Intestinal reconstruction of the lower urinary tract as a prerequisite for renal transplantation

Multicenter evaluation of complex urinary diversion for renal transplantation: outcomes of complex surgical solutions

PURPOSE

An abnormal lower urinary tract poses significant challenges for transplant surgeons. Besides the ureteral anastomosis to an ileal conduit, there are diverse complex reconstructive solutions. Due to its rarity, standardization and teaching of complex urinary diversion is extremely difficult.

METHODS

The indications and outcomes of complex urinary diversions after kidney transplantation (KT) were retrospectively investigated at eight urologic transplant centers including a current follow-up.

RESULTS

Of 37 patients with 21 (56%) males, vesicoureteral reflux (24%), spina bifida (22%), and glomerulonephritis (12%) were the most common causes of terminal renal failure. In 30 (81%) patients, urinary diversion was performed before KT, at a median of 107.5 (range, 10; 545) months before. Transplantations were held at a median patient age of 43 (10; 68) years, including six (16%) living donations. Urinary diversion was modified during 12 (32%) transplantations. After KT, the ileal conduit was the most common incontinent urinary diversion in 25 (67%) patients; a Mainz pouch I and bladder augmentation were the most frequent continent diversions (each n = 3). At a median follow-up of 120 months (range 0; 444), 12 (32%) patients had a graft failure with a 5-year graft survival of 79% (95%CI 61; 90). The median overall survival was 227 months (168; 286) and the 5-year overall survival 89% (69.3; 96.4).

CONCLUSION

The mid-term kidney transplant function with complex urinary diversion appears to be comparable to transplants with regular urinary diversions. Hence, complex urinary diversion should always be considered as a surgical option, even during transplantation, if necessary.

Kidney Transplantation After Multiple Urinary Tract Conversion with an Ileal Conduit: A Case Report

BACKGROUND

Kidney transplantation (KTx) after urinary tract conversion surgery is extremely difficult due to several complications. In our case, KTx was performed after multiple operative procedures, including diversion urethrostomy.

CASE REPORT

The patient was a 46-year-old woman with a right atrophic kidney, an ectopic opening of the left ureter, and urethral dysplasia since birth. The patient underwent a right nephrectomy, left ureteral sigmoidostomy, Stamey surgery, augmentation ileocystoplasty, and left ureteroileostomy. Thereafter, she underwent nephrostomy, ileal conduit diversion, open sigmoid colectomy, and total cystectomy because of persistent urinary incontinence, sigmoid colon cancer, and recurrent cystitis. Her renal function gradually deteriorated, and hemodialysis was initiated. Before the KTx, she underwent laparoscopic left nephrectomy, an intraperitoneal adhesion debridement, and left ileal conduit resection. We dissected the left ileal conduit in the abdominal cavity and penetrated the anorectal side of the free ileal conduit into the wall of the right side of the abdomen. Thereafter, a kidney from a living donor was transplanted into the right iliac fossa through the existing right ileal conduit when the patient was 46 years old. The allograft function was stable without rejection for 2 years.

CONCLUSIONS

We report the case of a patient who underwent multiple urethral modifications followed by ileal conduit transfer and living donor KTx, which progressed without major postoperative complications.

Timing of reconstruction of the lower urinary tract in pediatric kidney transplant recipients: A CERTAIN multicenter analysis of current practice

BACKGROUND

Preexistent LUTD are considered a hostile environment, which might negatively impact KTx survival. In such cases, surgical reconstruction of the bladder is required. However, there is still disagreement on the optimal timing of the reconstruction procedure.

METHODS

This is a multicenter analysis of data from the CERTAIN Registry. Included were 62 children aged 8.18 ± 4.90 years, with LUTD. Study endpoints were the duration of initial posttransplant hospitalization, febrile UTIs, and a composite failure endpoint comprising decline of eGFR, graft loss, or death up to 5 years posttransplant. Outcome was compared to matched controls without bladder dysfunction.

RESULTS

Forty-one patients (66.1%) underwent pretransplant and 14 patients (22.6%) posttransplant reconstruction. Bladder augmentation was performed more frequently in the pretransplant (61%) than in the posttransplant group (21%, p = .013). Outcome in the pre- and posttransplant groups and in the subgroups of patients on pretransplant PD with major bladder surgery either pre- (n = 14) or posttransplant (n = 7) was comparable. Outcomes of the main study cohort and the matched control cohort (n = 119) were comparable during the first 4 years posttransplant; at year 5, there were more events of transplant dysfunction in the study cohort with LUTD than in controls (p = .03).

