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Renal transplantation in patients with abnormal lower urinary tract
Renal Transplantation in Patients With Abnormal Lower Urinary Tract M. Al-Mousawi, M. Samhan, S. Ramesh, R. Gupta, and M.R.N. Nampoory
A
BNORMALITIES of the lower urinary tract (ALUT) are uncommon in patients with end-stage renal disease requiring renal transplantation, but these patients need special attention prior to transplant surgery. Many of these patients are children with renal failure due to these abnormalities. Some require surgical intervention before transplantation to protect the transplanted kidney and to prevent complications. In this study we reviewed the management and outcome of patients with ALUT transplanted in a single center.
PATIENTS AND METHODS The records of 216 renal transplants performed in Kuwait between November 1993 and November 1999 were reviewed. Twenty-six patients (12%) were found to suffer ALUT prior to transplantation. They were 20 males (76.9%) and six females. Seven were children aged 9 to 17 years (mean 13.6 years) and 19 were adults aged 18 to 63 years (mean 36.9 years). They received renal grafts from 20 living and six cadaver donors. The etiology of ALUT was primary vesicoureteric reflux (VUR) in 18 cases, neurogenic bladder in seven, posterior urethral stricture in six, and stress incontinence and multicystic seminal vesicles in one each. Eight patients had more than one ALUT. VUR was bilateral in 12 of 18 patients; 10, 5, 1, and 13 kidneys had grades I, II, III, and IV reflux, respectively. All kidneys and ureters with grade IV reflux were removed, eight before and five during transplant operation. Six of seven patients with neurogenic bladder were under the age of 18 years at the time of transplantation. All the patients had urodynamic study of the bladder before transplantation. Unilateral or bilateral nephrectomy was performed for four patients prior to transplantation for VUR. Augmentation cystoplasty using ileal loop was performed for one patient with high intravesical pressure and urethral stricture due to posterior urethral valve. After transplantation two patients continued using clean intermittent selfcatheterization (CIC) to empty the bladder and two recipients are receiving anticholinergic drugs. Posterior urethral stricture followed resection of posterior urethral valves in four patients, and nonspecific urethritis and transurethral resection of prostate in one each. Three patients required internal urethrotomy and repeated urethral dilatation after transplantation. Recurrent stress incontinence was diagnosed in a 63-year-old female secondary to a small cystocele and rectocele. She became asymptomatic after transplantation with no specific treatment for her incontinence. A large multicystic lesion was diagnosed in a 21-year-old patient, which was compressing the bladder and reducing its capacity. The cysts were excised surgically before transplantation.
RESULTS
Twenty-two (84.6%) patients are alive with functioning grafts 4 to 69 months after transplantation. One graft was lost due to noncompliance leading to rejection in a 15-yearold boy with neurogenic bladder. Another graft was lost in an 18-year-old girl with VUR due to recurrence of original renal glomerulopathy. A third graft was lost in a 53-year-old male patient due to his death with functioning graft 14 months after transplantation. The fourth graft was lost in a 10-year-old girl with VUR due to renal artery thrombosis. She was retransplanted but again lost the graft due to renal artery thrombosis. No graft was lost due to urological complications or as a result of ALUT. One patient with gross obesity and urethral stricture needed a suprapubic catheter during transplantation and developed postoperative urinary leak around the catheter, CMV infection, and incisional hernia. There was one episode of urinary tract infection (UTI) in the patient with bladder augmentation and another episode in a patient using CIC. The patient with resected seminal vesicle cysts developed three episodes of UTI. All these episodes resolved with short courses of antibiotics. DISCUSSION
Pathological findings of urinary tract can occur in up to 25% of patients with end-stage renal disease,1 necessitating careful examination to discover them prior to transplantation. A large proportion of the patients require no surgical interference before transplantation. Presence of VUR per se is not an indication for native nephrectomy unless it is of high grade, in which case the risk of stasis and subsequent infection necessitates removal of kidney and dilated ureter. We found no increase in the incidence of posttransplant UTI in patients with grades I to III VUR, without native nephrectomy. In patients with neurogenic bladder it is important to do urodynamic studies before transplant2 to measure intravesical pressure and study bladder compliance and capacity. To protect the transplanted kidney it is important to have a sterile, compliant, low-pressure reservoir that is continent and easily emptied.3 Urinary diversion From the Hamed Al-Essa Organ Transplant Center, Kuwait City, Kuwait. Address reprint requests to Hamed Al-Essa Organ Transplant Center, PO Box 288, Safat 13003, Kuwait City, Kuwait.
