Minimally Invasive Radiologic Uretero-calycostomy; a salvage procedure for late transplant rejection ureter necrosis

Uretero-calycostomy is a time-honored procedure that has primarily been advocated for the management of failed pyeloplasties associated with long segment upper ureter strictures (1-3). We have expanded this concept to serve as salvage procedure in patients with necrosis of the transplant ureter as consequence of late rejection. After satisfactory function of a cadaver transplant kidney for 4 years, this 36-year old female presented in the emergency room with evidence of rapidly progressing renal failure. Examination revealed 3+ edema of lower extremities, orthopnea, chest X ray bilateral pleural effusions, and laboratory findings: creatinine 14, BUN 52, K 4,8, urine output 240mL/qd, ultrasonogram showing hydronephrosis of the right transplant kidney. A percutaneous antegrade nephro-ureterogram demonstrated hydronephrosis of the right transplant kidney and strictures as well as ulcerated segments of the right transplant ureter (Figure-1). Necrosis of the transplant ureter as sequel of late rejection was suggested. Conservative management by percutaneous antegrade stent placement, anti-microbial therapy and corticosteroids failed to improve condition of the ureter (Figure-2). The uretero-neocystomy dehisced and a urinoma formed at the uretero-neocystostomy site. Small bowel interposition to re-establish drainage or replacement of the transplant kidney by a new transplant were considered as remedial actions (4-6). Vol. 43 (4): 776-778, July August, 2017