CONCLUSIONS

This multicenter analysis of the current practice of LUTD reconstruction in pediatric KTx recipients shows that pre- or posttransplant surgical reconstruction of the lower urinary tract is associated with a comparable 5-year outcome.

Surgical Challenge in Pediatric Kidney Transplant: Lower Urinary Tract Abnormality

Lower urinary tract abnormalities are difficult to resolve in pediatric kidney transplant patients. Measure of residual urine, voiding cystourethrography, retrograde urethrography, cystometry, electromyography of urethral external sphincter muscle, urethrometry, and uroflowmetry are the primary methods for evaluation of lower urinary tract abnormalities. Endoscopic resection or ablation of urethral valves is required in children with posterior urethral valve to treat obstruction, but bladder function does not always recover and may deteriorate to end-stage renal failure even after the obstruction is released. This bladder dysfunction in posterior urethral valve defines valve bladder syndrome. Vesicoureteral reflux caused by high vesical pressure can cause even worse renal graft function posttransplant. In our patient group, urinary diversion occurred with Mitrofanoff conduit using an appendix in 6 children, a Yang-Monti channel conduit using ileum in 1 patient, with cystostomy in 3 children, and with augmented cystoplasty in 9 children before or simultaneously with kidney transplant. These procedures should be selected based on the type of lower urinary tract abnormality including bladder function. Recently, we have preferred a continent diversion for self-catheterization in children with lower urinary tract abnormalities. We have conducted 9 augmented cystoplasty procedures using a portion of the sigmoid colon or ileum. Seventeen children retained their own bladders when the transplant ureter was implanted. Most patients needed clean intermittent catheterization, depending on the residual urine volume and a bladder function. Ten-year graft survival rate in kidney transplant in our department is 98% in 36 children with lower urinary tract abnormalities. Lower urinary tract abnormality is not always a risk factor for pediatric kidney transplant; however, a preoperative evaluation is important to choose the best option for urinary diversion.

Living-related kidney transplantation with catheterizable urinary conduit in prune belly syndrome: A case report

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Rare case of kidney transplantation with urinary diversion in PBS patients.

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Catheterizable urinary conduit using loop ureterostomy, not appendix or ileum.

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Folding procedure was performed to avoid ureteral stenosis and VUR.

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V-quadrilateral-Z flap technique was used to prevent conduit stenosis.

Introduction

Prune belly syndrome (PBS) presents with both renal dysplasia and urinary tract abnormalities. When performing kidney transplantation in PBS patients with kidney failure, extensive pretransplant urinary tract preparation may be necessary.

Presentation of Case

We report the case of a 36-year-old man with PBS who underwent living-related kidney transplantation with urinary diversion using the Mitrofanoff principle. The patient had a bilateral loop ureterostomy for a urethral obstruction. Cystourethrography before the operation showed tortuous and dilated ureters with vesicoureteral reflux (VUR), and complete occlusion of the urethra. Before transplantation, we created a catheterizable urinary conduit with the patient’s own malformed left ureter in accordance with the Mitrofanoff principle. The folding procedure was selected for ureteroplasty to preserve good blood supply. Extravesical detrusorrhaphy was performed as an antireflux procedure. V-quadrilateral-Z ureterostomy for catheterization was performed. Then, we performed living-related kidney transplantation from the patient’s mother. Postoperative cystourethrography did not show left VUR. The patient performed clean intermittent self-catheterization without complications, and had good graft function.

Discussion

The appendix and ileum are currently the most commonly used options for urinary conduits based on the Mitrofanoff principle. However, the patient had complications of diarrhoea and constipation, so we used the patient’s own malformed ureter. We performed a folding procedure to avoid ureteral stenosis and VUR, and used the V-quadrilateral-Z flap technique to avoid stoma stenosis

Conclusion

When performing kidney transplantation in patients with PBS, urinary tract anomalies should be thoroughly evaluated. Our surgical procedure will help to reduce complications after kidney transplantation.

Urinary Diversion in Renal Transplantation

Renal transplantation involving anatomically or functionally altered recipient urinary reservoirs is a challenging procedure. Initial reports discouraged kidney transplantation in patients with urinary diversion due to inferior outcomes. However, more recent studies have shown that although there are more infectious complications, patients with urinary diversions have comparable long-term graft survival with those with native anatomy. Careful preoperative assessment of these candidates is mandatory. Unique technical and surgical concepts must be considered before embarking on transplanting this specific cohort of kidney transplantation candidates.

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.

