ENDOSCOPIC TREATMENT OF BLADDER OUTLET OBSTRUCTION IN MEN AFTER PANCREAS TRANSPLANTATION

Chapitre E - Troubles vésico-sphinctériens et diabète sucré

Diabetic neuropathy can induce multi-organ functional disease including lower urinary tract dysfunction. After a review of the various neurological lesions associated with diabetes mellitus, the authors describe the voiding disorders observed in diabetics and their specificity. These disorders, usually characterized by a large, flaccid, underactive bladder, must always be interpreted as a function of other diseases of the male or female pelvis that alter an often precarious balance. The management problems raised by this neuropathy are related to the fact that it may not be correctly diagnosed prior to a surgical procedure, for example. A better knowledge of the risk factors and natural history of diabetic bladder must therefore be promoted.

Cystoenteric Conversion and Reduction Cystoplasty for Treatment of Bladder Dysfunction After Pancreas Transplantation

PURPOSE

Bladder drainage of pancreatic exocrine secretions during pancreas transplantation can lead to significant urological complications. Our experience with cystoenteric conversion (CEC) is reviewed with respect to safety and efficacy. Select patients underwent concurrent reduction cystoplasty.

MATERIALS AND METHODS

A total of 255 pancreas transplantations were performed at the University of Washington between 1990 and 2001, of which 236 were bladder drained and 33 required enteric conversion of bladder drainage. An additional patient from an outside institution required conversion. These cases were reviewed retrospectively. Of the patients 21 with large capacity (greater than 500 ml) bladders underwent concurrent reduction cystoplasty.

RESULTS

Mean age of the 20 male and 14 female patients was 44 years (range 33 to 60) and mean interval between transplantation and CEC was 4.3 years (0.6 to 9). The most frequent indication for CEC was recurrent urinary tract infections (15 of 34 cases, 44%). Mean followup after CEC was 2.5 years (range 0.3 to 6.5). Six complications requiring reoperation were seen in 5 of the 34 patients (15%), one of which led to death (3%). Normal pancreatic graft function persisted in 30 of the 34 cases (88%). After reduction cystoplasty mean bladder capacity in all 34 cases decreased from 900 to 465 ml intraoperatively (p <0.0001) and from 650 to 362 ml in 9 according to urodynamics (p <0.015). Of the patients 30 (88%) experienced resolution of symptoms, while 3 (9%) experienced improvement and 1 (3%) continued to have recurrent infections.

CONCLUSIONS

Although we advocate maximal conservative treatment of the urological complications of pancreas transplantation, CEC offers safe and effective management of these complications, and can easily be combined with reduction cystoplasty in select cases to optimize postoperative voiding function.

Urologic aspects of kidney-pancreas transplantation

The population of pancreas transplant recipients is growing steadily, and urologists most likely will be confronted with their unique anatomy and metabolic complications. The principles of diagnosis and management of these patients can be applied to other transplant recipients (e.g., heart, lung, and liver) who also are maintained on life-long immunosuppression and in whom urologic pathology develops commensurate with the incidence in the general population.