0041-1345/01/$–see front matter PII S0041-1345(01)02144-3
© 2001 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
2676
Transplantation Proceedings, 33, 2676–2677 (2001)
RENAL TRANSPLANT IN PATIENTS WITH ALUT
is associated with complications4 – 6 but is recommended in younger children who may find CIC painful and difficult. The Mitrofanoff method using the appendix as a continent catheterizable stoma is the preferred method of diversion.3 In adults and older compliant children CIC is a better alternative to diversion4,7–9 when the bladder is continent but fails to empty, provided bladder pressure is low. With high pressure augmentation is recommended6,10 as an alternative to diversion. In cases of urethral stricture, outflow obstruction is managed with internal urethrotomy or repeated dilatation. Graft survival of 84.6% is comparable to overall graft survival of 85.3% in the same period. We conclude that results of renal transplantation in patients with abnormal lower urinary tract are excellent and comparable to those obtained in recipients with normal lower urinary tract.
2677
REFERENCES 1. Jaeger P: Urol Int 49:94, 1992 2. Crowe A, Cairns HS, Wood S, et al: Nephrol Dial Transplant 13:2065, 1998 3. Koo HP, Bunchman TE, Flynn JT, et al: J Urol 161:240, 1999 4. Gill IS, Hayes JM, Hodge EE, et al: J Urol 148:1397, 1992 5. Koch MO, McDougal WS, Hall MC, et al: J Urol 147:1343, 1992 6. Thomalla JV: Surg Gynecol Obstet 170:349, 1990 7. Stanley OH, Chambers TL, Pentlow BD: Br Med J (Clin Res ED) 4:1775, 1983 8. Barnett M, Bruskewitz R, Glass N, et al: J Urol 134:654, 1985 9. Flechner SM, Conley SB, Brewer ED, et al: J Urol 130:878, 1983 10. Thomalla JV, Mitchell ME, Leapman SB, et al: J Urol 141:265, 1989
A
BNORMALITIES of the lower urinary tract (ALUT) are uncommon in patients with end-stage renal disease requiring renal transplantation, but these patients need special attention prior to transplant surgery. Many of these patients are children with renal failure due to these abnormalities. Some require surgical intervention before transplantation to protect the transplanted kidney and to prevent complications. In this study we reviewed the management and outcome of patients with ALUT transplanted in a single center.
PATIENTS AND METHODS The records of 216 renal transplants performed in Kuwait between November 1993 and November 1999 were reviewed. Twenty-six patients (12%) were found to suffer ALUT prior to transplantation. They were 20 males (76.9%) and six females. Seven were children aged 9 to 17 years (mean 13.6 years) and 19 were adults aged 18 to 63 years (mean 36.9 years). They received renal grafts from 20 living and six cadaver donors. The etiology of ALUT was primary vesicoureteric reflux (VUR) in 18 cases, neurogenic bladder in seven, posterior urethral stricture in six, and stress incontinence and multicystic seminal vesicles in one each. Eight patients had more than one ALUT. VUR was bilateral in 12 of 18 patients; 10, 5, 1, and 13 kidneys had grades I, II, III, and IV reflux, respectively. All kidneys and ureters with grade IV reflux were removed, eight before and five during transplant operation. Six of seven patients with neurogenic bladder were under the age of 18 years at the time of transplantation. All the patients had urodynamic study of the bladder before transplantation. Unilateral or bilateral nephrectomy was performed for four patients prior to transplantation for VUR. Augmentation cystoplasty using ileal loop was performed for one patient with high intravesical pressure and urethral stricture due to posterior urethral valve. After transplantation two patients continued using clean intermittent selfcatheterization (CIC) to empty the bladder and two recipients are receiving anticholinergic drugs. Posterior urethral stricture followed resection of posterior urethral valves in four patients, and nonspecific urethritis and transurethral resection of prostate in one each. Three patients required internal urethrotomy and repeated urethral dilatation after transplantation. Recurrent stress incontinence was diagnosed in a 63-year-old female secondary to a small cystocele and rectocele. She became asymptomatic after transplantation with no specific treatment for her incontinence. A large multicystic lesion was diagnosed in a 21-year-old patient, which was compressing the bladder and reducing its capacity. The cysts were excised surgically before transplantation.
