Objectives: Correction of structural urologic disorders and optimization of emptying and storage function of the bladder should be achieved before renal transplant in patients with abnormal urinary bladders to protect the new transplanted kidney. The aim of this study was to determine the outcomes of renal transplant among the differently treated abnormal bladder patients.
Materials and Methods: This was a retrospective study of 30 renal transplant recipients with abnormal bladders who were divided into 2 groups based on abnormal bladder management. Group A included 12 patients who required surgical procedures for their bladder, including 6 with augmentation cystoplasty, 1 with Mitrofanoff procedure, 2 with ileal conduit, 1 with vesicostomy, and 2 who required artificial urinary sphincter. Group B included 18 patients who were treated with oral anticholinergics or beta-3 sympath-omimetic drugs, clean intermittent catheterization, suprapubic catheterization, or a combination of these options. Graft function, survival, and complications were compared between both groups.
Results: Mean estimated glomerular filtration rates at 1, 3, and 5 years were higher in group A than in group B but not statistically significant. We also found no significant differences in graft survival between the 2 groups. Among all postoperative complications, only incidence of wound infection was significantly higher in group A than in group B (33% vs 5%; P = .04).
Conclusions: The options of abnormal bladder treatment (either by surgical procedures or other methods of treatment) did not have an impact on graft outcome after renal transplant as long as a safe and suitable bladder was achieved.
Key words : Augmentation cystoplasty, Clean intermittent catheterization, Posterior urethral valve, Spina bifida
Patients with end-stage renal disease who have a small-volume, poorly compliant bladder and/or inadequate voiding can benefit from renal transplant as long as the lower urinary tract dysfunctions are corrected either by clean intermittent catheterization (CIC), anticholinergic therapy, or surgery if needed.1
Surgical rehabilitation of the abnormal bladder (such as reconstructive bladder operations, urinary diversion, or artificial urinary sphincter insertion) is sometimes required to make it safe and suitable for the ongoing transplant if conservative measures have failed.2 In the past, urinary diversion was the usual approach to bypass the abnormal bladder. With the use of augmentation cystoplasty and CIC, in small-volume, poorly compliant bladders, a low-pressure and compliant reservoir can be created that can protect the upper urinary tract.1 The aim of this study was to determine outcomes of renal transplant among differently managed abnormal bladders.
Materials and Methods
This retrospective single-center study was conducted through review of electronic and paper records of patients with pretransplant structural and/or functional bladder abnormalities who received renal transplant procedures between 1990 and 2015. This study included 30 kidneys transplanted in 25 patients (5 patients received a second kidney transplant after failure of the first graft). For ease of statistical analyses, each transplanted kidney in the patients who received a second transplant was considered as a separate case.
Patients were divided into 2 groups based on the need for auxiliary surgical procedures on their bladder. Group A included 12 patients who required surgical procedures for their bladder, including augmentation cystoplasty in 6 patients, Mitrofanoff procedure in 1, ileal conduit in 2, vesicostomy in 1, and artificial urinary sphincter in 2 patients. Group B included 18 patients who were treated with oral anticholinergics or beta-3 sympathomimetic drugs, CIC, suprapubic catheterization, or a combination of these options.
Patient demographics, graft function, survival outcomes, and complications were compared between the groups. Data were collected between May and September 2015. End points were trans-plant failure or last follow-up at end of study. Graft failure was defined as estimated glomerular filtration rate (eGFR) less than 15 mL/min.
Statistical data analysis was performed with SPSS software (SPSS: An IBM Company, version 20, IBM Corporation, Armonk, NY, USA), with t test used for means and chi-square test used for categorical variables. P ≤ .05 was considered significant.
Patients were followed up to 21 years (106 ± 88 mo). In group B, 17 patients were males compared with only 6 patients in group A (P = .005). Four patients in group B received a second transplant compared with 1 patient in group A, although with no significant difference (P = .31). There were no significant differences in mean age at the time of renal transplant between the 2 groups (37 ± 17.6 y in group A vs 28 ± 15.7 y in group B; P = .18). Ratio of living-to-deceased donor kidneys was 2 of 10 in group A and 6 of 12 in group B (not significantly different; P = .31).
In group A, 6 patients received augmentation cystoplasty (4 patients with spina
bifida, 1 with neuropathic bladder secondary to paraplegia, and 1 with
vertebral-anal-tracheo-esophageal fistula-renal disorder association). One
patient with posterior urethral valve (PUV) required Mitrofanoff channel
formation (as the patient could not have CIC through the urethra), 2 patients
received ileal conduits (1 patient with PUV and 1 with spina bifida), 1 patient
with primary reflux received vesicostomy (as a form of urinary diversion with
stoma bags as the patient had learning difficulties and controlled seizures),
and 2 patients received artificial urinary sphincters
(1 patient with spina bifida and 1 patient with sacral agenesis).
