The urological evaluation and management of patients with congenital lower urinary tract anomalies prior to renal transplantation

Long-Term Renal Transplant Outcome in Patients With Posterior Urethral Valves. Prognostic Factors Related to Bladder Dysfunction Management

Introduction: To obtain a successful renal transplant (RT) outcome in patients with posterior urethral valves (PUV), it is necessary to accomplish an adequate bladder dysfunction treatment. Our aim was to determine prognostic factors related to bladder dysfunction management in long-term RT outcome in patients with PUV. Methods: A retrospective review of patients with PUV who received a first RT after 1985 in our institution with at least 5 years of follow-up was performed. Variables analyzed included prenatal diagnosis, age of diagnosis, initial presentation and management, bladder dysfunction treatment, other surgical treatments, pre-transplant dialysis, age of transplantation, type of donor, immunosuppression regimen, vascular and urological complications, rejections episodes, and graft survival. Results: Fifty-one patients were included in the analysis. Prenatal diagnosis was done in 37.3%. Median age of diagnosis was 0.30 (0-88) months. Initial presentation was vesicoureteral reflux (VUR) in 78% and obstructive ureterohydronefrosis in 35.3%. Initial management was valve ablation (29.4%), pyelo-ureterostomy (64.7%), and vesicostomy (5.9%). In 33.3%, a type of bladder dysfunction treatment was performed: 21.6% bladder augmentation (BA), 15.7% Mitrofanoff procedure, 17.6% anticholinergic drugs, and 27.5% clean intermittent catheterization (CIC). Pre-transplant dialysis was received by 66.7%. Transplantation was performed at 6.28 ± 5.12 years, 62.7% were cadaveric and 37.3% living-donor grafts. Acute rejection episodes were found in 23.6%. Urological complications included recurrent urinary tract infections (UTIs) (31.4%); native kidneys VUR (31.4%); graft VUR (45.1%); and ureteral obstruction (2%). Vascular complications occurred in 3.9%. Mean graft survival was 11.1 ± 6.9 years. Analyzing the prognostic factor that influenced graft survival, patients with had CIC or a Mitrofanoff procedure had a significant better long-term graft survival after 10 years of follow-up (p < 0.05), despite of the existence of more recurrent UTIs in them. A better graft survival was also found in living-donor transplants (p < 0.05). No significant differences were observed in long-term graft survival regarding native kidneys or graft VUR, BA, immunosuppression regimen, or post-transplant UTIs. Conclusion: Optimal bladder dysfunction treatment, including CIC with or without a Mitrofanoff procedure, might result in better long-term graft survival in patients with PUV. These procedures were not related to a worse RT outcome in spite of being associated with more frequent UTIs.

The standard of urological consultation of patients qualified for renal transplant - a review

Urological consultation is an important step in the procedure of a patient's preparation before placing him/her on a waiting list for a renal transplant. Urological work-up aims to diagnose, treat, and optimize any preexisting urological disease. In the present paper we present the review of the literature together with the authors' conclusions based on literature and their experience. There is not enough data in current literature and urology manuals on the adequate sequence of the urological management with patients qualified for renal transplant and the literature needs an update. This study presents the crucial steps of the qualification and emphasizes the urge for a more standardized urological approach in patients qualified for a kidney transplantation.

Pre-transplant management of valve bladder: a critical literature review

OBJECTIVE

Indications, timing and problems related to augmentation cystoplasty (AC), in the context of posterior urethral valves (PUV) and renal transplantation (RT) are ill defined. Associated bladder dysfunction (BD) is not a stable condition and may cause the loss of the renal graft. Polyuria, accentuates BD and seems to improve after RT. The objective of this research is to critically review the available literature, aiming to rationalize the treatment of PUV with BD in the context of end stage renal disease (ESRD).

MATERIALS AND METHODS

A thorough literature review was performed. Pertinent papers were, critically analyzed and classified according to the level of evidence.

