden triangle
Identify and confirm urine leak
Put the urethral catheter
Leave the drain in
Antibiotic cover
Percutaneous nephrostomy
Antegrade JJ stenting if already not stented.
Anticholenergics
If urine leak does not settle then sometime exploration is required. Options include revision of ureteroneocystostomy, ileal ureter, Boari flap or use of native ureter
Urine leak is usually due to error in ureteric reimplantation or uereteric ischemia. Gentle dissection in Golden triangle and safegaurding periureteric tissue and vascularity.
The outcomes can be affected by urine leak. There can be an effect on graft function including delayed graft function and graft loss.
Level of Evidence V
Thank you
Summary:
Introduction:
The article is about the occurrence of urine leaks in patients that are post-transplant. Urine leaks may occur after a few days post-transplant. It is very important due to the fact that it can determine the outcome of the graft. The incidence of urine leaks is about 1.2-8.9%. A urine leak can be categorized into two groups one is a low-volume urine leak that can be managed conservatively and the other one is a large-volume leak that needs to be explored surgically to be corrected. The aim of the article was to discuss urine leaks in the post-operative period and their differential diagnosis.
There were some surgical techniques used that were used to see which one is associated with the most complications. Surgical techniques like:
1) LICH-GREGOIR, Politano-Leadbetter, and U-stitch techniques. The LICH-GREGOIR had less incidence of a urine leak, with less hematuria and fewer complications as it related to the other techniques.
Some of the surgical complications are:
1) Urine leakage
2) Ureteral obstruction
3) Lymphocele
4) Others are atrophic or dysfunctional bladder, proximal calyceal leak, and also damage to the ureter.
To diagnose the urine leak, investigations must be done. They can be:
1) A comparison of serum creatinine and potassium with drain creatinine and potassium
2) The next important one is ultrasound to see areas affected.
3) Doppler ultrasound or duplex ultrasound can be done to see renal perfusion, etc.
4) Intravenous pyelogram is needed to identify the origin of the leak
5) Retrograde cystography can be done
6) Antegrade pyelogram can be performed once the nephrostomy is placed to help to localize the urine leak.
7) CT and MRI can be done but it will not show where the urine leak is from but may give details about if there is the perinephric collection and pelvicalyceal dilatation.
Some of the differential diagnoses are:
1) Haemorrhage
2) Urinary fistula
3) Perinephric abscess
4) Lymphocele and seroma
5) Urine leak and urinoma:
Once the urine leak has been diagnosed, the aim is to manage to avoid or prevent the graft from functional or rejection, or failure. The management plan is:
1) low volume leak. This type is treated conservatively. A foley catheter or ureteral stent can be placed by performing a nephrostomy. It can be removed in about 4-6 weeks
2) High urine leak. This problem will need an intervention that is surgical to explore and reimplantation.
How to prevent leakage: the golden triangle importance?
The ureter must be handled gently at the time of ureteral dissection during the harvesting. This is important as it will prevent urine leakage
Periurethral tissue must be preserved as much as possible in the golden triangle.
In conclusion, surgical techniques are very important and as they relate to the different types the most important one with less complication is the LICH-GREGOIR.
If a leak is detected, depending on the volume if it is low or high volume, the low volume can be managed conservatively while the high volume must be managed surgically.
It must be noted that urine leaks can cause longer hospitalization stays and more readmission with possible graft-delayed function or possibly other complications like infection.
The level of the article is level 5.
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
INTRODUCTION
· Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of these operations
· Low volume leak may improve without intervention
· Surgery indicated for large volume leak, or if low volume not resolved conservatively.
URETEROVESICAL ANASTOMOSIS AND A COMPARISON OF ASSOCIATED COMPLICATIONS
· Lich–Grégoir technique of ureterovesical anastomosis, associated with a lower incidence of urinary leakage
· also incidences of haematuria with the Lich–Grégoir method is less than other techniques
UROLOGICAL COMPLICATIONS DURING THE POST-OPERATIVE PERIOD IN KIDNEY TRANSPLANT RECIPIENTS
1. The most common surgical urology complications include urine leakage, ureteral obstruction, and lymphocele
· urine leak, induces fever, pain over the graft, and fluid leakage from the wound
· Intraoperative stenting of the ureter in kidney transplant recipients lessen the effects of ureteric complications but does not reduce the incidence of these complications
· Stent length>20 cm, or used for >6weeks, increases risk of infection, migration, and encrustation
· Leak treated with inserting a urethral catheter, and nephrostomy or placing an antegrade ureteric stent
2. Other urological complications include:
· A long ureter may cause kinking and obstruction due to ischaemia, and short ureter may not achieve tension-free anastomosis
· The recipient bladder atrophy or dysfunction, may cause perforation of bladder.
· Proximal calyceal leak may occur secondary to lower pole artery complications
· Damage to the ureter during dissection may cause ureteric ischaemia, necrosis, and distal leak
Investigations
· Compare drain creatinine and potassium levels with serum creatinine and potassium levels
· ultrasonography detects perinephric collection and dilatation of the pelvicalyceal system
· Perfusion defects detected with Doppler ultrasonography
· CT or MRI detect the perinephric collection and pelvicalyceal dilatation
· An intravenous pyelogram may be helpful to identify location of the leak
· Focal tracer scintigraphy can identify the location of the leak, but not useful if there is delayed graft function or ureteral stasis
· Retrograde cystography useful to diagnose urinary bladder dehiscence
· Antegrade pyelogram testing via a nephrostomy may accurately identify the location of the leak
Identifying Extraperitoneal Urine Leak Post Kidney Transplantation
· extraperitoneal urine leak should be suspected if the is high volume of clear drain fluid
· Ultrasonography, CT scan or MRI, and fluid biochemistry may support the diagnosis
· Antegrade pyelogram, cystogram, or scintigraphy may be required to identify the cause and to localise the leak
DIFFERENTIAL DIAGNOSIS AND CLINICAL REASONING
· Haemorrhage is not a common complication after kidney transplantation. If it occurs, it is usually from the vessels in the graft hilum that are not ligated, or from small, severed retroperitoneal vessels
· Urinary fistula occurs in 2–5% of kidney transplantations, and may lead to significant morbidity, graft loss, and mortality
· Perinephric abscesses uncommon, usually present in the first few weeks’ post-transplant
· Lymphoceles occur in 1-20% of kidney transplant operations and may occur from as early as 2 weeks to as late as 5 years post-transplant.
