Late Surgical Complications After Kidney Transplantation
Late-stage surgical complications affecting
long-term graft survival after kidney transplantation typically present with
atypical symptoms—such as an increase in creatinine, decreased urine output, or
asymptomatic hydronephrosis—rather than classic pain or fever. This is due to
the immunosuppressive drugs used by patients and the lack of a neural network
(denervation) in the transplanted kidney. Ureteral strictures, which are among the
leading complications and develop due to ischemic injury in most cases, are
managed using ultrasonography for diagnosis and the insertion of a percutaneous
nephrostomy to preserve kidney function. While endoscopic methods such as
lasers or balloons are preferred for strictures shorter than three centimeters,
surgical repair (reconstruction) utilizing the patient's own healthy ureter is
mandatory for longer and resistant cases. Stone disease, another significant issue, has a
bidirectional relationship with ureteral strictures and infections, and
patients do not experience typical kidney stone pain. In the treatment of
stones, those smaller than 4 mm are monitored, while depending on the size and
location, extracorporeal shock wave lithotripsy (ESWL), retrograde intrarenal
surgery (RIRS) performed with flexible ureteroscopes, or percutaneous
nephrolithotomy (PCNL) for stones larger than 2 cm are applied. In these patients, who have an increased risk
of cancer due to the suppression of the immune system, macroscopic hematuria
(visible blood in the urine) should always be considered a critical early
symptom for urothelial carcinoma; cystoscopy and careful imaging that does not
put kidney function at risk must be performed. Additionally, it is of vital
importance to conduct annual ultrasound screenings on high-risk groups for
renal cell carcinoma, which frequently emerges in the patients' own native
kidneys rather than the transplanted kidney. Finally, in late-stage urinary leaks
(fistulas), decompression is primarily attempted using conservative methods
such as stents and nephrostomy; if there is no response, open surgery is
initiated. Furthermore, because leaving ureteral stents—used during the healing
process—forgotten in the body for extended periods can lead to encrustation
(calcification) and resistant infections resulting in graft loss, it is
imperative for hospitals to implement strict stent follow-up protocols.
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