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Renal transplantation in the valve bladder: is bladder augmentation always necessary?
ESPU Meeting 2007
S45
# S07-10 (PwP)
RENAL TRANSPLANTATION IN RECONSTRUCTED BLADDERS: LESSONS LEARNED FROM A 5 YEAR EXPERIENCE WITH 33 PATIENTS Daniel ALCANTRA PEREIRA, Bruno LESLIE, Jesus APARECIDO SOUZA, Paula MACHADO, RIBERTO LIGUORI, Riberto LIGUORI, Gilmar GARRONE, Jose OSMAR MEDINA PESTANA, Antonio MACEDO and Valdemar ORTIZ Federal University of Sao Paulo, Urology, Sao Paulo, BRAZIL
PURPOSE The aim of this study was to review our experience with renal transplantation in children with bladder augmentation.
MATERIAL AND METHODS Between Jan 2001 and May 2006, 287 renal transplants were performed in children and adolescents at the Hospital do Rim e ~o (Kidney and Hypertension Hipertensa Hospital) / UNIFESP. Thirty three patients (12%) had previously undergone reconstruction of the lower urinary tract.
RESULTS The mean follow up was 24 months. Patient’s mean age was 11 years old (1-17
years old). Living related donor grafts were performed in 11 patients (33.3%) and 22 (66.6%) patients received cadaveric donor grafts. The etiologies of the bladder dysfunction were posterior urethral valves in 18 patients, neurogenic bladder in 12, vesicoureteral reflux in 2, other bladder malformations in 1. Ileocystoplasty or sigmoidcystoplasty were performed in 29 patients. In four patients a ureterocystoplasty was created. All patients had the augmentation prior to the renal transplant. The interval between the bladder augmentations and the transplantation ranged from 2 to 108 months (mean 31 months). Of the 33 patients with an augmentation 3 (10%) perform CIC through the urethra. In 20 patients abdominal urinary stomas (Mitrofanoff or Macedo) were created and all these patients perform CIC through
these stomas. Only 10 patients voided spontaneously. The mean creatinine level at the first 6 months post transplantation was 1.1 +/- 0.3 mg/dl and by 12 months, 1.0+/- 0.2 mg/dl. The incidence of UTI at the first 12 months was 83%. The graft survival rate was 91% at 1 year follow-up.
CONCLUSIONS Pediatric patients who underwent lower urinary tract reconstructution prior to renal transplantation present a high incidence of UTI’s in the first postransplant year. Nevertheless the graft survival is similar to the reported data in the literature without previous bladder reconstruction.
# S07-11 (PwP)
RENAL TRANSPLANTATION IN THE VALVE BLADDER: IS BLADDER AUGMENTATION ALWAYS NECESSARY? Nicola CAPOZZA, Simona NAPPO, Giuseppe COLLURA and Paolo CAIONE Bambino Gesu` Children’s Hospital e IRCCS, Division of Paediatric Urology, Rome, ITALY
PURPOSE In patients with a fibrotic bladder secondary to posterior urethral valves (‘‘valve bladder’’), pre-emptive bladder augmentation is generally recommended in order to preserve graft function. We report our preliminary experience in children with renal transplantation in valve bladders without a preliminary augmentation.
MATERIAL AND METHODS Out of 151 pediatric candidates for renal transplantation, 15 presented with a valve bladder and were considered candidates for bladder augmentation. In 10 patients the bladder augmentation was performed prior to renal transplantation. In the remaining 5 patients with oligo/anuria the decision for the bladder augmentation
was postponed to the post-transplant period. Serum creatinine, urinary ultrasound, voiding diary were reevaluated at 1,2,3,4 and 6 months and urodynamics at 6 months follow-up.
RESULTS Out of the 5 patients, in two grafts a ureterostomy was performed. The other 3 patients had a graft ureteral reimplantation associated with a transient suprapubic catheter which allowed for frequent bladder emptying and overnight bladder drainage for 2 months. At followup the 3 patients had normal renal function with an absence of hydronephrosis. At 6 months bladder capacity improved from av.40% of expected capacity for age (range 30 to 65%) to av.95% (range 90 to 120%), with end filling bladder pressure < 30 cm H2O.
In these children bladder augmentation was judged not necessary any longer.
CONCLUSIONS In oligo/anuric valve bladder patients it can be hard to decide whether a poorly compliant bladder is due to fibrosis or to defunctionalisation. Bladder cycling before transplantation is not always tolerated. Furthermore, pre-emptive bladder augmentation can be performed several months before transplantation. We think in selected cases bladder augmentation can be avoided before transplantation, and once the normal diuresis is restored the native bladder can show significant improvement in capacity and compliance. Frequent monitoring of graft function and bladder function is mandatory.
