Renal Transplantation in Patients with Urologic Abnormalities

Vol. 115, May Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright© 1976 by The Williams & Wilkins Co.

RENAL TRANSPLANTATION IN PATIENTS WITH UROLOGIC ABNORMALITIES JOHN H. SHENASKY, II* From the Department of Surgery, Urology Service, Wilford Hall United States Air Force Medical Center, Lackland Air Force Base, Texas

ABSTRACT

Of patients undergoing renal transplantation during a recent 18-month period 42 per cent had significant urologic abnormalities. A thorough pre-transplant evaluation is especially critical in these patients. Massive reflux is an indication for pre-transplantation nephroureterectomy. Reconstructive operations provided a functional bladder in some patients who had previously undergone urinary diversion. Other patients required formation of intestinal conduits. Suggestions for the management of transurethral prostatectomy in patients with renal failure are outlined. Patients with a variety of abnormalities of the urinary tract had a transplantation success rate comparable to that of azotemic patients with normal urinary systems. RESULTS

Renal transplantation has become an effective and common treatment modality for patients with renal insufficiency.'· 2 Although originally used primarily for patients with chronic medical renal disease, more recently an increasing number of patients evaluated for transplantation have been found to have urologic etiologies for the renal failure. Many articles have summarized the incidence and treatment of urologic complications of transplantation 3·• but few have emphasized the evaluation and preparation of patients with urologic abnormalities for kidney homografting. 10 • 11 Experience as the urologist on an active renal transplant team constitutes the basis of my report.

One kidney in this series was removed 6 days post-transplantation because of severe acute rejection. One patient died 9 months post-transplantation of sepsis. The kidney in this patient was functioning normally at the time of death. A third patient, whose second transplantation was done 1 year ago, shows signs of chronic rejection. Serum creatinine is stable at 4 mg. per cent. All other patients are alive with normal renal function (serum creatinine 1.5 mg. per cent or less). Average kidney survival is 12.3 months, excluding the patient with acute rejection but including the patient who died. These data compare favorably to the data from a group of patients undergoing transplantation during the same period without urologic abnormalities. A complete urologic evaluation must be performed on every

MATERIAL AND METHODS

Between September 1973 and March 1975, 31 renal transplantations were performed at our medical center. Of these, 13 (42 per cent) were in patients with urologic abnormalities. The conditions encountered are listed in the table. The largest single group of patients was those with reflux. The patient witl: myelodysplasia and the one with prune belly syndrome also had bilateral reflux. There were 2 patients with congenital renal dysplasia and obstruction that progressed to renal failure. Two adult male patients with azotemia secondary to chronic glomerulonephritis were discovered to have clinically significant obstructing prostatic hypertrophy during evaluation. The remaining patients represented 4 additional classification categories. One patient received a cadaveric homograft, while the other 12 patients received living related kidneys with at least a 2-antigen match. The kidneys were placed retroperitoneally in all but 3 patients-a small child who had his mother's right kidney transplanted intra-abdominally and the 2 patients with ilea! conduits. Vascular anastomoses were accomplished to the most convenient vessels, usually the hypogastric artery and external iliac vein. Urinary tract reconstitution was by transvesical ureteroneocystostomy with a submucosal tunnel 8 in 11 patients. The 2 patients with ilea! conduits had a direct anastomosis of the donor ureter to the proximal portion of the conduit. Accepted for publication September 5, 1975. The views expressed herein are those of the author and do not necessarily reflect the views of the United States Air Force. * Current address: 16 Medical Center, Salisbury, Maryland 21801.

