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The necessity of voiding cystourethrogram in the pretransplant urologic evaluation
THE NECESSITY OF VOIDING CYSTOURETHROGRAM PRETRANSPLANT UROLOGIC EVALUATION* KEVIN
C. SHANDERA,
THOMAS
A. ROZANSKI,
AND
IN THE
GREG JAFFERS
ABSTRACT Objectives. To determine the efficacy of limited use of voiding cystourethrogram (VCUG) in the evaluation of patients for renal transplantation. Methods. A retrospective review of 439 patients who underwent renal transplantation between October 1983 and May 1995; however, since September 1993 we used VCUG selectively in the pretransplant evaluation. Results. Since September 1993, only 5 1% of our renal transplant patients had a VCUG as part of their pretransplant evaluation. Only one urologic complication has occurred in a 68-year-old man with a history of glomerulonephritis. He had an episode of acute urinary retention, which was treated successfully with a temporary suprapubic tube followed by medical therapy. Conclusions. Our preliminary results reveal no adverse outcomes associated with the selective use of VCUG in the pretransplant evaluation, and indicate that this study is of little value in the routine evaluation of these patients. UROLOGY” 47: 198-200, 1996.
he urologic evaluation of patients with endstage renal disease (ESRD) awaiting renal transplantation is extensive and costly. The procedures necessary for a sufficient evaluation are controversial with the goal of the evaluation being to identify any abnormalities that may compromise the success of the transplant. Discontinuing the routine use of a voiding cystourethrogram (VCUG) in the pretransplant evaluation has been advocated by our group and other investigators. This article discusses our results of limiting the use of VCUG and makes further recommendations for more selective use of a VCUG in the evaluation of patients for renal transplantation.
T
MATERIAL
AND METHODS
We retrospectively reviewed the records of 439 patients who underwent renal transplantation at Wilford Hall Medical Center between October 1983 and May 1995. The majority of patients 370 (84%) received a cadaveric renal allograft, 42 patients (10%) received a living-related renal allograft, 22 patients (5%) received a renal/pancreas allograft, and 5 patients (1%) received a renal/liver allograft. We reviewed our first 348 renal transplant recipients in August *The opinions or assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Departments of the Ar-my, Air- Force or De/ense. From the Department of Surgery, Urology Surgery Sewice, Brooke Army Medical Center, Department of Surgical Transplantation, Wilford Hall Medical Center, San Antonio, Texas Reprint requests: Thomas A. Rozanski, M.D., Department of Surgery, Urology Surgery Service, Brooke Army Medical Center, San Antonio, TX 78234 Submitted:]une 29, 1995, accepted (with revisions): October 2,1995 198
1992 and concluded that a routine VCUG was not essential for the pretransplant evaluation, although its use remained efficacious for patients with a history of urologic disease or urologic abnormalities on physical examination or urinalysis. Since that report, 94 additional renal transplants have been performed, 63 since adopting the selective use of VCUG in the evaluation of patients for this program.
