Routine intraoperative ureteric stenting for kidney transplant recipients
Abstract
Background
Major urological complications (MUCs) after kidney transplantation contribute to patient morbidity and compromise graft function. The majority arise from the vesicoureteric anastomosis and present early after transplantation. Ureteric stents have been successfully used to treat such complications. A number of centres have adopted a policy of universal prophylactic stenting, at the time of graft implantation, to reduce the incidence of urine leaks and ureteric stenosis. Stents are associated with specific complications and some centres advocate a policy of only stenting selected anastomoses.
Objectives
To examine the benefits and harms of routine ureteric stenting to prevent urological complications in kidney transplant recipients.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL in The Cochrane Library), MEDLINE, EMBASE, reference lists of articles, books and abstracts and contacted companies, authors and experts to identify relevant randomised controlled trials (RCTs).
Selection criteria
All RCTs and quasi‐RCTs were included in our meta‐analysis.
Data collection and analysis
Four reviewers assessed the studies for quality against four criteria (allocation concealment, blinding, intention‐to‐treat and completeness of follow‐up). The primary outcome was the incidence of MUCs. Further outcomes of interest were graft and patient survival and the incidence of adverse events (urinary tract infection (UTI), haematuria, irritative symptoms, pain and stent migration). Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) with 95% confidence intervals (CI).
Main results
Seven RCTs (1154 patients) of low or moderate quality were identified. The incidence of MUCs was significantly reduced (RR 0.24, 95% CI 0.07 to 0.77, P = 0.02, NNT 13) by universal prophylactic stenting. This was dependent on whether the same surgeon performed, or was in attendance, during the operations. Two patients lost their grafts to infective urinary tract complications in the stented group. UTIs, in general, were more common in stented patients (RR 1.49, 95% CI 1.04 to 2.15) unless the patients were prescribed cotrimoxazole 480 mg/d: in which case the incidence was equivalent (RR 0.97, 95% CI 0.71 to 1.33). Stents appeared generally well tolerated, although studies using longer stents (≥ 20 cm) for longer periods (> 6 weeks) had more problems with encrustation and migration.
Authors' conclusions
Routine prophylactic stenting reduces the incidence of MUCs. Studies comparing selective stenting and universal prophylactic stenting, whilst difficult to design and analyse, would address the unresolved quality of life and economic issues.
PICOs
Plain language summary
Routine prophylactic stenting reduces the incidence of major urological complications in kidney transplant recipients
Kidney transplantation is the treatment of choice for end‐stage kidney disease, improving quality of life and extending the recipient's life expectancy. Interventions aimed at reducing the burden of post‐transplant complications are a major area of research amongst the transplant community. Major urological complications (MUCs) (e.g. urine leak, obstruction) can occur in the immediate post‐transplant period. This review aimed to determine the benefit and harms of the use of routine stenting in kidney transplant recipients in the prevention of urological complications. Seven studies (1154 patients) were identified. The incidence of MUCs were significantly reduced by the use of prophylactic stenting. Urinary tract infections (UTIs) were more common in stented patients however the addition of antibiotic prophylaxis resulted in no difference in the incidence of UTIs between the two groups. More studies are needed to investigate the use of selective versus universal prophylactic stenting for the unresolved issues of quality of life and cost.
