Transplant in abnormal bladder

1. KIDNEY
TRANSPLANTATION
IN ABNORMAL
BLADDER
Gaurav Nahar
DNB Resident
Deptt.of Urology, MMHRC

2. INTRODUCTION
 Structural urologic abnormalities resulting in
dysfunctional lower urinary tract leading to ESRD
constitute 15% in adults & 20-30% in children.
 An abnormal urinary bladder is no longer a
contraindication to renal transplantation.

3.  Normal urinary bladder stores urine at low pressure,
does not leak and completely empties by natural voiding.
 Defunctionalized bladder: UO/p is < 300 ml in 24h, or
 Bladder that is decompressed and has not been used for
several years.
 If voiding is normal before the patient develops
oligoanuria, bladder will develop normal capacity within
a few weeks after transplantation.

4.  When intravesical pressures exceed 40 cm H2O,
ureteral transport of urine ceases and it is
mandatory to maintain intravesical pressure less
than 30 cm H2O during filling to prevent upper
urinary tract damage.

5.  Routine functional bladder studies are not indicated in
potential recipients.
 Neurovesical dysfunction: a voiding cystourethrogram
(VCUG) and a pressure flow urodynamic study with or
without cystoscopy are indicated.

6. ABNORMAL BLADDER...??
A urinary bladder may be abnormal because of
 neuropathy,
 bladder outlet obstruction (posterior urethral valve,
urethral stricture),
 acquired voiding dysfunction(Hinman syndrome),
 acquired bladder disease (interstitial cystitis, post-
radiotherapy changes, fibrosis from intravesical
chemotherapy),
 perivesicular scar (pelvic hematoma, prior ipsilateral
transplant) and
 augmented bladders.

7. UROLOGICAL EVALUATION &
MANAGEMENT
Goals:
1. Normal drainage from kidney into a reservoir,
2. A urinary reservoir should permit low-pressure
storage for a socially acceptable time,
3. volitional emptying of the reservoir with
continence,
4. absence of infection and
5. fewest surgical procedures and patient trauma.

8. Urologic evaluation includes
 a history for urologic disease and operations on
the urinary tract;
 a physical examination including the location of
scars, abdominal catheters, and stomas that may
interfere with transplantation;
 urinalysis;
 urine or bladder wash culturing; and
 ultrasonography of the abdomen and pelvis to
include a postvoid bladder image.

9.  Urodynamic testing aims to assess bladder
capacity, compliance, and emptying, as well as
sphincter function.
 Indications for urodynamic studies(UDS)
include
a known neuropathic bladder,
prior severe posterior urethral valves, and
any patient with ongoing voiding dysfunction,
hydronephrosis, or recurrent UTI.

10.  UDS in transplant patients indicate that a bladder
capacity < 100ml or voiding pressures > 100 cm H2O
may predispose to complications after transplantation
and are best served by bladder augmentation.
 Anticholinergic drugs can be used to decrease bladder
filling pressure and unstable contractions.

11. ALGORITHM FOR EVALUATION AND MANAGEMENT OF
BLADDER IN PATIENTS FOR RENAL TRANSPLANTATION

12. GENERAL PRINCIPLES
 Graft implantation in native bladder is always preferred.
 If native bladder is unsuitable, then graft may be drained
into augmented bladder (preferably), a continent
diversion or into an enteric conduit.

13.  Native dilated ureter should be preserved during
pretransplant period for possible use of bladder
correction by ureterocystoplasty, which has advantages
of no mucus secretion and metabolic abnormality.
 Routine antibiotic prophylaxis and voiding using CSIC
does not increase the risk of UTI, even in the
immunocompromised patients

14.  Patients with abnormal bladder should be sterile at the
time of transplant.
 All culture-positive UTIs should be treated with
appropriate antibiotics;
 If PVRU high- encourage double and frequent voiding.

15. PRETRANSPLANT
ISSUES

16.  The most common bladder abnormality associated with
ESRD is the low-capacity, hypertonic bladder with poor
compliance.
 Typical picture with PUV.
 Hypertonicity is the most dangerous dynamic pattern, as
it will create an obstructive condition for the kidneys,
even in the absence of reflux.

17. HYPERTONICITY
 Managed with medication as a 1st line therapy, typically
with anticholinergics, and with augmentation as 2nd line
therapy.
 Usually require a combination of anticholinergics and
CIC.
 Compliance with CIC is often an excellent test of later
patient/family compliance with the stringent
requirements of renal transplant.

18. CIC/CISC
 Use of CIC in managing abnormal bladder- a
truly revolutionary lifesaver.
 safe and effective for patients with a poor flow
rate who fail to empty the bladder.
 possible with normal urethra and cooperative
patients.
 When bowel segments are used, voiding using
CSIC does not increase the risk of UTIs, even
in the immune-compromised patients.

