Generally, renal transplantation is considered a relatively safe surgery but sometimes it carries certain risks. Studying the impact of surgical complications on the short-term and long-term outcomes of patients with renal transplantation is an area of interest. In this single-center study we described surgical procedures, complications, their management and impact on patient and graft outcome. The overall incidence of surgical complications in our series was 35.5%.
In most literature, the incidence of urologic complications was estimated to be 2.6–14.1% with the most frequent complications being urinary leakage and obstruction [4, 5]. Although it is very unusual that these complications lead to mortality or graft loss; morbidity, graft dysfunction, re-hospitalization, and increased costs are common reported problems [6,7,8,9]. In our series the incidence of urological complications was 10.5%, the most frequently observed were urinary leakage and obstruction, reported to occur in 9.6% and 2.9% of cases respectively. All of which occurred in the first month post-transplant. Patients with urinary fistulas had lower serum creatinine at one-month post-transplant which was statistically significant (p = 0.021). It was also observed that patients with obstructive uropathy had rapid recovery of graft function after management and had lower serum creatinine at one month (p = 0.043). Importantly, regardless of the fact that 40% of patients with urine leakage was treated with surgical re-exploration, it did not affect graft survival at one and 5 years. The same had been observed for patients who developed obstructive uropathy managed by PCN and antegrade JJ stent insertion, graft survival was not affected (p = 0.78). For both groups renal function was stabilized at 6 months post-transplant. This indicates that 6 months post transplantation, complicated renal grafts mostly behave like other non-complicated grafts.
The major finding in our study is that long-term patient and graft survival was not statistically different between patients who had post-transplant surgical complications and those without. This is in the same line to what Coupel et al. described at 5- and 10-years long-term survival for patient with first or second grafts. [10] Our findings are in concordance with those of van Roijen et al., who documented that surgical intervention of urological complications during the early post-operative period did not affect patient or graft survival. [11]
It has been previously documented by Bruintjes et al. [12] and Faenza et al. [13] that there is no relationship between the type of urinary anastomosis and the risk for surgical urological complications. The success of ureterovesical anastomosis depends on the vascularity of the donor ureter, which may be compromised during the donor nephrectomy and by handling during transplantation. Vascular compromise produces ischemia that may affect both proximal and distal parts of ureter. [14,15,16,17]
It has been our policy to avoid dissection in the triangle between renal hilum, ureter and lower pole of the kidney to avoid damage to ureteral vasculature. As the ureter receives most of the blood from renal vessels, we use the minimum required length of the ureter.
Other factor which favored a lower incidence of Urinary complications was the routine use of extravesical Lich-Gregoir technique with a ureteric catheter. Interestingly a meta-analysis [18] of 2 RCTs and 24 observational studies recommended the extravesical Lich-Gregoir technique for decreasing the overall incidence of urological complications. The donor periureteral fat should be preserved to ensure adequate ureteric blood supply. Wilson et al. [19] stated that stents are favored to reduce major urological complications, especially urinary leaks. Sirvastava et al. [20], reported 7.7% complication rate with non-stented and 2.0% with stented ureteral anastomosis, this is lower than what had been observed in our series.
In most studies, the incidence of vascular complications varies from 1 to 23%. [21, 22] In our series 7 patients had arterial thrombosis and 4 patients developed arterial stenosis. Renal artery trauma and arterial kinking were risk factors for vascular complications. Management included percutaneous transluminal angioplasty with placement of an endovascular stent or surgical revision.
It was previously reported that Lymphatic complications has incidence rates of 0.6% to 22%. [23, 24] Our results showed an incidence of 8.6% which is parallel to what has been previously published. Lymphoceles occur mainly due to the vascular and graft hilum dissections.
In the current study, no mortality was related to surgical complications. Despite the fact that re-intervention was required for some recipients, there was no effect on recipient or graft survival.
