The use of long-term defunctionalized bladder in renal transplantation: is it safe?

OBJECTIVE: Evaluation of the use of defunctionalized bladder in renal transplantation, concerning surgical complications. METHODS: In order to assess the complication rate of ureteral reimplantation in long-term defunctionalized bladder, we compared 20 patients on haemodialysis for more than 15 years (group I) with another 20 patients on haemodialysis for less than 5 years (group II). None of these patients had renal failure due to urological causes or neurogenic bladder. Non-stented extravesical ureteroneocystostomy was done routinely in all patients except 1 in group II who underwent Politano-Leadbetter ureteroneocystostomy and 7 patients in group I who underwent Politano-Leadbetter (3 patients) and pyelo-ureteral anastomosis using the recipient's native ureter (4 patients). The amount of residual urine was insignificant (<100 cm(3)) in both groups. RESULTS: The mean postoperative bladder catheterization period was 7.8 days in group I and 4.2 days in group II. Postoperative urinary tract infections were observed in 9 cases of group I and in 4 cases of group II. No surgical complications occurred in patients of group II, while there were 6 patients with surgical complications in group I: stenosis after a pyelo-ureteral anastomosis (1 case), stenosis after a ureterovesical anastomosis with Politano-Leadbetter technique (1 case), urinary fistulae (3 cases; 1 with Politano-Leadbetter ureteroneocystostomy and 2 cases with pyelo-ureteral anastomosis), and vesico-ureteral reflux (1 case with Politano-Leadbetter ureteroneocystostomy). These 6 cases had the lowest bladder capacity (30-150 cm(3)) among our 40 patients. Graft losses were comparable between the two groups and were not due to surgical complications. CONCLUSION: Small defunctionalized bladders can be used in kidney transplantation, but it may represent an increased surgical risk due to difficulty in performing ureteral reimplantation.     

A new, unique and simple method for ureteral implantation in kidney recipients with small, defunctionalized bladders.

BACKGROUND: Major, almost insurmountable, deterrents exist to the use of the small capacity, defunctionalized, nonneurogenic urinary bladder in renal transplantation, namely, the technical difficulty in performing a satisfactory ureteral implantation with conventional methods and the potential secondary problems with high grade ureteral reflux and obstruction. Alternatives are less than ideal and include transplantation into a bowel-augmented urinary bladder with intermittent self-catheterization, ileal conduit urinary diversion, or avoidance of transplantation and relegating the patient to life-long dialysis. METHODS: Eight consecutive patients (ages 13 months to 29 years) with small, defunctionalized urinary bladders underwent a new method of intravesical implantation of the transplant ureter. The mean capacity of these bladders was 18.5+/-13.1 ml (range 6 to 45 ml), with the bladders defunctionalized for a mean 81.6+/-24.3% of the patients' total lifetime. The technique involved placement of the transplant ureter into a shallow, mucosa-denuded, rectangular trough extending from a superiorly placed ureteral hiatus distally to the trigone. We hypothesized that the mucosal margins on the two lateral aspects of the rectangular trough would grow over the anterior surface of the ureter until they met the advancing mucosal edges from the contralateral side to form a natural neosubmucosal tunnel. RESULTS: Posttransplantation cystoscopic examination demonstrated bladder mucosal regeneration and growth over the ureter, confirming the spontaneous development of a good length neosubmucosal tunnel. All patients demonstrated no evidence of ureteral reflux or ureteral obstruction, whereas an immediate prior cohort of four consecutive patients with bladder capacities < or =30 ml showed that three of four had ureteral reflux (P=0.02) and four of four developed hydronephrosis (P=0.002). All urinary bladders in the present cohort enlarged to expected normal or nearnormal capacities. Serum creatinines were stable throughout the entire follow-up period, with the exception of one patient who had rejection episodes. Two patients had urinary tract infections posttransplantation, but there were no episodes of acute pyelonephritis. CONCLUSIONS: This novel technique for ureteral implantation successfully capitalizes on the regenerative potential of the bladder mucosa, resulting in a physiological, anatomically natural, and very effective neosubmucosal tunnel. It appears to guarantee success against both ureteral reflux and obstruction, no matter how small the urinary bladder, and offers no hindrance to enlarging the bladder to near normal capacity posttransplantation. The implantation technique is simple and safe, and its use should eliminate the reluctance to use these bladders. Moreover, this procedure offers a major incentive for the successful rehabilitation of small, defunctionalized, nonneurogenic bladders after kidney transplantation.     

Frequency and nocturia after successful renal transplantation: a normal situation?

OBJECTIVE: To analyse lower urinary tract function before and after successful renal transplantation and compare the data with those from a healthy control group. PATIENTS AND METHODS: Data were gathered by retrospective analysis of 331 charts of patients transplanted between March 1998 and May 2003, using written questionnaires and personal interview, and investigation of 150 patients. The control group consisted of 150 urologically healthy volunteers. RESULTS: Frequency and nocturia were the main lower urinary tract symptoms. Frequency of more than six voids/day was reported by 87% and nocturia of more then one void/night by 93% of all patients after successful renal transplantation. There was no significant correlation with fluid intake, diuretic medication, gender or age. Over the years the number of voids tended to decrease but remained higher than in the control group. However, 94% of all patients were happy with the quality of life after renal transplantation. CONCLUSION: Frequency and nocturia are the two main characteristics of lower urinary tract function after renal transplantation, probably through a combination of high fluid intake, a long-term defunctionalized urinary bladder during renal replacement therapy, a denervated donor kidney, concomitant diseases and psychosocial distress. Quality of and satisfaction with life were not compromised.     

