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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 52-55

An urgent renal autotransplantation in patient with ureteral avulsion


1 Department of Transplantation and General Surgery, Tepecik Training and Research Hospital, Izmir, Turkey
2 Department of Urology, Tepecik Training and Research Hospital, Izmir, Turkey

Date of Web Publication8-Oct-2015

Correspondence Address:
Dr. Ismail Sert
Department Organ Transplantation and General Surgery, Tepecik Training and Research Hospital, Yenişehir, Izmir
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2148-7731.166855

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  Abstract 

Uretrorenoscopy (URS) has become the gold standard in the treatment of ureteral stones. Ureteral avulsion (0.1-0.3%) and ureteral perforation (1.7-6%) are the worst morbid complications of the URS. Ureteral avulsion has been mostly encountered in URS procedures for ureteral stones in the ureteropelvic junction. Renal autotransplantation is one of the elective treatment options in patients with ureteral avulsion. An urgent renal autotransplantation owing to an iatrogenic ureteral avulsion after a ureteral extraction in a 42-year-old female patient who underwent URS is presented in the light of literature.

Keywords: Autotransplantation, renal transplantation, ureteral avulsion, ureterorenoscopy, urgent autotransplantation


How to cite this article:
Tugmen C, Sert I, Zorlu F, Karaca C. An urgent renal autotransplantation in patient with ureteral avulsion. Sifa Med J 2015;2:52-5

How to cite this URL:
Tugmen C, Sert I, Zorlu F, Karaca C. An urgent renal autotransplantation in patient with ureteral avulsion. Sifa Med J [serial online] 2015 [cited 2019 Sep 18];2:52-5. Available from: http://www.imjsu.org/text.asp?2015/2/3/52/166855


  Introduction Top


Endoluminal therapeutic approaches and minimally invasive surgery is widely used in all areas of medicine. Especially, in the treatment of urological disorders, endoscopic procedures are applied with minimal mortality and morbidity. In case of ureterolithiasis, uretrorenoscopy (URS) is a treatment of choice. URS has become the gold standard in the treatment of ureteral stones. This procedure has 80-100% success rates in different localizations of ureter and in experienced hands. [1],[2]

When complication occurs during URS, treatment and rehabilitation procedures generally increase the morbidity. Ureteral avulsion (0.1-0.3%) and ureteral perforation (1.7-6%) are the worst morbid complications of URS. [1],[2],[3] Ureteral avulsion has been mostly encountered in URS procedures for ureteral stones in the localization of ureteropelvic junction. Because the muscle layer is weak and mucosa is thin in this area. [3] In this kind of injury, generally primary repair of ureter is not possible and the first treatment approach is to introduce a percutaneous nephrostomy catheter into the renal pelvis. Later, by performing variety of interventions, urinary system continuity has been ensured. In case of failing these reconstruction procedures, nephrectomy is indispensable. Autotransplantation is the one of the elective treatment options in patients with ureteral avulsion, as well. It is an alternative treatment in the complicated ureteral injuries with low morbidity rates.

An urgent renal autotransplantation owing to ureteral avulsion and iatrogenic ureteral extirpation in a 42-year-old female patient who underwent URS due to stone localized upper ureter of the right kidney is presented in the light of literature.


  Case Report Top


A 42-year-old female patient who underwent URS due to stone localized in the upper ureter of the right kidney had a ureteral avulsion. Approximately whole segment of ureter had been extracted from the urethra [Figure 1] and [Figure 2].
Figure 1: X-ray image of the ureteral stone prior to uretrorenoscopy (URS)

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Figure 2: Image of the extracted ureteral segment

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Patient was referred to our urology department and transplant unit. Abdominal CT scan revealed multifocal fluid collection in the retroperitoneal area [Figure 3]. Ultrasonography was performed to evaluate the renal pelvis. Renal pelvis was not suitable for introducing a nephrostomy catheter (renal pelvis was not dilated). And urgent renal autotransplantation was planned.
Figure 3: Fluid collection in the retroperitoneal area and nephrolithiasis

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Eight hours after the complication occurred, the patient had an urgent operation. Right kidney was harvested by the intraperitoneal approach. Ureteral avulsion was observed in right ureter, 2 cm distal from the ureteropelvic junction. Artery and vein of the right kidney was encircled and right nephrectomy was performed. The kidney was perfused by University of Wisconsin (UW) preservation solution at 4°C in the backtable. Ureteral tail was debrided and spatulated. Two ureteral stone were removed by irrigation of the ureter. The kidney is put into the cold storage bag. Autotransplantation was performed into the left inguinal retroperitoneal area. Urinary outflow was observed after the reperfusion. Zero hour kidney biopsy was carried out. Bladder was mobilized and attached to the psoas muscle (psoas hitch). Urinary continuity was obtained by Lich-Gregoir ureteroneocystostomy. Cold ischemia time was 155 min. Post transplant follow-up was uneventful. Acute tubular necrosis was seen at zero hour kidney biopsy report [Figure 4]. At postoperative 7 th day, patient was discharged. To reduce the ischemic injury, 500 mg Metilprednisolone was given for 3 days, then the dose was tapered to 20 mg and at postoperative 20 th day it was withdrawn.
Figure 4: Zero hour kidney biopsy (staining with hematoxylin and eosin)

