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Benefi ts of Subcutaneous Pyelovesical Bypass Graft in Evading

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					Benefits of Subcutaneous Pyelovesical
   Bypass Graft in Evading Ureteral
Stricture after Kidney Transplantation
     Reference: Azhar RA, Hassanain M, AlJiffry M,
      et al. Successful salvage of kidney allografts
                       threatened by
     ureteral stricture using pyelovesical bypass. Am
             J Transplant. 2010;10:1414–1419.
   Ureteral Stricture: Most Common
       Urological Complication
• Ureteral stricture is a frequent complication
  after renal transplantation with a prevalence
  rate of 2–5%. Ureteral stricture may occur
  – at the distal third of the ureter including
  – ureteroneocystostomy (73%),
  – at the mid-ureter level (12%) and
  – at the proximal third of the ureter (15%).
     Etiological Factors for Ureteral
                 Stricture
• The most common causes for ureteral
  stricture include ischemia (caused by faulty
  preparation of the ureter during donor
  nephrectomy), anastomotic technical
  complications, variations in vascular anatomy,
  allograft rejection episodes, and to some
  extent due to BK viral infection and
  medications.
  Subcutaneous Pyelovesical Bypass
   Graft: Safe and Effective Method
• Principally, the treatment adopted for
  symptomatic strictures is percutaneous
  nephrostomy followed by antegrade dilatation
  and stenting, and open ureteral reconstruction.
• Moreover, in cases where no ureter is present,
  bladder reconstructive techniques are performed.
• However, all these procedures are not always
  successful; they are technically demanding and
  may expose the patient to major complications.
• In such patients with irreversible malignant
  ureteral obstruction, subcutaneous pyelovesical
  bypass graft (SPBG) using an artifi cial ureter is
  regarded to be a safe and effective option.
• It consists of an internal silicone tube covered by
  an outer polyester sheath (see Fig. 1).
• Keeping this in view, a study was conducted
  investigating the effects of SPBG with a longer
  follow-up period.
                         Methods
• The study enrolled 8 patients, 6 men and 2 women with a mean age
  of 52 years, with refractory ureteral strictures following renal
  transplantation.
• The enrolled patients had unsuccessful repair with standard
  treatments and hence were subjected to SPBG to salvage their
  grafts.
• Seven patients presented with ureteral stricture early after renal
  transplantation and the eighth patient presented 10 years
  posttransplantation.
• The primary effi cacy variable was the glomerular fi ltration rate
  (GFR) calculated using Modifi cation of Diet in Renal Disease
  (MDRD) formula.
• The follow-up period was 1, 3, 6 and 12 months and annually
  thereafter with serial serum creatinine, urine culture and
  ultrasonography.
Findings
• Postoperatively, 2 patients suffered dislodgement of their
   SPBG that was diagnosed and repaired in 3 days.
• One patient developed recurrent urinary tract infections
   secondary to E. coli and P. aeruginosa.
• He was treated with intravenous ticarcillin/clavulanate
   followed by long-term oral antibiotic therapy using both
   cefi xime and ciprofloxacin for a total of 3 months.
• Treatment failure occurred in one patient due to resistant
   infection in the SPBG that led to graft nephrectomy
   including the removal of the SPBG to control the infection.
• However, later the patient had a successful living donor
   kidney transplant.
• One patient died of metastatic lung cancer after 15 months
   of follow-up with an intact and functioning SPBG.
Follow-up
• After a mean follow-up of 19.4 months, 6 patients with
  SPBG were alive without any evidence of encrustation,
  obstruction or erosion and with stable renal function.
• Mean GFR was 51.5 and 58.5 mL/min/1.73 m2 at 1 year
  and at last follow-up, respectively (see Table 1).
Conclusion
• Subcutaneous pyelovesical bypass graft offers a new
  treatment option for patients with renal transplantation
  who do not respond to conventional therapies. It has the
  ability to salvage many years of graft function.
• The most important requirement is that the patient should
  be free of infection during the SPBG procedure.
• Suppressive antibiotic therapy might be needed for
  patients with recurrent urinary tract infections.

				
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posted:10/31/2011
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