· Laparoscopic drainage is the method of choice for the treatment of post-transplant lymphocele. However, open drainage is preferred over laparoscopic technique in patients with wound complications
· Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of cases
Different clinical presentations of urine leak
· Early extraperitoneal high-volume leak;
· Early extraperitoneal small leak
· Late leak (1–2 weeks after transplant), due to ureter necrosis or early removal of double J stent
· intra-abdominal leak, which presents with an acute abdomen
Evidence-based management plan in extraperitoneal urine leak
· Low-volume leak at the anastomotic site: conservative
· Foley catheter and ureteral stent performing a nephrostomy for decompression
· Infected fluid collections or compression on the ureter: urgent percutaneous drainage
· Surgical re-exploration and reimplanting the transplant ureter if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain
Preventive measures: importance of the golden triangle
· Important factors that help to prevent major urological complications:
delicate dissection of the ureter during donor nephrectomy to preserve adventitia; fat and blood supply of the ureter; short ureter length; and fixation of the adventitia, fat, and blood supply of the ureter to the bladder wall to prevent kinking or twisting
Outcome of extraperitoneal urine leak: short-term and long-term effects on graft function and survival: urological complications post kidney transplant may lead to prolonged hospitalisation and reduced graft survival
CONCLUSION
· The Lich-Grégoir technique has a significantly lower incidence of urinary leakage compared to the Politano– Leadbetter procedure
· Risk factors for urine leak: ureteroneocystostomy error, vascularity defect of the transplanted ureter
· multiple renal arteries is also a risk factor for development of urological complications post kidney transplantation
· The color of the drained fluid and odor may indicate the development of a urological complication
· Ultrasonography, CT, or MRI may help to arrive at a diagnosis. Doppler ultrasonography, contrast pyelogram, focal tracer scintigraphy can be useful
· If conservative treatment failed, surgical exploration and correction may become necessary
What is the level of evidence provided by this article?
Evidence 5
I like your emphasis on preserving the tissues, mentioned as ‘Golden Triangle’.
I agree it is level 5 evidence.
Ajay
This article describes how to identify an extra-peritoneal leak post-transplantation and how to manage it
Introduction:
The number of kidney transplants are increasing worldwide due to its superior benefits over dialysis. However, graft dysfunction, especially in the early post-transplant period can affect the survival of the graft. Early graft dysfunction can be due to surgical complications or due to acute rejection.
Urological complication rates vary from 2.5%-30% and can include urinary leak, urinary fistula, lymphocyte, and ureteral obstruction.
Urine leak is an early post operative complication after kidney transplant and occurs in 1.2%-8.9% of surgeries.
Ureterovesical Anastomosis:
Many different techniques are used to achieve ureterovesical anastomoses in kidney transplantation. These include:
The authors concluded that Lich-Gregoir technique is better as it results in fewer urological complications
Use of ureteric stents during kidney transplant helps to mitigate the effects of the ureteric complications but does not reduce the incidence of these complications. The stents are generally well tolerated but they can lead to infections and can migrate.
Signs and symptoms:
The signs and symptoms of a urinary leak are varied and quite non-specific. They include:
Investigations:
The following investigations are helpful in evaluating extraperitoneal urine leak post kidney transplantation:
Differential Diagnosis
Management:
The initial management of a urinary leak is to decompress the bladder by inserting a urethral catheter as well as by inserting a nephrostomy tube of an antegrade stent. The stent should be left in situ for six weeks. If an infection develops, then exploratory laparotomy should be done. If the decompression fails, then re-anastomoses of the ureter to the bladder should be done
Conclusion:
Urologic complications post=kidney transplant are common. Urinary leak occurs 1.2%-8.9% of surgeries. It may be present with fever, graft tenderness and localized swelling over the graft. It can lead to graft dysfunction. The Lich-Gregoir technique for ureterovesical anastomoses had the least incidence of urological complications and hematuria. The management of a urine leak is to maximally decompress the bladder and put in a ureteric stent. If the site of leak does not heal then re-anastomes of the ureter to the bladder needs to be carried out.
Level of Evidence
It is level V evidence as it is a systemic review
I agree it is level 5 evidence.
Ajay
This article discusses about early post transplant surgical complications, especially extraperitoneal high volume urine leaks.
INTRODUCTION
Initial few days post transplantation are quite critical and close monitoring is needed to anticipate graft dysfunction or post operative complications earliest.
urine leak is a early post-operative complication in kidney transplantation. Low volume leaks usually resolve spontaneously but if there is no resolution or leak volume is high, then surgical exploration is usually indicated.
Techniques of ureterovesical anastomosis
To prevent reflux during voiding, the ureterovesical anastomosis must
be tension-free and protected by at least a 1 cm submucosal tunnel.
Urological complications during post operative period
Urine leak is usually associated with fever, pain over graft and fluid leak from the wound.
The first step in urine leak management is to decompress the urinary system by either:
If this technique fails or if large-volume extravasation occurs, surgical
exploration to reimplant the transplant ureter is the modality of choice.
Other urological complications
Colour of the drained fluid can be quite helpful in guiding towards diagnosis.
Investigations:
Differential diagnosis
Presentations of urine leak
management of urine leak
Preventive measures: The golden triangle
Technical errors in urine leak
During harvesting of the donor kidney, gentle handling of the ureter at the time of ureteral dissection is crucial to prevent urine leak post kidney transplantation.
The ‘golden triangle’ is bound by the lower border of the junction
between the renal vein and the inferior vena cava on the right, lower pole of the kidney on the left and the gonadal vein. There should be adequate periurethral tissue in the ‘golden triangle’
Extraperitoneal leak outcomes
LEVEL OF EVIDENCE IS 5
I like your emphasis on preserving the tissues, mentioned as ‘Golden Triangle’.
I agree it is level 5 evidence.
Ajay
Thank you sir
#Please summarise this article
# The aim of the study:
To discusses the identification of extraperitoneal urinary leak in a KTR in the post operative period, as well as the clinical clues that help to rule out the differential diagnoses.
* Early post kidney transplantation are the most important period in determining the outcome of the recipient and graft survival.
*Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% .
