CHAPTER 108: Urological Complications Associated With Bladder Drained Pancreatic Transplants

INTRODUCTION

Pancreas transplants with bladder drainage feature a variety of urological complications (most common: UTI, cystitis).

20–30% of these cases eventually require surgical conversion to enteric drainage within 3 years.

Effective treatment is required in order to minimize allograft injury.

PANCREATIC LEAKS

• Incidence:

  • 5–15%

• Origin:

  • 35% duodenum-bladder anastomosis

  • 30% transplant duodenum

  • 35% no clearly identifiable site

• Timing:

  • Early (≤4 post-op weeks)

  • Late (>4 weeks post-op)

• Clinical findings:

  • Pain

  • Fever

  • Distended abdomen

  • Diminished urinary output

  • Peritonitis

  • Vomiting

  • Improvement associated with urinary catheter placement

• Laboratory findings:

  • High serum amylase

  • Low urinary amylase

  • +/− increase in creatinine

EARLY PANCREATIC LEAKS (≤4 WEEKS POST-OP)

• Usually associated with technical complications

• Location:

  • Duodenum-bladder anastomosis

  • Duodenal graft

  • Ureter-bladder anastomosis (in instances of SPK)

• Diagnosis:

  • CT with retrograde injection of bladder contrast

  • Low pressure cystogram

  • Voiding cystogram

  • Nuclear medicine

  • Sampling of collection fluid

• Treatment:

  • Small contained collections (30%)

    • Percutaneous drainage of collection in association with urinary catheter

  • Collections with associated peritonitis

    • Surgical exploration

      • Repair (80% of cases, 10% failure rate)

      • Conversion to enteric drainage (10%)

      • Allograft removal (10%)

LATE PANCREATIC LEAKS (>4 WEEKS POST-OP)

• Usually associated with duodenal allograft pathologies

  • Ulcers

  • Perforations

  • Ischemia

  • Viral infections (such as CMV)

• Rarely may result from injury sustained during instrumentation of the bladder

• Diagnosis:

  • CT with retrograde injection of bladder contrast

  • Low pressure cystogram

  • Voiding cystogram

  • Nuclear medicine

  • Sampling of collection fluid

• Treatment:

  • Usually require conversion to enteric drainage

  • Treatment of underlying conditions (such as viral infections, ischemia)

PANCREATIC FISTULAS

• Incidence:

  • <5%

• Usually associated with previous pancreatitis and/or pseudocysts (native normal pancreas 1.5 L/day, denervated pancreas 700–800 ml/day)

• Initial conservative approach, with treatment of associated infections (if present)

• Parenteral nutrition (if needed)

• Percutaneous drainage

• Urinary catheter (to prevent reflux)

• Octreotide

HEMATURIA

• Incidence:

  • 10–50% in bladder-drained pancreas transplants

• Early

• Late

EARLY HEMATURIA (≤4 WEEKS POST-OP)

• Frequent finding

• Origin:

  • Allograft duodenum-bladder anastomosis (most frequent origin)

  • Allograft duodenitis (rejection, ischemia reperfusion injury)

  • Bladder catheter trauma

  • Post-biopsy

  • Reflux pancreatitis

  • Urinary infections

  • Cystitis (infectious, sterile)

  • Urethritis

  • Other

• Clinical findings usually limited

• Treatment:

  • Most cases respond to clinical management

    • Bladder irrigation

    • Discontinuation of anticoagulation

    • Correction of coagulopathies

  • Cystoscopy (in instances that don’t respond to less invasive approaches)

    • Fulguration

    • Evacuation of clots

  • Surgical intervention (very rarely)

LATE HEMATURIA (>4 WEEKS POST OP)

• Etiology:

  • Usually associated with duodenal allograft pathologies

    • Ulcers (e.g., CMV)

    • Ischemia

    • Duodenitis (infectious)

    • Rejection

  • Urinary infections

  • Cystitis (infectious, sterile)

  • Urethritis

  • Reflux pancreatitis

  • Pseudoaneurysms

  • Bladder ulcers

  • Stones

  • Tumors

  • Prostatitis

  • Urethritis

• Diagnosis:

  • Imaging studies

  • Biopsy

• Treatment:

  • Based on the underlying pathology

    • Antivirals

    • Antibiotics

    • Immunosuppression

    • Conversion to enteric drainage

    • Percutaneous embolization

    • Allograft resection

    • Other

DYSURIA AND URETHRAL COMPLICATIONS

• Incidence:

  • 2–20%

• Manifested as painful voiding

• Etiology:

  • Urethral (and/or glands/labia) injury as a result of exposure to pancreatic enzymes

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