Surgical results of the ureterovesical reimplantation in renal transplantation from living donor at vietduc hospital – Do Ngoc Son

Journal of military pharmaco-medicine n o 9-2018 158 SURGICAL RESULTS OF THE URETEROVESICAL REIMPLANTATION IN RENAL TRANSPLANTATION FROM LIVING DONOR AT VIETDUC HOSPITAL Do Ngoc Son¹; Hoang Long²; Vu Nguyen Khai Ca¹; Nguyen Tien Quyet¹ SUMMARY Objectives: To evaluate the results of the ureterovesical reimplantation technique in renal transplantation at Vietduc Hospital. Subjects and methods: Descriptive study on 101 patients with end-stage of chronic renal failure, who underwent renal transplantation from living donor at Vietduc Hospital from January 2011 to November 2013. Results: 69 males, 32 females, the age arranged from 12 to 63 years. The volume bladder capacity of the recipients was 171.51 ± 69.46 mL. The ureter with a length of 8.5 - 11 cm, most of the right kidney (98.25%) must be reversed when transplant. The Lich-Grégoir technique with JJ catheter was conducted on all the patients. Mean reimplantation duration was 23.98 mins (12 - 50 mins); no urine fistulas, ureteral necrosis; 1 patient had ureteral stenosis after removing JJ-stent (0.99%). Conclusion: The Lich- Grégoir technique is easy to perform and has the low rate of urological complication (no urinary leaking and ureteral necrosis); ureteral stenosis was very low. * Keywords: Kidney transplantation; Lich-Grégoir technique; Ureteral stenosis. INTRODUCTION Renal transplantation is one of treatments that effect for end-stage chronic kidney disease. The first case of renal transplantation was done in Vietnam in 1992 at the 103 Military Hospital. Ureterovesical reimplantation is an important technique and is applied after anastomosed vein and artery of transplanted renal. Ureterovesical reimplantation technique through vesica (Politano-Leadbetter) was firstly applied for several cases in Vietnam: 103 Military Hospital, National Peadiatric Hospital, Hue National Hospital, Choray Hospital (1992 - 2004). Recently, this technique is gradually replaced by ureterovesical reimplantation (Lich-Grégoir technique). At Vietduc Hospital, Lich- Grégoir technique was used for the first case of renal transplantion in 2000 with JJ stent. The aim of the our study was to: Evaluate the results of technique of ureteral implantation of transplanted renal to recipient’s vesica underwent Lich-Grégoir technique in renal transplantation from living donor at Vietduc Hospital. SUBJECTS AND METHODS 1. Subjects. 101 patients with end-stage of chronic renal failure underwent renal transplantation involved in this study at Vietduc Hospital from January 2011 to November 2013. 1. Vietduc Hospital 2. Hanoi Medical University Corresponding author: Do Ngoc Son (dongcson1976@gmail.com) Date received: 14/10/2018 Date accepted: 21/11/2018 Journal of military pharmaco-medicine n o 9-2018 159 2. Methods. Prospective, description study. * Surgical technique: Transplanted renals were put into right iliac fossa after cleaning, the transplanted renal vein is anastomosed end to side to the external iliac vein, the transplanted renal artery is anastomosed end to side to the external iliac artery or common iliac artery. * Ureteral preparing: Evaluate the length of the ureters and blood vessels nourishing the ureter, urethral stretching at the head about 1 cm, cutting beveled. Ureteral implants to vesica underwent Lich-Grégoir technique with JJ stent. Lich-Grégoir technique: Blend the vesica with physiological saline solution (the amount is based on vesical volume), reveal the right front wall of the vesica, incision of the bladder mucosa about 3 - 4 cm long. Open a small mucosal at the distal end of the muscle cut. Sutures 02 at the proximal and distal end of the ureter by vicril 5.0, JJ inoculation and suture of the ureteral tract with the lining of the vesical by vicril 5.0, the end suture must include the mucosal vesica. Close the ureteral tract lining of the ureters with vicril 5.0 to form 3 - 4 cm subcutaneous tunnel. Place 02 continuous aspirators: 01 vascular endothelium, 01 ureterovesical mouth. Figure 1: Ureterovesical implantation by Lich-Grégoir technique. (a: Incision of the bladder mucosa; b and c: Completion of the running anastomosis suture of the ureter end and the bladder mucosa; d, e, f: The anti-reflux-plasty sutures). Treatment and follow-up patients from 1 to 3 months, JJ stent removed after 1 month. Journal of military pharmaco-medicine n o 9-2018 160 RESULTS 1. The age of renal transplantation patients. There were 03 patients ≤ 20 year of age, approximately 2.97%; 27 patients were from 21 to 30 year of age (26.73%); 34 patients from 31 to 40 year of age (33.66%); 18 patients from 41 to 50 year of age (17.82%), and 19 patients above 50 year of age (18.82%). The youngest patient was 12 year olds, and oldest patient was 63 year olds. The major age of patients who were transplanted renal between 21 and 40 (60.39%). 