RESULTS

Data relating to PUV, RT and AC showed low levels of evidence. Results of RT in PUV cases with adequate management of BD were comparable to those suffering from other causes of ESRD. Bladder function can recover spontaneously after urinary undiversion. There were no established criteria to indicate AC in the context of ESRD and PUV or to define the ideal protocol to treat associated vesicoureteral reflux (VUR). Urinary tract infections (UTIs) were more frequent in transplanted PUV patients; this is possibly related to the inadequate control of BD, especially after AC. AC is feasible after RT with outcomes comparable to preemptive ones.

CONCLUSION

AC increases the risk of UTI after RT. Preemptive AC should be constructed only if the risks associated with increased bladder pressures exceed those associated with AC. Adequate management of BD is essential to improve bladder function and to minimize UTIs. AC is feasible after RT, with complication rates similar to the ones performed beforehand. Since a considerable number of PUV patients with high-pressure bladders eventually develop myogenic failure, it seems logical to postponing AC in this population, as long as they are under close surveillance.

Interventions for impaired bladders in paediatric renal transplant recipients with lower urinary tract dysfunction

Dysfunctional bladders in paediatric patients were thought to be a contraindication for renal transplantation, but advances in surgical techniques have meant that surgical correction can allow safe transplantation. This study compares the outcomes of renal transplantation for different interventions, and the timing of such interventions, in relation to transplantation. We identified all paediatric renal transplant recipients with LUTD that received intervention for their impaired bladders at two hospitals between 2002 and 2010. Outcome measures included patient and graft survival, perioperative complications, UTI incidence, acute rejection episodes and serum creatinine levels. A total of 288 allografts were transplanted, 77 were in 75 children with LUTD, of which 46 received intervention. Patient survival was 100% in the intervention group and 97% in the nonintervention group (P = 0.815). Death-censored graft survival was 96% and 100% respectively (P = 0.688). In the groups receiving intervention pretransplant or post-transplant, graft survival rates were 95% and 100% respectively (P = 0.476). The follow-up serum creatinine levels were higher in the pretransplant intervention group (P < 0.001). Interventions for dysfunctional bladders can be performed safely in paediatric renal transplant recipients. The mode of intervention and timing of intervention, in relation to transplant, do not influence outcomes if guided by careful assessment and investigation.

Low incidence of urinary tract infections following renal transplantation in children with bladder augmentation

PURPOSE

Children with end-stage renal disease and bladder dysfunction may require augmentation cystoplasty before kidney transplantation. Previous reports have suggested unacceptable urinary tract infection rates in these immunosuppressed patients. We reviewed our experience in this population.

MATERIALS AND METHODS

We retrospectively studied patients undergoing augmentation cystoplasty and subsequent renal transplantation by a single surgeon between 1989 and 2007. This cohort was compared with a control group on clean intermittent catheterization who had undergone transplantation without augmentation. Patient demographics, etiology of renal failure, surgical details, surgical/allograft outcomes and occurrence of urinary tract infection were analyzed.

RESULTS

The augmented group included 17 patients with a median age at reconstruction of 6.4 years. Stomach was used in 15 patients and colon in 2. Median time between reconstruction and transplantation was 1.2 years. Median followup after transplantation was 7.7 years. The control group included 17 patients with a median age at transplantation of 10.9 years. Median followup in the controls was 6.1 years. All ureteral reimplantations were antirefluxing. Patients on clean intermittent catheterization were maintained on oral antibiotic suppression and/or gentamicin bladder irrigations. In the augmented group 35 episodes of urinary tract infection were noted, and the number of documented infections per patient-year of followup was 0.22, compared to 32 episodes of urinary tract infection and 0.28 infections per patient-year of followup in the controls. No allograft was lost to infectious complications.