Seven patients in group B were treated with oral anticholinergics or beta-3 sympathomimetic drugs (mirabegron), 13 patients were treated with CIC, and 3 patients required suprapubic catheterization. Some patients required combinations of the previous treatment options.
Although patients in group A required auxiliary surgical procedures for their bladder, some also required nonsurgical treatments like those in group B (CIC was used in 8 patients, suprapubic catheteri-zation was required in 1, and oral drugs were used in 1 patient from group A).
Furthermore, patients in group B required some surgical procedures to treat the cause of the abnormal bladder itself (such as valve fulguration for PUV patients, epispadias repair, and urethrotomy for stricture urethra) or its complications (such as nephrectomy for nonfunctioning kidneys).
Graft survival at 1, 3, and 5 years was 91%, 91%, and 90% among patients in group A versus 88%, 84%, and 75% among patients in group B with no statistically significant differences (P = .80, .58, and .31 at 1, 3, and 5 y, respectively).
Although the mean eGFRs at 1, 3, and 5 years were higher among patients in group A than in those in group B, results were not statistically significant. In group A versus group B patients, mean eGFR was 55 ± 29 versus 39 ± 23 mL/min (P = .13) at 1 year, 47 ± 29 versus 30 ± 21 mL/min (P = .14) at 3 years, and 42 ± 28 versus 26 ±21 mL/min (P = .16) at 5 years.
On long-term follow-up, there was no significant difference in overall graft survival in group A versus group B patients (log-rank test; P = .42) as shown by Kaplan-Meier curves in Figure 1.
As shown in Table 1, there was a significantly higher incidence of postoperative wound infection in group A patients versus group B patients (33% vs 5%; P = .04). All other postoperative complications were not significantly different.
End-stage renal disease is associated with structural urologic abnormalities in about 15% of patients in the adult population and up to 20% to 30% in the pediatric population.3 An abnormal urinary bladder is no longer a contraindication to renal transplant. With appropriate selection, patient and graft survival outcomes are not significantly different from those of the general transplant population.4
Patients with an abnormal bladder need careful evaluation, and the bladder should be suitable to receive the renal graft. This includes facilitating emptying when spontaneous voiding is not possible, restoring bladder capacity and compliance, and increasing the outlet resistance when sphincter failure causes urinary incontinence, all allowing improved quality of life.5
In our study, 12 patients required auxiliary surgical procedures for their bladder to be suitable for renal transplant. All of the procedures of bladder rehabilitation in our study (except vesicostomy) were performed before renal transplant.
Most authors have performed the augmentation procedure before transplant. In 1998, Fontaine and associates suggested that reconstructive surgery be done before transplant to avoid the deleterious effects of immunosuppressive drugs on the healing process.6
In a study conducted by Taghizadeh and associates in 2007 to compare the outcomes of renal transplant before and after augmentation cystoplasty, there was no difference between both groups regarding the inpatient stay, the incidence of urinary tract infection (UTI) during the first 3 months after transplant, and renal allograft survival. Three patients in the group transplanted first developed significant ureteric pathology, of which 1 developed graft failure.7
In 2009, Basiri and associates compared the outcomes of renal transplant before and after bladder augmentation. Augmentation cystoplasty preceded transplant in 21 children and was performed after transplant in 23 children. They concluded that the timing of cystoplasty in relation to transplant had no apparent significant effect on renal transplant outcomes as both graft survival and the incidence of febrile UTIs were not significantly different in the 2 groups of bladder augmentation.8
In our study, there were no significant differences in graft survival at 1, 3, and 5 years or the current graft function and the overall graft survival between patients with abnormal bladder who had undergone rehabilitation surgery of their bladder and those who did not undergo surgery of their bladder. In addition, no significant differences were found in the mean eGFR among both groups at 1, 3, and 5 years.
