Presented by: Clara Cerrato MD
University Hospital Southampton NHS Trust

Introduction

Renal transplantation remains the best therapeutic approach to treat end-stage renal disease (ESRD). Allograft urolithiasis is an uncommon, challenging, and a potentially dangerous clinical problem. Treatment of allograft stones include external shockwave lithotripsy (ESWL), flexible ureteroscopy and lasertripsy (fURSL) or percutaneous nephrolithotomy (PCNL). A gap in the literature and guidelines exists regarding the treatment in this setting of patients. The aim of this Cochrane style review was to collect preoperative and treatment characteristics, and to evaluate the outcomes of post-transplant ESWL for stone disease. 

Materials

A comprehensive search in the literature was performed including articles between January 1987 and March 2023. Only English original articles with a minimum of five patients were selected.  

Results

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Eight articles (81 patients) were included in the review (Table 1). Patients were mainly males and mean age was 41.9 years (±7.07). The diagnosis was mainly incidental, and the most cited symptoms at presentation were macrohematuria, urinary tract infection (UTI), and deterioration of renal function. Stones were predominantly located in the kidney (65.5 %), with a mean stone size of 13.1 mm (± 2.28mm). Pre-operative drainage, either ureteral stent or nephrostomy tube, was placed in 11 patients (13.5%). Post-operatively one study reported about the routine use of ureteral stent and another about the use of alpha-blocker therapy. The overall stone free rate was 81% (range: 50-100%). Five patients (6.1%) required a second treatment for residual fragments, either fURS (n=1) or PCNL (n=4). Two studies reported stone recurrences in 3 patients. The overall complication rate was 17.2% (14/81), and complications reported were graded as follows: seven Clavien I (transient hematuria, conservative management), six Clavien II (UTI requiring antibiotic therapy), and one Clavien IIIa (steinstrasse requiring a nephrostomy placement and a subsequent reintervention).

Conclusion

ESWL remains a safe and effective option to treat de-novo stones after transplantation. Higher level studies are needed to better address allograft urolithiasis management.

Funding

None.

Co-Authors

Victoria Jahrreis, MD
University Hospital Southampton NHS Trust

Carlotta Nedbal, MD
University Hospital Southampton NHS Trust

Francesco Ripa, MD
Department of Urology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano

Vincenzo De Marco, MD
Azienda Ospedaliera Universitaria Integrata di Verona

Manoj Monga, MD, FACS
Department of Urology, University of California San Diego, San Diego

Amelia Pietropaolo, MD, FEBU
University Hospital Southampton NHS Trust

Bhaskar Somani, MRCS, FEBU, FRCS
University Hospital Southampton NHS Trust