42 UROLOCICAL COMPLICATIONS AFTER KIDNEY-PANCREAS TRANSPLANTATION

EDITORIAL COMMENT traneplantation with bladder drainage. 'hn8plant. Proe., eS: 458,1994. The m n t study is a review of 65 pancreafdrenal transplants

4. Sutherland, D. E. R., Rainer, w. G., Gruemner, p. F.* Bra-an, performed using bladder drainage of the pancreas from an institu- K, WahOff, D. and Gruessner* A.: tion that has been performing these procedures for many years and an update. Diabetes Metab. Rev., 11: 337,1995. has accumulated vast experience in this area. The mean age was 33

% 7 and the mean time of diabetes was 21 minus 6 years. 4 1 PmCreaMuodenal *-Plantation with patienu had progressive diabetic neuropathy, retinopathy and ne- pancreatic secretion. h e r . J. Surg., 153: 405, 1987. phropathy, and/or renal failure. Perioperative urodynamics were

on 50 patients (77%) and voiding cystourethrogram in 40 clinical Tr-Plmb- Edited (62%). The pancreas was transplanted in the standard bladder UCLA Tissue Typing Laboratory, p. 29,1991. drained procedure using a duodenal cystostomy side-to-side anasto-

mask. The ureter was connected to the bladder with a standard Lich clinical -Plants. Edited p. I. implant with all ureters stented. Immunosuppression consisted of UCLA Tissue Typing Laboratory, p. 31,1991. quadruple therapy. Complications were noted in 51 of the patients

8. Sollinger, H. W., Messing, E. M., Eckhoff, D. E., Pirsch, J. D., (79%), including urinary tract infection in 59% (3% had pyelonephri- DAlessandro, A. M., Kalayoglu, M., Knechtle, s. J., Hickey, tis), hematuria in 262, paft pancreatitis in 19%, duodenal leaks in and Belzer, F. 0.: Urolo@cal complicatio~ in 210 consecutive 1746, ureteral lesions in 99b (3 obstructions and 3 leaks) and urethral Simultaneous Panaas-kiheY transplants with lesions in 6%. The 1 and 5-year survival rates for patientAcidney/ drainage. Ann. Surg., 218 561,1993. pancreas were 92,91 and 86% and 61,59 and 55%, respectively.

9. Stephhan, E., Gruesner, R. W. G., Brayman, K. L., Gores, p.2 patient and graft survival results are considered good and compa- Dunn, D. L. and Sutherland, D. E. R.: Converting e x ~ r i n e rable to many cited in the literature.' Overall infection rates of drainage from bladder to pan'* bladder drained pancreases are also comparable. What is new is the aticoduodenal transplants. Transplant. h., comparison with preoperative d y n a m i c s and voiding cystowe-

10- s m e r i H. w.1 Knechtlet s. J-9 A.1 D M a s a n h . A. M.i t h g r a m findings with postoperative complications. In essence, UM- KalaY%lU* M., &her, F. 0- and -1 J.: with dynamic findings do not predict which cases will have urological loo simultaneous kiheY-panmas transplanta- complication. Many centers have independently realized that routine tion with bladder drainage. Ann. Surg., 214: 703,1991. preoperative umlogical screening is seldom productive for diabetic

11. Douzdjian, V., -is, M. M., Cooper, J. L., Smith, J. L- and transplant candidates and it is an uncommon practice today. Uri- Cow, R. J.: Incidence, management, and significance of Sur- nary retention is a problem in diabetics aRer transplan- gid Pancreatic surg.* tation because of associated sensory neuropathic bladder damage. Gynec. & Obst., 171: 451,1993. Monitoring post-void residuals will identify those patients who will

12. Smith, J. L., See, W. A, Ames, S. A., Piper, J. B. and C o w , R. J.: 9- temporary and/or prolonged intermittent urethral catheter- Lower urinary tract complications in Patients with duoden* ization. unfortunately, some patients may not respond to this ther- CYstobmies for exocrine drainwe Of the t m P 1 = M Pan- apy. Additionally, urological complications can occur independently creas. Transplant. Proc., 23: 1611,1991. of clinical urinary retention. For instance, this study had high duo-

13. D o d i m , V., Gugliuzza, K. K. and Fish, J. c.: Urolo& WmPli- denal leakage rates (17%) compared to a recent review by Pem catione Simultaneous Panmas-EheY transplantation: (range 6 to la%).' The question arises since no bladder to enteric hand-sewn Versus Stapled duodenWSbbmY. Clin. Trans- drainage conversions were performed, whether an overzealous at- plant., 9: 396, 1995. tempt to keep the pancreas in bladder drain mode led to higher rates

and Hefty, T. R.: COmPlimtiOns of duodenal leakage. The range for acceptable conversion of bladder following unstented parallel incision extravesical ureterone- drain to enteric drainage is to be between 10 and 20% OCYStotomY in transplants. J- uml., 148: 38,1992. (reference 8 in article). The incidence of graft pancreatitis is also

15. Mw, S. R., Engen, D. E., B m , D., Carpenter, H. A. and elevated at 19% (32 episodes in 12 patients). Again, an over protec- Perkins, J. D.: Differential diagnosis OfhypoamYlasia in Pan- tiveness of bladder drainage of the pancreas may lead to this rate.

dograft recipients with exmine drainage- Recent experiences from other centers seem to support these conten- Transplantation, 49: 359,1990. tions. Kuo et al compared their institutional experiences with blad-

