Long-term clean intermittent self-catheterization in renal transplant recipients

Safety of augmentation cystoplasty in patients with bladder abnormalities undergoing renal transplantation: a systematic review

BACKGROUND Augmentation cystoplasty (AC) has been recently proposed to improve a bladder condition before or after a renal transplantation for an optimal allograft function. Until now, AC in adults with end-stage renal disease (ESRD) is uncommon and rarely practiced. This study aimed to investigate the safety of AC in patients with bladder abnormalities who required renal transplantation. METHODS Studies of patients with ESRD and abnormal bladder who underwent AC were searched in ProQuest, PubMed, EBSCO, and Cochrane Library online databases. Only studies published in English from January 1985 to May 2020 were included. The keywords used were renal transplantation, bladder dysfunction, cystoplasty, and their synonyms. Data were extracted by two independent authors who selected, screened, and assessed the articles’ eligibility and quality. The outcomes were graft survival rate and complications of AC. RESULTS A total of 19 articles were included. AC improved an intravesical pressure, a bladder capacity, and a compliance in patients with ESRD and bladder abnormalities, allowing patients to undergo the renal transplantation. Even though AC in patients with renal transplantation resulted in a significantly higher urinary tract infection rate than patients who underwent renal transplantation only, performing AC after renal transplantation was considered safe. CONCLUSIONS AC was considered safe for patients with bladder abnormalities who underwent renal transplantation.

Kidney transplantation in abnormal bladder

Structural urologic abnormalities resulting in dysfunctional lower urinary tract leading to end stage renal disease may constitute 15% patients in the adult population and up to 20-30% in the pediatric population. A patient with an abnormal bladder, who is approaching end stage renal disease, needs careful evaluation of the lower urinary tract to plan the most satisfactory technical approach to the transplant procedure. Past experience of different authors can give an insight into the management and outcome of these patients. This review revisits the current literature available on transplantation in abnormal bladder and summarizes the clinical approach towards handling this group of difficult transplant patients. We add on our experience as we discuss the various issues. The outcome of renal transplant in abnormal bladder is not adversely affected when done in a reconstructed bladder. Correct preoperative evaluation, certain technical modification during transplant and postoperative care is mandatory to avoid complications. Knowledge of the abnormal bladder should allow successful transplantation with good outcome.

TERMINAL LOOP CUTANEOUS URETEROSTOMY IN RENAL TRANSPLANTATION: AN UNDER UTILIZED URINARY DIVERSION TECHNIQUE

PURPOSE

We evaluated the effectiveness of terminal loop cutaneous ureterostomy as a means of urinary drainage in kidney transplant recipients during a 20-year period.

MATERIALS AND METHODS

Five cadaveric and 2 living related patients underwent kidney transplantation with terminal loop cutaneous ureterostomy between 1984 and 2004. These patients had no usable bladder or they were not suitable candidates for intermittent catheterization.

RESULTS

Followup was 20 months to 17 years. One patient underwent stomal revision 5 months after renal transplantation. Current serum creatinine 4 years later was 166 mumol/l. The remaining 6 patients had no evidence of ureteral obstruction and rarely had bacteriuria or urinary tract infections. Four patients had a functioning allograft with normal serum creatinine. One patient died with a normally functioning allograft and the remaining patient lost his graft due to chronic rejection. No patient in this series lost the graft due to a urological cause. Overall outcomes included excellent allograft function with minimal infection or stomal stenotic complications.

CONCLUSIONS

Terminal loop cutaneous ureterostomy is a simple, safe and alternative means of urinary diversion in patients with renal transplant and a defunctionalized lower urinary tract.

