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Urinary Fistula After Kidney Transplant — Repair

This is the surgical-technique atlas for urinary fistula after kidney transplantation. For epidemiology (1.2–8.9% incidence, ~76.7% from distal ureteral ischemic necrosis), the anatomic basis of distal-ureter vulnerability, full etiology and risk factors, anastomotic-technique comparisons (Lich-Gregoir vs. Leadbetter-Politano vs. ureteroureterostomy), clinical presentation, and diagnostic workup (ultrasound, fluid creatinine, MAG3 scintigraphy, antegrade nephrostogram, CT urography), see the clinical-conditions page: Urinary Fistula After Kidney Transplant. This page focuses on the stepwise repair framework, surgical repair options, and outcomes.

Stepwise Repair Framework​

Most transplant urinary fistulae are managed in three sequential phases. The decision to escalate from percutaneous diversion to open reconstruction is driven by the location and length of ureteral loss, viability of the remaining transplant ureter, demonstration of contrast passage to the bladder on antegrade study, and infection control.[1][2][3]

StageGoalModalities
1. Acute stabilizationSepsis control, urinary diversion, immunosuppression balanceBroad-spectrum antibiotics, urethral Foley, percutaneous drainage of urinoma, temporary IS reduction
2. Percutaneous / endoscopic diversionAllow ischemic ureter to declare and small leaks to sealPercutaneous nephrostomy (PCN) ± antegrade double-J stent ± ureteral 8 Fr catheter
3. Definitive surgical repairRestore tension-free, well-vascularized urinary continuityRe-ureteroneocystostomy, native ureteroureterostomy / pyeloureterostomy, Boari flap ± psoas hitch, pyelovesicostomy, pyelo-pyelostomy, omental wrap, ileal conduit, transplant nephrectomy as last resort

Stage 1 — Acute Stabilization​

  • Broad-spectrum antibiotics with attention to urinary pathogens; infected urinomas drive morbidity and mortality[4]
  • Continuous Foley drainage (≥ 18 Fr) to drop intravesical pressure at the ureteroneocystostomy
  • Percutaneous drainage of any peritransplant urinoma; submit fluid creatinine (fluid-to-serum ratio > 1.0 confirms urinoma)
  • Immunosuppression adjustment — temporary modest reduction in mycophenolate ± corticosteroids during active fistula management, balanced against rejection risk; mTOR inhibitors should be held while wound healing is required[5]

Stage 2 — Percutaneous Nephrostomy and Endoscopic Management​

Percutaneous nephrostomy (PCN) is the cornerstone of conservative management and the single most important determinant of repair success. In a literature survey of 4,307 transplants, surgical repair failure rates were 87% without nephrostomy vs. 13% with nephrostomy.[6]

PCN ± antegrade double-J stenting​

  • PCN decompresses the collecting system and diverts urine from the leak; antegrade stenting bridges the defect
  • Achieves leak closure in ~87% (20/23) of patients in one series, with a mean diversion duration of 68 days[7]
  • Provides definitive treatment in ~62% of patients presenting beyond 72 hours posttransplant[8]
  • Predictor of percutaneous success — contrast passage into the bladder on antegrade nephrostogram predicts success in 77% (10/13); absence of bladder filling predicts failure in 100% (3/3)[8]

Foley catheter alone (vesical fistulae)​

  • Effective in 42.4% of vesical fistulae but 0% of ureteral fistulae[4]
  • In another series, stent + Foley drainage for 1–2 weeks was definitive in 8 of 43 patients (18.6%)[9]

Ureteral 8 Fr Foley catheterization​

A novel temporizing technique for infected fistulae unsuitable for primary repair — an 8 Fr Foley is advanced retrograde or antegrade through the necrotic ureter to stent and drain across the defect, with 80% success (4/5 patients) reported.[4]

Stage 3 — Definitive Surgical Repair​

When percutaneous management fails — or the fistula is from extensive distal ureteral necrosis that will not seal — surgical reconstruction is required. Technique is dictated by ureteral viability and bladder reach.[1][2][10]

Re-ureteroneocystostomy​

The most commonly performed primary repair when adequate viable transplant ureter remains:[2][10][11]

