American Journal of Transplantation 2006; 6: 352–356
Blackwell Munksgaard
Late Ureteral Stenosis Following Renal
Transplantation: Risk Factors and Impact on Patient
and Graft Survival
G. Karama,b, ∗ , J.-F. Héteta , F. Mailleta , J. Rigauda ,
M. Hourmantb , J.-P. Soulilloub and M. Giralb
a
Clinique Urologique, CHU Hôtel-Dieu, Place Alexis
Ricordeau 44093 Nantes Cedex, France
b in incidence of ureteral complications has been linked to
ITERT, Institut de Transplantation et de Recherche en
Transplantation, Centre Hospitalier et Universitaire de
Nantes, 30 bd Jean Monnet, 44035, Nantes, France
∗ Corresponding author: Georges Karam,
gkaram@chu-nantes.fr
The aim of this retrospective study of a cohort of
1787 consecutive kidney transplantations was to an-
alyze the risk factors associated with the occurrence
of ureteral stenosis and the impact of ureteral steno-
sis on graft and patient survival. Between January
1990 and December 2002, 1787 renal transplantations
were performed at our center. Only stenosis observed
after the first month, were considered. Among the
parameters studied were: donor age and serum cre-
atinine before procurement; recipient age, cold is-
chemia time, delayed graft function (DGF), number
of arteries and the presence of a double J stent. The
follow-up parameters were the number and timing of
acute rejection episodes, cytomegalovirus (CMV) in-
fection, acute pyelonephritis, renal function and death.
Ureteral stenosis occurred in 4.1% of patients and was
correlated with donor age > 65 years (p = 0.001), kid-
neys with more than 2 arteries (p = 0.009) and DGF
(p = 0.016). Ureteral stenosis did not affect 10-year pa-
tient and graft survival rates, which were respectively
90% and 64% for the stenosis group, 86% and 63% for
the no-stenosis group (p = NS). These data suggest
an important role for donor age, number of renal ar-
teries and DGF for the occurrence of ureteral stenosis
following renal transplantation.
Key words: Graft survival, kidney transplantation,
ureteral stenosis
Received 10 May 2005, revised 10 October 2005 and
accepted for publication 11 October 2005
Introduction
Results of renal transplantation, considered nowadays as
the treatment of choice of end stage renal disease, has
352
C 2005 The American Society of Transplantation
and the American Society of Transplant Surgeons
doi: 10.1111/j.1600-6143.2005.01181.x
dramatically improved throughout the last decades. Acute
graft rejection has been considerably reduced by the in-
troduction of combinations of highly effective immunosup-
pressive drugs (1). Similarly, surgical complications, initially
around 30%, have also decreased to 10% (2,3). Decrease
improvement of harvesting techniques with better ureteral
vasculature preservation, utilization of a short ureter with or
without a double J stent (4) and a sharp decrease in the av-
erage cumulative steroid dose (5). Early obstruction is rare
and generally related either to a technical defect such as a
narrow anti-reflux tunnel, or to a surgical complication such
as a hematoma or a lymphocele. In contrast, obstruction
occurring beyond the first post-operative month remains
frequent (2–7.5%) (6,7) and mostly related to ureteral
stenosis. The etiology of this stenosis remains poorly un-
derstood. Obstruction insidiously affects graft function jus-
tifying routine follow-up for this problem with serum cre-
atinine measurements and transplant ultrasonography to
allow for early diagnosis and treatment. Open surgery has
been the treatment of choice for ureteral stenosis. More re-
cently, endoscopic and percutaneous techniques appear to
be replacing the open surgical approach (8–10). Despite the
fact that the incidence of ureteral complications following
kidney transplantation is as important as acute rejection in
our experience, no systematic analysis of risk factors and
impact on graft outcome has been performed on a large
cohort. The aim of this single-center cohort review of 1787
consecutively performed kidney transplant, was to analyze
the risk factors for ureteral stenosis and to evaluate the
possible impact on graft and patient survival during an era
of stable clinical care available to our patients.
Patients and Methods
This study is a report of 1787 consecutive kidney transplants performed
in a single center between January 1990 and December 2002 (5.3% from
living donor, CI = 4.4–6.4%), a relatively homogeneous period in terms of
surgical techniques and of clinical care. In addition, every patient had a min-
imal follow-up of 1 year. Data were extracted from the DIVAT multi-center
data bank (i.e., données informatisées et validées en transplantation (com-
puterized and validated data in transplantation)) that prospectively recorded
biological and clinical data of transplanted patients since 1990. Data are
computerized by a clinical research assistant independently of the medical
team, in real time and at each anniversary of the graft. Data are submitted
to an annual audit according to the data sources. Less than 1% error is
tolerated to guarantee the quality of the data bank.