Urologic conditions in 31 patients undergoing renal transplantation No. Pts. Vesicorenal reflux* Renal dysplasia with congenital obstruction Prostatic hypertrophy Polycystic kidney disease Myelodysplasia with neurogenic bladder* Prune belly syndrome Bilateral Wilms tumors Total

(%)

5

2 2 1 1 1 1 13

(42)

* One patient in each of these categories had an ilea! conduit used for transplantation.

potential renal transplant recipient. The presence of urinary tract abnormalities does not contraindicate transplantation. Rather, it poses several questions. Can reconstructive operations provide a normally functioning bladder that will be usable for transplantation? Is construction of an intestinal diversion necessary to prepare for homografting? Is pre-transplant nephroureterectomy necessary? CASE REPORTS

Case 1. A cystogram was obtained from a 6-year-old patient who had undergone bilateral loop cutaneous ureterostomy 2 years previously (fig. 1, A). No further urinary tract reconstruction was feasible because of advanced renal destruction. The urine from both kidneys was chronically infected. Although the bladder was of small capacity it emptied completely. While dialysis was instituted the patient's mother was

490

RENAL TRANSPLANTATION IN PATIENTS WITH UROLOGIC ABNORMALITIES

evaluated and found to be a suitable donor. The patient underwent bilateral nephrectomy through separate flank incisions, the cutaneous ureterostomy sites were excised and the proximal three-fourths of each ureter was resected. A month later the mother's right kidney was transplanted intraperitoneally (fig. 1, B). The distal ureteral stumps were removed at the time of transplantation. Convalescence has been uneventful and the bladder functions normally. Case 2. A cystogram was obtained from a 13-year-old boy with reflux into a non-functioning left kidney (fig. 2, A). The patient previously had undergone cutaneous ureterostomy drainage of a poorly functioning right kidney. Voiding did not effectively empty the bladder. Endoscopy revealed a small capacity bladder with a contracture of the vesical neck. After stabilization on dialysis the patient underwent nephroureterectomies and transurethral resection of the bladder neck. A suprapubic cystostomy tube was left indwelling to enable us to hydrodilate the previously defunctionalized bladder. Bladder capacity increased and the bladder emptied completely (fig. 2, B). The suprapubic cystostomy tube was removed 2 weeks before transplantation after irrigation with neomycin and the tube tract healed rapidly. The bladder readily accepted a ureteral reimplant at the time of transplantation. Although the patient initially had nocturnal enuresis post-transplantation, this has cleared and the voiding pattern and urine volumes are now normal. DISCUSSION

I I

I

The case reports emphasize that the bladders of some patients who previously have required urinary diversion for urologic problems may well be functional organs usable for transplantation. Often relatively straightforward measures or common urologic procedures can ensure the functional capabilities of the recipient bladder. Patients awaiting cadaveric transplants should have the bladder status assessed periodically-at least annually. Patients with minimal urine output can develop diminished bladder capacity insidiously. 12 Reimplantation into a small contracted bladder is fraught with technical problems and the results can be disastrous.

491

We recently obtained a cystogram of 1 of our chronic dialysis patients whose previous transplant had been removed 2 years earlier. This patient's own kidneys had been removed before the initial transplant. The result of this defunctionalization was a bladder capacity of only 100 cc with reflux into the right ureter. The patient was begun on a program of weekly hydrodilations with dilute neomycin solution instilled through a Foley catheter by gravity at 40 cm. pressure. The bladder slowly expanded during a 3-month period to a 225 cc capacity, enabling us to use it for the second transplant. Interestingly, reflux had disappeared on repeat cystography. A normally functioning bladder is far superior to any type of urinary diversion as a receptacle for urine from a renal transplant, not only in terms of social convenience but, more importantly, in terms of obviating infectious complications that could lead to destruction of the graft. This is not to say that kidneys cannot be transplanted into various types of urinary diversion, as is necessary when the bladder cannot be rehabilitated. Figure 3 shows the postoperative excretory urogram (IVP) of 1 of the 2 patients in this series whose kidney was anastomosed into an ilea! conduit. The patient also had bilateral reflux and 2 unsuccessful attempts at bilateral reimplantation. Eventually cutaneous ureterostomies were performed. When the kidneys failed dialysis was instituted. The patient underwent bilateral nephroureterectomy through flank incisions with simultaneous excision of the ureterostomy stomas. When an evaluation showed a heavily trabeculated bladder, which did not empty effectively, an ilea! conduit was isolated and its stoma was formed. A month later a kidney from the patient's brother was transplanted intraperitoneally. The proximal ureter just below the ureteropelvic junction was anastomosed to the proximal end of the previously constr~cted conduit. Kidney function is excellent although urine is chronically infected despite suppression with urinary acidifiers. Patients with renal failure on the basis of neurogenic bladder dysfunction can be considered for transplantation through the use of urinary diversions. Such intestinal diversion should always be accomplished before transplantation. If the ureteroileal anastomosis is large enough and kinking of the ureter and conduit is avoided few difficulties should be encountered. 11

