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CHAPTER 54: Variants and Complications Encountered During Implantation: Urological

Ernesto P Molmenti

SUTURE MATERIALS

  • Throughout this chapter we describe anastomotic techniques involving the urinary tract.

  • We routinely construct such anastomoses with resorbable sutures that (theoretically) will not act as a nidus for the formation of stones.

  • Our preferred suture is 5-0 polydioxanone.

RENAL PELVIS–TO–BLADDER ANASTOMOSIS (FIGURES 54-1–54-3)

  • In cases where the donor ureter has been injured proximally (such as in severe stripping of its surrounding tissues, high transections, and partial transections Figures 54-1 and 54-2), the transplant renal pelvis can be anastomosed to the recipient bladder (Figure 54-3).

  • In these instances, it is usually necessary to mobilize the bladder in order for it to reach the transplant renal pelvis.

  • The bladder is mobilized by manually freeing the tissues surrounding it in its entire circumference. This maneuver does not require the transection of any blood vessels.

  • An attaching stitch/stitches can be placed in between bladder and tendon of the psoas muscle (or other steady structures in the area) to maintain the bladder close to the transplant kidney and avoid tension at the anastomosis.

FIGURE 54-1

Stripped and partially transected ureter in a deceased donor kidney. Excessive stripping of the ureter can lead to post-transplant ureteral strictures since the blood supply (arising exclusively from the renal artery in transplanted organs) is frequently compromised. In the non-transplant setting, the ureter is surrounded by a peri-ureteral fascia, carrying a blood supply derived from the renal artery, the gonadal artery, and the superior vesical artery (branch of the internal iliac artery).

A partially transecred ureter is placed on a plastic surface. The surface of the ureter and artery is stripped.
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FIGURE 54-2

Stripped and partially transected ureter. Further inspection showed that the ureter had also been accidentally incised and partially transected close to the renal parenchyma.

A close-up view shows a kidney. Forceps point to the ureter which is cut off in a straight line and close to the renal parenchyma.
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FIGURE 54-3

Donor renal pelvis-to-recipient bladder anastomosis. An anastomosis between the transplant renal pelvis/proximal ureter and the recipient bladder was constructed in order to avoid any postimplantation ureteral strictures. In this specific case, preserving a long ureter would be at risk of stenosis based on the potentially compromised blood supply associated with the excessive stripping as well as the damage from the partial transection.

A renal pelvis of a donor is placed within the bladder of the recipient. The border of skin is extended and clipped for a clear internal view.
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DOUBLE URETER (FIGURES 54-4–54-12)

  • In instances of double ureters, we usually reconstruct both ureters distally into a common opening that in turn is anastomosed onto the bladder. (Figures 54-4–54-12.)

  • Alternatively, each ureter can be individually implanted onto the bladder.

FIGURE 54-4

Double ureter (arrows) in the donor can be addressed in a variety of ways. Each ureter can be potentially implanted independently into the bladder. Alternatively, as in this instance, both ureters can be fishmouthed and implanted together.

2 arrows point close up view of a donor kidney with double ureters. Two yellow arrow marks point on the tip of two ureters placed adjacent to each other. The two ureters protrude a little above the external surface, which appears like a small white ball. A forceps is placed near the ureters.
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