The mean follow-up was 74.9 months (95% CI = 72.6–77.1) and the follow-
up rate was 88.6%. One hundred and six patients (6%) were lost to follow-
up and the 10-year survival was based upon 467 patients with a functional
graft. This cohort was composed of first transplantation in 81.9% (CI = 80–
83%) of the cases, a second in 14.9% (CI = 13.3–16.6%), a third in 2.9%
(CI = 2.2–3.8%) and a fourth in 0.3% (CI = 0.12–0.65%). The Lich-Gregoir
ureterovesical reimplantation technique was similar during the entire review
period. The shortest ureter, an approximately 3 cm anti-reflux tunnel and
5/0 or 6/0 absorbable running suture were used. Double J stent was used
electively depending on local per operative conditions. In kidney–pancreas
recipients, the kidney was transplanted similarly as in isolated kidney recip-
ients. Only patients with distal ureteral stenosis were considered for this
study. Ureteral necrosis was excluded from this study. Thus the cohort was
divided into two groups, depending on the presence (G1, n = 74) or ab-
sence of ureteral stenosis (G2, n = 1713). Patients with early obstruction,
by hematoma, for example, were included in G2 to look for a possible role
in late ureteral stenosis.
Diagnosis of ureteral stenosis
Obstruction was defined by the presence of both an increasing serum cre-
atinine and hydronephrosis on ultrasound. All other causes of graft func-
tion impairment, i.e. acute rejection, hematoma, lymphocele and urine
collections were ruled out. A percutaneous echo-guided nephrostomy
was generally performed to allow the graft function to recover and to
confirm the obstruction. Subsequently, an antegrade pyelo-ureterogram
was carried out to specify the nature, the site and the severity of the
obstruction.
Clinical parameters
The clinical parameters used in this study, were prospectively obtained from
DIVAT and were as follows:
For the donors and grafts: Cadaveric or living donor, age, cause of death,
hemodynamic status and creatinine before harvesting, right/left kidney, kid-
ney weight, cold ischemia time, dual transplant, number of arteries (2 vs.
>2), type of urinary anastomosis, presence or not of double J stent, kidney
alone or combined with pancreas, heart or liver.
For the recipients: Age, gender, number of transplant, HLA mis-
matches and historical anti-T panel reactive antibodies (PRA). For the post-
transplantation period, the effect of the type of immunosuppressive treat-
ment (induction and maintenance), the presence of delayed graft function
(DGF) as defined by the number of days to reach a Cockcroft calculated
creatinine clearance above 10 mL /min (11), the occurrence and the pos-
sible onset of an acute rejection episode (biopsy proven or clinically diag-
nosed if biopsy was not possible) or of a cytomegalovirus (CMV) infec-
tious disease (viremia, blood PCR, viral inclusion in biopsy) were all an-
alyzed. The existence of acute pyelonephritis (worsening graft function,
fever, and positive urine culture (12), hematoma and lymphocele were also
recorded.
The immunosuppressive treatment was progressively modified during the
time course of the survey: 57.4% of the recipients received an induction
treatment by anti-thymocyte serum (13), 12.3% by an anti-R-IL2 receptor
antibody (14,15), 16.4% by other agents and finally 13.9% did not receive
induction treatment. All patients were on the combination of a calcineurin
inhibitor (cyclosporine A or tacrolimus) and azathioprin or mycophenolate
mofetil after 1994. Anti-CMV prophylaxis, using valaciclovir, has been sys-
tematically used since August 1998 when recipients with negative serol-