2. The relative between donors and recipients. There were 20.79% of donor-recipient pairs (21 pairs) are related donors. Unrelated donors pairs were main portion (80 patients = 79.21%). This portion was different from Le Anh Tuan et al (75% blood line pairs) [3]. 3. Ureterovesical implantation. Table 1: The bladder capacity of the recipients. The bladder capacity of the recipients Number (%) ≥ 100 mL 84 83,17 < 100 mL 17 16,83 Average ± SD 171,51 ± 69,46 Min - max: 50 - 400 The volume bladder capacity of the recipients was 171.51 ± 69.46 mL (the lowest: 50 mL; the highest 400 mL). Most cases of kidney transplants had normal bladder capacity. Table 2: Ureteral size of the kidney. Ureters Right kidney (n = 57) Left kidney (n = 44) p-value Length 14.71 ± 1.97 14.76 ± 2.1 0.898 Diameter 0.57 ± 0.54 0.45 ± 0.11 0.423 All kidneys had the ureter long enough to graft, with a length of 8.5 - 11 cm. The mean length and diameter of the bilateral kidney ureter showed no difference with p > 0.05. Table 3: Characteristics of transplanted renal transplants. Left (n = 44) Right (n = 57) Position of the kidney n % n % Total (%) No reserve 43 97.73 1 1.75 44 (43.56) Reserve 1 2.27 56 98.25 57 (56.44) p-value < 0.0001* There was a statistically significant difference in the percentage of transplanted renal transplants in the renal transplant group. Specifically, almost the kidney from the left did not need to be polarized when placed in the right (97.73%). In contrast, most of the right kidney (98.25%) must be reversed when transplant. The average time to perform this technique was 23.98 minutes, minimum was 12 minutes, and maximum was 50 minutes. Our results were similar with other studies [1, 3]. Patients with bladder volume ≥ 100 mL were shorter than those in the bladder group (23.83 ± 7.98 and 24.71 ± 7.49 minutes). However, this difference was not statistically significant (p > 0.05). Journal of military pharmaco-medicine n o 9-2018 161 4. Result after remove JJ. After the operation, there were no urine fistulas, ureteral necrosis complications, one case needed to be re-ureterovesical implantation because of ureteral stenosis (0.99%), no vesicoureteral reflux complication. DISCUSSION In the 1970s, the complications of urinary after renal transplantation were usually high from 10 to 25%, depend on each authors [8]. Ureteral complications can induce transplatated renal unsuccess, eventhough can affect to patient’s life [9]. Hence, this is very importance to choose method and technique for ureterovesical implantation. Previously, the technique for ureteral implantation to recipient’s vesical (Politano - Leadbetter) usually used in renal transplantation because of frequency with ureteral surgeons and the effect to protect from of vesicoureteral reflux complication. But this method had have high rate of urinary complication because of too many opened points on vesica in decrease immune system of patients and long lasting to get recover from the surgical operation. Evenmore, the long surgical operative time induced the high risk of urine fistula complication, from 1 to 25% [2]. The ureterovesical technique out side of vesica (Lich-Grégoir) with the advantage of smaller of vesica open point. If so, reducing infectious risk, urine fistulas, and surgical operative time compared to Politano-Leadbetter technique. Moreover, underwent Lich-Grégoir technique, the necessary of urinary length is shorter than that, so minimizing the complication of lacking blood for ureter, low rate of urinary stenosis, and not require big value of vesica like Politano-Leadbetter technique [2]. However, the original of Lich-Grégoir technique had high ureteral complications, up to 13.3% and 10.3% were reported by Pleases and