*This leaks may be of low volume which subside with conservative management and provided there is no distal obstruction. If not resolved, or it is large-volume, surgical exploration and correction may be needed.
#The ureterovesical anastomosis techniques:
1) Lich–Grégoir technique
2) Politano-Leadbetter technique
3) U-stitch technique.
*Alberts et al. in meta-analyses showed that the Lich–Grégoir technique has a lower risk of urinary leakage and haematuria compared to other methods.
*To prevent reflux during voiding, the ureterovesical anastomosis must be tension-free and protected by at least a 1 cm submucosal tunnel.
# Urological complication during the post operative period in KT recipients
*Urine leakage
*Ureteral obstruction
*Lymphocele
* Stent-related complications (infection, migration, and encrustation)
* Kinking and obstruction of ureter
* Atrophic or dysfunctional bladder
* Proximal calyceal leak
* Damage to the ureter during dissection (ureteric ischaemia, necrosis, and distal leak)
# The incidence rates of urological complications range from 2.5% to 30.0% of all recipients.
# Signs and Symptoms
A)Local: (graft pain, tenderness and swelling over )
B)Systemic: (fever, tachycardia, hypotension, and tachypnoea).
*Signs may be masked because of immunosuppression and analgesics.
# Investigations
*Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
*Ultrasonography to identify the perinephric collection and dilatation of the pelvicalyceal system.
*Doppler ultrasonography to identify defects in perfusion.
*CT or MRI scans to identify the perinephric collection and pelvicalyceal dilatation.
*An intravenous pyelogram to identify location of the leak.
*Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak.
*Retrograde cystography for urinary bladder dehiscence.
*Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak.
# Differential diagnosis and clinica reasoning
***Haemorrhage:
*Not a common complication PKT.
* It is usually from the vessels in the graft hilum that are not ligated, or from small, severed retroperitoneal vessels, other risk factors recipient obesity, use of antiplatelet agents, and anticoagulation.
*The presentation are haemorrhagic drain, tachycardia, anaemia, local swelling over the graft, hypotension.
*Bleeding usually stops spontaneously. But, if there haemodynamic instability or compression of the kidney by haematoma, surgical re-exploration may be required.
***Urinary Fistula
*Occurs in 2–5% of KT.
*Result in significant morbidity, graft loss and mortality
* Ureteral ischaemia, necrosis and technical problems are most important causes.
* The risk factors include younger age, uretero-ureteric anastomosis, use of high-dose steroids in immunosuppression, number of renal arteries, and bladder problems.
*The management by different techniques including ureteral ligature and nephrostomy, ureteroureterostomy, pyeloureterostomy, ureteroneocystostomy, percutaneous nephrostomy and ureteral stenting, and prolonged vesical drainage.
***Perinephric Abscess
*Uncommon complications. present in the early PKT.
* The causes include pyelonephritis, infection of lymphocele, haematoma, or urinoma.
***Lymphocele and Seroma
*It is collection of lymph in the perigraft area. Occur in 1-20%.
*May occur from as early as 2 weeks to as late as 5 years PKT.
* Usually they are small and asymptomatic which require no intervention, but may present with features of compression symptoms (retention of urine, decreased urine output, elevated serum creatinine, thrombosis of iliac vein, and limb oedema).
*In lymphocele and seroma, the drainage fluid is clear and If drain fluid creatinine and potassium values are not much different from the serum values, then the possibilities of lymphocele or seroma are higher.
* Treatment options include aspiration (nearly 100% chances of recurrence), percutaneous drainage (50% success rate), drainage by laparoscopic method, or open marsupialisation.
*Laparoscopic drainage is better for the treatment of PT Lymphocele, while open drainage is preferred over laparoscopic in wound complications and small lymphocele adjacent to vital renal structures, which increases the risk of vessel or ureter injury.
***Urine Leak and Urinoma
*Early post-operative complication occurs in 1.2–8.9% of cases.
*Manifest as free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma).
# Different clinical presentations of urine leak
*Early extraperitoneal high-volume leak
*Early extraperitoneal small leak.
* late leak (1–2 weeks PKT)
*Intra-abdominal leak, which presents with an acute abdomen.
# Evidence-based management plan in extraperitoneal urine leak
*Low-volume leak at the anastomotic site can be managed conservatively by performing maximum decompression (by lacing a Foley catheter and ureteral stent performing a nephrostomy).
* Antegrade pyelogram to identify the site of the leak is helpful.
*If the fluid collections become infected, or cause ureteral obstruction and extrinsic compression on the ureter, then urgent percutaneous drainage is required.
* Surgical re-exploration and reimplanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain.
# Preventive measures: importance of the golden triangle
* During harvesting of the donor kidney, gentle handling of the ureter at the time of ureteral dissection is crucial to prevent urine leak PKT.
*An adequate periurethral tissue in the ‘golden triangle’ must be carefully preserved.
*Delicate dissection of the ureter during donor nephrectomy to preserve adventitia; fat and blood supply of the ureter; short ureter length; fixation of the adventitia, fat, and blood supply of the ureter to the bladder wall to prevent kinking or twisting.
# What is the level of evidence provided by this article?
* Level (5)
Hi Dr Amiri,
I like your emphasis on preserving the tissues, mentioned as ‘Golden Triangle’.
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
*Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9% of these operations.
*Many different techniques are used to achieve ureterovesical anastomosis in kidney transplantation wiyh different outcome.
*The rates of urological complications range from 2.5% to 30.0% of all recipients.
The most common Are:
1-urine leakage
2-ureteral obstruction
3- lymphocele
*Other urological complications include:
-Complications caused by the length of the transplanted ureter.
-Atrophic bladder or dysfunctional
-Proximal calyceal leak
-Damage to the ureter during dissection
*Signs and Symptoms
–local (graft pain and tenderness, and local swelling over the graft)
-systemic (fever, tachycardia, hypotension, tachypnoea)
Signs may be masked because of immunosuppression and analgesics.
A high index of suspicion is warranted in a patient with
high drain output
Investigations
1-Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
2- ultrasonography to define perinephric collection and dilatation of the pelvicalyceal system.
3-Doppler ultrasonography can be used to identify defects in perfusion.
4-CT or MRI scans are a useful tool to identify and define the perinephric collection and pelvicalyceal dilatation.