RESULTS In September 1993, we began selectively using VCUG in those pretransplant patients with a history of urinary tract infections or pyelonephritis, diabetic nephropathy, reflux nephropathy, or in pediatric patients. Prior to this, 376 renal transplants were performed, of which 360 of these patients had a VCUG as part of their pretransplant evaluation. Fifty-three (15%) patients had an abnormal VCUG, with the most common abnormality being vesicoureteral reflux (VUR) in 37 (10.3%) patients (Table I). Between September 1993 and May 1995, 63 additional renal transplants were performed. Thirty-two (51%) patients had a VCUG. The indications for VCUG in these 32 patients included 17 whose pretransplant evaluation occurred prior to September 1993, 7 with diabetic nephropathy, 4 pediatric patients, 3 with reflux nephropathy, and 1 with a nonurologic cause of ESRD. Four (13%) of these VCUGs were abnormal with VUR diagnosed in 3 (9%) (Table II>. None of these four abnormal VCUGs occurred in patients with diabetic nephropathy. Of the patients transplanted since the selective use of VCUG, 26 have at least a 12-month followup. Of these 26 patients, 9 (35%) did not have a VCUG as part of their pretransplant evaluation, UROLOGYa 47 (21, 1996
TABLE I. Distribution of urologic abnormalities diagnosed by voiding cystourethrogram between October 1983 and August 1993 No. of Pts. 37 4 3 3 3 1 1 1
Abnormality Vesicoureteral reflux Postvoid residual (moderate) Bladder diverticulum Posterior urethral valves Urethral stricture disease Neurogenic bladder Prune belly syndrome Hematuria Total
53
Percentage (%) (n = 360) 10.3 1.1 0.8 0.8 0.8 0.3 0.3 0.3 14.7
TABLE II. Distribution of urologic abnormalities diagnosed by voiding cystourethrogram between September 1993 and May 1995 Abnormality Vesicoureteral reflux Bladder diverticulum Total
No. of Pts. 3 1
Percentage (%) (n = 32) 9.4 3.1
4
12.5
but the remaining 17 (65%) had a VCUG. In the 12 or more months since transplant, none of these 26 patients have had a urologic complication. Forty-seven patients have at least a 6-month follow-up since transplantation. Of these 47 patients, 20 (43%) did not have a VCUG, and 27 (57%) had a VCUG. Only 1 of these 47 patients has had a urologic complication. This patient, a 68-yearold man, required a temporary suprapubic tube for acute urinary retention, which was subsequently successfully treated with medical therapy COMMENT The pretransplant evaluation in patients with ESRD has typically been extensive, invasive, and expensive. Classically, the urologic portion of this evaluation has been no exception. It often includes an extensive history and physical examination, urinalysis, urine culture, renal ultrasound, and VCUG. The goal of this evaluation is to identify any urologic abnormality that might increase the morbidity or mortality associated with renal transplantation. Recently, several authors have analyzed the efficacy of this evaluation and made recommendations for a more problem-specific urologic evaluation. The VCUG is the most invasive of these tests. Barry’ suggested that a VCUG was “probably” not necessary for patients without a urologic history UROLOGY”
47 (21, 1996
and a negative urinalysis, urine culture, and renal ultrasound. Two recent articles have made an attempt to validate the efficacy of a VCUG in these patients. We reported our results in July 1993, retrospectively studying 333 patients who had a VCUG prior to renal transplantation.2 Fifty-one (15%) patients had an abnormal VCUG, of which VUR was the most common finding, occurring in 36 (11%). Two of our patients had a bladder perforation (0.6%) during VCUG. None of the abnormalities identified on VCUG prompted a pretransplant surgical procedure or resulted in a patient not being eligible for transplant. Yang et aL3 in February 1994 reported on a prospective study of the efficacy of a standardized urologic evaluation in 100 potential adult transplant recipients. A VCUG was part of this evaluation and was abnormal in 26%. The most common abnormalities included an “abnormal bladder capacity (less than 200 cc or more than 600 cc)” in 13% and VUR (more than I/V) in 6%. They recommended that potential renal transplant patients with a history of diabetes mellitus, urinary tract infections, or voiding symptoms undergo a VCUG. As a result of our original findings, we modified our indications for pretransplant VCUG to those patients with the highest risk of postoperative infectious complications, namely, pediatric patients (less than 18 years old), and patients with a history of urinary tract infection, pyelonephritis, diabetic nephropathy, or reflux nephropathy. An analysis of the results of the effect of the pretransplant evaluation on the early postoperative course in