S45
# S07-10 (PwP)
RENAL TRANSPLANTATION IN RECONSTRUCTED BLADDERS: LESSONS LEARNED FROM A 5 YEAR EXPERIENCE WITH 33 PATIENTS Daniel ALCANTRA PEREIRA, Bruno LESLIE, Jesus APARECIDO SOUZA, Paula MACHADO, RIBERTO LIGUORI, Riberto LIGUORI, Gilmar GARRONE, Jose OSMAR MEDINA PESTANA, Antonio MACEDO and Valdemar ORTIZ Federal University of Sao Paulo, Urology, Sao Paulo, BRAZIL
PURPOSE The aim of this study was to review our experience with renal transplantation in children with bladder augmentation.
MATERIAL AND METHODS Between Jan 2001 and May 2006, 287 renal transplants were performed in children and adolescents at the Hospital do Rim e ~o (Kidney and Hypertension Hipertensa Hospital) / UNIFESP. Thirty three patients (12%) had previously undergone reconstruction of the lower urinary tract.
RESULTS The mean follow up was 24 months. Patient’s mean age was 11 years old (1-17
years old). Living related donor grafts were performed in 11 patients (33.3%) and 22 (66.6%) patients received cadaveric donor grafts. The etiologies of the bladder dysfunction were posterior urethral valves in 18 patients, neurogenic bladder in 12, vesicoureteral reflux in 2, other bladder malformations in 1. Ileocystoplasty or sigmoidcystoplasty were performed in 29 patients. In four patients a ureterocystoplasty was created. All patients had the augmentation prior to the renal transplant. The interval between the bladder augmentations and the transplantation ranged from 2 to 108 months (mean 31 months). Of the 33 patients with an augmentation 3 (10%) perform CIC through the urethra. In 20 patients abdominal urinary stomas (Mitrofanoff or Macedo) were created and all these patients perform CIC through
these stomas. Only 10 patients voided spontaneously. The mean creatinine level at the first 6 months post transplantation was 1.1 +/- 0.3 mg/dl and by 12 months, 1.0+/- 0.2 mg/dl. The incidence of UTI at the first 12 months was 83%. The graft survival rate was 91% at 1 year follow-up.
CONCLUSIONS Pediatric patients who underwent lower urinary tract reconstructution prior to renal transplantation present a high incidence of UTI’s in the first postransplant year. Nevertheless the graft survival is similar to the reported data in the literature without previous bladder reconstruction.
# S07-11 (PwP)
RENAL TRANSPLANTATION IN THE VALVE BLADDER: IS BLADDER AUGMENTATION ALWAYS NECESSARY? Nicola CAPOZZA, Simona NAPPO, Giuseppe COLLURA and Paolo CAIONE Bambino Gesu` Children’s Hospital e IRCCS, Division of Paediatric Urology, Rome, ITALY
PURPOSE In patients with a fibrotic bladder secondary to posterior urethral valves (‘‘valve bladder’’), pre-emptive bladder augmentation is generally recommended in order to preserve graft function. We report our preliminary experience in children with renal transplantation in valve bladders without a preliminary augmentation.
MATERIAL AND METHODS Out of 151 pediatric candidates for renal transplantation, 15 presented with a valve bladder and were considered candidates for bladder augmentation. In 10 patients the bladder augmentation was performed prior to renal transplantation. In the remaining 5 patients with oligo/anuria the decision for the bladder augmentation
was postponed to the post-transplant period. Serum creatinine, urinary ultrasound, voiding diary were reevaluated at 1,2,3,4 and 6 months and urodynamics at 6 months follow-up.
RESULTS Out of the 5 patients, in two grafts a ureterostomy was performed. The other 3 patients had a graft ureteral reimplantation associated with a transient suprapubic catheter which allowed for frequent bladder emptying and overnight bladder drainage for 2 months. At followup the 3 patients had normal renal function with an absence of hydronephrosis. At 6 months bladder capacity improved from av.40% of expected capacity for age (range 30 to 65%) to av.95% (range 90 to 120%), with end filling bladder pressure < 30 cm H2O.
In these children bladder augmentation was judged not necessary any longer.
CONCLUSIONS In oligo/anuric valve bladder patients it can be hard to decide whether a poorly compliant bladder is due to fibrosis or to defunctionalisation. Bladder cycling before transplantation is not always tolerated. Furthermore, pre-emptive bladder augmentation can be performed several months before transplantation. We think in selected cases bladder augmentation can be avoided before transplantation, and once the normal diuresis is restored the native bladder can show significant improvement in capacity and compliance. Frequent monitoring of graft function and bladder function is mandatory.