Urologic complication rates after kidney transplantation using donor kidneys with duplicated or multiple ureters: a systematic review and meta-analysis of case series

Abstract

Abstract Background The scarcity of donor kidneys often turns anatomically variant grafts into an allocation problem, with duplicated ureters frequently declined because of concerns about ischemic vulnerability and subsequent urological complications. This systematic review and meta-analysis aimed to estimate pooled rates of urological complications in such grafts to inform acceptance and operative planning. Methods Scopus, PubMed, Europe PMC, Epistemonikos, and Web of Science were searched through June 2026. Eligible case series and cohort studies included at least five patients and reported urological outcomes after kidney transplantation using donor kidneys with duplicated or multiple ureters. Pooled prevalence was estimated using a generalized linear mixed model with binomial likelihood, and certainty of evidence was evaluated using GRADE. Results Eleven retrospective studies comprising 226 transplant recipients were included. The pooled prevalence of overall structural urological complications was 5.35% (95% CI 2.02–13.4%), with no statistical heterogeneity (I 2 = 0%). Pooled rates were 3.42% for urinary leak, fistula, or urinoma; 0.88% for ureteral stricture or obstruction; and 3.33% for urological surgical revision. Delayed graft function had a pooled prevalence of 9.38%. More recent publication year, younger recipient age, and a higher proportion of living-donor grafts were associated with lower overall complication rates. Certainty of evidence was very low. Conclusions Kidney allografts with duplicated or multiple ureters had urological complication rates broadly comparable to those reported for standard single-ureter grafts. Routine discard based solely on ureteral anatomy is not supported by the available evidence, although careful surgical technique remains essential.