Long-term outcome of simultaneous or staged urinary diversion and kidney transplantation

OBJECTIVES

We retrospectively analyzed the long-term outcomes of simultaneous or staged urinary diversion and kidney transplantation.

PATIENTS AND METHODS

Between June 2001 and December 2012, 4 patients with dysfunctional bladder resulting from spina bifida (n = 3) or bladder contraction following urologic tuberculosis (n = 1) underwent cadaveric kidney transplantation and urinary diversion simultaneously (n = 3) or 6 months post-transplantation (n = 1). Urinary diversion consisted of cutaneous ureterostomy in 1 patient and ileal conduits in 3 patients. All patients were followed prospectively.

RESULTS

All 4 patients received deceased donor transplants. Median follow-up was 110.5 months (range 50-120). At the last follow-up, serum creatinine levels ranged from 1.1 to 1.8 mg/dl. One patient with a functioning graft died of severe cirrhosis 105 months following transplantation. Graft function remained stable without any severe complications in 3 patients. Hematoma (Clavien-Dindo grade IIIa) and urinary leakage (grade II) occurred in 1 patient in the early postoperative period, but no surgical revision was required. Two patients developed cytomegalovirus pneumonia. Urinary tract infection was a common problem in all patients.

CONCLUSIONS

For patients with lower urinary tract dysfunction, simultaneous kidney transplantation and urinary diversion with an ileal conduit may be a safe, feasible approach, with a satisfactory long-term outcome.

Urological complications and vesicoureteral reflux following pediatric kidney transplantation

PURPOSE

Ureteral complications of renal transplantation can dramatically impact renal outcomes. We studied whether complications are associated with preexisting genitourinary pathology or transplant using a deceased donor allograft.

MATERIALS AND METHODS

We retrospectively reviewed all patients undergoing renal transplantation at our institution between 2000 and 2010. We abstracted patient demographic details, donor type (living vs deceased), end-stage renal disease etiology, reimplant technique, stent use, preoperative and postoperative imaging, history of lower genitourinary pathology and postoperative complication management.

RESULTS

A total of 211 kidneys were transplanted into 206 patients (mean age 13.7 years, mean followup 4.6 years). Most patients (89%) underwent extravesical ureteroneocystostomy without stenting (97%), with roughly half (47%) of transplants being from living donors. Preexisting urological pathology was present in 34% of cases. Postoperative obstruction or extravasation occurred in 16 cases (7.6%), of which 15 were acute. Complications were not associated with donor type, preexisting urological pathology other than posterior urethral valves, surgical technique, etiology of end-stage renal disease or patient age. However, posterior urethral valves or other preexisting genitourinary pathology was not associated with an increased likelihood of genitourinary complications. Posterior urethral valves were associated with development of postoperative vesicoureteral reflux (OR 6.7, p = 0.004) but were not associated with stent placement, surgical technique, donor type or etiology of end-stage renal disease.

CONCLUSIONS

Patients with posterior urethral valves undergoing renal transplantation are at increased risk for postoperative vesicoureteral reflux but not for other acute surgical complications. There is no association between donor type, etiology of end-stage renal disease, surgical technique or patient age and increased complications.

Bladder augmentation and continent urinary diversion in boys with posterior urethral valves

Posterior urethral valve (PUV) is a condition that leads to characteristic changes in the bladder and upper urinary tract. Dysfunction of the bladder such as a hyperreflective, hypertonic, and small capacity bladder as well as sphincter incompetence and/or myogenic failure should be adequately treated. Poor compliance/small bladder could be treated with anticholinergics, but bladder augmentation will probably be indicated. Although bladder reconstruction with gastrointestinal segments can be associated with multiple complications, including metabolic disorders, calculus formation, mucus production, enteric fistulas, and malignancy formation, enterocystoplasty is still the gold standard. In contrast to a neuropathic or exstrophic bladder, augmentation of the valve bladder allows spontaneous voiding without significant residual urine in the majority of cases, but some require CIC (clean intermittent cathterization). Augmentation cystoplasty is also an efficient approach in those children who will require kidney transplantation in the future.

