Ileo-Pelvic Anastomosis and Augmentation Cystoplasty for Treatment of Encrusted Pyelitis in a Transplanted Kidney
A 51-year-old female patient received a kidney from her sister after a double nephrectomy owing to renal tuberculosis 12 years previously. At that time, the transplanted ureter was anastomosed to the ileum in the left lower abdomen with an ileal conduit on the opposite side. Ureteroileal anastomosis was performed by using 2 sutures of 3-0 Vicryl. The patient experienced no problems for 12 years. At a routine checkup, she complained of abdominal pain, gross hematuria, and increased debris in the ileal conduit. Her serum creatinine was elevated to 1.7 mg/dL (normal, 0.6 to 1.1 mg/dL), and her transplanted kidney developed hydronephrosis with calcified debris observed by sonography (). Neither hydronephrosis nor calcified debris had been observed 6 months before in a routine outpatient checkup.\nProteus mirabilis and Pseudomonas aeruginosa were detected by urine culture. Abdominopelvic computed tomography revealed hydronephrosis with encrusted pyelitis and ureteritis in the transplanted kidney ().\nThe patient was treated by percutaneous nephrostomy and empirical antibiotics. Microorganisms in the urine showed no evidence of tuberculosis. A cystogram showed that the bladder was not refluxed but had a small capacity (50 mL).\nAfter 3 weeks, we operated to anastomose the transplanted renal pelvis to one end of the ileal conduit, performing augmentation cystoplasty with new ileum and to anastomosis the other end of the remnant ileum with the augmented bladder. Augmentation cystoplasty is a reconstructive technique for creating a compliant, large-capacity urinary storage unit to protect the upper urinary tract.\nThe operation was performed via a midline incision. Because it was difficult to approach the major calices of the transplanted kidney in the left pelvic rim, we anastomosed one end of the ileal conduit to the pelvis of the transplanted kidney in an end-to-end fashion. The ileal conduit was lengthened by 30 cm to extend from the pelvis to the augmented bladder chimney. The encrusted upper ureter of the transplanted kidney was retained. We observed that the encrusted ureteritis involved the entire upper ureter. Bladder atrophy was remarkable, with only the trigon portion remaining. After exposure of the urinary bladder, a transverse wide V-shaped cystostomy incision was created, with the apex approaching the anterior bladder neck and the base extending posteriorly past the midcoronal plane of the bladder dome. A 20 cm segment of new ileum at least 15 cm proximal to the ileocecal junction was used for ileocystoplasty. For the small bowel, a V-shaped plate was created by a side-to-side anastomosis with 2-0 Vicryl. A circumferential, continuous, full-thickness, single layer anastomosis of the bowel to the bladder was started posteriorly by using 2-0 braided absorbable sutures. Bladder drainage was maintained with a 24 French urethral catheter. The other end of the ileal conduit was anastomosed through small separate ileotomies (1.5 cm length) in the limb of the augmentation cystoplasty.\nAfter surgery, calcified debris was decreased and encrusted pyelitis was absent on sonography. The patient's creatinine level was also normalized on follow-up. A follow-up cystogram showed increased bladder capacity to approximately 300 mL with well-preserved end-to-end anastomosis of the ileo-pelvic portion with the other end of one chimney of augmentation cystoplasty with the elongated ileal conduit (, ).