ogy received a kidney from a donor with positive serology and extended
after 2003 to recipients with positive serology, regardless of the donor’s
serology.
American Journal of Transplantation 2006; 6: 352–356
Late Ureteral Stenosis Following Renal Transplantation
Treatment of ureteral stenosis
Ureteral stenosis was traditionally treated by open neo-ureterocystostomy
or by the use of the native ureter when available. However, during the last 5
years percutaneous and endoscopic techniques were used every time they
were feasible. A double J stent was systematically used regardless of the
technique and removed 1 to 3 months later in an ambulatory setting. Serum
creatinine levels were checked on a regular basis. Transplant ultrasound was
realized one week after the removal of the double J stent and once as soon
as a rise in serum creatinine level was noticed. Treatment was considered as
successful when serum creatinine level remained stable, after the removal
of the double J stent, and equal to the trough level obtained by the initial
drainage of the transplanted kidney.
Statistical analyses were performed using Statview® software (SAS Insti-
tute, Inc., USA). The percentages were calculated and compared for a 5%
alpha risk and a 95% confidence interval (CI). The quantitative and qualita-
tive variables were compared using the Student t-test and chi-square test,
respectively. Patient and transplant survival was analyzed according to the
Kaplan-Meier method and a Log-rank test was used to compare the sur-
vival curves. Finally, the predictive factors of ureteral stenosis were studied
using the multivariate Cox proportional model.
Results
Incidence and risk factors
Seventy-four out of the 1787 consecutive transplants an-
alyzed (4.1%, CI = 3.3–5.1%) presented an obstruction
related to a distal ureteral stenosis. The mean time of oc-
currence was 5.4 months (CI = 3.16–7.66). Among the pre-
transplant parameters analyzed, two were found to be sig-
nificantly different. The number of transplants with more
than two arteries was higher in the stenosis group than
in the no-stenosis group (p = 0.009). The average number
of arteries was 1.39 (95% CI = 1.27–1.51) in the stenosis
group vs. 1.25 (95% CI = 1.22–1.27) in the no-stenosis
group. Average DGF of the transplant was 9.4 d (CI =
7.1–11.6) in the group with stenosis versus 6.4 d (CI =
6.05–6.76) in the no-stenosis group (p = 0.001). Donor age
was not significantly different between the two groups.
Despite this, we found that donor age stratification and
analysis according to the Kaplan-Meier method revealed
an elevated risk (relative risk 2.8) for ureters obtained from
donors above 65 years of age (p = 0.001).
In the stenosis group, 13.5% of the patients had a double
J stent inserted during the transplantation surgery versus
18.5% in the no-stenosis group (p = NS). On the other
hand, the incidence of lymphocele was higher in the steno-
sis group 9.4% versus 1.8% (p < 0.0001). The incidence
of ureteral stenosis was not higher in recipients with an
early obstruction by hematoma. The type of induction and
maintenance immunosuppression regimen was also sim-
ilar in the two groups. The incidence of ureteral steno-
sis was not statistically different between kidney alone
and kidney–pancreas recipients. In 1998, Mycophenolate
and tacrolimus were introduced in our immunosuppressive
regimen without any impact on the incidence of ureteral
stenosis (p = NS). Moreover, transplant year did not have
any impact on the incidence of ureteral stenosis, which
353
Karam et al.