CONCLUSIONS

In our series there was no increase in urinary tract infection rate following renal transplantation in patients with augmented bladders compared to controls. This finding may be due to the use of gastric augmentation, antirefluxing reimplantation and gentamicin irrigations.

Strategies to treat children with end-stage renal dysfunction and severe lower urinary tract anomalies for receiving a kidney transplant

Dealing with children with bladder dysfunction and kidney transplant is certainly not a new issue. Nevertheless, it is still a matter of discussion and dilemma, based on few, not standardized, institutional center experiences. The authors perform a review of the techniques employed to restore the bladder condition in terms of storage and drainage of urine to receive a kidney transplant in a safer condition. Aspects of the etiology and the way of evaluation of such a group of patients are discussed. The strategies and individualized therapeutic options are presented and compared with the author's experience based upon 25 children with urinary anomalies who received 28 kidney transplants. Nevertheless, the number of complications, mainly UTI, graft and patient survival rates are equivalent to the group of children with non-urological causes of ESRD. Patients with severe lower urinary tract abnormalities and ESRD may receive a kidney transplant with comparable success.

Pediatric kidney transplantation is safe and available for patients with urological anomalies as well as those with primary renal diseases

The aim of the current study was to evaluate long-term outcomes of pediatric live kidney transplantation in patients with genitourinary anomalies relative to those with primary kidney diseases. The study included 35 pediatric patients who received a live kidney transplantation during the last 25 yr (28 males, six females). Median age at the time of transplantation was nine yr (range 1-15 yr), and the median follow-up period was 151 months (range 6-239 month). The patients were divided into two groups. The urological group (n = 14) included patients with primary obstructive/reflux nephropathy. The renal group (n = 20) included patients with primary renal disorders. Differences between groups in graft survival, clinical course, and final graft function were evaluated. Original diseases represented in the urological group included five cases with primary VUR and eight cases with secondary VUR. Diseases in the renal group included eight cases with bilateral hypo-dysplastic kidney, three cases with focal/segmental glomerular sclerosis, two cases with membranous proliferative glomerulonephritis, two cases with congenital nephrotic syndrome and five cases with other forms of chronic nephritis. Ten of 14 cases in the urological group, relative to six of 20 in the renal group, were preemptive. Median age at transplantation was 7.5 or 10 yr old, respectively, in the urological or renal group. Twelve kidney recipients in the urological group had also undergone other urinary surgeries, including upper urinary tract drainage, ureteroneocystostomy, augmentation cystoplasty, endoscopic incision of posterior-urethral valve, urethroplasty, etc. Cumulative post-operative complications occurred in nine or 16, respectively, in the urological or renal group. The acute rejection free and overall graft survival were similar in both groups. One patient in the urological group lost his graft while six patients in the renal group lost their grafts. Thus, the post-transplant clinical outcome of pediatric transplantation in patients with urological anomalies is comparable to that of recipients with primary renal disease. Appropriate urinary tract reconstruction and management is essential to reduce the risk of graft dysfunction because of urinary problems.

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.

Kidney Transplantation in Children With Augmentation Cystoplasty

PURPOSE

Treatment of children with end stage renal disease, especially those with significant bladder dysfunction, is difficult. A high pressure and low capacity bladder is a major risk factor for a transplanted kidney. Cystoplasty can protect the kidney allograft by reducing the intravesical pressure and creating an appropriate capacity. The aim of this study was to evaluate the outcome of kidney transplantation in children with and without prior cystoplasty.

MATERIALS AND METHODS

A total of 43 children with bladder dysfunction in urgent need of cystoplasty were enrolled in the study and were compared to a control group with regard to acute and chronic rejection rates, survival of the transplanted kidney, surgical complications and febrile urinary tract infection.

