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Ureteral Stricture after Pediatric Kidney Transplantation: Is There A Role for Percutaneous Antegrade Ureteroplasty?
Hannah Agard Bachtel, MD1, Syed Hamza Hussaini, DO1, Nicolette K. Janzen, MD1, Edmond T. Gonzales, MD1, Paul F. Austin, MD1, Jose Alberto Hernandez, MD1, N. Thao N. Galvan, MD, MPH2, Sarah J. Swartz, MD1, Eileen D. Brewer, MD1, Chester J. Koh, MD1, Kamlesh U. Kukreja, MD1.
1Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA, 2Baylor College of Medicine, Houston, TX, USA.

BACKGROUND: Ureteral obstruction following pediatric kidney transplantation is a challenging complication that occurs in 5-8% of cases. Management options include minimally invasive approaches. We evaluated our outcomes using percutaneous antegrade ureteroplasty for the treatment of ureteral stricture in pediatric renal transplant patients.
METHODS: We retrospectively reviewed all transplant kidney patients who presented with ureteral obstruction and underwent percutaneous antegrade ureteroplasty at our institution from July 2009 to July 2021. We excluded patients without a documented nephrostogram following ureteroplasty. Variables of interest included patient demographics, timing of presentation, location and extent of stricture, ureteroplasty technique and clinical outcomes. Our primary outcome was persistent obstruction of the renal transplant. Secondary outcomes included need for open surgical revision and development of vesicoureteral reflux (VUR). Paired t-test, Fisher's exact test and Kruskal-Wallis test were used for analysis.
RESULTS: Thirteen patients were identified (4.6% of all transplants) and 12 patients (5 male, 7 female) met inclusion criteria. Median age at the time of percutaneous antegrade ureteroplasty was 11.5 years (range: 3 to 17.5 years) and was noted primarily in deceased donor kidneys in this series (Figure 1). Obstruction occurred after primary transplant ureteral reimplantation in 7 patients (58%) and redo transplant ureteral reimplantation in 5 patients (42%). Median time from kidney transplantation to antegrade ureteroplasty was 3 months (range: 11 days to 4.4 years). The majority of strictures (75%) occurred in the distal ureter near the ureterovesical anastomosis. Three patients (25%) underwent repeat antegrade ureteroplasty at a median of 1 month (range: 1 week to 1.3 months) following initial percutaneous ureteroplasty. Patency was maintained in 50% of patients at an average follow-up of 4.6 years. Seven patients (58%) required additional surgical intervention at a median of 3.3 months (range: 2 to 9 months) following percutaneous ureteroplasty. Four patients (33%) developed VUR. Location, length and width of stricture, stricture etiology (primary vs redo reimplant), use of preoperative stenting, ureteroplasty technique and type of postprocedural drainage were not associated with persistent obstruction following antegrade ureteroplasty (Table 1). Median time from transplant to antegrade ureteroplasty was longer in patients with persistent obstruction compared to those who achieved patency following intervention (19.3 vs 1.3 months, p=.016). Of those treated within 6 months after transplantation, only one patient (17%) required surgery for persistent obstruction (p=.08). All patients treated > 1 year after transplantation had persistent obstruction following antegrade ureteroplasty (p=.06).
CONCLUSIONS: Percutaneous antegrade ureteroplasty seems to be an effective treatment for pediatric patients who develop early (<1 year) ureteral obstruction following kidney transplantation. One third of patients treated with percutaneous ureteroplasty will develop vesicoureteral reflux into the transplant kidney. Since percutaneous antegrade ureteroplasty has limited success 1 year or later after transplantation, upfront surgical intervention is recommended for these patients.


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