RENAL TRANSPLANTATION IN CHILDREN WITH RECONSTRUCTED BLADDERS

In this article, we review the outcome and complications of renal transplantation in patients with reconstructed bladders and address specific issues and controversies regarding the management of such cases. Twenty-five articles covering the subjects of renal transplantation, lower urinary tract anomalies, and bladder reconstruction have been selected. Although urologic complications are higher when kidneys are transplanted into reconstructed bladders or urinary diversions, the graft and patient survival rates in most series are comparable with those transplanted into nonreconstructed bladders. The reported series of renal transplantation into abnormal bladders are small, and controlled studies are lacking. Bladder reconstruction should be performed before transplantation when clinically indicated.

Renal transplantation in patients with an augmentation cystoplasty

OBJECTIVE

To retrospectively review our experience over a 10-year period of renal transplantation in patients with augmented bladders and thus assess the safety of this procedure.

PATIENTS AND METHODS

Ten transplant recipients who had previously undergone augmentation cystoplasty were reviewed; a cadaveric kidney was transplant in each case. The donor ureter was anastomosed to the augment bladder in six patients, in three to the native ureter and in one the donor renal pelvis was anastomosed to the native ureter.

RESULTS

No patients died and nine of the 10 grafts were functioning at a mean follow-up of 27 months. The mean (SD) serum creatinine level at the follow-up was 100.8 (27.25) mmol/L. Four patients had 10 episodes of urosepsis requiring hospital admission, with only one graft lost.

CONCLUSION

Renal transplantation can be performed safely in patients with an augmentation cystoplasty.

Kidney transplantation in patients with neurovesical dysfunction

BACKGROUND

Five renal recipients with neurovesical dysfunction (NVD) were retrospectively reviewed focusing on anatomical and urodynamic abnormalities of the lower urinary tract and their management prior to kidney transplantation.

METHODS

The underlying anomalies in these 5 patients were a posterior urethral valve (1 with an imperforate anus; n = 2), meningomyelocele (n = 2) and a congenital short urethra with an imperforate anus (n = 1). Their urinary tracts were evaluated prior to transplantation with voiding cystourethrography, urethrocystoscopy, cystometrography and electromyography of the external urethral sphincter to identify a possible focus of urinary tract infection, urine storage and voiding function.

RESULTS

All 5 patients had NVD proven by urodynamic studies or by documentation of urinary retention in the absence of mechanical outlet obstruction. Bilateral high grade vesicoureteral reflux was noted in all patients, requiring ureteroneocystostomy. Clean intermittent catheterization (CIC) was ultimately employed for bladder emptying in all patients. Two patients with poor bladder compliance underwent augmentation cystoplasty before transplantation. The Mitrofanoff procedure was used in 2 patients with structural urethral abnormalities to access the bladder for catheterization. After eradication of possible sources of infection and establishment of a low-pressure urine storage system with bladder emptying by CIC, kidney transplantation was performed. Following kidney transplantation, all of the recipients were asymptomatic for urinary tract infections using CIC. Although 1 patient lost his graft due to chronic rejection, the other 4 other patients have good renal function.

CONCLUSION

Kidney transplantation in patients with NVD can be performed provided that their urinary tract problems are properly resolved.

Evaluation of voiding cystourethrography prior to renal transplantation

In many centers, voiding cystourethrography is a routine part of pretransplantation assessment of the lower urinary tract. To assess the value of this investigation, a retrospective review of transplant candidates evaluated in our center over 2 years was undertaken. A total of 517 patients were fully evaluable. Only 13 voiding cystourethrograms (VCUGs) (2.5%) of 517 were found to be abnormal. Three patients with reflux alone did not require intervention before transplantation. Four patients with decreased bladder capacity underwent hydrodistention. Two patients increased their capacity to over 150 ml and two patients failed distention, one requiring an ileal conduit and the other requiring an augmentation cystoplasty. Three patients had increased postvoid residual (PVR). Two patients started clean intermittent catheterization. One required prostate resection for benign prostatic hypertrophy. One patient with reflux and decreased bladder capacity refused treatment. One patient with reflux combined with increased PVR started clean intermittent catheterization and was cleared for transplant surgery. One patient with decreased bladder capacity and increased PVR had a stroke and was excluded from transplantation. All 13 patients with abnormal VCUGs had a prior urologic history. In total, only 56 of 517 patients evaluated had a prior urological history. Each VCUG costs approximately $500. Limiting VCUG studies to those patients with a prior urological history would have resulted in a significant cost savings. Hence, we recommend that only patients with a prior urological history should undergo this costly and often distressing examination.

