For multivariate analyses (Table 3), owing to the small number of ureteral complications, only four factors were included in the assessment: donor age, donor BMI, recipient sex, and placement of ureteral stent. Donor BMI and recipient sex were not associated with ureteral complications on the multivariate analysis. Increased donor age remained associated with the occurrence of a ureteral complication, with an odds ratio of 1.058. Thus, for each added year of age of the donor, the odds of a ureteral complication increases 5.8%. Omission of a ureteral stent also remained associated with ureteral complications, with an odds ratio of 10.593, suggesting a greater than 10-fold increased odds of having a ureteral complication when a stent is omitted. Of the 24 transplants managed without placement of a ureteral stent, 6 (25%) suffered a ureteral complication, compared to a 2.6% incidence in the 456 transplants in which a ureteral stent was placed (Table 1).
Recently, laparoscopy has become the preferred technique for living donor nephrectomy, especially in large centers with large experience in laparoscopic renal surgery (12). Among different studies, the rate of complications of LLDN ranged from 6% to 29% (13). Much of this wide range is likely attributable to variations in reporting; some authors include lymphocele and others also include urinary tract infections. Ureteral leaks and strictures, however, are the most common major urological complications after LLDN.
In the present study, ureteral complications are significantly related to the donor’s age and omission of a ureteral stent. Recipient age has been found to be a risk factor for ureteral complications in some studies (9, 14). Specifically, an increased rate of complications in the youngest recipients was found. In our cohort, the age of the recipient was not associated with ureteral complications, but the age of the donor was associated, with older donors having a greater risk. Although several series suggest that increased age of living donors is associated with poorer long-term graft survival (15–18), to our knowledge, ours is the first study to suggest that increased donor age is associated with increased incidence of ureteral complications.
The factor that seems to have the greatest impact on the increasing ureteral complication rate is omission of a ureteral stent. A ureteral stent was placed in 95% of renal transplants, and in these patients, the ureteral complication rate was 2.6%. Among the 24 transplants managed without placement of a ureteral stent, 6 (25%) suffered a ureteral complication. The protective effect of ureteral stent placement has been confirmed in a meta-analysis of randomized clinical trials (19) and seems to be a cost-effective strategy (20). The lack of ureteral stent placement in 5% of our cohort based on surgeon judgment needs to be reevaluated in light of this meta-analysis and the findings of our current study.
In their retrospective study, Englesbe et al. (8) found that male recipients had a greater incidence of ureteral complications. The same observation was noted by Rigg et al. (9), who reported an increased occurrence of ureteral leaks in male recipients. In our study, there was no association between recipient sex and ureteral complications. In addition, we did not find race to be significantly associated with ureteral complications, either for the donor or for the recipient. This was in contrast to other studies that found that African American recipients are more likely to suffer from ureteral complications (8).
Some have proposed that maintaining the gonadal vein along with the ureter during nephrectomy might ensure preservation of the periureteral tissue and therefore improve ureteral blood flow and reduce ureteral complications (6), although other authors have disputed this (21). In our institution, urologists maintain the gonadal vein with the ureter, whereas the transplant surgeons do not. Although our analysis might be biased by other unknown factors, we found no difference in the incidence of ureteral complications after urologist versus transplant surgeon renal procurement, so it seems likely that maintaining the gonadal vein with the ureter during LLDN does not improve outcomes. It might be possible that preservation of the gonadal vein is important in patients “at risk” for ureteral complications, such as older donors. We explored this with our data by evaluating the subset of patients 43 years or older (above the median). Among this group, 16% of LLDN cases not associated with ureteral complications were performed by the urologist, similar to the 25% of LLDN cases associated with ureteral complications (Fisher exact test, P=0.1133). Thus, even in older donors, maintaining the gonadal vein with the ureter during LLDN does not improve outcomes.
