Introduction: Despite some advances/refinements in the operative technique of kidney transplantation, urologic complications may still occur post-transplant and are associated with recurring morbidity, repeat hospitalizations, and possibly even graft failure or death.
Method: Since 2014, 707 consecutive recipients of a kidney-alone transplant at our center received the following modified ureteral reimplantation technique: bladder mobilization before the kidney transplant, a post-reperfusion check for ureteral blood flow demarcation, and ureteral trimming. Then, a 3cm oblique cystostomy on the bladder dome, exposing the bladder mucosa with detrusor layer(BMDL), was performed, using a posterior ureteral spatulation of 2cm. The heel and apex of the ureter were anchored to the BMDL at almost full thickness with 6-0polydioxanone suture(PDS). Two stay sutures with 6-0PDS were placed lateral and medial anchored to the BMDL to keep the ureter open. The ureteral anastomosis was performed in a running manner with 6-0PDS, lateral wall first and then medial wall. An anti-reflux tunnel was performed using the remaining detrusor muscle and closed with interrupted sutures of 4-0PDS. There was no initial placement of a ureteral stent. All patients were followed for a minimum of 12mo post-transplant.
Results: The percentage of patients developing a urologic complication during the first 12mo post-transplant was 2.3%(16/707). One patient with an ischemic, necrotic ureter was treated with ureteral reimplantation/stent placement. Another patient experienced a ruptured ureteral anastomosis/bladder which was treated by ureteral reimplantation/bladder closure. Two patients who developed a ureteral leak with ureteral necrosis were treated with ureteral reimplantation/stent placement. Two additional patients who developed a developed a ureteral obstruction/stricture due to fibrous tissue surrounding the ureter were treated with surgical dissection of the fibrous tissue/ureteral reimplantation/stent placement. One patient, who developed two ureteral strictures that were treated by interventional radiology(IR), was finally diagnosed as having multiple kidney stones which were occluding the distal ureter; surgical removal of the kidney stones and ureteral reimplantation was performed.  Another patient developed a ureteral stricture due to malrotation of the transplanted kidney, and two patients experienced grade 4 vesicoureteral reflux. In total, surgical repair with ureteral reimplantation was required in 1.0%(7/707) of patients. Surgical repair was required in 2 additional cases(allograft repositioning in one case; bladder augmentation in one case). The other 7 patients who developed a urologic complication were successfully treated by IR. 
Conclusions: We believe that this modified ureteral reimplantation technique clearly helped in reducing post-transplant urologic complication risk and without the need of initial ureteral stent placement.