Research Article Trends in Transplantation Trends in Transplant, 2018 doi: 10.15761/TiT.1000246 Volume 11(1): 1-4 ISSN: 1887-455X Post-transplant urinary leak; the perennial ‘Achilles heel’ in renal transplant surgery Nalaka Gunawansa 1,2 *, Ajay Sharma 2,3 and Ahmed Halawa 2,4 1 National Institute of Nephrology Dialysis and Transplant, Sri Lanka 2 Faculty of Health and Science, Institute of Learning and Teaching, University of Liverpool, UK. 3 Royal Liverpool University Hospital, Liverpool, UKA 4 Sheffield Teaching Hospitals, Sheffield, UK Abstract Post-transplant urinary leak remains one of the commonest surgical complications in the early transplant recovery phase causing signifcant patient morbidity. Timely diagnosis and intervention is needed in minimizing associated morbidity in addition to avoiding unnecessary hospital stay and potential adverse outcomes. Prevention of urinary leak requires meticulous planning and technique in organ harvest as well as implantation. Any suspicious fuid leak from surgical drains or peri-graft collections need to be aggressively investigated in order to diferentiate urine leak from benign conditions such as lymphatic leak. A combination of clinical, biochemical and imaging tests assists in clear diferentiation and confrmation of diagnosis. While endo-urological management techniques are available especially for small volume leaks and unstable patients, open surgical repair remains the gold standard in treating large volume urinary leak after transplantation. *Correspondence to: Nalaka Gunawansa MBBS MS MCh (Edin) FCSSL, Consultant Vascular, Endovascular & Transplant Surgeon, National Institute of Nephrology Dialysis and Transplantation (NINDT), National Hospital of Sri Lanka, Sri Lanka, Tel: +94 773737644, 0115777888; E-mail: vascular@drnalakagunawansa.com Key words: renal transplant, urological complications, urine leak, ureter dehiscence Received: July 02, 2018; Accepted: July 13, 2018; Published: July 16, 2018 Introduction Compared to the transformations seen in medical management, tissue crossmatch and post-transplant immunosuppression, surgical technique and associated outcomes have shown little change since the inception. While laparoscopic donor nephrectomy has revolutionized the living donor surgery, the recipient operation technique has remained relatively constant, with minimal variations based mostly on individual surgeons’ preferences. Apart from post-operative haemorrhage, the commonest surgical complications following renal transplantation, ofen termed its ‘Achilles heel’ have been related to the ureteric anastomosis. Te reported incidence of major urological complications following transplant vary from 2.4%-9.2% in recent literature [1,2]. Among them, urinary leak has been reported at an incidence of 1.8% - 2.9% and remains the commonest early ureteric complication with potential implications on patient and graft outcome [3]. Surgical drains and excess drainage Heterotopic renal transplantation in to the iliac fossa, involves preparation of the renal bed with dissection of the iliac vessels in the retroperitoneal space. Tis dissection leaves behind a potential dead space for fuid collection. Placement of intra-operative drains in this space adjacent to the graf is commonly practiced, although there is no conclusive evidence of its beneft in reducing post-operative complications [4,5]. Nevertheless, when a drain is placed, one advantage is it allows easy bed-side access to any potential peri-graf collection for visual and biochemical assessment. Excess drainage from surgical drain could be blood, urine, lymph or rarely ascitic fuid. Drainage of blood is obvious due to the colour and appearance and would require prompt intervention, when signifcant. Leakage of urine, lymph or ascitic fuid may be indistinguishable requiring further investigation. Urinary leak; the background Early urinary leakage (day-01-04) is primarily due to technical errors in construction of the neo-uretero-cystostomy. Less frequently, it could be mechanical damage to the graf ureter or renal pelvis during harvesting or stent insertion. It could also occur due to calyceal damage especially afer ex-vivo instrumentation such as calculi extraction [2,6]. Late urinary leakage (Day 05-10) is usually due to ischemic necrosis of ureter resulting in anastomotic dehiscence [7]. Tis is more frequent in deceased donor transplants with prolonged cold ischemia times. Rarely, it is also possible afer live donor transplants where peri- ureteric tissue has been damaged, stripping the ureteric blood supply or where excessive length of the ureter renders it ischemic at the distal end [8,9]. Another possibility is thrombosis or ligation of inferior polar arterial branches that supply the ureter [10,11]. Other forms of leakage that could mimic urinary leak include lymphatic leak and ascitic fuid leakage. Lymphatic leak results from damage to recipient pelvic lymphatics during dissection or due to untied donor lymphatics in the allograf hilum [12]. Ascitic fuid drainage is extremely rare and can occur where the peritoneum has been breached in a recipient with pre-existing ascites. Clinical manifestation Clinical manifestation of urinary leak depends on timing and degree of leak. High-volume leaks occurring early, would manifest as