  • Excise the necrotic distal segment to bleeding ureter; spatulate
  • Extravesical (Lich-Gregoir) preferred over transvesical (Leadbetter-Politano) — complication rates 6.15% vs. 8.33%[2]
  • Performed over a double-J ureteral stent; Foley drainage 7–10 days
  • Success rates 91–98% for distal ureteral injuries with adequate length[12]

Native ureteroureterostomy / pyeloureterostomy​

When the transplant ureter is too short or extensively necrotic for reimplantation, the recipient's ipsilateral native ureter is the workhorse conduit:[1][13][14][15]

  • Ureteroureterostomy — anastomose remaining viable transplant ureter to native ureter (end-to-end or end-to-side)
  • Pyeloureterostomy — anastomose transplant renal pelvis to native ureter when no transplant ureter remains
  • Salvage outcomes > 90% success with a 3.9% reintervention rate[2]
  • Largest single-center experience (Schult, 48 patients): technically feasible in all, 83% (40/48) achieved normal graft function, only 1 graft lost to pyelonephrosis[14]
  • Robotic / laparoscopic transplant-to-native ureteroureterostomy and pyeloureterostomy are feasible — no obstruction or leak in 7 patients at mean 20.9 months[13]
  • Native ureter ligation without ipsilateral nephrectomy has a low (~2%) rate of clinically indicated native nephrectomy; caution in ADPKD and neurogenic bladders[15]

See also: Ureteroureterostomy.

Boari flap ± psoas hitch​

For extensive ureteral defects when reimplantation cannot achieve a tension-free anastomosis:[16][17][18][11]

  • Full-thickness bladder flap is tubularized and swung cephalad to bridge the gap to the transplant renal pelvis (pyelovesicostomy with Boari flap)
  • Success 93.7–100% in transplant-specific series[17][18]
  • Boari flap as primary treatment was significantly more successful than other methods (p < 0.05)[17]
  • In a 10-patient series with strictures refractory to a median of 4 endoscopic procedures, pyelovesicostomy with Boari flap achieved 100% success with no recurrence at 18 months[18]
  • Decade-long single-center experience (1,560 transplants): 18 of 40 patients requiring reconstruction utilized a Boari flap with no 90-day mortality[11]

See also: Boari Flap & Psoas Hitch.

Direct pyelovesicostomy​

For complete ureteral necrosis when the transplant renal pelvis can reach the bladder dome directly:[16][18]

  • Anastomose the mobilized transplant renal pelvis to the bladder dome
  • 80–100% long-term success in complex cases
  • All 5 patients treated with direct pyelovesicostomy in del Pizzo's series had successful reconstruction[16]
  • Reflux into the transplant pelvis occurred in 6/20 (30%) in a combined Boari/pyelovesicostomy series, without clinical consequence

See also: Pyelovesicostomy.

Pyelo-pyelostomy​

Rescue maneuver when the native ureter is unavailable or inadequate — anastomosis of the transplant renal pelvis to the native ipsilateral renal pelvis:[19]

  • In Wagner's series of 6 patients with total/subtotal ureteral necrosis, 4 maintained functioning transplants at median 6-year follow-up

Pedicled omentum wrap (recurrent fistula)​

A technique developed specifically for recurrent urinary fistulae after kidney transplantation:[20]

  • Pedicled greater omentum is mobilized and wrapped around the anastomotic site, providing well-vascularized tissue coverage that promotes healing and prevents recurrence
  • Ye series of 13 patients with recurrent fistulae: 100% success at first attempt with no recurrence over 1–7 years of follow-up

See also: Omental flap.

Ureteroenterostomy / ileal conduit​

For patients with non-functioning native urinary tracts (prior cystectomy, severe neurogenic bladder):[2][21]

  • Transplant ureter is anastomosed to a pre-existing or newly created ileal conduit
  • 5-year graft survival ~63%, comparable to standard drainage, despite higher infection rates (~65%)
  • Fistulae are more common after transplantation into ileal conduits; negative-pressure wound therapy (VAC) has eradicated local sepsis and healed recurrent urinary fistula wounds in this setting[21]

Transplant nephrectomy (last resort)​

Reserved for uncontrolled sepsis, complete renal-pelvis necrosis, or unreconstructible loss of both transplant ureter and adequate native conduit. Modern series report 1–4 patients per cohort requiring transplant nephrectomy for fistula-related complications.

