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 Table of Contents  
BRIEF REVIEW
Year : 2019  |  Volume : 19  |  Issue : 1  |  Page : 24-29

Practical approach to urine leak after kidney transplant


1 Department of Liver Transplant and Hepato-Biliary Surgery, Global Hospital, Mumbai, Maharashtra; Department of Medical Sciences, University of Liverpool, Liverpool, India
2 Department of Urology, Global Hospital, Mumbai, Maharashtra, India
3 Department of Medical Sciences, University of Liverpool; Department of Renal Transplantation, Royal Liverpool University Hospitals, Liverpool
4 Department of Medical Sciences, University of Liverpool; Department of Renal Transplantation, Sheffield Teaching Hospitals, Sheffield, UK

Date of Submission13-Aug-2018
Date of Acceptance09-Dec-2018
Date of Web Publication01-Apr-2019

Correspondence Address:
Dr. Ahmed Halawa
Sheffield Teaching Hospital, S5 7AU, UK
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jesnt.jesnt_18_18

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  Abstract 


Urological complications can cause significant morbidity after kidney transplant but can be prevented by following well-known good surgical principles and techniques. The key is early identification and appropriate intervention. This article discusses clinical presentation, investigations, and principles of management of a urine leak after kidney transplant on the background of a clinical case. The presence of a ureteric catheter, double J ureteric anastomotic stent, vascularity of transplanted ureter, and bladder capacity is critical for differential diagnosis, choice of investigation, and management of ureteral leak. The given case demonstrates an early extraperitoneal high-volume urinary leak. Additional information about the surgery, graft quality, and postoperative clinical course may help in differential diagnosis. Drain fluid creatinine and potassium analysis compared with serum can confirm the leak, whereas radiological imaging can localize it. Depending on the cause and site of leak identified, a conservative management approach using maximal decompression or surgical repair or reconstruction may be appropriate.

Keywords: kidney transplant, management, urine leak


How to cite this article:
Mohanka R, Sinha L, Jagtap J, Sharma A, Halawa A. Practical approach to urine leak after kidney transplant. J Egypt Soc Nephrol Transplant 2019;19:24-9

How to cite this URL:
Mohanka R, Sinha L, Jagtap J, Sharma A, Halawa A. Practical approach to urine leak after kidney transplant. J Egypt Soc Nephrol Transplant [serial online] 2019 [cited 2019 Jun 25];19:24-9. Available from: http://www.jesnt.eg.net/text.asp?2019/19/1/24/255241




  Background Top


A 28-year-old CKD 5 patient underwent kidney transplantation from his brother with primary function. Post-surgery, the drain is quite productive (820 mls on day 2 and 750 mls on day 3). Drain fluid biochemistry showed K of 28 mmol/L and creatinine of 16000 μmol/l. His serum creatinine on that day was 416 μmol/l and serum K is 5.1 mmol/L.


  Introduction Top


Kidney transplant, the preferred treatment for end-stage chronic kidney disease, is associated with risk of surgical, vascular, or urological complications [1]. Urological complications are associated with the following risk factors, although it rarely causes graft loss.

Long graft ureter can cause kinking and obstruction, whereas a short ureter may prevent tension-free anastomosis [2]. Extensive peri-ureteric tissue dissection during recovery of kidney from the donor could cause ureteric ischemia and necrosis and a distal leak [2]. Some authors found fewer urinary leaks with Lich-Gregoir technique compared with Leadbeter-Politano or U-stitch techniques [3],[4], although it was not observed by others [5],[6],[7],[8],[9],[10],[11]. Prophylactic use of transanastomotic double J (DJ) stenting is controversial, with some studies reporting reduced anastomotic leak [12],[13],[14] with stenting, whereas others found no difference, in low-risk cases to higher infection rates with stenting [15],[16],[17]. Atrophic thin-walled or dysfunctional bladder may risk bladder dehiscence or perforation [10],[18]. A thrombosed, ligated, and unreconstructed lower polar artery may cause proximal caliceal leak [19].