Table 1: Donor’s and transplants characteristics: transplants with Table 3: Multivariate analysis of risk factors according to the Cox
more than 2 arteries were at a significantly higher risk of ureteral proportional model
stenosis (p = 0.009)
Relative risk
Stenosis No stenosis v2 p Value (95% CI)
(n = 74) (n = 1713) p-value DGF∗ 9.824 0.002 1.03 (1.01–1.05)
Donor age 40.8 ± 15.4 38.3 ± 15.7 O.174∗ Number of arteries 4.483 0.034 1.45 (1.00–2.00)
Cardiac collapse 30% 22.8% NS ∗ Delayed graft function.
Donor serum creatinine 95.1 ± 42.3 97.5 ± 47.6 NS
(lmol/L)
Transplant weigh (g) 200 ± 46 185 ± 33 NS
n = 488
Number of arteries > 2 10.8% 3.7% 0.009
Cold ischemia time (hours) 24.2 ± 11.3 24.3 ± 11.5 NS
Local/nonlocal 31/43 790/923 NS
procurement
Right/left transplant 51.4/48.6% 53.3/46.5% NS
Living/cadaveric donor 2/72 92/1621 NS
∗ Kaplan-Meier analysis showed higher risk for donors above 65

years of age.

Table 2: Pre- and post-transplant characteristics of the recipients

Stenosis No stenosis
(n = 74) (n = 1713) p-value
Figure 1: Ten-year Kaplan-Meier patient (P) and transplant (T)
Recipient age 45.7 ± 15.2 43.6 ± 14.9 NS survival: 90% in the ureteral stenosis group (P1) versus 86%
Sex ratio M/F 1.96 1.6 NS in no-stenosis group (P2) p = 0.36 (NS), 64% in the ureteral
Number of 62/12 1402/311 NS stenosis group (T1) versus 63% in the no-stenosis group (T2)
transplantation (1 p = 0.3 (NS).
vs. ≥1)
PRA > 0% 37.6% 34.8% NS
DGF∗ (days) 9.4 6.4 0.001 chronic allograft nephropathy, rejection and recurrence of
Acute rejection 15.3% 19.5% NS the initial nephropathy. None was lost because of urologi-
(within 1 year) cal complication. Similarly, the 10-year patient survival was
Combined kidney 13.5% 9.6% NS 90% in the group with versus 86% in the group without
and pancreas
stenosis p = 0.30 (Figure 1).
JJ stent present 13.5% 18.7% NS
Duration of stenting 2.1 3.4 NS
(months) (CI = 1.3–2.9) (CI = 2.6–4.2) CMV infections
Post-transplantation 6% 5% NS The number of CMV infections following transplantation
hematoma was not statistically different between the stenosis and
∗ Delayed graft function. no-stenosis groups (18% vs. 21%).

Acute pyelonephritis (APN)

remained stable during this study. Type and severity of re-
jection were similar in the two groups. Similarly, acute re-
jection episodes were treated, according to our practice,
either by steroids or anti-thymocyte globulin or OKT3 in
kidney–pancreas recipients. Finally, the other listed param-
eters (Tables 1 and 2) had no significant effect. A multivari-
ate analysis of risk factors according to the Cox proportional
model showed that delayed graft function and number of
arteries were independent risk factors for ureteral stenosis
(Table 3).
Ureteral stenosis and graft survival
The presence of ureteral stenosis had no significant im-
pact on the 10-year graft survival (64% in the group with
vs. 63% in the group without stenosis, p = 0.36). In the
ureteral stenosis group, the reasons for lost kidney were
The number of acute pyelonephritis episodes was higher
in the stenosis group 29% versus 14.4% (p = 0.0002).
An analysis of these episodes revealed that 36% occurred
after the diagnosis of the stenosis and its treatment. This
higher incidence of serious urinary infection could be likely
explained by the presence of the double J stent inserted
systematically during stenosis repair and removed within
2 to 3 m after placement.
Discussion
Despite the continuous improvements in harvesting and
ureteral reimplantation techniques, ureteral stenosis fol-
lowing kidney transplantation (4.1% in our series) remains
the most common long-term urological complication (5),

