Urinary leak after kidney transplantation - unusual late appearance after seven months

We report an unusually late urinary leakage which appeared seven months after kidney transplantation. A 48-year old female patient received a cadaveric kidney on November 5 th 1999, after six years spent on hemodialysis. Her end-stage renal disease was vesicorenal reflux. Before implantation of the kidney a transvesical Gil Vernet's antireflux operation was performed. An ureteroneocystostomy according to Politano-Leadbetter technique was done. The kidney function established with a delay of 15 days. Serum creatinine reached a normal level 6 weeks later. She received sequential immunosuppression. At the beginning of June 2000 the patient was admitted urgently because of fever (41 C)and urinary retention. After bladder catheterisation micturition was normal. Ultrasound examination and i.v. urography revealed pyelocaliceal and ureteral dilatation. Gynecological examination suggested a right tubo-ovarial abscess. Under antibiotic treatment the patient became afebrile after three days and she left the hospital two weeks later. At discharge the patient was informed about the possibility of surgical intervention. At the end of June 2000 the patient was readmitted because of pain in the right lumbal and inguinal regions. Ultrasound examination confirmed an earlier revealed pelvic and ureteric dilatation. A retrograde ureteropyelography demonstrated a contrast extravasation from the prevesical part of the transplant ureter. Discovery of the urinary leakage accelerated an operative intervention. Through a lower median laparotomy the transplant ureter was resected and an end-to-side anastomosis to the native right ureter was performed using a J stent. The postoperative course was uneventful. A pathological examination of the resected ureter found fibrotic changes with a short area of necrosis and a hole at the place of urinary extravasation. We consider that fibrotic changes were the consequence of impairment in ureteral circulation. Ureteral dilatation contributed to additional worsening of blood circulation and caused necrosis and urinary leakage. Since at the laparotomy the right ovary and Fallopian tube had a normal appearance, we can suppose that a tubo-ovarian abscess never existed and an urinary leak was probably present yet at the beginning of symptomatology.