Management of Incidentally Detected Urinary Tract Calculus in Patients Awaiting Living Donor Liver Transplantation: A Protocol-Based Approach.

Abstract

Background: Urinary tract calculi (UTC) in patients awaiting living donor liver transplant (LDLT) requires proper management due to increased risk of infections in the post-liver transplant (LT) period.

Materials and methods: A retrospective analysis of records of LDLT recipients with UTC was conducted between July 2019 and July 2023. No prisoners or paid participants were included.

Results: Thirty patients (25 women and 5 men) with a mean age of 44.45 ± 9.67 years, model of end stage liver disease with sodium (MELD-Na) of 20.5 ± 12.2 were diagnosed to have a UTC during pre-LT evaluation. Twenty-five patients had renal stones, whereas five patients had ureteric calculus (22 were unilateral and 8 were bilateral calculi). Fifteen patients underwent double J (DJ)-stenting prior to LT. The mean stone size in patients who underwent DJ stenting was 13.6 (±9.83) mm vs 4.78 (±5.3) mm in whom stenting was not done. Patients with preoperative DJ stenting had a significantly reduced hospital stay (18.5 ± 2.1 days), lower mortality rates (0%), and lower rates of hematuria (6.66%) vs (23.4 ± 12.8 days, 13.33% and 13.3%, respectively). Patients with preoperative DJ stenting underwent post-transplant definitive procedure for UTC without any complications. Our Protocol for Incidentally Detected Ureteric Stones in LT Recipients: a. Proximal-ureteric calculi: Preoperative DJ stenting (2-3 days prior/ on day of LT) → LT → ESWL/URS 2-3 weeks later → DJ stent removal after 2-3 weeks. b. Distal-ureteric calculi: Preoperative DJ stenting ± URS (2-3 days prior/ day of LT) → LT → DJ stent removal after 2-3 weeks. Our protocol for incidentally detected renal stones in LT recipients: a. Stone size (< 5 mm) and nonobstructive calculi with no active UTI: No surgical intervention → Liver transplant under antibiotics cover → medical management of stone. b. Multiple calculi sized < 5 mm or single stone 5-10 mm: DJ stent placement → LT → ESWL/RIRS after 4-6 weeks → DJ stent removal after 3 weeks. c. Single stone size > 10 mm or multiple calculi > 5 mm: DJ stent placement → LT → RIRS/PCNL after 4-6 weeks→DJ stent removal after 3-4 weeks.

Conclusion: A systemic minimally invasive approach is needed for pre-LT management of UTC for better patient outcomes.