The utilization of Boari flap vesicocalycostomy for salvage repair of kidney transplant ureteric injury after robotic radical prostatectomy

摘要

To the Editor The prevalence of prostate carcinoma in male kidney transplant recipients approaches 1.1%.1Carvalho J Nunes P Dinis P et al.Prostate cancer in renal transplant recipients: diagnosis and treatment.Transpl Proc. 2017; 49: 809-812Crossref PubMed Scopus (13) Google Scholar Despite increasing reports of robotic radical prostatectomy (RRP) performed for aging kidney transplant recipients, there are no publications addressing postoperative complications including transplant ureteric injuries.2Polcari A Allen J Nunez-Nateras R et al.Multicenter experience with robot-assisted radical prostatectomy in renal transplant recipients.Urology. 2012; 80: 1267-1272Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar,3Smith D Jellison F Heldt J et al.Robot-assisted radical prostatectomy in patients with previous renal transplantation.J Endourol. 2011; 25: 1643-1647Crossref PubMed Scopus (22) Google Scholar These complications are potentially devastating and difficult to salvage, as illustrated by the following report of an opportunistic use of Boari flap vesicocalycostomy (BFV) to manage complete ureteric obstruction of the transplant kidney after an RRP. A 61-year-old man was diagnosed with localized prostatic adenocarcinoma 6 years after kidney transplantation, which was previously complicated by partial ureteric stenosis and managed conservatively at a baseline estimated glomerular filtration rate of 60 to 70 mL/min/1.73 m2. He subsequently underwent an RRP with only left-sided pelvic lymph node dissection. The patient became anuric after surgery, requiring emergent insertion of a percutaneous nephrostomy tube (PCN). The nephrostogram showed exacerbated hydronephrosis with contrast hold-up within the proximal ureter. Reconstructive surgery was performed 5 days later via a lower midline laparotomy. The transplant ureter was found to have multiple long-segment strictures, which did not permit passage of a guidewire; it was therefore excised. A suitably dilated lower pole kidney calyx with minimal overlying parenchyma was identified via ultrasound. A Boari flap was created by tubularizing an inverted-U bladder flap after adequate mobilization.4Stein R Rubenwolf P Ziesel C Kamal M Thüroff J Psoas hitch and Boari flap ureteroneocystostomy.BJU Int. 2013; 112: 137-155Crossref PubMed Scopus (44) Google Scholar This flap was then anastomosed to the incised selected calyx over a ureteric stent with interrupted absorbable full-thickness sutures (Figure 1). The anastomotic suture lines were protected with the interposition of a peritoneal flap. No leakage was seen after methylene blue instillation via the PCN. Blood loss was 50 mL with 251-minute operative time. His renal function improved, and the postoperative cystogram performed showed no contrast leakage (Figure 2). Histology showed stage T3b Gleason 5 + 4 prostatic ductal adenocarcinoma. At the 12-month follow-up, his estimated glomerular filtration rate was 77 mL/min/1.73 m2 with a PSA level of 0.33 ng/mL. This is an initial case report of the rescue of the transplant kidney with BFV to bypass the complete ureteral obstruction after RRP. Gowda et al.5Gowda BD Goldsmith P Ahmad N Boari flap vesicocalycostomy: a salvage drainage procedure for complete ureteric stricture and pyelocalyceal fistula.Clin Transplant. 2009; 23: 129-131Crossref PubMed Scopus (15) Google Scholar performed a similar repair in a womanwith ureteropelvic junction obstruction of the transplant kidney attributed to renal artery stenosis. Uniquely, our case was complicated by the prior RRP, necessitating attention to preserve the vesicourethral anastomosis while performing the bladder to kidney reconstruction. The laterally positioned renal pelvis was in close apposition to the iliac vessels and vascular anastomosis, resulting in potentially difficult access to the kidney pelvis. However, the transplanted kidney anatomical orientation provided the opportunity for a BFV. Correspondingly, the relative prox