RESULTS

The rates of febrile urinary tract infection and chronic rejection were significantly higher in patients with prior cystoplasty (p<0.001 and p=0.004, respectively). Also, graft loss was much more frequent in these patients (34.9% vs 20.9%), although this difference was not statistically significant. In patients with prior cystoplasty graft survival rates were 92%, 73%, 58% and 45% at postoperative years 1, 3, 5 and 7, respectively. In the control group these rates were 94%, 87%, 81% and 75%, respectively (p=0.007).

CONCLUSIONS

Based on our findings, the survival rate of the kidney is significantly lower in children with prior cystoplasty, possibly due to the higher prevalence of chronic rejection and febrile urinary tract infection in this group.

Kidney transplants in patients with bladder augmentation: correlation and evolution

OBJECTIVE

To review the literature, analyse the evolution of kidney transplants (KT) in patients with bladder augmentation (BA) and investigate the relation between BA and KT.

MATERIALS AND METHODS

Six patients with a history of severe lower urinary tract dysfunction and BA, received a KT at our Unit between 1993 and 2003. Three had moderate renal failure at the moment of the BA. The remaining three had end stage renal failure.

RESULTS

With a follow-up of 7 years (mean) we have a patient survival of 100% and a graft survival of 83%. No complications occurred between the BA and the KT. The few KT complications were not related to BA.

CONCLUSION

When a bladder dysfunction is present, it should be treated before KT. In noncompliant bladders, BA is the best treatment. This can be done to try to avoid end stage renal failure or only to prepare the lower urinary tract for reception of the transplant. The presence of a BA did not worsen the evolution of the KT.

Kidney transplantation with two donor ureters in patient with previous ileogastric conduit

The purpose of our publication is to focus upon the technical aspects of a rare combination of kidney transplant with two donor ureters in a patient with neurogenic bladder and previous reconstruction of a continent ileogastric conduit.

Urological evaluation prior to renal transplantation

Renal transplantation is the best available therapy for patients with end-stage renal failure. Urologists are often consulted regarding pretransplant evaluation and treatment of potential renal transplant recipients. Frequently the urologist is the primary surgeon in the transplant unit. This review highlights the importance of performing a comprehensive urological assessment before renal transplantation. A retrospective review of the urological and transplant literature using Medline was performed from 1976 to 2002, searching for renal transplantation and its association with urological cancers and urinary tract malformations. The pretransplant urological assessment aims to diagnose, treat, and optimize any preexisting urological disease. On occasion, certain urological diseases may not be obvious or may not have contributed to the progression to end-stage renal failure such as occult urinary tract neoplasms, urinary calculus disease, or benign prostatic hyperplasia. A thorough evaluation of the urinary tract prior to renal transplantation is mandatory to avoid unforeseen problems occurring posttransplant. If this assessment is consistently adhered to, only in very rare circumstances does a potential recipient have to be denied the opportunity of receiving an allograft based on a preexisting urological disease.

Kidney transplantation in children with reconstructed bladder

There is some controversy about the safety of renal transplantation in patients with an augmentation cystoplasty because of the possibility of urinary tract infection in immunosuppressed patients leading to pyelonephritis and graft loss. Nevertheless, it is now well known that in patients with a small volume and poorly compliant bladder, reconstructive bladder surgery (augmentation cystoplasty or continent reservoir) creates a low-pressure and compliant reservoir, which protects the upper urinary tract and restores a functional lower urinary tract. Graft survival is not adversely affected when a kidney transplant is drained into a reconstructed bladder. When bowel segments are used for augmentation, a voiding modality with clean intermittent self-catheterization does not increase the risk of urinary tract infections, even in immunosuppressed patients.