5-An intravenous pyelogram may be helpful to identify location of the leak.18
6-Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to
identify the location of the leak. This technique is not useful if there is delayed graft function or ureteral stasis.
7-Retrograde cystography helps clinicians to look for urinary bladder dehiscence.
8-Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak. This can be done in delayed graft function scenarios too.
Pelvicalyceal dilatation makes it easier to do
this procedure.26
DIFFERENTIAL DIAGNOSIS AND CLINICAL REASONING
>Haemorrhage
>Urinary Fistula
>Perinephric Abscess
>Lymphocele and Seroma
>Urine Leak and Urinoma
Evidence-based management plan in extraperitoneal urine leak
*Low-volume leak can be managed conservatively by performing maximum
decompression By Placing a Foley catheter and ureteral stent performing
a nephrostomy and the patient is carefully followed-up.
*If the fluid collections become infected, or cause ureteral obstruction and
extrinsic compression on the ureter, then urgent
percutaneous drainage is required.
*Surgical re-exploration and reimplanting the transplant ureter becomes necessary if conservative measures for stopping low-volume urine leak fail, or if there is a high-volume drain
Outcome of extraperitoneal urine leak:
short-term and long-term effects on graft
function and survival
Surgical complicationsmay lead to prolonged hospitalisation
and reduced graft survival
* the patients with urine leak had a statistically significant
longer length of hospital stay, more readmissions,
more delayed graft function, and lower rates
of graft survival.
** level 5 **
Hi Dr Esraa,
I agree it is level 5 evidence.
Ajay
● Urine leak is an early complication after kidney transplantation
● occurs in 1.2–8.9% of these
● Most techniques used to ureterovesical anastomosis in kidney transplantation include :
** the Lich–Grégoir
** Politano-Leadbetter
** U-stitch techniques
● Lich–Grégoir technique is associated with a lower urinary leakage and haematuria compared to the Politano-Leadbetter technique.
● The most common surgical urology complications include
** urine leakage
** ureteral obstruction
** lymphocele
● The rates of urological complications range from 2.5% to 30.0% of all recipients.
● urin leak manifest with a fever, tachycardia, hypotension, and tachypnoea
pain and swelling over the graft, and fluid leakage from the wound.
● in case of urin leak inserting a urethral catheter, as well as performing a nephrostomy or placing an antegrade ureteric stent.
● If this technique fails, surgical exploration to reimplant the transplant ureter becomes necessary.
● Other urological complications include:
** Ureter kinking and obstruction
** A short ureter may not be appropriate for achieving tension-free anastomosis.
** Atrophic or dysfunctional bladder may result in bladder perforation or anastomotic dehiscence.
** Proximal calyceal leak
** Ureteric ischaemia, necrosis, and distal leak.
● Drained fluid’s colour and odour important to assess urological complications
● Investigations includes comparsion drain creatinine and potassium levels with serum creatinine and potassium levels
● Urinoma will easily be picked up on an ultrasound scan or nuclear scan
Antegrade pyelogram, cystogram, or scintigraphy may be required to identify the cause and to localise the leak.
● If drain fluid creatinine and potassium values are similar to the serum values, then the possibilities of lymphocele or seroma are higher.
● DIFFERENTIAL DIAGNOSIS
** Haemorrhage
** Urinary Fistula
** Perinephric Abscess
** Lymphocele and Seroma
● Urological complications post kidney transplant may lead to prolonged hospitalisation and reduced graft survival
● Extraperitoneal low-volume urine leak may be managed conservatively by Foley catheterisation, nephrostomy, and placement of an antegrade ureteric stent. If conservative management fails, or if there is extraperitoneal high-volume leak,
then surgical exploration and correction may become necessary.
● Level 5
Dear Dr Huda,
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
Early post-transplant period is very crucial in determining the long-term graft and recipient outcomes. Urinary leak in early post-operative period is seen in 1.2-8.9% with the low-volume leaks requiring conservative management alone while the large-volume urinary leaks require surgical intervention.
The most common techniques used for ureterovesical anastomosis (which should be tension-free and with a submucosal tunnel of minimum 1 cm) include Lich-Gregoir (having lower incidences of hematuria and urine leak), Politano-Leadbetter, and U-stitch techniques.
Post-operative urological complications in kidney transplant, with a frequency of 2.5% to 30%, include urine leak, ureteral obstruction (due to kinking of long ureter or ischemic damage to ureter), and lymphocele. Prophylactic ureteric stenting can mitigate the effects of ureteric complications, but not the incidence of these complications. Stent use is associated with complications like infection, migration, encrustation etc.
Signs and symptoms of urine leak include fever, pain and swelling at the graft site, decreased urine output, and increased drain fluid. Late (1-2 weeks post-transplant) presentation is with acute abdomen features.
Investigations for evaluating urine leak include drain fluid creatinine and potassium (higher than serum values in case of urine leak), ultrasound (for perinephric collection and pelvicalyceal system dilatation), Doppler ultrasound (for perfusion defects), CT or MRI (if ultrasound is non-conclusive), IVP, antegrade pyelogram or scintigraphy for identifying location of leak, and retrograde cystography for urinary bladder dehiscence.
Differential diagnosis:
1) Hemorrhage: presents with bloody drain and hypotension, anemia, bleeding, hematoma on imaging. May require surgical exploration, if severe.
2) Urinary fistula: due to ureteral ischemia and necrosis, and needs surgical intervention.
3) Perinephric abscess: It happens due to infection of lymphocele, hematoma or urinoma, and requires aspiration and antibiotics.
4) Lymphocele and seroma: They have clear fluid with the fluid creatinine and potassium similar to that of serum. Aspiration is associated with recurrence. Laparoscopic drainage is treatment of choice.
Management of urine leak include decompression of the urinary system by urethral catheterization, nephrostomy or antegrade ureteric stenting for low-volume leaks, or exploration and ureteric reimplantation in large volume leak. Percutaneous drainage is required if the fluid collection compresses ureter or gets infected. The stent should be removed 4-6 weeks after stopping of the urinary leak.
Prevention: it can be achieved by avoiding technical errors including using Lich-Gregoir technique, meticulous dissection, and preserving periureteral tissue in the ‘golden triangle’.
Outcomes: Urine leak is associated with prolonged hospital stay, increased readmissions and delayed graft function, and reduced graft survival. Follow-up is required in case of conservative management.