We could not address more specific surgeon-level differences owing to the large number of surgeons involved (8) relative to the number of events (18). Of note, however, 5 of the 7 transplant surgeons were associated with the 14 ureteral complications after LLDN not performed by the urologist, and ureteral complications occurred after at least 1 kidney transplantation was performed by each of the 7 transplant surgeons.
The primary limitation of this study is its retrospective design, which exposes the analysis to unknown bias. In addition, the small number of events (ureteral complications) limited the factors that could be assessed with the multivariate analysis.
In summary, ureteral complications after LLDN are uncommon. Our study confirmed that the use of a ureteral stent is protective, as has been well demonstrated in randomized controlled trials. The only other factor associated with ureteral complications after LLDN is donor age, with increased donor age being associated with increased incidence of ureteral complications. We were unable to identify any other factors associated with the incidence of ureteral complications.
MATERIALS AND METHODS
From our institutional review board–approved prospective database, we identified 480 consecutive cases of renal transplantation after hand-assisted LLDN in the period from January 2008 to February 2013. There were no planned open surgical donor nephrectomies done during this period. We selected this period because only after January 2008 were ureteral complications reliably entered into the database prospectively. Cases were subdivided into three time-based tertiles (i.e., first 160 cases, second 160 cases, and third 160 cases), as a surrogate for surgeon and institutional experience.
All renal donors were evaluated by a transplant nephrologist and a transplant surgeon. Standard donor evaluation was applied (12), including computed tomography or magnetic resonance imaging with angiographic phase to define the exact renal anatomy.
Laparoscopic donor nephrectomy was performed using a hand-assisted approach, with two or three additional laparoscopic ports. The attending surgeons included seven transplant (general) surgeons and one urologist, all fellowship trained. Over time, the procedure has become standardized (6), with some minor variations between surgeons with regard to instrumentation and technique of handling the ureter. In all cases, the donated kidney was initially prepared with cold perfusion and packaging as per the United Network for Organ Sharing protocol.
Renal transplantation was performed by one of seven transplant surgeons using an extraperitoneal open surgical approach, with vascular anastomoses to the iliac vessels for adult recipients. The surgeon performing the transplant was not necessarily the same performing the LLDN. The method used to establish ureteral anastomosis to the urinary bladder was extravesical ureterocystostomy (modified Lich-Gregoir technique) or intravesical ureterocystostomy (Politano-Leadbetter technique). In no case was the donor ureter anastomosed to the recipient ureter. In a few cases, the ureter was connected to a previously created ileal conduit. Ureteral stents were placed at the discretion of the operating surgeon; stents were placed routinely by the majority of surgeons but selectively by others.
Study data collected regarding the renal donor included age, sex, race, type (living related or unrelated), BMI, side of kidney removed (left or right), arterial anatomy, ureteral anatomy, and total ischemia time. This is in addition to the category of surgeon, that is, transplant surgeon versus urologist.
Study data collected regarding the recipient included age, sex, race, BMI, history of prior renal transplantation, technique of ureteral anastomosis, use of ureteral stent, serum creatinine on discharge, and need for temporary posttransplant hemodialysis.
During the postoperative period, staff regularly reviewed the medical record to ascertain the presence or absence of ureteral complications. All cases in which ureteral complications were reported underwent review by the first author to confirm ureteral leak or ureteral stricture. Owing to their low incidence, we analyzed ureteral complications as a whole, without subgroup analysis for leaks or strictures.
To determine the bivariate association of donor and recipient factors with ureteral complications, we used exact logistic regression analysis to take into account the small number of ureteral complication events. For multivariable analysis, we performed backward model building procedure to determine significant clinical predictors for the incidence of ureteral complications. Associations between predictors and the outcome are shown as odds ratios with 95% confidence limits. Statistical analyses were performed using SAS version 9.2 software (SAS Institute, Cary, NC).
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Keywords:© 2014 by Lippincott Williams & Wilkins
Laparoscopy; Nephrectomy; Renal transplantation