Successful renal transplantation in children with spina bifida: long term single center experience

We report long-term follow up data on cadaveric renal transplantation for end stage renal failure (ESRF) in spina bifida children. Between February 1989 and July 2001, 12 cadaveric renal transplants were performed in 10 children, eight females and two males. Mean age at transplantation was 13.4 yr (range 9-16). Of the patients, eight were wheelchair bound and two were independently mobile. Before transplantation surgical management of the urological tract included, enterocystoplasty and clean intermittent-self catheterization in five patients and ileal conduit urinary diversion in one. A total of eight patients were on renal replacement therapy before receiving the graft while two underwent preemptive transplantation. The 1- and 5-yr graft survival rates were 81 and 81%, respectively. Four grafts failed--two patients have successfully undergone subsequent transplantation. Causes of graft failure were chronic rejection in two, acute rejection and vascular thrombosis in one and vascular thrombosis in one patient, respectively. Two patients died after graft nephrectomy. At a median follow-up of 4.08 yr (range 1 day to 10.65 yr), eight of the 12 grafts are functioning with median serum creatinine of 123 mmol/L (range 65-169). These data demonstrate the feasibility of cadaveric renal transplantation in patients with spina bifida and ESRF. We currently recommend that patients with spina bifida should not be deprived of the benefits of renal transplantation.

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.

Long-term results of pediatric renal transplantation into a dysfunctional lower urinary tract

BACKGROUND

The authors reviewed their long-term experience with pediatric renal transplantation into a dysfunctional lower urinary tract to evaluate the results of contemporary lower urinary tract evaluation and management on graft survival and function.

METHODS

Between 1990 and 1996, 21 renal transplants were performed in 20 children with dysfunctional lower urinary tracts and 61 transplants were performed in 61 patients with normal lower urinary tracts. The minimum follow-up was 36 months (mean, 62.0 +/- 19.6 months). The cause of lower urinary tract dysfunction included posterior urethral valves (n=13), prune belly syndrome (n=4), meningomyelocele (n=2), and urogenital sinus abnormality (n=1). Urodynamics were performed on all children with dysfunctional lower urinary tracts. Using these perioperative assessments, lower tract management strategies were devised, including timed voiding alone (n=6), clean intermittent catheterization (n=8), bladder augmentation (n=4), and supravesical urinary diversion (n=2).

RESULTS

Overall 5-year actuarial patient and graft survival rates were 100% versus 95% (P=not significant [NS]) and 83% versus 69% in the dysfunctional and normal urinary tract groups (P=NS), respectively. Mean serum creatinine levels in dysfunctional and normal urinary tract patients with functioning grafts at 3 years were 1.3 +/- 0.5 and 1.3 +/- 0.7 mg/dL, respectively (P=NS). However, 35% of patients with a dysfunctional lower urinary tract experienced urologic complications.

CONCLUSIONS

Pediatric renal transplantation into a dysfunctional lower urinary tract yields outcomes comparable to transplantation into the normal lower urinary tract. Because of the high urologic complication rates, careful surveillance of lower urinary tract function by urodynamic evaluation is essential to optimize these outcomes.

Augmentation cystoplasty in renal transplantation: a good and safe option--experience with 25 cases

OBJECTIVES

To assess the surgical and long-term results of renal transplantation in 25 patients with bladder dysfunction and augmentation cystoplasty.

METHODS

We retrospectively reviewed the evolution and surgical outcome of 25 renal transplants in 24 recipients with augmentation cystoplasty. The mean patient age at transplantation was 27.6 years. The etiology of bladder dysfunction was neurogenic bladder with detrusor hyperreflexia (11 patients), tuberculosis (5 patients), vesicoureteral reflux (4 patients), posterior urethral valves (3 patients), and interstitial cystitis (1 patient). Seventeen transplants were from living donors. Augmentation cystoplasty was performed before transplantation in 21 patients. The bowel segments used in the augmentation cystoplasty included ileum in 16, ileocecal segments in 2, and sigmoid in 5 patients. The donor ureter was anastomosed to the native bladder in 16 patients, to the bowel segment in 6, and to the native ureter in 3.