Outcomes Summary​

TechniqueSuccessNotes
Foley alone0–42%Effective only for vesical fistulae; fails for ureteral fistulae[4]
PCN ± antegrade stent59–87%Mean diversion ~68 days; definitive in 62% beyond 72 h[7][8]
Re-ureteroneocystostomy91–98%Requires adequate viable ureteral length[12]
Native pyeloureterostomy / UU> 90%3.9% reintervention; robotic feasible[2][13][14]
Boari flap ± psoas hitch93.7–100%Best for extensive defects; superior as primary treatment[17][18]
Direct pyelovesicostomy80–100%For complete ureteral necrosis[16][18]
Pedicled omentum wrap100% (13/13)Specifically for recurrent fistulae[20]
Ileal conduitComparable graft survivalFor non-functioning native tract[2]
Transplant nephrectomySalvageLast resort for unreconstructible disease

Special Considerations​

Nephrostomy before reconstruction​

In a literature survey of 4,307 transplants, surgical repair failure was 87% without nephrostomy vs. 13% with nephrostomy.[6] Pre-reconstruction PCN is therefore strongly encouraged in every patient progressing to operative repair — not only as a temporizing diversion but as a determinant of definitive-repair success.

Immunosuppression during repair​

The immunocompromised state impairs wound healing and increases infection risk, yet reducing immunosuppression risks acute rejection — infection-related IS reduction during the first 2–6 months posttransplant is associated with higher rejection risk.[22] A balanced approach is generally favored: temporary modest reduction in mycophenolate ± corticosteroids during active fistula management, mTOR inhibitors held, and close immunologic monitoring. No standardized protocol exists.[5]

Damage-control approach in sepsis​

When patients are septic or hemodynamically unstable, stage repair: PCN + percutaneous urinoma drainage + antibiotics first, then delayed definitive reconstruction once stable.[6][10]

Choice of conduit when both transplant and native ureter are inadequate​

Ladder: transplant ureteroneocystostomy → native ureteroureterostomy / pyeloureterostomy → Boari flap ± psoas hitch → direct pyelovesicostomy → pyelo-pyelostomy → ileal conduit → transplant nephrectomy.

Key Takeaways​

  • PCN before any operative repair is the single most important determinant of success (87% failure without vs. 13% with nephrostomy)
  • Most fistulae from distal ureteral ischemic necrosis — debride to viable ureter before reanastomosing
  • Reconstruction ladder: re-ureteroneocystostomy → native ureteroureterostomy / pyeloureterostomy → Boari flap → direct pyelovesicostomy → pyelo-pyelostomy → ileal conduit → transplant nephrectomy
  • Pedicled omentum wrap is the workhorse adjunct for recurrent fistulae
  • Robotic/laparoscopic transplant-to-native reconstruction is feasible and safe in experienced hands
  • Immunosuppression must be temporarily moderated, with rejection monitoring, while wound healing is required

References​

1. Nie ZL, Zhang KQ, Li QS, et al. "Treatment of Urinary Fistula After Kidney Transplantation." Transplant Proc. 2009;41(5):1624–6. doi:10.1016/j.transproceed.2008.10.103

2. Novacescu D, Abol-Enein H, Latcu S, et al. "Ureteric Complications and Urinary Tract Reconstruction Techniques in Renal Transplantation: A Surgical Essay." J Clin Med. 2025;14(12):4129. doi:10.3390/jcm14124129

3. Li Marzi V, Filocamo MT, Dattolo E, et al. "The Treatment of Fistulae and Ureteral Stenosis After Kidney Transplantation." Transplant Proc. 2005;37(6):2516–7. doi:10.1016/j.transproceed.2005.06.049

4. Suaid HJ, Cassini MF, Tucci S, et al. "Therapeutic Option for Infected Urinary Tract Fistulas in Renal Transplantation." Transplant Proc. 2010;42(2):479–82. doi:10.1016/j.transproceed.2010.01.029

5. Yamanaka K, Kakuta Y, Nakazawa S, et al. "Surgical and Infectious Complications Following Kidney Transplantation: A Contemporary Review." J Clin Med. 2025;14(10):3307. doi:10.3390/jcm14103307

6. Goldstein I, Cho SI, Olsson CA. "Nephrostomy Drainage for Renal Transplant Complications." J Urol. 1981;126(2):159–63. doi:10.1016/s0022-5347(17)54426-2