354 American Journal of Transplantation 2006; 6: 352–356


ranging from 0.5 to 6.3% in the recent literature (16,17).
Ureteral obstruction is related to a variety of etiologies such
as ureteral ischemia, ureteral kinking or peri-ureteral fibro-
sis (18) and may be located in any portion of the ureter.
However, the distal ureter and the ureterovesical areas are
particularly vulnerable. This is evidenced by previous re-
ports (60–95% of anastomotic stenosis (19,20) and by our
study (82.4%).
Although previous reports have commented on a similar
incidence, none have analyzed the risk factors and the im-
pact on patient and graft survival. Our retrospective study
performed on 1787 consecutive transplants has revealed
the role of several factors implicated in the occurrence of
ureter stenosis such as number of graft arteries, DGF and
donor age, likely related to vascular alteration. Old donors
have more frequent vascular alterations that favor gener-
ally ureteral ischemia and consequently ureteral necrosis
(21). However, mild ischemia may lead to ureteral fibrosis
and not to necrosis but confirmation of this hypothesis is
lacking in the literature. In our series, DGF was significantly
associated with a higher incidence of ureteral stenosis that
has not yet been well documented in the literature except
by Dominguez et al. (22). One can suggest that ureteral
edema could decrease both ureteral arterial blood supply
and venous drainage leading to development of ureteral
fibrosis as well as ischemia. It is known that kidneys with
multiple arteries are at a higher risk for ureteral necrosis
but data on the risk of ureteral stenosis are lacking. The hy-
pothesis of peri-ureteral fibrosis related to the occurrence
of post-transplantation hematoma was not confirmed in
our study. On the other hand, post-transplantation lympho-
cele was higher in the stenosis group but its relation with
the occurrence of stenosis remains unexplained, keeping
in mind that we have excluded from the ’stenosis group’
early obstruction caused by hematoma or lymphocele.
The causes of late stenosis are still poorly understood. Is-
chemia is probably the main reason, but it is difficult to
demonstrate this directly. This hypothesis is indirectly sup-
ported by the fact that donor age, DGF and more than two
graft arteries all increase the risk of stenosis. These factors
all produce deterioration in the distal ureteral vasculariza-
tion. We did not find, as Faenza did, that rejection was a risk
factor (6). Using the shortest possible ureter, thus allowing
the most direct route possible and also guaranteeing the
best vascularization should avoid stenosis (23).
Ureteral stenosis was observed in an average of 5.4
months after transplantation. Indeed, 70% of obstructions
are observed within 3 months (10) but the risk of develop-
ing ureteral stenosis persists for a long time. The 10-year
risk is estimated at 9% after the transplantation (6).
Some authors have described cases of ureteral stenosis
caused by CMV infection of the ureter (24,25). In our series
the incidence of CMV was not statistically different in the
two groups. However, histological study looking for viral
American Journal of Transplantation 2006; 6: 352–356
Late Ureteral Stenosis Following Renal Transplantation
inclusions was not carried out as we did for graft ureteral
necrosis because the stenosed part of the ureter was not
routinely resected to allow analysis.
Living donor was not a risk factor: recipients of cadaveric
kidneys not having a greater frequency of ureteral steno-
sis than those receiving living donor kidneys. This concurs
with other reports (17,26). We have, almost exclusively
(92.2%), carried out extra-vesical Lich-Gregoir anastomo-
sis, of which the risk of stenosis (4.2%) is comparable to
that described in the literature (2.8–4%) (6,27). In addition,
the risk of other types of ureteroneocystostomy used in
this series (7.8%) was similar (4%). We cannot compare
precisely our results to those achieved with different tech-
niques because of biases related to time period, center
practices and the use of JJ stent. However, the technique
called “’extra-vesical’ currently gives the best and most
reproducible results, even if the initial technique has been
modified (28). The interest of routine JJ stent is still contro-
versial, with some authors being in favor (28,29) and some
against (22). A meta-analysis, including five randomized tri-
als and 44 case series, supports the use of ureteral stenting
because of a significant reduction in urologic complications
(9% in nonstented patients vs. 1.5% in stented patients
(30). However, one of the five randomized trials (22) did
not find any difference in an intention-to-treat analysis (3.5
vs. 6.6%) and concluded that routine ureteral stenting is
unnecessary in recipients at low risk for urological com-
plications. Although the use of ureteral stents is globally
beneficial, stents have drawbacks such as hematuria, uri-
nary infection and additional costs except when the stent
is removed early (31). In our experience, the presence of a
JJ stent has delayed the diagnosis of stenosis, but has not
reduced its incidence 3% versus 4.4% (NS). For all these
reasons, we have adopted in our practice elective and not
routine use of ureteral stents when performing the Lich-
Gregoir technique.
Also, a significant controversy exists whether the treat-
ment should be by open surgery or endoscopically. Endo-
scopic treatment is increasing in popularity justified by the
mini-invasive character of the procedure of placing a J stent
via incisions made by scalpel, electrically or by laser (32).
The reported long-term results of all these procedures are
inconclusive, probably due to differences in the length of
follow-up and the duration and extent of the stenosis. The
prognosis is the best in cases of short stenosis treated
within 3 months (9) and these techniques should there-
fore probably be used as first-line approaches. As for open
surgery, the results are more consistent with a global suc-
cess rate of 83% (33). Open surgery is currently reserved
for stenosis that are both lengthy and of long duration and
obviously, for endoscopic failures.
In conclusion, our data have identified a link between
this classical surgical complication following kidney trans-
plantation and donor age, number of renal arteries and
DGF. These data suggest an important role for factors
355
Karam et al.
affecting ureteral vascularization, re-emphasizing the in-
terdependence between surgical complications and some
medical parameters.
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