In the post-operative period, the indicators of urological complications are drain color (clear, hemorrhagic, purulent) and odor (uriniferous, foul) [20]. Urinary obstruction may be due to early transurethral catheter removal (prostatic hypertrophy) or blockage (retained clot) [21],[22],[23],[24]. With delayed graft function (DGF), a leak may only be apparent after the urine output increases. Serum creatinine may be disproportionately high compared with urea owing to peritoneal reabsorption. Patients may present with systemic signs such as fever, tachycardia, hypotension, tachypnea, anemia, or local signs such as swelling or pain over graft. Local signs may be masked owing to the use of immunosuppressants, and hence, a high index of suspicion should be kept for any patient with high drain output. Some nontechnical factors such as recipient age, immunosuppressive regimen, rejection episodes, obesity, and others may be responsible for urological complications [13],[14],[18].


  Investigations Top


A systematic algorithmic approach for investigation of suspected urine leak is used to establish the diagnosis ([Figure 1]a, b):
  1. Drain/aspirate creatinine and potassium levels in comparison with serum [14],[23],[25].
  2. Ultrasonography (most commonly used) for nature and size of perinephric collection and pelvicalyceal dilatation and Doppler for perfusion defects, and vascularity.
  3. Computed tomography (CT)/MRI: a noncontrast study for nature and size of perinephric collection and pelvicalyceal dilatation; contrast pyelogram may localize the leak; and an angiogram for graft vascularity, although uncommonly done with high creatinine [23],[26]. Very rarely, a migrated DJ stent may be seen with longer (>20 cm) DJ stents or with their delayed (>6 weeks) removal either incidentally or on investigation for presenting symptoms such as pain.
  4. Scintigraphy: focal tracer imaging using MAG3 or Tc99 may localize the leak, although not useful with DGF or ureteral stasis [27],[28].
  5. Cystography: retrograde contrast may demonstrate bladder or anastomotic dehiscence.
  6. Antegrade pyelogram through a nephrostomy to accurately localize the leak, possible even with DGF, but is difficult without pelvicalyceal dilatation [29].
Figure 1 (a) Algorithmic approach to investigate suspected urine leak. (b) Three-dimensional reconstruction of computed tomographic urogram showing ureteric leak with contrast extravasation.

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Differential diagnoses

The chronology of complications after transplant and their clinical presentation in given case is helpful in differential diagnosis, such as follows [20]:
  1. Postoperative hemorrhage.
  2. Urine leak/urinoma/urinary fistula.
  3. Lymphocele/seroma.
  4. Perinephric abscess.


If the drain is hemorrhagic with tachycardia, hypotension, local swelling, anemia, or bleeding is likely. Imaging may show a hematoma warranting an emergency re-exploration [23],[24],[30]. Purulent drain with fever, swelling, or tenderness over the graft may indicate a perinephric abscess, which could be confirmed with imaging, and aspiration of the collection with microscopy and culture.

If the drain is clear, its nature can be confirmed with imaging and fluid biochemistry. If drain fluid creatinine and potassium are similar to corresponding serum values, a lymphocele or seroma is likely, whereas if they are significantly higher than the serum values, a urine leak or urinoma is confirmed [25]. Scintigraphy, cystogram, or antegrade pyelogram may identify the cause and location of the leak [20].

In the given case, there was large-volume drainage very early postoperatively with high creatinine and potassium compared with serum without systemic signs, which indicates urine leak rather than lymphocele, hemorrhage, or perinephric abscess. Imaging may demonstrate perinephric collection or pelvicalyceal dilatation. With high creatinine, a CT pyelogram or scintigraphy may not be feasible. Nephrostomy and antegrade pyelogram may be used for localization and stabilization, although surgical re-exploration may be preferred because of high volume [31].

