Transcript Benefi ts of Subcutaneous Pyelovesical Bypass Graft in

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.
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%).
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.
Subcutaneous Pyelovesical Bypass
Graft: Safe and Effective Method
• Principally, the treatment adopted for
symptomatic strictures is percutaneous
nephrostomy 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.
• In such patients with irreversible malignant
ureteral obstruction, subcutaneous pyelovesical
bypass graft (SPBG) using an artifi cial ureter 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.
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 effi cacy variable was the glomerular fi ltration rate
(GFR) calculated using Modifi cation 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.
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
cefi xime 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.
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.