Surgical, Vascular & Urologic

The contract between this chapter and the reader.

1. 1. Recognise and manage graft vascular thrombosis.
2. 2. Diagnose and treat transplant renal artery stenosis.
3. 3. Recognise and manage a urine leak.
4. 4. Recognise and manage ureteric obstruction.
5. 5. Diagnose and manage a lymphocele.
6. 6. Differentiate the perigraft fluid collections.
7. 7. Recognise wound complications and the role of immunosuppression.
8. 8. Select the diagnostic tools for surgical complications.

A sixty-second reading. Each bullet stands alone.

• Graft vascular thrombosis presents early with sudden anuria and graft pain and is a surgical emergency that usually causes graft loss.
• Transplant renal artery stenosis presents later with refractory hypertension and graft dysfunction and is treated by angioplasty, often with a stent.
• A urine leak presents early with urine in the drain or wound, a rising creatinine, and a perigraft collection.
• A urine leak is confirmed by a high fluid creatinine and managed by decompression and, if needed, surgery.
• Ureteric obstruction causes hydronephrosis and a rising creatinine, early from technical causes or late from a stricture.
• Obstruction is relieved by a nephrostomy or stent before definitive repair.
• A lymphocele is a lymphatic collection that appears weeks to months later and is often asymptomatic.
• A symptomatic lymphocele can compress the ureter or iliac vessels and is drained or fenestrated.
• A perigraft collection is differentiated by fluid analysis: urinoma (high creatinine), lymphocele (lymph), hematoma (blood), abscess (infected).
• Immunosuppression impairs wound healing, and mTOR inhibitors worsen it.
• Doppler ultrasound is the first-line tool for perfusion, stenosis, hydronephrosis, and collections.
• A rising creatinine with hydronephrosis points to obstruction.

The medical core. An expert should agree the surgical complications are fully covered here.

Why it matters at the bedside

Not every failing transplant is rejecting. A plumbing problem — a thrombosed vessel, a leaking or blocked ureter, a stenosed artery, a compressing collection — can mimic rejection or DGF, and many of these are reversible if caught. The discipline of this chapter is to think mechanically: when a graft falters, ask what is obstructed, leaking, bleeding, or cut off, and reach for the ultrasound.

Vascular thrombosis

• Arterial or venous thrombosis is the catastrophic vascular complication: it presents early, with sudden anuria and graft pain in a previously working kidney, and it is a surgical emergency. Doppler confirms absent flow, and only immediate exploration offers any chance of salvage — in practice the graft is usually lost (developed as an early emergency in the operation chapter).

Transplant renal artery stenosis

• Stenosis of the transplant renal artery is a later, more insidious vascular problem: refractory or worsening hypertension, graft dysfunction, sometimes a bruit, and classically a rise in creatinine when an ACE inhibitor or ARB is started. Doppler shows elevated arterial velocities; angiography confirms it; and treatment is percutaneous angioplasty, often with a stent — a treatable cause that must not be mistaken for native hypertension.

Bleeding and post-biopsy vascular lesions

• Early bleeding presents with haemodynamic instability, a falling haemoglobin, and a perigraft haematoma; a large or expanding collection needs transfusion and sometimes re-exploration. After a graft biopsy, arteriovenous fistulae and pseudoaneurysms can form; most are managed conservatively, with embolization reserved for those that bleed or cause problems.

Urine leak

• A urine leak is the early urologic complication, usually at the ureteric anastomosis: urine appears in the drain or wound, the creatinine rises, and a perigraft collection (urinoma) forms, often with pain. It is confirmed by a high fluid creatinine — far above serum — and managed by decompression (bladder catheter and ureteric stent) and, if it does not settle, surgical repair.

Ureteric obstruction

• Obstruction of the transplant ureter causes hydronephrosis and a rising creatinine. Early obstruction is usually technical (oedema, clot, kinking); late obstruction is usually a stricture from ischemia or rejection. It is relieved promptly by a percutaneous nephrostomy or a stent to protect function, with definitive repair to follow — a reversible cause of graft dysfunction that must not be missed.

Lymphocele

• A lymphocele is a collection of lymph from the iliac dissection, appearing weeks to months after transplant. Most are small and asymptomatic, but a large one exerts mass effect — compressing the ureter (obstruction), the iliac vein (leg swelling, deep-vein thrombosis), or causing pain. Small asymptomatic lymphoceles are observed; symptomatic ones are drained, sclerosed, or fenestrated into the peritoneum (often laparoscopically).

Differentiating perigraft collections

• Any perigraft collection raises the same question — what is in it — and fluid analysis answers it: a high fluid creatinine means urinoma (urine leak); fluid resembling serum means lymphocele; blood means haematoma; and purulent or culture-positive fluid means abscess. Imaging localises the collection; aspiration characterises it; and the diagnosis dictates the treatment.

Wound complications

• Transplant wounds heal poorly because immunosuppression impairs healing — and mTOR inhibitors (sirolimus, everolimus) impair it further, so their timing relative to surgery matters (the immunosuppression chapter). Wound infection, dehiscence, and incisional hernia are commoner than in the non-immunosuppressed, and are managed accordingly.

Diagnostic tools

• Doppler ultrasound is the first-line investigation for nearly all of these — perfusion (thrombosis), arterial velocities (stenosis), hydronephrosis (obstruction), and collections. Fluid creatinine distinguishes urinoma from lymphocele; nuclear (MAG3) studies show a leak or obstruction functionally; angiography confirms and treats stenosis; and antegrade or retrograde studies define a ureteric obstruction before repair.

Five fully-built tables.

Table A — Vascular complications

Table B — Urologic complications

Table C — Perigraft collections

Table D — Lymphocele

Table E — Diagnostic tools

Visualise & Map

Numbered rules. These numbers are the cross-reference handle for the cases and flowcharts.

Clinical Reasoning

Five cases. Each stops you at a decision before it answers it.

Exhaustive. Every rule in the chapter is here.

Safety & Evidence

Panel A — Red flags

Panel B — NEVER DO

Anti-patterns clinicians fall into. Each becomes a Level 22 distractor.

The grade reflects strength of evidence, not importance.

Apply & Test

Copy-paste chart notes that map to the real decisions in this chapter.

Template 1 — Surgical complication assessment note

• Presentation: anuria/pain / refractory HTN / urine in drain / hydronephrosis / collection / wound.
• Doppler: perfusion ___; arterial velocities (TRAS?) ___; hydronephrosis ___; collection ___.
• Working diagnosis: thrombosis / TRAS / leak / obstruction / lymphocele / hematoma / abscess / wound.
• Further tests: fluid creatinine ___; angiography ___; MAG3 / antegrade study ___.
• Plan: emergency surgery / angioplasty / decompression / drainage; urgency ___.

Template 2 — Perigraft collection / intervention note

• Collection: size, location, timing ___.
• Fluid analysis: creatinine (vs serum) ___; appearance/culture ___.
• Diagnosis: urinoma / lymphocele / hematoma / abscess.
• Symptomatic (obstruction / leg swelling / pain)? ___.
• Intervention: observe / drain / sclerose / fenestrate / repair; outcome ___.

Pre-rounds compression. Rules only.

Active recall. At least one card per objective.

Micro-teaching for rounds. Two scenarios, five steps each.

Eight items, each anchored in this chapter. At least one per objective.