Level of evidence: level 5 – Narrative review
Dear Dr Amit
I am not sure if MRi is a choice of imaging in patient with urine leak.
I agree it is level 5 evidence.
Ajay
Summary of the Article;
Perioperative area is vital in the success of the graft, which involve a close monitiring of all graft parameters.
Drain fluid colour in the post operative period can make a remark for urological complication, (clear, hemorrhogic, or purulent).
Post-operative concerns;
Urological complications during the post-operative period in kidney transplant recipients;
The most common;
Urological complication ranging from 2.5-30% of all recipients.
Manifestation of urine leak;
So intraoperative prophylactic stenting to avoid such complication but does not affect the rate of occurrence.
Stent are usually tolerated, but some complication may develop specially if stent was long >20 cm, or used for longer period.
Stent related complication;
Urological complication;
Signs and Sympoms;
Local;
Systemic;
Signs some times masked because of immunosuppressant medication, analgesics and antibiotics.
Investigation;
Identifying Extraperitoneal Urine leak, post kidney Tx;
1.High fluid volume, US-CT-MRI, fluid biochemistry, can help diagnosis.
2.The possibility of lymphocele or seroma, are higher if fluid Cr and K, are not dissimilar to serum Cr and K.
3.Urinoma or urinary leak are possible if fluid Cr and K are very high or incompatible with life.
Differential diagnosis;
Different ureteric leak clinical presentation;
Evidence based management plan in extraperitoneal urine leak;
Golden triangle;
Bounded by the lower border of the junction between the renal vein and the IVC on the right, lower pole of the kidney in the left side, and the gonadal vein.
The peri-urethral tissue must be carefully preserved ( the golden triangle).
Care to be taken to prevent complication; delicate dissection, to prevent adventitia, fat and blood supply, short ureter length, fixation of the adventitia, fat, and blood supply of the ureter to the bladder wall to prevent kinking or twisting.
Outcome of the extraperitoneal urine leak, short and long-term on graft function and survival;
Conclusion;
Level of evidence;
level((V)) observational review
Dear Dr Kamal,
I am not sure if MRi is a choice of imaging in patient with urine leak.
I like your emphasis on preserving the tissues, mentioned as ‘Golden Triangle’.
I agree it is level 5 evidence.
Ajay
thank you Prof; Ajay
MRI i found it on my search, it may be an other option if the issue is beyond than urine leak or lymphocele.
Thank you.
Please summarise this article
Urinary complications after kidney transplantations are
– Urinary leak /urinoma – 1.2-8.9% – complications caused by the length of the transplanted ureter, proximal calyceal leak may occur because of lower pole artery complications,or distal due to ureteric ischaemia, necrosis, or anastomosis dehiscence due atrophic dysfunctional bladder.
– Ureteral obstruction
– Lymphocele-incidence 1-20% depends on how gentle the kidney harvested, occurs 2 weeks – 5 years post transplant, usually asymptomatic but can produce obstructive symptoms
– Haemorrhage– drop hematocrit, hemodynamic instability me be the presentation usually early post transplant.
– Urinary fistula- incidence 2–5% associated with 8% mortality, and high risk for graft loss.
– Perinephric abscesses – fever, swelling, tenderness over the graft.
Investigations to differentiate:
– Compare drain creatinine and potassium levels with serum creatinine and potassium levels, if both are high to levels incompatible with life support diagnosis of urine leak.
– Ultrasonography to identify and define the perinephric collection and dilatation of the pelvicalyceal system.
– Doppler ultrasonography can be used to identify defects in perfusion.
– CT or MRI scans are a useful tool to identify and define the perinephric collection and pelvicalyceal dilatation.
– An intravenous pyelogram may be helpful to identify location of the leak.
– Focal tracer scintigraphy used to identify the location of the leak. This technique is not useful if there is delayed graft function or ureteral stasis.
– Retrograde cystography helps clinicians to look for urinary bladder dehiscence.
– Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak.
Surgical procedures and their outcomes:
– Lich-Gregoir has the lowest risk of urinary leak, and less hematoma.
– Politano–Leadbetter
– U-stitch techniques
Risk factors for urine leak are : compromised ureter vascularity ,may be damaged while harvesting the kidney, multiple renal arteries, adequate periurethral tissue in the Golden triangle must be preserved.
Outcome of urine leak
The urinary leak was associated with longer hospital stay, more readmissions , more delayed graft function, but conflicting results on graft survival but most of the studies identified lower graft survival with urine leak.
Conclusion:
Urine leak is the commonest urological complication post kidney transplant the clinician should be aware off, and how to differentiate.
Using Lich-Gregior technique decrease the risk of this complication significantly, with better knowing the Golden triangle when implanting the ureter to the bladder, and excellent handling of the kidney while harvesting all decrease the risk of complications.
Urine leak associated with long hospital stay and decreased graft survival.
What is the level of evidence provided by this article?
Review article – level of evidence V.
Dear Dr Muhammad,
I am not sure if MRi is a choice of imaging in patient with urine leak.
I like your emphasis on preserving the tissues, mentioned as ‘Golden Triangle’. Y
I agree it is level 5 evidence.
Ajay
This article discusses the occurrence of urine leak in post kidney transplant recipients. incidence is up to 8.9%. if low volume urine leak , can be managed conservatively , but large volume urine leak , surgical exploration & correction may be needed .
Regarding the anastomosis, the article here concluded that Lich-Grégoir technique results in fewer urological complications than the other two ureterovesical anastomosis procedures & the anastomosis should be tension free to avoid reflux during voiding.
Pt can present with local symptoms (graft pain and tenderness, and local swelling over the graft) and systemic symptoms (fever, tachycardia, hypotension, and tachypnoea). Signs may be masked because of immunosuppression and analgesics. A high index of suspicion is warranted in a patient with high drain output.
main differential diagnosis include Haemorrhage , Urinary Fistula , Perinephric Abscess , Lymphocele and Seroma .
investigations:
> Compare drain creatinine and potassium levels with serum creatinine and potassium levels.
> Use ultrasonography to identify and define the perinephric collection and dilatation of the pelvicalyceal system.
> Doppler ultrasonography can be used to identify defects in perfusion.
> CT or MRI scans are a useful tool to identify and define the perinephric collection and pelvicalyceal dilatation.