those patients transplanted since the selective use of a VCUG has demonstrated that no patient with diabetic nephropathy had an abnormal pretransplant VCUG or had a post-transplant urologic complication. A single patient with glomerulonephritis-induced ESRD developed acute urinary retention since September 1993. The controversy as to what constitutes an adequate pretransplant evaluation in patients with diabetic nephropathy is controversial. Acknowledging the possibility of neurogenic bladder in these patients, some authors have recommended an extensive evaluation to include VCUG, cystoscopy, and urodynamics.4 Jefferson and Bums5 limit their pretransplant urologic evaluation to a history and physical examination, urinalysis, and urine culture, even in diabetic patients. Barring any abnormality of these tests, they will proceed with transplantation.5 They do state that it would “probably be worthwhile to determine the postvoid residual volume in diabetic patients several months after transplantation.” Of our diabetic patients evaluated and transplanted since September 1992, none had an abnormal VCUG. Diabetic cystopathy is not a contraindication to renal transplantation; however, 199
diabetics with large postvoid residual urine volumes should be considered for intermittent bladder catheterization. This is particularly relevant for patients undergoing kidney-pancreas transplant, since urinary retention may be associated with anastomotic leaks. Bladder ultrasonography is reliable, less expensive, and a less invasive method than VCUG to evaluate postvoid urine volumes. In summary, we found no efficacy in the routine use of VCUG in the pretransplant urologic evaluation. Our preliminary results reveal no adverse outcomes associated with the selective use of VCUG in the pretransplant evaluation nor do we find VCUG efficacious in patients with diabetic nephropathy in the absence of other indications for VCUG. The majority of patients awaiting renal transplant do not require evaluation of the lower urinary tract. Pretransplant VCUG should be limited to patients with an abnormal urinaly-
200
sis or urine culture, ongoing symptoms, or a history of significant lower urinary tract disease, and highly selected cases where results might change the management of the patient. REFERENCES 1. Barry JM: Renal transplantation, in Walsh PC, Retik AB, Stamey TA, and Vaughan ED Jr (Eds): Campbell’s Urology, 6th ed, vol. 3. Philadelphia, WB Saunders, 1992, pp 2501-2520. 2. Shandera K, Sago A, Angstadt J, Peretsman S, and Jaffers G: An assessment of the need for the voiding cystourethrogram for urologic screening prior to renal transplantation. Clin Transplant 7: 299-301, 1993. 3. Yang CC, Rohr MC, and Assimos DG: Pretransplant urologic evaluation. Urology 43(2): 169-173, 1994. 4. Confer DJ, and Banowsky LH: The urologic evaluation and management of renal transplant donors and recipients. J Urol 124: 305-310, 1980. 5. Jefferson RH, and Bums JR: Urologic evaluation of adult renal transplant recipients. J Urol 153: 615-618, 1995.
UROLOGY~ 47 (21, 1996
C. SHANDERA,
THOMAS
A. ROZANSKI,
AND
IN THE
GREG JAFFERS
ABSTRACT Objectives. To determine the efficacy of limited use of voiding cystourethrogram (VCUG) in the evaluation of patients for renal transplantation. Methods. A retrospective review of 439 patients who underwent renal transplantation between October 1983 and May 1995; however, since September 1993 we used VCUG selectively in the pretransplant evaluation. Results. Since September 1993, only 5 1% of our renal transplant patients had a VCUG as part of their pretransplant evaluation. Only one urologic complication has occurred in a 68-year-old man with a history of glomerulonephritis. He had an episode of acute urinary retention, which was treated successfully with a temporary suprapubic tube followed by medical therapy. Conclusions. Our preliminary results reveal no adverse outcomes associated with the selective use of VCUG in the pretransplant evaluation, and indicate that this study is of little value in the routine evaluation of these patients. UROLOGY” 47: 198-200, 1996.
he urologic evaluation of patients with endstage renal disease (ESRD) awaiting renal transplantation is extensive and costly. The procedures necessary for a sufficient evaluation are controversial with the goal of the evaluation being to identify any abnormalities that may compromise the success of the transplant. Discontinuing the routine use of a voiding cystourethrogram (VCUG) in the pretransplant evaluation has been advocated by our group and other investigators. This article discusses our results of limiting the use of VCUG and makes further recommendations for more selective use of a VCUG in the evaluation of patients for renal transplantation.