Urinary leak: clinical presentations

Urine leak occurs in 1–10% of kidney transplants, with clinical presentation depending on the location and degree of leak, DJ stenting, and graft function [2],[11],[20],[32],[33].
  1. Early extraperitoneal high-volume leak with good graft function may present with high output through drains or wound, especially if DJ stent was selectively not used [1],[34]. Low urine output through the transurethral catheter and elevated serum creatinine owing to reabsorption may be perceived as DGF. Imaging may show perinephric collection with or without pelvicalyceal dilatation. High drain fluid creatinine and potassium compared with corresponding serum values confirm the leak. Often this presentation is owing to technical failure, anastomotic (most common), or bladder dehiscence, which may be confirmed on antegrade pyelogram or cystogram and requires surgical repair [14],[30],[35],[36] ([Figure 1]a).
  2. Early extraperitoneal small leak presents with persistent low output through the drains or wound, urinoma, graft site swelling, pain, and low urine output. Imaging may reveal a urinoma with or without pelvicalyceal dilatation and can be used for guidance for fluid aspiration and sampling. High fluid creatinine and potassium compared with serum confirm the leak and may be localized with CT pyelogram or scintigraphy. Such a presentation is often owing to downstream urinary obstruction (blocked transurethral catheter or DJ stent) and stabilizes with catheter change [21],[22],[23],[24]. Undrained urinomas may get infected, forming perinephric abscesses, requiring percutaneous or surgical drainage [23].
  3. Late (1–2 weeks) leak after a transplant is often owing to ureteric necrosis (most common) or early (<3–6 weeks) DJ stent removal [12],[13],[14], presents insidiously with reduced urine output and requires surgical resection of the necrotic ureter and re-implantation.
    • Thrombosis of unreconstructed lower polar artery may also present late, with imaging showing a perinephric collection and Doppler or CT/MRI angiogram showing segmental infarction which often resolves with conservative management but rarely requires a partial nephrectomy [2],[12].
  4. Intra-abdominal leaks: intra-abdominal leaks may present with acute abdomen, shock, prolonged ileus or insidiously and always requires surgical re-exploration [12],[19],[22],[30],[38],[39].


Management plan

Conservative management consists of maximal decompression by diversion from the leak, prevention of obstruction, and urinoma drainage to prevent infection and depends on the presence of the transurethral catheter and transanastomotic DJ stent. The transurethral catheter is changed if blocked and removed after 2 weeks in high-risk cases [24]. If DJ stent is not present, it is placed either retrograde cystoscopically, which is technically challenging, or antegrade through a nephrostomy, which is more accessible and safer, although owing to lack of backpressure, fixation of nephrostomy tube may be difficult, warranting the expertise of an experienced radiologist or endo-urologist [24],[40]. A blocked DJ stent can be changed cystoscopically over a guide wire. Conservative management is effective in approximately 60% of cases, especially for small, distal, late leaks [41],[42],[43],[44],[45],[46],[47],[48].Large-volume or proximal leaks not responding to conservative management require surgery with resection of the necrosed ureter and tension-free re-implantation of well-vascularized ureter over a DJ stent [1], closure of a perforated bladder, or others [41] ([Figure 2]). Reconstructing a short ureter may be challenging requiring anastomosis with the native ureter [49],[50], a bladder (Boari) flap, or ileal neo-ureter [51],[52] ([Figure 3]). A partial nephrectomy may rarely be required [53].
Figure 2 Management algorithm for urine leak.

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Figure 3 Surgical techniques for ureteric reconstruction. (a) Standard primary ureteroneocystostomy. (b) Pyeloureterostomy (to native ureter). (c) Pyelo-cystostomy (to Boari flap). (d) Ileal neo-ureter.

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Summary

Urine leaks are uncommon, cause postoperative morbidity, rarely lead to graft loss, and are most commonly anastomotic owing to ureteric necrosis. Avoiding extensive peri-ureteric dissection in donor surgery and DJ stenting the anastomosis may be helpful. Conservative management with maximal decompression and drainage is the first line of treatment and is often successful in patients with distal and low volume leaks. Surgery is required for failure of conservative treatment and for large-volume and proximal leaks. The complexity of surgery depends on the source of leak and length of well-vascularized ureter available. The given case has an early extraperitoneal high-volume leak confirmed with biochemical tests and should undergo surgical re-exploration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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