> An intravenous pyelogram may be helpful to identify location of the leak.
> Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak. This technique is not useful if there is delayed graft function or ureteral stasis.
> Retrograde cystography to look for urinary bladder dehiscence.
> Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak. This can be done in delayed graft function scenarios too. Pelvicalyceal dilatation makes it easier to do this procedure.
– A high volume of clear drain fluid may indicate the possibility of extraperitoneal urine leak. Ultrasonography, CT scan or MRI, and fluid biochemistry further aid diagnosis. If drain fluid creatinine and potassium values are not dissimilar from the serum values, then the possibilities of lymphocele or seroma are higher. However, if they are significantly higher than the serum values, or are values that are incompatible with life, then it is a urine leak or urinoma. Urinoma will easily be picked up on an ultrasound scan or nuclear scan. Antegrade pyelogram, cystogram, or scintigraphy may be required to identify the cause and to localise the leak
– Important factors that help to prevent major urological complications include delicate dissection of the ureter during donor nephrectomy to preserve adventitia; fat and blood supply of the ureter; short ureter length; and fixation of the adventitia, fat, and blood supply of the ureter to the bladder wall to prevent kinking or twisting.
– urine leak had a statistically significant longer length of hospital stay, more readmissions, more delayed graft function, and lower rates of graft survival.
Dear Dr Mohamed,
I am not sure if MRi is a choice of imaging in patient with urine leak.
I like your emphasis on preserving the tissues, but you did not mention it as ‘Golden Triangle’. Your headings and sub-headings should be in bold or underline. That will make it easy to read.
I agree it is level 5 evidence.
Ajay
Please summarise this article
INTRODUCTION
The first few days after kidney transplantation are the most critical in determining the fate of the graft and the recipient
Urine leak is an early post-operative complication after kidney transplantation and occurs in 1.2–8.9%
The aim of this article is to discuss urinary leak in in the post-operative period and the differential diagnoses
URETEROVESICAL ANASTOMOSIS AND A COMPARISON OF ASSOCIATED COMPLICATIONS
Techniques for ureterovesical anastomosis include Lich–Grégoir, Politano-Leadbetter, and U-stitch techniques
Lich–Grégoir technique is significantly associated with a lower incidence of urinary leakage compared to the Politano-Leadbetter technique (Alberts et al. meta-analyses study)
Significantly fewer incidences of haematuria with the Lich–Grégoir method than both the Politano-Leadbetter and U-stitch techniques, regardless of ureteral stenting
Lich-Grégoir technique results in fewer urological complications than the other two ureterovesical anastomosis procedures
UROLOGICAL COMPLICATIONS DURING THE POST-OPERATIVE PERIOD IN KIDNEY TRANSPLANT RECIPIENTS
Common surgical urology complications include urine leakage, ureteral obstruction, and lymphocele
Other urological complications include long ureter, atrophic or dysfunctional bladder, proximal calyceal leak and damage to the ureter during dissection
Investigations
Compare drain creatinine and K levels with serum creatinine and K
USS to for perinephric collection and dilatation of the pelvicalyceal system
Doppler USS for perfusion defects
CT or MRI for perinephric collection and pelvicalyceal dilatation
An intravenous pyelogram may be helpful to identify location of the leak
Focal tracer scintigraphy uses mercaptoacetyltriglycine or technetium 99 to identify the location of the leak. This technique is not useful if there is DGF or ureteral stasis
Retrograde cystography for urinary bladder dehiscence
Antegrade pyelogram testing through a nephrostomy may accurately identify the location of the leak. This can be done in DGF
Identifying Extraperitoneal Urine Leak Post Kidney Transplantation
A high volume of clear drain fluid
USS, CT scan or MRI, and fluid biochemistry (urinary leak or urinoma if drain fluid creatinine and K is significantly higher than the serum, and lymphocle if the same)
Antegrade pyelogram, cystogram, or scintigraphy
DIFFERENTIAL DIAGNOSIS AND CLINICAL REASONING
Haemorrhage
Tachycardia, anaemia, graft swelling and haemorrhagic drain
USS, CT scan, or MRI
Surgical re-exploration
Not common and usually from the vessels in the graft hilum that are not ligated, or from small, severed retroperitoneal vessels
Risk factors include recipient obesity, use of antiplatelet agents, and anticoagulation
Urinary Fistula
Occurs in 2–5% of kidney transplant and may lead to significant morbidity, graft loss, and mortality
Causes are ureteral ischaemia and necrosis and technical problems
Risk factors include younger recipient age (aged <10 years), uretero-ureteric anastomosis, use of high-dose steroids in immunosuppression, number of renal arteries, and bladder problems
Management techniques are ureteral ligature and nephrostomy, ureteroureterostomy, pyeloureterostomy, ureteroneocystostomy, percutaneous nephrostomy and ureteral stenting, and prolonged vesical drainage
Perinephric Abscess
Early post-transplant (in the first few weeks’ post-transplant)
Causes include pyelonephritis, infected lymphocele, haematoma, or urinoma
Fever, swelling, and tenderness over the graft and purulent drained fluid
USS, CT scan, or MRI
Aspiration of the collection and performing microscopy and culture of the aspirate
Lymphocele and Seroma
Occur in 1-20% of kidney transplant (2 weeks -5 years)
Small and asymptomatic, no intervension
Compression symptoms are retention of urine, decreased urine output, elevated serum creatinine, thrombosis of iliac vein, and limb oedema
Risk factors are technical problems, lymph leakage from the hilum of the allograft itself, and sirolimus use
Drainage fluid is clear
USS, CT scan, or MRI, and fluid biochemistry (drain fluid creatinine and K values are the same of serum)
Treatment options:
1. aspiration (nearly 100% chances of recurrence)
2. percutaneous drainage (50% success rate)
3. Laparoscopic drainage (preferred method)
4. open drainage (if wound complications a small lymphocele adjacent to vital renal structures, which increases the risk of vessel or ureter injury)
5. Continuous drainage with sclerosants like povidone iodine, fibrin glue, and doxycycline, tetracycline, ethanol, bleomycin (risk of periureteral fibrosis)
Urine Leak and Urinoma
Occurs early and in 1.2–8.9% of cases
Urine leaks may be free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma)
Different clinical presentations of urine leak
1. Early extraperitoneal high-volume leak
2. Early extraperitoneal small leak
3. Late leak (1–2 weeks after kidney transplant). caused by ureter necrosis or early removal of double J stent (<3–6 weeks)
4. Intra-abdominal leak (presents with an acute abdomen)
Evidence-based management plan in extraperitoneal urine leak
Low-volume leak at the anastomotic site: conservatively with maximum decompression (Foley catheter and ureteral stent). The ureteral stent is only removed after 4–6 weeks
Urgent percutaneous drainage if the fluid collections become infected, or cause ureteral obstruction and extrinsic compression on the ureter
Surgical re-exploration and reimplanting the transplant ureter if conservative measures fail, or if there is a high-volume drain
Preventive measures: importance of the golden triangle
Gentle handling of the ureter at the time of ureteral dissection during harvesting of the donor kidney is crucial to prevent urine leak post kidney transplantation
An adequate periurethral tissue in the ‘golden triangle’ must be carefully preserved
Outcome of extraperitoneal urine leak: short-term and long-term effects on graft function and survival
Longer length of hospital stay, more readmissions, more delayed graft function, and lower rates of graft survival
CONCLUSION
Technical errors (the Lich-Grégoir technique has a significantly lower incidence of urinary leakage compared to the Politano– Leadbetter procedure) and presence of multiple renal arteries are important risk factors for development of urological complications post kidney transplantation
A high index of suspicion is needed to identify the complications as the symptoms and signs may be masked by the immunosuppressive drugs and the analgesics used
Low-volume leak is managed conservatively with maximum decompression and if conservative management fails, or if there is extraperitoneal high-volume leak, then surgical exploration and correction may become necessary
Urine leak may be associated with significant longer length of hospital stay, more readmissions, more delayed graft function, and lower rates of graft survival
What is the level of evidence provided by this article?