RESULTS

Twenty kidneys (80%) were functioning at a mean follow-up of 53.2 months (range 6 to 118). The mean serum creatinine was 1.56 mg/dL (range 0.7 to 2.6). Three patients died of unrelated causes and 1 of adenocarcinoma that originated at the vesicointestinal anastomosis. The actuarial graft survival at 1, 2, and 5 years was 96%, 92%, and 78%, respectively. Complications included symptomatic urinary infection, ureteral stenosis, and lymphocele.

CONCLUSIONS

Augmentation cystoplasty is a safe and effective method to restore function in noncompliant bladders. Renal transplantation can be performed safely after augmentation cystoplasty.

Kidney transplantation in children with urinary diversion or bladder augmentation

PURPOSE

Urinary tract anomalies or dysfunction leaves the bladder unsuitable for urine drainage in a significant proportion of children presenting for kidney transplantation. We reviewed a multi-institutional experience to determine the ramifications of kidney transplantation in children with bladder augmentation or urinary diversion.

MATERIALS AND METHODS

During a 28-year period 18 boys and 12 girls 1.7 to 18 years old (mean age 12.1) received 31 kidney transplants. Cause of end stage renal disease was renal dysplasia in 8 cases, posterior urethral valves in 5, obstructive uropathy in 5, neurogenic bladder/chronic pyelonephritis in 4, spina bifida/chronic pyelonephritis in 3, prune belly syndrome in 3 and reflux in 2.

RESULTS

Of the patients 17 had augmented bladder (ileum 9, ureter 5, sigmoid 2 and stomach 1), 12 had incontinent urinary conduits (8 ileum, 6 colon) and 1 had a continent urinary reservoir. Surgical complications included 1 case each of stomal stenosis, stomal prolapse, renal artery stenosis, urine leak, enterovesical fistula and wound dehiscence. Medical complications included urinary tract infection in 21 cases and metabolic acidosis in 5. A bladder stone developed in 1 patient. There was no correlation between the incidence of symptomatic urinary tract infections and type of urinary drainage. Acidosis was more common in patients with augmented bladder (4 of 17 versus 1 of 14) but there was no correlation between the bowel segment used and the occurrence of acidosis. Graft survival was 90% at 1 year, 78% at 5 years and 60% at 10 years. Etiology of graft loss included chronic rejection in 6 cases, noncompliance in 4 and acute rejection in 1. There were no deaths.

CONCLUSIONS

Drainage of transplanted kidneys into an augmented bladder or urinary conduit is an appropriate management strategy when the native bladder is unsuitable or absent. Patients with kidney transplants drained into augmented bladder or urinary conduit are at increased risk for urine infection. Graft survival is not adversely affected compared to historical controls when a kidney transplant is drained into a urinary conduit or augmented bladder.

Kidney transplantation in children with urinary diversion or bladder augmentation

PURPOSE

Urinary tract anomalies or dysfunction leaves the bladder unsuitable for urine drainage in a significant proportion of children presenting for kidney transplantation. We reviewed a multi-institutional experience to determine the ramifications of kidney transplantation in children with bladder augmentation or urinary diversion.

MATERIALS AND METHODS

During a 28-year period 18 boys and 12 girls 1.7 to 18 years old (mean age 12.1) received 31 kidney transplants. Cause of end stage renal disease was renal dysplasia in 8 cases, posterior urethral valves in 5, obstructive uropathy in 5, neurogenic bladder/chronic pyelonephritis in 4, spina bifida/chronic pyelonephritis in 3, prune belly syndrome in 3 and reflux in 2.

RESULTS

Of the patients 17 had augmented bladder (ileum 9, ureter 5, sigmoid 2 and stomach 1), 12 had incontinent urinary conduits (8 ileum, 6 colon) and 1 had a continent urinary reservoir. Surgical complications included 1 case each of stomal stenosis, stomal prolapse, renal artery stenosis, urine leak, enterovesical fistula and wound dehiscence. Medical complications included urinary tract infection in 21 cases and metabolic acidosis in 5. A bladder stone developed in 1 patient. There was no correlation between the incidence of symptomatic urinary tract infections and type of urinary drainage. Acidosis was more common in patients with augmented bladder (4 of 17 versus 1 of 14) but there was no correlation between the bowel segment used and the occurrence of acidosis. Graft survival was 90% at 1 year, 78% at 5 years and 60% at 10 years. Etiology of graft loss included chronic rejection in 6 cases, noncompliance in 4 and acute rejection in 1. There were no deaths.