Urinary tract reconstruction in children undergoing renal transplantation

In children, congenital urinary tract anomalies contribute to end-stage renal disease in 20% to 30% of cases. As more and more children with myelomeningocele, posterior urethral valves, prune belly syndrome, and other serious congenital anomalies of the urinary tract survive early infancy, more of these patients will be in need of renal transplantation. Of these, a significant proportion will have persisting abnormal anatomic and physiological characteristics of the urinary tract requiring reconstructive surgery before transplantation. Before undertaking these procedures, urologic evaluation should be performed in all such children. Comprehensive evaluation includes a careful history and physical examination with radiological imaging of the urinary tract (renal ultrasonography and voiding cystourethrography). In selected instances, further evaluation of bladder function and urethral anatomy may require urodynamic evaluation or cystourethroscopy. The goal of these investigations is to ensure that the bladder will hold urine at a low intravesical pressure during the storage phase and that it can be evacuated with certainty. This presentation focuses on the pretransplantation evaluation and the various possible urinary tract reconstructions that may be performed in children destined for renal transplantation.

Renal transplantation into the dysfunctional bladder: the role of adjunctive bladder reconstruction

A retrospective review of pediatric renal transplantation at 3 centers identified 9 patients who had undergone major bladder reconstruction. Seven patients underwent bladder augmentation (5 gastric, 1 colonic, 1 ureteral) and 2 received gastric neobladders. Six patients required Mitrofanoff neourethras. Patient survival was 100% with initial graft survival of 56% during a mean followup of 29.4 months. Eight patients (89%) are presently dialysis-free with functioning allografts and all 9 (100%) are continent of urine. We conclude that renal transplantation and reconstruction to ensure continence are justifiable in even the most anatomically compromised children with end stage renal disease. It is essential that the pediatric urologist should have an integral role in the management of such cases.

Long-term outcome in renal transplantation with terminal cutaneous ureterostomy

We have reviewed the complications and follow-up in 6 patients who underwent kidney transplantation with cutaneous ureterostomy. Four patients had tuberculosis, 1 myelomeningocele and another congenital stenosis of the posterior urethra. Cutaneous ureterostomy was performed by suturing the edges of the distal end of the ureter to the skin. The mean follow-up was 40.6 months (range 2-105). The patient and graft survival rates were 83.3% and 66.6% respectively during the 249 months of total follow-up. Significant bacteriuria and leukocyturia were constantly present and the incidence of urinary infection was 3.1 episodes/patient/year. The early complications of the stoma were partial necrosis in 1 case and haematoma in another. The most frequent late complication was stomal stenosis requiring periodic dilatation. A plasma creatinine of 61.88 to 114.92 mumol/l reflected good long-term graft function in the remaining patients. Terminal cutaneous ureterostomy is a simple technique with good long-term results.

Enterocystoplasty in renal transplantation candidates: urodynamic evaluation and outcome

In anticipation of renal transplantation 11 patients with end stage renal disease and small volume, poorly compliant bladders underwent enterocystoplasty. The etiology of bladder dysfunction included myelodysplasia in 4 patients, posterior urethral valves in 4 and vesicoureteral reflux in 3. Mean patient age at the time of bladder augmentation was 16.4 years (range 10 to 28). Detubularized bowel segments were used in all patients and included ileum in 7, ileocecal segment in 3 and sigmoid in 1. Urodynamic evaluation before and after enterocystoplasty demonstrated marked improvement in bladder capacity and compliance. These 11 patients have received 13 renal transplants with an 85% graft survival at a mean followup of 30.1 months. No bladder ruptures or other perioperative complications have occurred. All patients remain continent on clean intermittent catheterization. Our experience suggests that enterocystoplasty is a safe and effective method of restoring lower urinary tract function in the patient with end stage renal disease and a small, noncompliant bladder.

