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Ureteral Stricture: Most Common Urological Complication

Benefits of Subcutaneous Pyelovesical Bypass Graft in Evading Ureteral Stricture after Kidney Transplantation. Reference: Azhar RA, Hassanain M, AlJiffry M, et al. Successful salvage of kidney allografts threatened by

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Ureteral Stricture: Most Common Urological Complication

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  1. Benefits of Subcutaneous Pyelovesical Bypass Graft in Evading Ureteral Stricture after Kidney Transplantation Reference: Azhar RA, Hassanain M, AlJiffry M, et al. Successful salvage of kidney allografts threatened by ureteral stricture using pyelovesical bypass. Am J Transplant. 2010;10:1414–1419.

  2. Ureteral Stricture: Most Common Urological Complication • Ureteral stricture is a frequent complication after renal transplantation with a prevalence rate of 2–5%. Ureteral stricture may occur • at the distal third of the ureter including • ureteroneocystostomy (73%), • at the mid-ureter level (12%) and • at the proximal third of the ureter (15%).

  3. Etiological Factors for Ureteral Stricture • The most common causes for ureteral stricture include ischemia (caused by faulty preparation of the ureter during donor nephrectomy), anastomotic technical complications, variations in vascular anatomy, allograft rejection episodes, and to some extent due to BK viral infection and medications.

  4. Subcutaneous Pyelovesical Bypass Graft: Safe and Effective Method • Principally, the treatment adopted for symptomatic strictures is percutaneousnephrostomy followed by antegrade dilatation and stenting, and open ureteral reconstruction. • Moreover, in cases where no ureter is present, bladder reconstructive techniques are performed. • However, all these procedures are not always successful; they are technically demanding and may expose the patient to major complications.

  5. In such patients with irreversible malignant ureteral obstruction, subcutaneous pyelovesical bypass graft (SPBG) using an artificialureter is regarded to be a safe and effective option. • It consists of an internal silicone tube covered by an outer polyester sheath (see Fig. 1). • Keeping this in view, a study was conducted investigating the effects of SPBG with a longer follow-up period.

  6. Methods • The study enrolled 8 patients, 6 men and 2 women with a mean age of 52 years, with refractory ureteral strictures following renal transplantation. • The enrolled patients had unsuccessful repair with standard treatments and hence were subjected to SPBG to salvage their grafts. • Seven patients presented with ureteral stricture early after renal transplantation and the eighth patient presented 10 years posttransplantation. • The primary efficacy variable was the glomerularfiltration rate (GFR) calculated using Modification of Diet in Renal Disease (MDRD) formula. • The follow-up period was 1, 3, 6 and 12 months and annually thereafter with serial serum creatinine, urine culture and ultrasonography.

  7. Findings • Postoperatively, 2 patients suffered dislodgement of their SPBG that was diagnosed and repaired in 3 days. • One patient developed recurrent urinary tract infections secondary to E. coli and P. aeruginosa. • He was treated with intravenous ticarcillin/clavulanate followed by long-term oral antibiotic therapy using both cefixime and ciprofloxacin for a total of 3 months. • Treatment failure occurred in one patient due to resistant infection in the SPBG that led to graft nephrectomy including the removal of the SPBG to control the infection. • However, later the patient had a successful living donor kidney transplant. • One patient died of metastatic lung cancer after 15 months of follow-up with an intact and functioning SPBG.

  8. Follow-up • After a mean follow-up of 19.4 months, 6 patients with SPBG were alive without any evidence of encrustation, obstruction or erosion and with stable renal function. • Mean GFR was 51.5 and 58.5 mL/min/1.73 m2 at 1 year and at last follow-up, respectively (see Table 1). Conclusion • Subcutaneous pyelovesical bypass graft offers a new treatment option for patients with renal transplantation who do not respond to conventional therapies. It has the ability to salvage many years of graft function. • The most important requirement is that the patient should be free of infection during the SPBG procedure. • Suppressive antibiotic therapy might be needed for patients with recurrent urinary tract infections.

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