CONCLUSIONS

Drainage of transplanted kidneys into an augmented bladder or urinary conduit is an appropriate management strategy when the native bladder is unsuitable or absent. Patients with kidney transplants drained into augmented bladder or urinary conduit are at increased risk for urine infection. Graft survival is not adversely affected compared to historical controls when a kidney transplant is drained into a urinary conduit or augmented bladder.

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.

Renal transplantation in children with augmentation cystoplasty: long-term results

PURPOSE

We assessed the long-term results of renal transplantation in children with augmentation cystoplasty.

MATERIALS AND METHODS

We retrospectively reviewed the complications and followup in 14 pediatric renal transplant recipients with augmentation cystoplasty. The etiology of bladder dysfunction included posterior urethral valves in 10 cases, neurogenic bladder in 3 and vesicoureteral reflux in 1. All transplants were cadaver donor kidneys. Mean patient age at transplantation was 12.1 years (range 5 to 18). Augmentation cystoplasty was performed before and after transplantation in 10 and 4 cases, respectively. Detubularized ileum was used in 5 cases, tubular ileum in 4, tubular sigmoid in 4 and stomach in 1.

RESULTS

Of the 14 transplanted kidneys 10 (71%) were functioning at a mean followup of 80 months (range 12 to 151). Serum creatinine was less than 1.4 mg./dl. in 9 patients. Four grafts were lost to chronic rejection. The 5 and 10-year graft survival rates were 84 and 73%, respectively. Two patients with a functioning kidney died of causes unrelated to augmentation cystoplasty. Complications included symptomatic urinary infections in 4 patients, hyperchloremic metabolic acidosis in 2, nephrolithiasis in the allograft in 2 and the hematuria-dysuria syndrome in 1. All patients were continent.

CONCLUSIONS

Augmentation cystoplasty is a safe and effective method of restoring lower urinary tract function in the pediatric renal transplant population with a small noncompliant bladder.

Use of small and large bowel in renal transplantation

The continued success of renal transplantation has provided a higher quality of life for properly selected patients with ESRD. It is also a much more cost-effective and efficient treatment of ESRD compared with chronic dialysis. Innovative urologic reconstructive surgery using enteric segments for both continent and incontinent urinary diversions has permitted this therapeutic modality to be offered to the recipient with lower urinary tract disease not previously amenable to renal transplantation. These same reconstructive techniques using ileal segments have also permitted preservation of renal allografts with previously nonreconstructable renal pelvic or ureteral disease.

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.

Renal transplantation using external continent urinary diversion

A 29-year-old man born with bladder exstrophy presented with end stage renal failure many years after ileal conduit diversion. Bilateral nephrectomy and continent external urinary diversion were performed, and 1.5 months later a cadaveric kidney was grafted into the right iliac fossa. The patient was well at 18 months with a serum creatinine level of 1.2 mg./dl. and he was completely dry with 4 or 5 daily catheterizations. Although followup is still short, renal transplantation with drainage into an external continent urinary diversion permits excellent quality of life and good renal function. Therefore, this alternative is worth consideration whenever other reconstructive alternatives are not possible in candidates for renal transplantation.

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 and Kock pouch: a case report

We report on a young woman with anuric, terminal renal insufficiency whose bladder could not be used for renal transplantation. A Kock pouch was implanted during stage 1 of treatment and the capacity of the pouch was increased artificially with physiological saline solution. The patient subsequently underwent renal transplantation. Results were excellent with regard to continence and ease of catheterization. No complications due to infection were observed despite immunosuppression and electrolyte disorders were minor.