FIG. 1. A, cystogram of 6-year-old child with reflux who had undergone bilateral loop cutaneous ureterostomy 2 years previously. Reflux persists to ureterostomy stomas bilaterally. Otherwise smooth bladder, which emptied completely on post-voiding film. B, IVP post-transplantation. Donor kidney was placed intra-abdominally. Renal and bladder function is normal.

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SHENASKY

FIG. 2. A, cystogram of 13-year-old patient demonstrates reflux into non-functioning left kidney. Other films showed small capacity bladder, narrow bladder neck and incomplete emptying. B, after bilateral nephroureterectomy, transurethral resection of bladder neck and hydrodilatation via cystostomy tube bladder capacity has increased. Bladder neck funnels normally with voiding and residual urine volume (not shown) decreased to zero.

FIG. 3. Post-transplantation IVP of patient with ilea! conduit. Kidney was placed intra-abdominally. Ureter just below ureteropelvic junction is anastomosed to proximal portion of conduit. Prompt function without obstruction.

Our patients underwent a transabdominal kidney placement but in some situations retroperitoneal kidney placement would be feasible and preferred. Since older patients are being accepted for transplantation men with prostatic hypertrophy will be encountered. In these patients the importance of a thorough pre-transplantation urologic evaluation including cystoscopy, when indicated, cannot be underestimated. We have encountered 2 patients in this series whose voiding cystourethrograms revealed narrow caliber prostatic urethras. The residual urine volumes were more than 100 cc. Both patients underwent transurethral prostatic resection, which enabled them to empty their bladders completely. The time for a reconstructive operation is before transplan-

tation. While patients in renal failure are not ideal surgical candidates patients receiving immunosuppression are less so. If the patient can empty the bladder the necessity for long-term catheterization post-transplantation will be obviated and the likelihood of urinary infection, especially chronic prostatitis, will be decreased. Preoperative evaluation of the patient with renal failure who is to undergo transurethral prostatectomy must be as thorough as for transplantation, particularly in regard to the hematologic and coagulation status. Hemostasis intraoperatively must be meticulous. A 3-way catheter is left indwelling so that urine output, which is often quite low, can be supplemented with isosmotic irrigation. The catheter is not removed until the urine has been clear completely with the patient fully ambu-

RENAL TRANSPLANTATION IN PATIENTS WITH UROLOGIC ABNORMALITIES

lant. This period is usually several days longer than the routine transurethral resection of the prostate but has not exceeded 7 days. The oliguria present may contribute or even predispose to postoperative bladder neck contracture, which occurred in 1 of our 2 patients. The contracture was easily corrected by repeat transurethral incision. Ideally, resection should be accomplished approximately 6 weeks before transplantation to allow complete healing of the fossa by the time of grafting. These suggestions should enable the dialysis patient with significant prostatic hypertrophy to be adequately prepared for transplantation. In addition to the aforementioned situations involving reflux, chronically infected kidneys or previously diverted kidneys polycystic renal disease usually requires pre-transplantation nephrectomy in order to provide space for homografting as well as to remove the kidneys as sources of bleeding and infection. Other disease processes, including hyper-renin hypertension, antiglomerular basement membrane disease and Goodpasture's syndrome, also require pre-transplant nephrectomy. 1s-1s Patients with renal malignancy, including Wilms tumors, adenocarcinoma or transitional cell carcinoma, can also be candidates for transplantation after an appropriate period free of metastases has been demonstrated. 16 - 1 • We had 1 such patient in our series who had undergone bilateral nephrectomy for non-concurrent Wilms tumor. REFERENCES