19.  Native urethra may be unsuitable for CISC in children
with anatomical anomalies→ difficult or painful
catheterization; consider alternate Mitrofanoff
neourethra.
 This facilitates catheterization easy, convenient and pain-
free.
 Appendix, ureter or ileum can be used.

22. CSIC TECHNIQUE

23. CSIC CATHETERS

24.  Sizes range from 6 to 12 Fr for children and 14 to 22 Fr
for adults.
 Catheters with lengths of approx.2 inches (about 40 cm)
allow for adequate passage through a male urethra.
 Women and children, with shorter urethras may suffice
for shorter-length catheter of 6 to 12 inches (20 to 40
cm).

25. VUR
 Refluxing system in immunosuppressed transplant patient may
contribute to UTI, especially when a/w voiding dysfunction.
 When VUR exists, preoperative evaluation should be
performed to rule out bladder outlet obstruction or spastic
bladder.
 Neurogenic bladders causing severe reflux may require
augmentation to produce low-pressure reservoir.
 Best- ureterocystoplasty; others- ileo-, gastrocystoplasty.

26.  Endoscopic subureteral(Deflux) injection therapy; but
not suitable for high grade reflux.
 Ureteric Reimplantation is the Gold Standard treatment.

27. PRETRANSPLANT NEPHRECTOMY
 Seldom required nowadays.
INDICATIONS

28. PERITRANSPLANT
MANAGEMENT

29. TRANSPLANT IN
URETEROSTOMY
 A preexisting native cutaneous ureterostomy may serve
as a conduit for graft ureteral drainage in select patients
with excellent long-term function.
 Donor ureter can be used to create a cutaneous
ureterostomy at the time of renal transplantation.
 Complications frequently seen- pyelonephritis,
urosepsis, stomal retraction, stomal stenosis and uretero-
ureteric anastomotic stricture.
 There is also need for repeated stomal dilatation to
prevent functionally significant stenosis.

30. TRANSPLANT IN PUV
 PUV presents management dilemma for
augmentation. Bladder that appears inadequate
before renal transplant may behave normally
once the polyuria resolves.
 On the other hand, poor-compliance bladder for
a given bladder volume may contribute or
accelerate renal failure.
 Limited intervention approach in PUV patients
resulted in better outcome than extensive
urologic procedures.

31. TRANSPLANT IN AUGMENTED
BLADDER
 Cycling can be done in augmented bladder with
reservoir filling twice a day with 300 ml NS, to maintain
adequate bladder volume and to remove enteric
secretions that can accumulate and become a source of
obstruction and infection.

32. TRANSPLANT IN INTESTINAL
CONDUIT
 Transplants into ileal conduit usually result in high
surgical complication rate although with good graft
survival rate.
 Conduit stoma should be created at least six to eight
weeks before renal transplantation.

34. TRANSPLANT IN CONTINENT
RESERVOIR
 Transplantation into continent urinary diversion
(Kock, Mainz and Indiana pouch) described.
 Problems with obstruction & infection are
common in these patients and require close
observation.
 Most patients with continent diversion empty by
CISC.
 Although this results in virtually universal
bacteriuria, the safety of CIC and renal
transplantation has withstood the test of time.

35. PEROPERATIVE MANAGEMENT
 Protocol: SPC catheter drainage to be continued for 2
weeks post-op.
 After recovery from surgical trauma, Bladder training or
CISC.
 POSTOPEARTIVE M/M:UTI - Patients with conduit,
augmentation & reservoir- urobowel is colonized with
bacteria.

36.  If the patient is asymptomatic and pyelonephritis does
not ensue, bacteriuria does not require treatment.
 Exception- colonisation with urea-splitting
organisms(ex.Proteus), predisposing to struvite stones.
 Antibiotic prophylaxis recommended for 6-12 months.

37. COMPLICATIONS
 Electrolyte abnormalities can occur depending on the
bowel segment used. Acidosis should be treated because
of its contribution to metabolic bone disease.
 Mucus production d/t to use of bowel can be dealt with
by daily bladder irrigations and use of alkalizers.
 Megaloblastic anemia associated with use of distal ileum
requires replacement with vitamin B12.

38.  Bladder or upper tract stones occur in 8-52% of patients
with bladder augmentation.
 Patients of continent diversion having large bowel have
risk of adenocarcinoma developing at the anastomosis.
Careful surveillance is indicated as chronic
immunosuppression may increase the risk of cancer.

39. CONCLUSION
 An abnormal bladder is no longer a contraindication for
renal transplant.
 Knowledge of the abnormal bladder should allow
successful transplantation with good outcome.

40. THANK YOU !!!