T
MATERIAL
AND METHODS
We retrospectively reviewed the records of 439 patients who underwent renal transplantation at Wilford Hall Medical Center between October 1983 and May 1995. The majority of patients 370 (84%) received a cadaveric renal allograft, 42 patients (10%) received a living-related renal allograft, 22 patients (5%) received a renal/pancreas allograft, and 5 patients (1%) received a renal/liver allograft. We reviewed our first 348 renal transplant recipients in August *The opinions or assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Departments of the Ar-my, Air- Force or De/ense. From the Department of Surgery, Urology Surgery Sewice, Brooke Army Medical Center, Department of Surgical Transplantation, Wilford Hall Medical Center, San Antonio, Texas Reprint requests: Thomas A. Rozanski, M.D., Department of Surgery, Urology Surgery Service, Brooke Army Medical Center, San Antonio, TX 78234 Submitted:]une 29, 1995, accepted (with revisions): October 2,1995 198
1992 and concluded that a routine VCUG was not essential for the pretransplant evaluation, although its use remained efficacious for patients with a history of urologic disease or urologic abnormalities on physical examination or urinalysis. Since that report, 94 additional renal transplants have been performed, 63 since adopting the selective use of VCUG in the evaluation of patients for this program.
RESULTS In September 1993, we began selectively using VCUG in those pretransplant patients with a history of urinary tract infections or pyelonephritis, diabetic nephropathy, reflux nephropathy, or in pediatric patients. Prior to this, 376 renal transplants were performed, of which 360 of these patients had a VCUG as part of their pretransplant evaluation. Fifty-three (15%) patients had an abnormal VCUG, with the most common abnormality being vesicoureteral reflux (VUR) in 37 (10.3%) patients (Table I). Between September 1993 and May 1995, 63 additional renal transplants were performed. Thirty-two (51%) patients had a VCUG. The indications for VCUG in these 32 patients included 17 whose pretransplant evaluation occurred prior to September 1993, 7 with diabetic nephropathy, 4 pediatric patients, 3 with reflux nephropathy, and 1 with a nonurologic cause of ESRD. Four (13%) of these VCUGs were abnormal with VUR diagnosed in 3 (9%) (Table II>. None of these four abnormal VCUGs occurred in patients with diabetic nephropathy. Of the patients transplanted since the selective use of VCUG, 26 have at least a 12-month followup. Of these 26 patients, 9 (35%) did not have a VCUG as part of their pretransplant evaluation, UROLOGYa 47 (21, 1996
TABLE I. Distribution of urologic abnormalities diagnosed by voiding cystourethrogram between October 1983 and August 1993 No. of Pts. 37 4 3 3 3 1 1 1
Abnormality Vesicoureteral reflux Postvoid residual (moderate) Bladder diverticulum Posterior urethral valves Urethral stricture disease Neurogenic bladder Prune belly syndrome Hematuria Total
53
Percentage (%) (n = 360) 10.3 1.1 0.8 0.8 0.8 0.3 0.3 0.3 14.7
TABLE II. Distribution of urologic abnormalities diagnosed by voiding cystourethrogram between September 1993 and May 1995 Abnormality Vesicoureteral reflux Bladder diverticulum Total
No. of Pts. 3 1
Percentage (%) (n = 32) 9.4 3.1
4
12.5
but the remaining 17 (65%) had a VCUG. In the 12 or more months since transplant, none of these 26 patients have had a urologic complication. Forty-seven patients have at least a 6-month follow-up since transplantation. Of these 47 patients, 20 (43%) did not have a VCUG, and 27 (57%) had a VCUG. Only 1 of these 47 patients has had a urologic complication. This patient, a 68-yearold man, required a temporary suprapubic tube for acute urinary retention, which was subsequently successfully treated with medical therapy COMMENT The pretransplant evaluation in patients with ESRD has typically been extensive, invasive, and expensive. Classically, the urologic portion of this evaluation has been no exception. It often includes an extensive history and physical examination, urinalysis, urine culture, renal ultrasound, and VCUG. The goal of this evaluation is to identify any urologic abnormality that might increase the morbidity or mortality associated with renal transplantation. Recently, several authors have analyzed the efficacy of this evaluation and made recommendations for a more problem-specific urologic evaluation. The VCUG is the most invasive of these tests. Barry’ suggested that a VCUG was “probably” not necessary for patients without a urologic history UROLOGY”
47 (21, 1996