1. Belzer, F. 0. and Kountz, S. L.: The role of clinical transplanta-

tion in patients with end-stage renal disease. Transplant. Proc., 5: 793, 1973. 2. Lawson, R. K., Talwalkar, Y. B., Musgrave, J.E., Campbell, R. A. and Hodges, C. V.: Renal transplantation in pediatric patients. J. Urol., 113: 225, 1975. 3. Edelbrock, H. H., Riddell, H., Mickelson, J. C., Grushkin, C. M., Lieberman, E. and Fine, R. N.: Urologic aspects of renal transplantation in children. J. Urol., 106: 934, 1971. 4. Anderson, E. E., Glenn, J. F., Seigler, H. F. and Stickel, D. L.: Urologic complications in renal transplantation. J. Urol., 107: 187, 1972.

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5. Malek, G. H., Uehling, D. T., Daouk, A. A. and Kisken, W. A.: Urological complications of renal transplantation. J. Urol., 109: 173, 1973.

6. DeWeerd, J. H., Woods, J. E. and Leary, F. J.: The allograft ureter. J. Urol., 109: 958, 1973. 7. Salvatierra, 0., Jr., Kountz, S. L. and Belzer, F. 0.: Prevention of ureteral fistula after renal transplantation. J. Urol., 112: 445, 1974.

8. Marx, W. L., Halasz, N. A., McLaughlin, A. P. and Gittes, R. F.: Urological complications in renal transplantation. J. Urol., 112: 561, 1974.

9. Barry, J. M., Lawson, R. K., Strong, D. and Hodges, C. V.: Urologic complications in 173 kidney transplants. J. Urol., 112: 567, 1974. 10. Tunner, W. S., Whitsell, J. C., II, Rubin, A. L., Stenzel, K. H.,

David, D.S., Riggio, R.R., Schwartz, G. H. and Marshall, V. F.: Renal transplantation in children with corrected abnormalities of the lower urinary tract. J. Urol., 106: 133, 1971. 11. Stenzel, K. H., Stubenbord, W. T., Whitsell, J. C., Lewy, J. E., Riggio, R. R., Cheigh, J. S., Marshall, V. F. and Rubin, A. L.: Kidney transplantation. Use of intestinal conduits. J.A.M.A., 229: 534, 1974. 12. Schmaelzle, J. F., Cass, A. S. and Hinman, F., Jr.: Effect of disuse and restoration of function on vesical capacity. J. Urol., 101: 700, 1969. 13. Konnak, J. W., Hyndman, C. W. and Cerny, J. C.: Bilateral nephrectomy prior to renal transplantation. J. Urol., 107: 9, 1972. 14. Mitchell, T. S., Halasz, N. A. and Gittes, R. F.: Renal transplantation: selective preliminary bilateral nephrectomy. J. Urol., 109: 796, 1973. 15. Viner, N. A., Rawl, J.C., Braren, V. and Rhamy, R. K.: Bilateral nephrectomy: an analysis of 100 consecutive cases. J. Urol., 113: 291, 1975.

16. David, H. S. and Lavengood, R. W., Jr.: Bilateral Wilms' tumor: treatment, management, and review of the literature. Urology, 3: 71, 1975. 17. Stroup, R. F., Shearer, J. K., Traurig, A. R. and Lytton, B.: Bilateral adenocarcinoma of the kidney treated by nephrectomy: a case report and review of the literature. J. Urol., Ill: 272, 1974. 18. Ehrlich, R. M., Goldman, R. and Kaufman, J. J.: Surgery of

bilateral Wilms' tumors: the role of renal transplantation. J. Urol., Ill: 277, 1974.