Urologic complications occur in 2% to 10% of renal transplant recipients, with ureteral complications accounting for the majority (182-184). The rate of posttransplant ureteral stenosis is 9.7% at five years (182). Ureteral strictures can be related to one or more of the following: postoperative urine leak with periureteral fibrosis, ureteral ischemia with resultant necrosis, selective ureteral rejection, and surgical technique used to harvest the ureter as well as to create the ureteroneocystostomy (UNC) (185-187). Uret-eral obstruction due to such intraluminal pathology as a blood clot, fungus ball, or calculus is less common, as is extrinsic compression by the spermatic cord.
The most common site of ureteral obstruction is at the distal ureter, near the UNC site (182,187-189), likely due to the surgical manipulations required to create the anastomosis. Strictures in the proximal and middle ureter are more likely to be ischemic in nature. Urinary obstruction is suspected if the serum creatinine levels increase, urinary output is poor, or if renal ultrasonography or radioisotope renal scan indicate hydronephrosis.
Transplant ureteral leaks are also most frequent at the UNC site and usually present in the second or third postoperative week and almost always within five to six weeks of transplantation (187,188). Leaks are usually the result of ureteral necrosis due to rejection or vascular insufficiency. Extensive dissection during donor nephrectomy can jeopardize the ureteral blood supply because the ureteral vessels traverse the renal hilus and periureteral soft tissues. Urinary leaks are reportedly more common in living donors than with cadaveric kidneys because more dissection is required to harvest a kidney from a living donor (190). Other complications that can affect renal transplants are renal artery stenosis and perirenal fluid collections, which can occur in the early or late postoperative periods.
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