A similar observation was also reported by Srinivasan and associates in 2016 in their study of renal transplant in patients with bladder dysfunction. They found no significant differences in graft survival among patients with normal bladder, those with abnormal bladder who required surgery of their bladder, and those with abnormal bladder who did not require surgery. For these respective patient groups, graft survival rates at 1 year were 92.5%, 85.7%, and 95%; at 5 years, these were 77.3%, 66.6%, and 86.3% (log-rank test; P = .11).9
In 2011, Sager and associates also found no significant differences (P = .9) in graft survival among patients with normal bladder, those with abnormal bladder who did not require surgery of their bladder, and those with abnormal bladder who required surgery of their bladder. In the respective patient groups, graft survival rates at 1 year were 93.38%, 95.45%, and 93%; at 5 years, graft survival rates were 82.45%, 79.85%, and 86.58%. The average values of plasma creatinine for the grafts at 1 year were 1.12, 1.12, and 0.98 mg/dL and at 5 years were 1.46, 1.34, and 1.53 mg/dL in the respective groups.10
One study that showed negative results with augmentation cystoplasty was the 1997 study from Alfrey and associates on 8 patients with bladder augmentation who presented for transplant. The augmentation was taken down before transplant in 5 patients, and the kidney was transplanted into the augmentation in the remaining 3 patients. All 3 patients who were transplanted into the augmen-tation had severe UTI. One died, one lost the graft, and the third patient was considered for an incontinent diversion. In contrast, the other 5 patients in whom the augmentation was taken down before transplant fared well. However, these “catastrophic results” as reported by Alfrey and associates are not the rule in the published literature, and their sample size was small.11
Although augmentation cystoplasty had no significant impact on graft outcome, the procedure has special difficulties due to the high risk of surgical complications such as UTIs, mucus production, urinary retention, stone formation, metabolic acidosis, spontaneous perforation, and carcinoma development due to immunosuppressive treatment.12
With regard to the surgical complications encoun-tered in our study group, there were no significant differences in the incidence of all postoperative complications except wound infection, which was significantly higher in patients with abnormal bladder who required surgical interference than in those who did not require surgery (33% vs 5%; P = .04).
Among all postoperative complications reported in group A, UTI that required hospital admission was reported in all patients, 4 patients (33%) had stricture ureter, 2 patients (16%) developed urinary stones, and 2 patients (16%) developed posttransplant malignancy (1 patient who had ileal conduit at the age of 4 years developed adenocarcinoma of the urinary bladder 13 years posttransplant; the other patient developed carcinoma in situ of the scrotal skin).
In the largest pediatric series reported by Hatch and associates in 2001 on patients with bladder augmentation (17 patients) and urinary diversion (13 patients), surgical complications were reported in 19% of the patients. These included renal artery stenosis (1 patient), urinary leak and fistula (2 patients), bladder calculus (1 patient), wound dehiscence (1 patient), stoma-related problems (2 patients), and metabolic acidosis (5 patients). Postoperative UTI was reported in 21 patients (68%).13
Another multi-institutional review on renal transplant in patients with diversion or aug-mentation included 20 patients with bladder augmentation, 8 with continent diversion, and 23 with incontinent diversion, with all receiving deceased-donor renal transplants. Thirteen of 51 patients (25%) required reoperations. Among these, there were 3 ureteral complications, 3 urinary stones, and 1 adenocar-cinoma of the pouch. The incidence of UTI was 18%.14
Although our study was retrospective, not randomized, and had a small sample size due to the low incidence of abnormal bladder as a cause of renal failure, the results were comparable with the previously published reports in the literature.
Because of the complex nature of the disorder and the various patients with the disorder, it is essential to provide a careful and individualized evaluation of the lower urinary tract before transplant and provide a strict postoperative follow-up to diminish and control possible urologic complications. Because no sound guidelines or protocols presently exist for the care of patients with lower urinary tract disorders and end-stage renal disease, it is necessary to design randomized multicenter studies with large sample sizes for better evaluation of those patients with abnormal bladders who require renal transplant.
In conclusion, the approach of abnormal bladder treatment (either by surgical procedures or all other methods of treatment) did not have a significant effect on graft function, survival, and postoperative complications after renal transplant as long as a safe, low-pressure, and suitable bladder was achieved.
Volume : 16
Issue : 6
Pages : 660 - 664
DOI : 10.6002/ect.2016.0360
From the 1Urology Department, Menofia University Hospitals, Egypt; and the
2Sheffield Kidney Institute, Sheffield Teaching Hospitals, Sheffield, United
Acknowledgements: The authors have no sources of funding for this study and have no conflicts of interest to declare. Work was done at Sheffield Kidney Institute, Sheffield Teaching Hospitals (Sheffield, UK).
Corresponding author: Ahmed Halawa, Renal Transplant Unit, Sheffield Teaching Hospitals, Sheffield, UK S5 7AU
Phone: +44 1142715316
Figure 1. Kaplan-Meier Graft Survival Curves Among Patients Who Required Operative Procedures for Their Bladder (Group A) and Those Who Did Not (Group B)
Table 1. Postoperative Complications