A single-center experience with kidney transplantation in the verteberal, anal, cardiac, tracheoesophageal, renal, and limb birth detects (VACTERL) association

VACTERL association is a nonrandom association of birth defects in vertebral, anal, cardiac, tracheoesophageal, renal, and limb structures. Renal anomalies are observed in ∼60%-90% of VACTERL patients. We present 3 cases to demonstrate the clinical and surgical challenges that these patients present for renal transplantation. One pediatric and 2 adult patients with the VACTERL association were transplanted at a single center; their follow-up times were 6 years, 4 years, and 3 months. Only 1 of them had a suitable native bladder to receive the kidney graft; the other 2 required bladder augmentation, 1 of which was performed after the loss of the first graft. None of these patients had an uneventful posttransplantation course. Two patients had acute rejection episodes, and 2 had reoperations for urologic complications. One patient needed a surgical intervention owing to a sigmoid prolapse. All 3 grafts worked at last examination. The 2 patients with bladder reconstructions and longer follow-ups suffered recurrent pulmonary and urinary infections and had been hospitalized several times during each posttransplantation year. In conclusion, multiorgan involvement in VACTERL patients greatly complicates medical care after transplantation; urinary tract reconstruction seems to be essential before transplantation.

CKD and bladder problems in children

Approximately 35% of children with CKD who require renal replacement therapy have a significant urological abnormality, including posterior urethral valves, a neuropathic bladder, prune belly syndrome, Hinman syndrome, or severe vesicoureteral reflux. In such children, abnormal bladder function can have a significant deleterious effect on the renal function. In children with bladder outlet obstruction, bladder compliance and capacity often are abnormal, and a sustained intravesical pressure of >40 cm H(2)O impedes drainage from the upper urinary tract. Consequently, in these conditions, regular evaluation with renal sonography, urodynamics, urine culture, and serum chemistry needs to be performed. Pediatric urological care needs to be coordinated with pediatric nephrologists. Many boys with posterior urethral valves have severe polyuria, resulting in chronic bladder overdistension, which is termed as valve bladder. In addition to behavioral modification during the day, such patients may benefit from overnight continuous bladder drainage, which has been shown to reduce hydronephrosis and stabilize or improve renal function in most cases. In children with a neuropathic bladder, detrusor-sphincter-dyssynergia is the most likely cause for upper tract deterioration due to secondary vesicoureteral reflux, hydronephrosis, and recurrent urinary tract infection (UTI). Pharmacologic bladder management and frequent intermittent catheterization are necessary. In some cases, augmentation cystoplasty is recommended; however, this procedure has many long-term risks, including UTI, metabolic acidosis, bladder calculi, spontaneous perforation, and malignancy. Nearly half of children with prune belly syndrome require renal replacement therapy. Hinman syndrome is a rare condition with severe detrusor-sphincter discoordination that results in urinary incontinence, encopresis, poor bladder emptying, and UTI, often resulting in renal impairment. Children undergoing evaluation for renal transplantation need a thorough evaluation of the lower urinary tract, mostly including a voiding cystourethrogram and urodynamic studies.

Evaluation of video-urodynamic studies before renal transplantation in chronic renal failure patients

OBJECTIVES

To evaluate the role of video-urodynamic examination prior to renal transplantation.

METHODS

Sixty-four kidney transplant recipients were included into the study. All patients underwent video-urodynamic examination and separate uroflowmetry. Results were evaluated based on daily mean amount of urine, duration of chronic renal failure and presence of diabetes mellitus.

RESULTS

Thirty-five (54.6%) patients showed video-urodynamic abnormalities. The mean detrusor capacity was 234 ml, the mean detrusor compliance was 17.5 cm H(2)O/ml, the mean maximum detrusor pressure was 61.9 cm H(2)O and the mean Q (max) was 13.8 ml/s in all patients. Vesicoureteral reflux was detected in 15 (23%) patients. The mean detrusor compliance and detrusor capacity significantly decreased as the daily amount of urine decreased and as the duration of chronic renal failure increased. Also, there was no significant relation between presence of diabetes mellitus and detrusor capacity and detrusor compliance.

CONCLUSION

Video-urodynamic studies before renal transplantation provide earlier diagnosis of lower tract abnormalities, which are likely to cause graft dysfunction.

CONGENITAL URINARY BLADDER OUTLET OBSTRUCTION

The term congenital ‘bladder outlet obstruction (BOO)’ describes the collection of conditions in which the normal, urethral egress of urine from the fetal bladder is impaired. The term is interchangeable with fetal ‘lower urinary tract obstruction’, as used by other authors. After considering normal urinary tract embryology, we describe the epidemiology of congenital BOO and the primary anatomical disorders associated with it. We then proceed to describe its fetal and postnatal clinical manifestations and then consider therapies and interventions which have been used to manage the condition. We not only focus on urethral and bladder disease with constitutes BOO itself, but also describe associated kidney disorders which, via chronic renal excretory failure, are important causes of morbidity. Rather than provide an exhaustive review, we emphasise studies published in the last decade, and therefore readers are referred to other reviews citing numerous earlier references.