Is pyeloureterostomy with native ureter ligation a safe first-line option in pediatric kidney transplantation?

Urological complications remain a significant cause of morbidity in pediatric kidney transplantation (KT). While ureteroneocystostomy (UNC) according to Lich-Gregoir is the standard technique for urinary reconstruction, pyeloureterostomy (PU) with native ureter ligation has emerged as a potential alternative, though its role as a first-line approach is still debated.

We retrospectively reviewed all pediatric KTs performed in two university hospitals between January 2013 and January 2023. Patients with documented vesicoureteral reflux were excluded. Two groups were compared according to the urinary reconstruction technique: PU with native ureter ligation versus UNC. Data collected included patient demographics, perioperative characteristics, postoperative complications, renal function, pain management, and 2-year graft survival.

A total of 74 patients were analyzed (26 PU; 48 UNC). Baseline characteristics were comparable between groups. Two-year graft survival was similar (PU: 90% vs. UNC: 89%). Renal function, assessed by glomerular filtration rate (GFR) at follow-up, showed no significant difference. The overall rate of major urological complications requiring surgical revision was comparable (PU: 11% vs. UNC: 10%). PU was associated with a higher incidence of transient graft pelvic dilatation (27% vs. 0%), which spontaneously regressed in most cases, while symptomatic vesicoureteral reflux occurred only in the UNC group (6.2%). Ligation of the native ureter did not result in specific morbidity or increased pain.

First-line PU with ligation of the native ureter is a safe and effective alternative to UNC in pediatric KT. It avoids bladder dissection, preserves better vascularization of the donor ureter, and facilitates endourological procedures, without increasing complication rates. Prospective multicenter studies with longer follow-up are warranted to confirm long-term outcomes and better define optimal surgical strategies.