Level 5 (narrative study)
Dear Dr Mohamed,
I am not sure if MRi is a choice of imaging in patient with urine leak.
I like your emphasis on preserving the tissues, mentioning as ‘Golden Triangle’.
I agree it is level 5 evidence.
Ajay
1. Please summarise this article
Introduction
Urine leak usually present early post KTX & occurs in 1.2–8.9% of transplants.
This paper discusses the identification of high-volume extra–peritoneal urine leaks in the early post KTX period as well as its differential diagnoses & impact on both patient & graft outcome.
Techniques of ureterovesical anastomosis
1. Lich–Grégoir technique:
Lower incidence of urinary leakage compared to other techniques
Fewer incidences of haematuria
2. Politano-Leadbetter technique
3. U-stitch technique
The anastomoses must be tension-free & protected by a 1 cm submucosal tunnel in order to prevent reflux during voiding.
The most common surgical urology complications include:
1. Urine leakage
2. Ureteral obstruction
3. Lymphocele
4. Kinking of a long ureter
5. Atrophic bladder or dysfunctional bladder (may lead to perforation or dehiscence).
6. Proximal calyceal leak
7. Damage to the ureter during dissection may result in ureteric ischaemia, necrosis, & distal leak
Signs & Symptoms
Fever
Pain over the graft
Fluid leakage from the wound
Stent-related complications (longer stents or if left for >6 weeks): infection, migration, & encrustation.
Investigations
1. Compare creatinine & potassium levels in the drain with that of serum: both are higher in the drain versus serum in case of leak or urinoma.
2. USS to identify & define perinephric collection & pelvicalyceal system dilatation.
3. Doppler USS to identify defects in perfusion.
4. CT or MRI can identify & define the perinephric collection & pelvicalyceal dilatation.
5. IV pyelogram may identify location of the leak.
6. Focal tracer scintigraphy used to identify the location of the leak; however, it is not useful if there is DGF or ureteral stasis.
7. Retrograde cystography to look for urinary bladder dehiscence.
8. Antegrade pyelogram testing through a nephrostomy: accurately identify the location of the leak.
Differential diagnosis
1. Haemorrhage:
Usually not common
Presents withtachycardia, anaemia, or local swelling over the graft.
Recipient obesity, antiplatelet use, & anti-coagulation are risk factors.
2. Urinary fistula
Occurs in 2–5% of KTXs.
Causes significant morbidity, graft loss, & mortality.
Caused by ureteral ischaemia & necrosis & technical problems associated with the TX operation.
Risk factors include:
Younger recipient age (<10 yrs)
Uretero-ureteric anastomosis
Use of high-dose steroids.
Number of renal arteries
Bladder problems.
3. Perinephric Abscess
Uncommon
Present early post-TX
Causes include:
Pyelonephritis
Infection of lymphocele, haematoma, or urinoma.
Symptoms & signs: fever, swelling, & tenderness. Diagnosed: USS, CT scan, or MRI.
4. Lymphocele & Seroma
Lymphoceles occur in 1-20% of cases & may occur as early as 2 weeks up to 5 years post-TX.
Present with pressure symptoms: retention of urine, decreased UOP, high creatinine, thrombosis of iliac vein, & limb oedema.
5. Urine Leak & Urinoma
Occurs in 1.2–8.9% of cases.
Presents early post-operatively after KTX.
ManifestS as free fluid (urine ascites), extravasation in local tissues, or may be encapsulated (urinoma).
Management plan
Low-volume leak: treated conservatively by maximum decompression (placing a Foley catheter or ureteral stent performing a nephrostomy).
Surgical re-exploration & reimplantation of TX ureter if conservative measures fail, or if there is a high-volume drain.
Preventive measures:
Avoidance of errors in anastomosis techniques.
Gentle handling of the ureter at the time of ureteral dissection.
An adequate periuretral tissue must be preserved in the ‘golden triangle’(bound by the lower border of the junction between the renal vein & the IVC on the right, lower pole of the kidney on the left & the gonadal vein).
Impact of urological complications post KTX on duration of hospitalisation & graft survival:
1.Buggs et al., 2019:
Total number: 1,308
Number of patients urine leak 36(2.75%)
Observations: prolonged hospitalization,increased DGF & lower graft survival.
2. Carvalho et al., 2019:
Total number: 3,102
Number of patients urinary complications 184 (5.93%)
Observations: prolonged hospitalization & lower graft survival.
