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Kidney transplantation: urological aspects and complications
The transplanted kidney is placed extraperitoneally in the iliac fossa through a Gibson incision, the artery and vein are joined to the external iliac vessels, and the ureter is implanted into the bladder by an extravesical technique (Lich-Gregoir) over a stent; the common urological complications are early urine leak, ureteral stricture and lymphocele.
Why it matters in the exam
The exam asks about the incision, the ureteral implantation technique and distinguishing complications by time. The extravesical Lich-Gregoir technique is shorter and causes less haematuria and leakage than the intravesical Leadbetter-Politano technique, in which haematuria in the first days is more common. A JJ stent lowers the rate of major urological complications and is removed after 2 to 6 weeks. The graft ureter receives blood only from the renal artery, so its distal part is vulnerable to ischaemia — the main reason for leak and stricture.
Urine leak usually occurs in the first weeks: falling urine output, rising creatinine, pain and fluid from the drain; creatinine in the drain fluid is much higher than in blood. Treatment: a bladder catheter, nephrostomy and stent, and surgical repair for a large leak. Ureteral stricture usually appears months after transplantation and is treated with dilation and a stent or reimplantation. A lymphocele is the commonest fluid collection around the graft; most are asymptomatic, and when it presses on the ureter or veins it is treated with percutaneous drainage with a sclerosing agent (sclerotherapy) or laparoscopic opening into the peritoneum.
Vascular complications: graft renal vein thrombosis appears early with sudden pain, graft swelling, haematuria and anuria, and on Doppler reversed diastolic flow — and usually ends in graft loss; transplant renal artery stenosis appears later with resistant hypertension, a bruit and rising creatinine, and is treated by angioplasty with a stent. Before transplantation bladder function is assessed. Indications for native nephrectomy before transplantation: very large polycystic kidneys or ones with infections and bleeding, infected stones, heavy proteinuria, uncontrolled hypertension and suspected tumour. After transplantation the risk of skin cancer, PTLD and RCC in the native kidneys rises.
Key points
- Gibson incision, extraperitoneal in the iliac fossa.
- Lich-Gregoir over a stent.
- Early leak — high creatinine in the drain.
- Lymphocele — the commonest fluid collection.
- Venous thrombosis — reversed diastolic flow.
Summary table
| Complication | Typical time | Finding | Treatment |
|---|---|---|---|
| Urine leak | First weeks | High creatinine in drain fluid | Catheter, nephrostomy and stent; repair |
| Ureteral stricture | Months | Graft hydronephrosis, rising creatinine | Dilation and stent or reimplantation |
| Lymphocele | Weeks to months | Fluid collection, pressure on the ureter | Drainage with sclerosant or laparoscopic opening |
| Graft vein thrombosis | First days | Sudden pain, anuria, reversed diastolic flow | Urgent surgery; usually graft loss |
| Graft artery stenosis | Months | Resistant hypertension, bruit | Angioplasty and stent |
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Sources
- EAU Guidelines on Renal Transplantation, 2025 edition — Surgical technique and urological complications
- KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation, 2020 — Urological evaluation of the candidate
- Campbell-Walsh-Wein Urology, 12th edition (2020) — Renal Transplantation
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.