RESULTS
Twenty-two (84.6%) patients are alive with functioning grafts 4 to 69 months after transplantation. One graft was lost due to noncompliance leading to rejection in a 15-yearold boy with neurogenic bladder. Another graft was lost in an 18-year-old girl with VUR due to recurrence of original renal glomerulopathy. A third graft was lost in a 53-year-old male patient due to his death with functioning graft 14 months after transplantation. The fourth graft was lost in a 10-year-old girl with VUR due to renal artery thrombosis. She was retransplanted but again lost the graft due to renal artery thrombosis. No graft was lost due to urological complications or as a result of ALUT. One patient with gross obesity and urethral stricture needed a suprapubic catheter during transplantation and developed postoperative urinary leak around the catheter, CMV infection, and incisional hernia. There was one episode of urinary tract infection (UTI) in the patient with bladder augmentation and another episode in a patient using CIC. The patient with resected seminal vesicle cysts developed three episodes of UTI. All these episodes resolved with short courses of antibiotics. DISCUSSION
Pathological findings of urinary tract can occur in up to 25% of patients with end-stage renal disease,1 necessitating careful examination to discover them prior to transplantation. A large proportion of the patients require no surgical interference before transplantation. Presence of VUR per se is not an indication for native nephrectomy unless it is of high grade, in which case the risk of stasis and subsequent infection necessitates removal of kidney and dilated ureter. We found no increase in the incidence of posttransplant UTI in patients with grades I to III VUR, without native nephrectomy. In patients with neurogenic bladder it is important to do urodynamic studies before transplant2 to measure intravesical pressure and study bladder compliance and capacity. To protect the transplanted kidney it is important to have a sterile, compliant, low-pressure reservoir that is continent and easily emptied.3 Urinary diversion From the Hamed Al-Essa Organ Transplant Center, Kuwait City, Kuwait. Address reprint requests to Hamed Al-Essa Organ Transplant Center, PO Box 288, Safat 13003, Kuwait City, Kuwait.
0041-1345/01/$–see front matter PII S0041-1345(01)02144-3
© 2001 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
2676
Transplantation Proceedings, 33, 2676–2677 (2001)
RENAL TRANSPLANT IN PATIENTS WITH ALUT
is associated with complications4 – 6 but is recommended in younger children who may find CIC painful and difficult. The Mitrofanoff method using the appendix as a continent catheterizable stoma is the preferred method of diversion.3 In adults and older compliant children CIC is a better alternative to diversion4,7–9 when the bladder is continent but fails to empty, provided bladder pressure is low. With high pressure augmentation is recommended6,10 as an alternative to diversion. In cases of urethral stricture, outflow obstruction is managed with internal urethrotomy or repeated dilatation. Graft survival of 84.6% is comparable to overall graft survival of 85.3% in the same period. We conclude that results of renal transplantation in patients with abnormal lower urinary tract are excellent and comparable to those obtained in recipients with normal lower urinary tract.
2677
REFERENCES 1. Jaeger P: Urol Int 49:94, 1992 2. Crowe A, Cairns HS, Wood S, et al: Nephrol Dial Transplant 13:2065, 1998 3. Koo HP, Bunchman TE, Flynn JT, et al: J Urol 161:240, 1999 4. Gill IS, Hayes JM, Hodge EE, et al: J Urol 148:1397, 1992 5. Koch MO, McDougal WS, Hall MC, et al: J Urol 147:1343, 1992 6. Thomalla JV: Surg Gynecol Obstet 170:349, 1990 7. Stanley OH, Chambers TL, Pentlow BD: Br Med J (Clin Res ED) 4:1775, 1983 8. Barnett M, Bruskewitz R, Glass N, et al: J Urol 134:654, 1985 9. Flechner SM, Conley SB, Brewer ED, et al: J Urol 130:878, 1983 10. Thomalla JV, Mitchell ME, Leapman SB, et al: J Urol 141:265, 1989