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Renal function tests were usual at post transplant 1 st month. Double J catheter was removed. Diethylenetriaminepentaacetic acid (DTPA) and dimercaptosuccinic acid (DMSA) renal perfusion scintigraphy revealed normal perfusion and extrusion function in autotransplanted kidney [Figure 5]. Due to the measurement obtained on the anterior side, and it is close to the gama camera, the functional activation of the autotransplanted kidney was measured higher (differential function of left kidney was 28.6% and autotransplanted kidneys' was 71.4%). Informed consent of the patient had been obtained.
Figure 5: Kidney diethylene triamine pentaacetic acid (DTPA) scintigraphy. Autotransplanted kidney is seen near the bladder on left side

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  Discussion Top


Fifty to seventy-five percent of the ureteral injuries areiatrogenic and 14-30% of these injuries occur during interventions for urologic problems. [4],[5] The treatment options for repair of the injured ureter depends on the localization, type, and degree of injury. In these injuries, ureteral avulsion in the ureteropelvic junction is the most dramatic injury type. The management of these injuries is difficult and generally required complex urologic interventions. In noncomplicated injuries, when the diagnosis is made immediately, the ureteral segment is viable, and end-to-end anastomosis of the ureteral segments should be the first treatment of choice. [3],[5] Transureteroureterostomy may be another treatment option, as well. But these treatment approaches are dependent on localization of the injury and time of the diagnosis and could not be utilized in delayed cases. Other treatment method is ileal ureteral replacement techniques for the long ureteric defects, but this technique is less suited for young patients due topotential complication of infections and stone formations. [6] Vesicopsoas hitch and Boari flap procedures may be performed in selective cases by experienced hands. Nephrectomy is generally the last treatment option. [3],[4],[7]

Autotransplantation in the ureteral avulsion was first performed by Hardy. [8] The procedure was improved and became popular due to sustained renal function for a long time with minimal complication rates. Kidney autotransplantation in patients with ureteral avulsion may be easily performed in experienced transplant units and have 75-92% success rates in the long time period. [5],[9] Surgical complications of kidney allotransplantation may be seen after autotransplantation as well. But some studies reported higher incidence of the venous thrombosis after autotrasplantation. [3],[4],[5],[7],[8]

Autotransplantation in ureteral avulsion is generally performed in elective condition days after the complication. The diagnosis process and patient's clinical condition may also cause the delay. We suggest that autotransplantation in ureteral avulsion can be safely performed in urgent conditions as well.

Ensuring the urinary continuity is one of the important points in ureteral avulsions. In case of having adequate length of ureter, ureteroneocystostomy may be performed. Ureteroneocystostomy is the most used technique in patients with ureteral avulsion. When the adequate length of ureter did not exist, ureteroureterostomy may be a treatment approach. The other options to ensure the urinary continuity ispsoas hitch or Boari flap techniques. Only 2 cm viable ureter segment from the ureteropelvic junction was available in our case. By mobilizing the bladder and attaching it to the psoas muscle, we performed a tension-free ureteroneocystectomy. This procedure is called as vesicopsoas hitch technique. It was first described by Zimmerman et al. [10]

In conclusion, ureteral avulsion is the one of the serious complications of the URS. In case of ureteral upper segment avulsions, renal autotransplantation may be safely performed in urgent conditions with high success rates. When the ureter segment of autotransplant kidney is short, psoas hitch or Boari flap techniques may be used to implant the ureter into the bladder.

All authors of this case report declare that there is no conflicts of interest and financial support.

 
  References Top

1.
Turk C, Knoll T, Petrik A, Sarica K, Skalarikos A, Straub M, et al. Guideline on Urolitiazis. European Association Guideline; 2014. p. 19-51. (http://www.uroweb.org/guidelines/online-guidelines/)  Back to cited text no. 1
    
2.
Huri E, Akgül T, Yücel Ö, Ayyıldız A, Karakan T, Germiyanoğlu C. What is the difficult case in ureteroscopic stone surgery? Turk J Urol 2011;37:34-7.  Back to cited text no. 2
    
3.
Aki FT, Koni A, Bilen CY, İnci K, Ergen A, Özen H, et al. Renal ototransplantation for managing severe proksimal ureteric injury. Turk Neph Dial Traspl J 2010;19:143-6.  Back to cited text no. 3
    
4.
Ergenekon E, Arısan S. Renal and ureteral traumas. Klin Geliş 2008;21:191-200.  Back to cited text no. 4
    
5.
Neo EN, Zulkifli Z, Sritharan S, Lee BC, Nazri J. Renal autotransplantation after an iatrogenic left urinary injurt. Med J Malaysia 2007;62;164-5.  Back to cited text no. 5
    
6.
Al-Awadi K, Kehinde EO, Al-Hunayan A, Al-Khayat A. Iatrogenic ureteric injuries: Incidence, aetiological factors and effect of early management on subsequent outcome. Int Urol Nephrol 2005;37:235-41.  Back to cited text no. 6
    
7.
Delacroix SE Jr, Winters JC. Urinary tract injures: Recognition and management. Clin Colon Rectal Surg 2010;23:104-12.  Back to cited text no. 7
    
8.
Hardy JD. High ureteral injuries. Management by autotransplantation of the kidney. JAMA 1963;184:97-101.  Back to cited text no. 8
    
9.
Morin J, Chavent B, Duprey A, Albertini JN, Favre JP, Barral X. Early and late result of ex vivo repair and autotransplantation in solitary kidneys. Eur J Vasc Endovasc Surg 2012;43:716-20.  Back to cited text no. 9
    
10.
Zimmerman IJ, Precourt WE, Thompson CC. Direct uretero-cysto-neostomy with the short ureter in the cure of ureterovaginal fistula. J Urol 1960;83:113-5.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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