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.

Renal transplantation in end stage renal disease patients with existing urinary diversion

From 1971 to 1984 renal transplantation was performed in 20 patients with end stage renal disease who presented with an existing form of urinary diversion. These patients were evaluated with a cystometrogram, voiding cystourethrogram and cystoscopy. In some cases bladder function was studied further by cycling through a suprapubically placed catheter. The bladder was considered unstable in 13 patients and undiversion was done at transplantation. The period of prior diversion ranged from 3 to 20 years (mean 12.7 years). There were no surgical complications postoperatively and normal bladder function returned in all patients. Currently, 8 patients have a functioning renal allograft 16 months to 9 years after transplantation (mean 4.2 years). Seven patients were considered to have a nonusable bladder owing to severe neurogenic disease or refractory contracture. In these patients transplantation was done into a pre-fashioned intestinal conduit (5) or cutaneous ureterostomy (2). Currently, 4 patients have a functioning renal allograft 16 months to 6.2 years after transplantation (mean 3.8 years). Transplantation candidates who present with an existing form of urinary diversion should be evaluated carefully, since many will have a usable bladder. Regardless of whether the bladder is usable, transplantation can be performed safely with no increased surgical or immunological risk.

Pediatric renal transplantation

This article outlines the current status of pediatric renal transplantation and emphasizes a practical approach to patient management. It discusses two areas of renal transplantation in children in which results differ significantly between children and adults. These areas are renal transplantation in the very young child and transplantation in children with renal failure secondary to urologic disease.

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

Eight renal transplant recipients with neurogenic bladders or lower urinary tract dysfunction were managed with clean intermittent self-catheterization after transplantation instead of urinary diversion. A total of 85 treatment months was reviewed. Of the patients 5 continue to do well after 10 to 17 months of intermittent catheterization and 3 suffered immunological graft failures. In selected renal transplant recipients with lower urinary tract dysfunction clean intermittent catheterization is a reasonable alternative to urinary diversion.

Renal transplantation using ileal conduits in 5 cases

We report our experience with 5 cases of renal transplantation into ileal conduits and review the literature. In 2 cases a modified surgical procedure was used, which combines a groin extraperitoneal approach for the vascular portion of the operation and a peritoneal window for the anastomosis between the urinary collecting system and the ileal loop. Of our 5 patients 3 are alive with functioning grafts, 1 has undergone retransplantation and 1 with a functioning kidney died of sepsis originating in a decubitus ulcer. Two patients had conduit-related complications. In our literature review of 16 reports 52 per cent of 68 patients were alive with functioning grafts and 32 per cent had conduit-related complications, usually involving urosepsis, calculous disease or stenosis. With a high index of suspicion, and an aggressive diagnostic and therapeutic approach to these problems, a good prognosis can be expected when transplantation is performed in these patients.

Intermittent clean catheterization: an alternative to diversion in continent transplant recipients with lower urinary tract dysfunction

A total of 3 renal transplant recipients who were candidates for urinary diversion underwent successful transplantation using a planned program of intermittent clean catheterization. The urinary tract dysfunction was caused by a lower motor neuron neurogenic bladder, prune belly syndrome and myelodysplasia. The patients remain dry between catheterizations and maintain serum creatinine levels of 1.1, 0.8 and 0.5 mg. per cent, respectively, with a followup of 6 to 25 months. There has been only 1 urinary tract infection during 42 patient-months at risk while on self-catheterization. Pre-transplant urologic evaluation and patient education are mandatory. The ideal candidate for intermittent clean catheterization is a patient with a low pressure bladder that fails to empty and who is continent between catheterizations. Intermittent clean catheterization is a safe and effective alternative to diversion in continent transplant recipients with lower urinary tract dysfunction.