and a negative urinalysis, urine culture, and renal ultrasound. Two recent articles have made an attempt to validate the efficacy of a VCUG in these patients. We reported our results in July 1993, retrospectively studying 333 patients who had a VCUG prior to renal transplantation.2 Fifty-one (15%) patients had an abnormal VCUG, of which VUR was the most common finding, occurring in 36 (11%). Two of our patients had a bladder perforation (0.6%) during VCUG. None of the abnormalities identified on VCUG prompted a pretransplant surgical procedure or resulted in a patient not being eligible for transplant. Yang et aL3 in February 1994 reported on a prospective study of the efficacy of a standardized urologic evaluation in 100 potential adult transplant recipients. A VCUG was part of this evaluation and was abnormal in 26%. The most common abnormalities included an “abnormal bladder capacity (less than 200 cc or more than 600 cc)” in 13% and VUR (more than I/V) in 6%. They recommended that potential renal transplant patients with a history of diabetes mellitus, urinary tract infections, or voiding symptoms undergo a VCUG. As a result of our original findings, we modified our indications for pretransplant VCUG to those patients with the highest risk of postoperative infectious complications, namely, pediatric patients (less than 18 years old), and patients with a history of urinary tract infection, pyelonephritis, diabetic nephropathy, or reflux nephropathy. An analysis of the results of the effect of the pretransplant evaluation on the early postoperative course in those patients transplanted since the selective use of a VCUG has demonstrated that no patient with diabetic nephropathy had an abnormal pretransplant VCUG or had a post-transplant urologic complication. A single patient with glomerulonephritis-induced ESRD developed acute urinary retention since September 1993. The controversy as to what constitutes an adequate pretransplant evaluation in patients with diabetic nephropathy is controversial. Acknowledging the possibility of neurogenic bladder in these patients, some authors have recommended an extensive evaluation to include VCUG, cystoscopy, and urodynamics.4 Jefferson and Bums5 limit their pretransplant urologic evaluation to a history and physical examination, urinalysis, and urine culture, even in diabetic patients. Barring any abnormality of these tests, they will proceed with transplantation.5 They do state that it would “probably be worthwhile to determine the postvoid residual volume in diabetic patients several months after transplantation.” Of our diabetic patients evaluated and transplanted since September 1992, none had an abnormal VCUG. Diabetic cystopathy is not a contraindication to renal transplantation; however, 199
diabetics with large postvoid residual urine volumes should be considered for intermittent bladder catheterization. This is particularly relevant for patients undergoing kidney-pancreas transplant, since urinary retention may be associated with anastomotic leaks. Bladder ultrasonography is reliable, less expensive, and a less invasive method than VCUG to evaluate postvoid urine volumes. In summary, we found no efficacy in the routine use of VCUG in the pretransplant urologic evaluation. Our preliminary results reveal no adverse outcomes associated with the selective use of VCUG in the pretransplant evaluation nor do we find VCUG efficacious in patients with diabetic nephropathy in the absence of other indications for VCUG. The majority of patients awaiting renal transplant do not require evaluation of the lower urinary tract. Pretransplant VCUG should be limited to patients with an abnormal urinaly-
200
sis or urine culture, ongoing symptoms, or a history of significant lower urinary tract disease, and highly selected cases where results might change the management of the patient. REFERENCES 1. Barry JM: Renal transplantation, in Walsh PC, Retik AB, Stamey TA, and Vaughan ED Jr (Eds): Campbell’s Urology, 6th ed, vol. 3. Philadelphia, WB Saunders, 1992, pp 2501-2520. 2. Shandera K, Sago A, Angstadt J, Peretsman S, and Jaffers G: An assessment of the need for the voiding cystourethrogram for urologic screening prior to renal transplantation. Clin Transplant 7: 299-301, 1993. 3. Yang CC, Rohr MC, and Assimos DG: Pretransplant urologic evaluation. Urology 43(2): 169-173, 1994. 4. Confer DJ, and Banowsky LH: The urologic evaluation and management of renal transplant donors and recipients. J Urol 124: 305-310, 1980. 5. Jefferson RH, and Bums JR: Urologic evaluation of adult renal transplant recipients. J Urol 153: 615-618, 1995.
UROLOGY~ 47 (21, 1996