3.van Roijen et al., 2001:
Total number: 695
Number of patients required revision of vesico-ureteral anastomoses 42 (6.04%)
Observations: no effect on long-term graft survival by a surgically treated urological complication within 1-year post-TX
4.Pillot et al.,2012
Total number: 200
Number of patients urinary complications 49 (24.50%), 66 surgical complications in 49 patients, with the majority being urological complications
Observations: Increased incidence of DGF & graft rejection episodes among patients with surgical complications. No impact on patient or graft survival
5.Kaskarelis et al.,2008
Total number: 21
Number of patients urinary complications: 21 (9 urinary leak, 6 ureteric obstruction, & 6 with obstruction preceded by leak)
Observations: No impact on patient and graft survival
//////////////////////////////////////
2. What is the level of evidence provided by this article?
Level V
Dear Dr Mohamed,
I am not sure if MRi is a choice of imaging in patient with urine leak.
I like your emphasis on preserving the tissues, mentioning as ‘Golden Triangle’.
I agree it is level 5 evidence.
Ajay
Summary:
Urological complications during the postoperative period in kidney transplant recipients:
The most common:
urine leakage, ureteral obstruction, and lymphocele.
Other:
Signs and Symptoms:
Investigations:
DDX and Clinical Reasoning:
Different clinical presentations of urine leak:
Evidence-based management plan in extraperitoneal urine leak:
Preventive measures: importance of the golden triangle:
——————————————————————————————————————-
Level of evidence:
level 5 ( review article)
Hi Dr Huda,
I am not sure if MRi is a choice of imaging in patient with urine leak.
I like your emphasis on preserving the tissues, mentioning as ‘Golden Triangle’.
I agree it is level 5 evidence.
Ajay
thank you
Introuduction :
The first few days after kidney transplantation are the most critical in determining the fate of the graft and the recipient
Urine leak is an early postoperative complication after kidney transplantation and occurs in 1.2–8.9% of these operations
Low-volume leaks may subside with conservative management
large-volume urine leak, surgical exploration, and correction may be needed
URETEROVESICAL ANASTOMOSIS AND A COMPARISON OF ASSOCIATED COMPLICATIONS
Many different techniques are used to achieve ureterovesical anastomosis in kidney transplantation. The most popular methods include the following:
Lich–Grégoir, Politano-Leadbetter, and U-stitch techniques
Lich–Grégoir technique is significantly associated with a lower incidence of urinary leakage and also showed significantly fewer incidences of haematuria and fewer urological complications
UROLOGICAL COMPLICATIONS DURING THE POSTOPERATIVE PERIOD IN KIDNEY TRANSPLANT RECIPIENTS
The most common surgical urology complications include :
1-urine leakage
2- ureteral obstruction
3- lymphocele (fluid collection between the urinary bladder and the kidney allograft).
4 -Complications caused by the length of the transplanted ureter A long ureter is liable to kink and obstruction. A short ureter may not be appropriate for achieving tension-free anastomosis.
5-Atrophic bladder or dysfunctional bladder in the recipient may result in bladder perforation or anastomotic dehiscence
6-Proximal calyceal leak may occur because of lower pole artery complications (thrombosed, ligated, not reconstructed). In addition, damage to the ureter during dissection may result in ureteric ischemia, necrosis, and distal leak.
The drained fluid’s color can identify
7-Urological complications in the postoperative period.
Signs and Symptoms
(graft pain and tenderness, local swelling over the graft, and systemic (fever, tachycardia, hypotension, and tachypnoea). Signs because of immunosuppression and analgesics. A high index of suspicion is warranted in a patient with a high drain output
Investigations:
Ø Compare drain creatinine and potassium levels with serum creatinine and potassium levels
Ø ultrasonography to identify and define the perinephric collection and dilatation of the pelvicalyceal system
Ø Doppler ultrasonography can be used to identify perfusion defects.
Ø CT or MRI scans
Ø An intravenous pyelogram.
Ø Focal tracer scintigraphy
Ø Retrograde cystography
Ø Antegrade pyelogram
Identifying Extra peritoneal Urine Leak Post Kidney Transplantation
A high volume of clear drain fluid may indicate the possibility of an extraperitoneal urine leak: ultrasonography, CT scan, or MRI and fluid biochemistry.
Ante-grade pyelo gram, cysto gram, or scintigraphy may be required to identify the cause and to localize the leak.
DIFFERENTIAL DIAGNOSIS AND CLINICAL REASONING:
Hemorrhage.
Urinary Fistula.
Perinephric Abscess.
Lymphocele and Seroma.
Urine Leak and Urinoma.
Different clinical presentations of urine leak:
The different clinical presentations could be early extraperitoneal high-volume leak; early extraperitoneal small leak, defined by a persistent low urine output through drains, associated with low urine output, graft site swelling, and pain (imaging with contrast may help identify urinoma); late leak (1–2 weeks after kidney transplant), which may be caused by ureter necrosis or early removal of double J stent (<3–6 weeks); and intra-abdominal leak, which presents with an acute abdomen.
CONCLUSION
Different ureteroneocystostomy techniques, including the Lich-Grégoir, Politano–Leadbetter, and U-stitch techniques, impact the development of urine leaks.
The Lich-Grégoir technique has a significantly lower incidence of urinary leakage than the Politano– Leadbetter procedure.
Level 5
Hi Dr Allam,
I am not sure if MRi is a choice of imaging in patient with urine leak.
I wish you could have emphasised on preserving the tissues, mentioning as ‘Golden Triangle’.
I agree it is level 5 evidence.
Ajay
Urinary leak is not uncommon complication occurring in 1.2–8.9% usually in early post operative period
Urinary leak is classified into
Clinical presentation
The diagnosis may be delayed till urine output increase in case of DGF, and the systemic manifestation can be masked due to immunosuppression, so it needs high index of suspicion
Risk factors for urinary leak
Diagnosis
Differential diagnosis
Prevention
Treatment of urinary leak
A- Conservative measures
B- Surgical repair
What is the level of evidence provided by this article?
Hi Dr Yusuf,
I am not sure if MRi is a choice of imaging in patient with urine leak.
I like emphasis on preserving the tissues, mentioning as ‘Golden Triangle’.
You mention ‘less commonly retrograde douple j stenting’. This is would be tricky to do, even most expert urologists struggle to do retrograde stenting. We, in Liverpool, have never used this in the management of a patient with urine leak.
Ajay