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The native ureter receives its blood supply from three different arterial sources:

  • Renal artery

  • Gonadal artery

  • Superior vesical artery

The transplant ureter receives its arterial supply solely from the

  • Renal artery

  • This is especially relevant in instances of accessory arteries to the lower pole of the kidney that may constitute the main supply to the transplant ureter. Failure to preserve/reconstruct such arteries, as well as to preserve the peri-ureteral fascia, has the potential to cause ischemic injuries of the ureter.


  • Usually occur within the first 3 months after transplantation

  • In most instances they can be addressed by imaging-guided percutaneous interventions

  • Three main categories as follows:

    • Obstructions/strictures (most frequent)

    • Leaks/extravasations

    • Other (least frequent)


Peri-ureteric fascia. The surrounding fascia / tissues of the ureter are essential components in preserving its blood upply.



  • Associated with the ureter

    • Edema (usually in the immediate postoperative period)

    • Ischemia (early in the postoperative period)

    • Fibrosis (delayed)

    • Torsion/redundancy

    • Stones (retained or new stones)

    • Clots (early postoperative or post biopsy)

    • Stent malpositioning

    • Tumors/malignancies

    • Infections

    • Other (Figures 68-3 and 68-4)

  • Extrinsic to the ureter

    • Urine leaks

    • Lymphoceles

    • Hematomas

    • Abscesses

    • Compression by the transplant kidney (continuous or positional)

    • Compression by the bladder (usually associated with full bladder)

    • Tumors (benign/malignant/urological/nonurological)


Lower pole hematoma. In this specific instance, there is a hematoma and the lower pole of the kidney has not flushed like the remaining parenchyma. This finding should be of concern, since it raises the possibility of an injury to an accessory lower pole artery and a potential devascularization of the ureter. Although at the time of transplantation such findings may not be of major concern (the majority of the renal parenchyma will be well perfused), delayed ischemic ureteral injuries are a frequent corollary.


Increased risk of urinary complications. Less frequent anatomic findings (such as the duplicated ureter illustrated here) should be addressed thoroughly. The blood supply to the ureter (whether single or double) should be preserved in order to avoid preventable post-transplant complications.


Increased risk of urinary complications. Ureters in instances of horseshoe kidneys should be evaluated with caution (in addition to the frequent damage that the organ tends to suffer during procurements)

Clinical Findings

  • Elevated creatinine

  • Decreased urinary output

  • Pain

  • Fevers/chills/urosepsis


  • Imaging studies

    • Ultrasound (US)

    • Computed tomography (CT)

    • Nuclear medicine

    • Magnetic resonance imaging ...

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