Benoit, respectively [5]. Hence, the Lich-Grégoir modified technique with one JJ stent was applied to reduce the urinary complications after the transplantation like as urine fistulas, stenosis of the ureterovesical implantation. Our results showed that only one patient had ureteral stenosis complication, approximately 0.99%, no urine fistulas or ureteral necrosis or vesicoureteral reflux complications. Hoang Khac Chuan et al (2010) reported 123 renal transplantation patients, the ureterovesical implantation underwent Lich-Grégoir technique with JJ stent at Choray Hospital showed 3.3% (4/123) of urinary complications [1]. Le Anh Tuan et al reported 100 renal transplantation cases at 103 Military Hospital had 2% of urine fistulas, and 1% of both urinary necrosis and urinary stenosis complications. Elela (2007) reported 120 renal transplantation cases with ureterovesical implantation underwent Lich-Grégoir technique with JJ stent showed 6.6% of the general urinary complications, including 4/120 (3.3%) urinary stenosis, 2/120 (2.5%) urine fistulas, and 1/120 (0.8%) vesicoureteral reflux [6]. There was no significantly differcence between applying stent and non-stent when doing ureterovesical implantation. However, applying JJ stent is gradually Journal of military pharmaco-medicine n o 9-2018 162 accepted because of significantly reduce of urinary complications. The purpose of applying JJ stent is to avoid ureter engle blending, distortion or blocking from outside, urinary stenosis, reduce pressure internal ureter, avoid bloodless of the walls of ureter, support urine fluently flow when the ureterovesical implantation is swollen, avoid urine fistulas through ureterovesical implantation [1, 2, 4]. Pleases commonly applies JJ stent for all renal transplantation patients reported significantly reduce urinary complications. Khauli et al (2001) reported 300 renal transplantation cases of ureterovesical implantation underwent Lich-Grégoir technique with JJ stent without urine fistulas and only 0.7% of urinary stenosis. Similar to Mangus (2014), within 395 renal transplantations follow Lich- Grégoir technique with JJ stent reported 1% urinary complications and recommended using JJ stent for all renal transplantations [7]. The time for remaining JJ stent depends on authors: Benoit was 4 weeks [5]; Mangnus was 1 - 12 weeks [7]. We usually remove JJ stent after more than 1 month without any complications that affect transplanted renal. CONCLUSIONS Ureterovesical of Lich-Grégoir technique with JJ stent was used for the first case at Vietduc Hospital. Follow-up 101 cases for renal transplantation that received from living donor at Vietduc Hospital, we concluded that Lich-Grégoir technique is easy to perform with low rate of urinary complications and should apply JJ stent for all renal transplantation patients. The result was not different in group reserver or not reserve the kidney. REFERENCES 1. Hoang Khac Chuan et al. Results of utlzing assited endoscopic for modified Lich- Grégoir technique in renal transplantation at Choray Hospital. J Vietnam Med. 2010, 375, pp.520-527. 2. Do Ngoc Son, Hoang Long, Vu Nguyen Kha: The technique of ureterovesical implantation in renal transplantation. J Med Pharma Info. 2011, 3, pp.11-14. 3. Le Anh Tuan et al. The technique of ureterovesical reimplantation in renal transplantation at 103 Military Hospital. J Military Med. 2012, 37, pp.122-126. 4. Barry J.M, Morris P.J. Surgical techniques of renal transplantation. Renal Transplantation Principles and Practice. W.B SAUDERS. 6th edition. 2008, pp.159-171. 5. Benoit G et al. Insertion of a double pigtail ureteral stent for the prevention of urological complications in renal transplantation: A prospective randomized study. J Urol. 1996, 156, pp.881-884. 6. Elela A.A et al. Modified extravesical ureteral reimplantation technique for renal transplants. Int Urol Nephrol. 2007, 39, pp.1005-1009. 7. Mangus R.S et al. Stented Lich-Gresgoir ureteroneocystostomy: Case series report and cost-effectiveness analysis. Transplant Proc. 2004, 36, pp.2959-2961. 8. Moray G et al. Effect of routine insertion of a double-J stent after living related renal transplantation. Transplantation Proceeding. 2005, 37, pp.1052-1053. 9. Samhan M et al. Urologic complications after renal transplantation. Transplant Proc. 2005, 37, pp.3075-3076.