Long-Term Management of Post-Transplant Ureteral Stricture with Surgical Reconstruction: A Case Series and Literature Review

Abstract

Introduction: Ureteral stricture is the most common complication after kidney transplant and is largely responsible for graft dysfunction. Surgical intervention is the definitive treatment if conservative management with stenting and percutaneous nephrostomy tube placement fails and has been shown to have comparable long-term survival rates and limited post-operative complications. Methods: This is a single-center retrospective study following seven patients who received a kidney or a kidney and pancreas transplant between August 2012 and January 2021. These patients underwent surgical ureteral reconstruction after failed conservative management of a ureteral stricture. The reconstruction procedures performed were native ureter to transplanted kidney ureteropyelostomy, native bladder to transplanted renal pelvis vesicopyelostomy, non-transecting side-to-side ureteroneocystostomy, and a Boari flap creation. Data collected from electronic medical records included recipient age, gender, delayed post-transplant complications, ureteral reconstruction technique, and post-reconstruction outcomes. Renal ultrasound (RUS), renogram, nephrostogram, serum creatinine (Cr), and graft biopsy were used to assess for severity of hydronephrosis, ureteral stricture, and graft dysfunction. Serum Cr and RUS were used to assess renal function after the ureteral reconstruction. Results: Six out of seven cases resulted in reduced or resolved hydronephrosis and preserved graft function without future nephrostomy or ureteral stenting. One case required immediate revision due to persistent obstruction, and this patient had concomitant rejection leading to intrarenal stricture requiring ureterocalycostomy. Conclusions: Formal ureteral reconstruction is the definitive treatment for many cases of ureteral strictures after transplant. The surgical technique chosen for these procedures must consider the physical and functional state of the bladder, ureter, and kidney. Our series outlines multiple surgical approaches that should be considered early in the management of post-transplant ureteral strictures to limit graft dysfunction.