Clean intermittent catheterization and urinary diversion in the management of renal transplant recipients with lower urinary tract dysfunction

Renal transplant recipients with lower urinary tract dysfunction may be managed by urinary diversion or clean intermittent catheterization. To evaluate the comparative problems associated with each mode of therapy we studied 13 patients managed by clean intermittent catheterization (group 1, 6 patients) or urinary diversion (group 2, 7 patients). All 6 and 2 of 7 recipients in groups 1 and 2, respectively, had a neuropathic bladder. Mean followup was 3.7 +/- 1.5 (group 1) and 5.7 +/- 4.9 (group 2) years. Three allografts were lost in group 2 due to rejection (2) and death (1). Two patients each in groups 1 and 2 had febrile urinary tract infections requiring hospitalization and intravenous antibiotics. Complications related to urinary diversion developed in 4 patients in group 2. The serum creatinine at 1 and 3 years, number of hospital days per patient, total number of rejection episodes and number of patients employed in a full-time job following transplantation were similar in both groups. In summary, clean intermittent catheterization appears to have more morbidity in immunosuppressed transplant versus nontransplant patients but it may be preferable in renal transplant recipients due to the overall simplicity, positive psychological effect and comparable morbidity to other forms of management.

Outcome of renal transplantation after urinary diversion and enterocystoplasty: a retrospective, controlled study

A total of 17 patients with intestinal urinary diversion of enterocystoplasty underwent renal transplantation between 1970 and 1988. Patient age ranged from 4 to 35 years (mean age 20 years). The patients were divided into 2 groups. In group 1 (10 patients, 2 of whom required retransplantation) the ureter of the transplanted kidney was implanted into an ileal (7) or colonic (1) conduit or enterocystoplasty (2). In group 2 (7 patients, 1 of whom required a second transplant) the diversion was taken down and the transplanted ureter was implanted into the defunctionalized bladder. There were 14 living related and 6 cadaveric kidneys transplanted. Graft survival rates were 58 and 87% in groups 1 and 2, respectively, with an over-all rate of 70% (14 of 20 kidneys). There was no statistical difference in the graft survival rate between the 2 groups. The complications in group 1 included ureteroileal anastomotic leak (3 patients), ureteroileal stenosis (1), calculus formation (1), urosepsis (1), hyperchloremic metabolic acidosis (1), and wound infection and dehiscence (1). There were no complications in group 2. Renal transplantation into a pre-existing urinary intestinal conduit or augmented bladder does not statistically adversely affect patient or graft survival. However, the complication rate is much higher when the ureter is implanted into an intestinal segment. Therefore, it is preferable whenever possible to implant the ureter into the native bladder.

Renal transplantation into the reconstructed bladder

In our experience with 821 renal transplants performed between 1974 and October 1987 we used the native or reconstructed bladder of the patient in all but 2 instances. Seven patients have undergone enterocystoplasty and subsequent renal transplantation, while 1 underwent bladder augmentation after transplantation. Of these 8 patients 4 have functioning grafts 6 months to 7 years after transplant or reconstruction. Renal transplantation coupled with enterocystoplasty in properly selected patients has acceptable morbidity and should be considered as an alternative to other forms of urinary diversion in allograft recipients.

Ileocecocystoplasty bladder augmentation and renal transplantation

In 4 patients with a small contracted bladder and end stage renal failure ileocecocystoplasty bladder augmentation was done in conjunction with renal transplantation. All 4 patients have stable renal and bladder function 13 to 46 months after transplantation. In carefully selected patients bladder augmentation may be an alternative to urinary diversion.