7. Matalon TA, Thompson MJ, Patel SK, et al. "Percutaneous Treatment of Urine Leaks in Renal Transplantation Patients." Radiology. 1990;174(3 Pt 2):1049–51. doi:10.1148/radiology.174.3.174-3-1049

8. Alcaraz A, Bujons A, Pascual X, et al. "Percutaneous Management of Transplant Ureteral Fistulae Is Feasible in Selected Cases." Transplant Proc. 2005;37(5):2111–4. doi:10.1016/j.transproceed.2005.03.118

9. Bhagat VJ, Gordon RL, Osorio RW, et al. "Ureteral Obstructions and Leaks After Renal Transplantation: Outcome of Percutaneous Antegrade Ureteral Stent Placement in 44 Patients." Radiology. 1998;209(1):159–67. doi:10.1148/radiology.209.1.9769827

10. Hau HM, Tautenhahn HM, Schmelzle M, et al. "Management of Urologic Complications in Renal Transplantation: A Single-Center Experience." Transplant Proc. 2014;46(5):1332–9. doi:10.1016/j.transproceed.2014.04.002

11. Pike TW, Pandanaboyana S, Hope-Johnson T, Hostert L, Ahmad N. "Ureteric Reconstruction for the Management of Transplant Ureteric Stricture: A Decade of Experience From a Single Centre." Transpl Int. 2015;28(5):529–34. doi:10.1111/tri.12508

12. Johnsen N, Wessells H, Archer-Arroyo K, et al. "Best Practices Guidelines: Management of Genitourinary Injuries." American College of Surgeons. 2025.

13. Yang KK, Moinzadeh A, Sorcini A. "Minimally-Invasive Ureteral Reconstruction for Ureteral Complications of Kidney Transplants." Urology. 2019;126:227–231. doi:10.1016/j.urology.2019.01.002

14. Schult M, Küster J, Kliem V, et al. "Native Pyeloureterostomy After Kidney Transplantation: Experience in 48 Cases." Transpl Int. 2000;13(5):340–3. doi:10.1007/s001470050711

15. Neto HM, Tedesco Silva Junior H, Pestana JM, Foresto RD, Aguiar WF. "Urological Complications Associated With Pyeloureterostomy Without Ipsilateral Nephrectomy in Renal Transplant Recipients." Transpl Int. 2021;35:10213. doi:10.3389/ti.2021.10213

16. del Pizzo JJ, Jacobs SC, Bartlett ST, Sklar GN. "The Use of Bladder for Total Transplant Ureteral Reconstruction." J Urol. 1998;159(3):750–2; discussion 752–3.

17. Boonjindasup A, Smith A, Paramesh A, et al. "A Rationale to Use Bladder Boari Flap Reconstruction for Late Kidney Transplant Ureteral Strictures." Urology. 2016;89:144–9. doi:10.1016/j.urology.2015.10.028

18. Kroczak T, Koulack J, McGregor T. "Management of Complicated Ureteric Strictures After Renal Transplantation: Case Series of Pyelovesicostomy With Boari Flap." Transplant Proc. 2015;47(6):1850–3. doi:10.1016/j.transproceed.2015.02.020

19. Wagner M, Dieckmann KP, Klän R, Fielder U, Offermann G. "Rescue of Renal Transplants With Distal Ureteral Complications by Pyelo-Pyelostomy." J Urol. 1994;151(3):578–81. doi:10.1016/s0022-5347(17)35019-x

20. Ye J, Li Q, Liu R, et al. "Pedicled Greater Omentum Graft: A New Technique to Repair Recurrent Urinary Fistulae After Kidney Transplantation." Cell Biochem Biophys. 2012;62(1):69–72. doi:10.1007/s12013-011-9260-y

21. Heap S, Mehra S, Tavakoli A, et al. "Negative Pressure Wound Therapy Used to Heal Complex Urinary Fistula Wounds Following Renal Transplantation Into an Ileal Conduit." Am J Transplant. 2010;10(10):2370–3. doi:10.1111/j.1600-6143.2010.03237.x

22. Yang B, Ye Q, Huang C, Ding X. "Impact of Infection-Related Immunosuppressant Reduction on Kidney Transplant Outcomes: A Retrospective Study." Transpl Int. 2023;36:11802. doi:10.3389/ti.2023.11802