16. Sethi, p. s., mammas , E. A., Pollifrone, D- L.. H e m , M. L. der versus enteric drained pancreas transplants.2 Although the and F e W n , R- M.: High in t ra~s ica l PmS8mS and related study was nonrandomized and a small experience, it tended to sup- urolO& complications in Simuhm~US ~ ~ e Y / P ~ ~ ~ trans- port other series having the same conclusion. Their study showed plant recipients. Transplant. Proc., 21: 3085, 1995. that 5 of the 23 bladder drained pancreases required conversion to

17. sthi, p. s., E b m , E. A, Pollifrone, D. L., Cohen, s. D., enteric drainage (21%). Overall graft survival in both groups was H e w , M. L. and FergueOn, R- M-: and POst -~SPlant comparable as well as mean length of hospital stay (20 days). Hos- W l e C WOrk-UP in Simukaneom kheY/Panmas b m P l = t pital cost was likewise comparable ($110,000 versus $125,000). The preliminary results of an o w i n g study. -plant. M., 21: most interesting aspect of the study is that enteric drained pancre- 3083,1995. ases had significantly decreased genitourinary complications, fewer

18. b a , A., Hand, M. F.9 C h h o h G. D- and Anderton, J. L.: urinary tract infections, less pancreatitis and no episodes of sepsis. Cystometrosraphy a ~ r e i o u s b unrecognized OPpOr- Graber et al support these findings and reported on their clinical M t y for SUceeesful management of -arY leaks a h r renal experience comparing primary enteric drained with bladder drained transplantation. J. Urol., 151: 973,1994. pancreas recipients, and showed comparable graft and patient sur-

19. &plan, s. A., Te, A. E. and Blaivas, J. G.: Urodynamic findings vival.3 However, the urinary tract infection rate decreased from 89 to in patients with diabetic cystopathy. J. Urol., 153: 342,1995. 26%. In addition, episodes of urinary retention and reflux graft

20. Taylor, R. J., Mays, S. D., Grothe, T. J. and Stratta, R. J.: pancreatitis diminished from 32 to 5.3% (p c0.028). Thus, there Correlation of preoperative Urodynamic findin@ to podper- seems to be a growing trend toward primary enteric drainage as ative complications following pancreas transplantation. more institutions report on similar favorable results.4 J. Urol., 1W: 1185, 1993. While today the optimal drainage port (enteric versus bladder) for

21. Cony, R. J., Egidi, M. F., Shapiro, R., Jordan, M., Vivas, C., the pancreatic allograft remains controversial, a larger controversy scantlebury, V., Gritsch, A., Sugitani, A., Fung, J. and S-1, exists as the ultimate question continues to plague pancreatic trans- T. E.: Enteric drainage of pancreas transplants revisited. plantation, whether these procedures are overused. There is still no Transplant. pmc., 21: 3048,1995. strong and solid evidence of arrest of microangiographic damage

22. Hammontree, L. N., COX, C. C. and Gaber, 0.: Comparison of caused by diabetes that can be observed in patients receiving SUC- urologic morbidity between recipients of simultaneous cessful pancreadrenal transplant.6 Until these controversial issues pancreas-kidney transplantation by Merent techniques. are better elucidated, primary enteric drainage should be considered J. Urol., part 2,151: 622A, abstract 1177,1994. as an alternative to bladder drained pancreas transplantation, and

these procedures should be more selectively reserved for those young panmatitie. Transplantation, W: 257.1990. enough and without significant neurological or vascular damage

5. Ngheim, D. D. and C O T , R. J.: Techniqueofsimultan'?Ous renal &me Of

c.: Angeles:

c.:

6. Sutherland, D. E. R., Gfingham, K. and M o u d V - M m * p. I. Terasaki.

7. Sutherland, D. E. R., Gillinghami K and Mou*-Mm,

in recipients Of

808, 1992.

14. Gibbons, w. s.3 BarrY, J.

23. Lindor, R, Tyden, G., Tibell, A. and Groth, C-G.: Late graft

UROLOGICAL COMPLICATIONS AFTER KIDNEY-PANCREAS TRANSPLANTATION 43

from diabetes to enjoy the potential benefits of pancreatic transplan- tation.

Peter N . Bretan, Jr. Transplant Service, Moffett Hospital University of California, Sun Francisco Sun Francisco, California

1. Penn, I.: The morbidity of pancreatic transplantation. Literature scan. Transplantation, 11: 23, 1995.

2. Kuo, P. C., Johnson, L. B., Schweitzer, E. J. and Bartlett, S. T.: Simultaneous pancreaskidney transplantation-a compari- son of enteric and bladder drainage of the exocrine pancreatic

secretions. Transplantation, 83: 238, 1997. 3. Gaber, A. O., Shokouh-Amiri, M. H., Hathaway, D. K,

Hammontree, L., Kitabebi, k E., Gaber, L. U., Saad, M. F. and Britt, L. G.: Results of pancreas transplantation with portal venous and enteric drainage. Ann. Surg., 221: 613, 1995.

4. Gritch, H. A., Cony, R. J., Vivas, C. A., Shapiro, R., Scantlebury, V. P., Egidi, M. F., Dodson, F., Sugitani, A., Fung, J. J., Stanl, T. E. and Jordan, M. L.: Pancreas transplantation under ta- crolimus (FK506) immunosuppression. J. Urol. part 2, 167: 275, abstract 1068, 1997.

5. Manske, C. L., Wang, Y. and Thomas, W.: Mortality of cadaveric kidney transplantation vs. kidney pancreas transplantation in diabetic patients. Lancet, 346: 1658, 1995.