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tive intervention with reimplantation of the ureter or a uretero-ureterostomy utilizing the ipsilateral native ureter.

5. Ureteral Stenosis/Obstruction

This is a relatively late complication occurring months or years posttransplant, which could result from ischemia of the ureter or a tight ureteroneocystostomy. Ureteral stenosis is manifested by elevated creatinine and hydronephrosis. Sometimes infectious pyelonephritis occurs. Diagnosis is made by several complimentary evaluations beginning with the observation of elevated creatinine followed by renal ultrasound showing moderate or severe hydronephrosis. Mild hydroneph-rosis is a benign common finding. To demonstrate that hydronephrosis is functional, a foley catheter should be placed at the time of ultrasound. Also, it is useful to obtain a diuresis renogram. If a functional stenosis or obstruction is present, there will be delayed excretion of nuclear material in the bladder. This result logically leads to percutaneous nephrostomy to confirm the diagnosis with contrast imaging. The percutaneous nephrostomy access is used for treatment by placement of an internal ureteral stent into the bladder, and an external drain of the renal pelvis. Those procedures solve the problem in the majority of cases; however, there are times when a surgical approach is necessary.

If surgery is required, one must be prepared to re-implant the transplant ureter, perform a ureteroureterostomy to the native ureter, or perform a ureteropyelos-tomy. Pre-operative retrograde stenting of the native ureter is often helpful in dissecting the native ureter in the reoperative field. Also, stenting of the transplant ureter is helpful as well. It is prudent to consult the initial operative report to understand the surgical techniques used during the initial kidney transplant procedure. It is also very useful to know if the allograft is a left or right kidney, since this has implications for understanding the anatomical relationship between the pelvic collecting system and the renal vasculature. Kidneys placed in the contralateral iliac fossa will have the collecting system relatively anterior to the renal vessels and therefore a less treacherous dissection can be carried out, especially if a ure-teropyelostomy is necessary. The surgical results are very satisfactory with immediate and long-term sustainable renal allograft function.

6. Lymphocele

A lymphocele is a circumscribed collection of retroperitoneal lymph that originates from lymphatic vessels about the iliac vasculature and the hilum of the kidney. The incidence of lymphocele is greatly reduced by careful suture ligation of lymph vessels overlying the iliac vessels. The true incidence of lymphoceles is unknown because not all patients are evaluated for its presence (in otherwords, the denominator is unkown). However, significant secondary problems may arise by external compression of the iliac vein causing leg swelling and discomfort, or compression of the transplant ureter causing hydronephrosis and renal dysfunction. Significant collections are usually diagnosed during the work-up for hypercreatinemia by ultrasonography. A perinephric fluid collection that is lymph is confirmed by percutaneous access and analysis of the fluid for white blood count,

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