Terminal loop cutaneous ureterostomy in renal transplantation: an under utilized urinary diversion technique

PURPOSE: We evaluated the effectiveness of terminal loop cutaneous ureterostomy as a means of urinary drainage in kidney transplant recipients during a 20-year period. MATERIALS AND METHODS: Five cadaveric and 2 living related patients underwent kidney transplantation with terminal loop cutaneous ureterostomy between 1984 and 2004. These patients had no usable bladder or they were not suitable candidates for intermittent catheterization. RESULTS: Followup was 20 months to 17 years. One patient underwent stomal revision 5 months after renal transplantation. Current serum creatinine 4 years later was 166 mumol/l. The remaining 6 patients had no evidence of ureteral obstruction and rarely had bacteriuria or urinary tract infections. Four patients had a functioning allograft with normal serum creatinine. One patient died with a normally functioning allograft and the remaining patient lost his graft due to chronic rejection. No patient in this series lost the graft due to a urological cause. Overall outcomes included excellent allograft function with minimal infection or stomal stenotic complications. CONCLUSIONS: Terminal loop cutaneous ureterostomy is a simple, safe and alternative means of urinary diversion in patients with renal transplant and a defunctionalized lower urinary tract.     

Transplantation into the Long-term Defunctionalized Bladder

Purpose

We evaluated the outcome of transplantation into a long-term defunctionalized bladder.

Materials and Methods

Since 1985 we performed transplantation in 5 dialysis dependent patients after excision of the ileal conduit and native kidneys. The bladder was evaluated before transplantation with cystoscopy, voiding cystography, urodynamics and demonstration of continence. Bladder rehabilitation was accomplished by cycling through a suprapubic tube or urethral catheter, and no bladder augmentation was done. All patients received antibiotic prophylaxis for several years.

Results

Five male recipients underwent transplantation at ages 22, 29, 30, 31 and 55 years, and they had had a defunctionalized bladder for 15, 17, 23, 25 and 26 years. All patients were alive with a functioning allograft at 6, 84, 90, 112 and 120 months after transplantation. Current serum creatinine values are 1.2, 1.6, 1.8, 2.3 and 2.5 mg./dl. Median urodynamic values before and after transplantation were bladder capacity 60 and 300 cc, respectively, peak flow rate 5 and 18 cc per second, respectively, and post-void residual 20 and 15 cc, respectively. One patient required self-catheterization.

Conclusions

Renal transplantation into a long-term defunctionalized bladder can be performed safely in carefully selected patients. Bladder function and continence should be confirmed before transplantation using a program of progressive bladder rehabilitation.     

Nephrogenic metaplasia: long-term haemodialysis and anuria as potential risk factors and reversibility with renal transplantation

AIM.: To determine the incidence of nephrogenic metaplasia in patientswith defunctionalized bladders due to long-term end-stage renalfailure on haemodialysis. METHODS.: From the dialysis registry of the Princess Alexandra Hospital13 anuric patients who had been on haemodialysis for 10 or moreyears were identified. Of these, seven were currently awaitingrenal transplantation and six had successful transplants. Endoscopicassessment of their lower urinary tracts was performed. RESULTS.: Three cases of nephrogenic metaplasia were identified. In onecase this led to significant haematuria following transplantation.However, the changes of nephrogenic metaplasia disappeared overthe subsequent 18 months without specific treatment. CONCLUSIONS.: It appears that a chronically defunctionalized bladder in thepresence of end-stage renal failure is associated with an increasedrisk of nephrogenic metaplasia. These changes may spontaneouslyregress following transplantation and restoration of bladderfunction.     

Pyocystis in a renal transplant recipient with a defunctionalized bladder

Fever occurred in a man 6 weeks after renal transplantation. At the time of transplantation, the donor ureter had been anastomosed to a ureteroileal conduit created 6 years previously because of traumatic neurogenic bladder. Initial evaluation failed to reveal the cause of the fever, but ultimately, drainage of the defunctionalized bladder yielded a large amount of pus infected with Klebsiella pneumoniae. Our patient's course suggests that, when fever develops after renal transplantation in patients with previous urinary diversion, pyocystis should be included in the differential diagnosis.     

Hyperammonaemia due to Klebsiella infection in a neuropathic bladder

A boy with a neuropathic bladder and a single hydronephrotic kidney developed hyperammonaemic encephalopathy during a urinary tract infection with Klebsiella oxytoca. Although particularly associated with Proteus infections and prune belly syndrome, hyperammonaemia can complicate infection with any urease-producing bacteria if there is urinary stasis. Received February 9, 1998; received in revised form April 13, 1998; accepted April 14, 1998     

The defunctionalized bladder

Supravesical urinary diversion without cystectomy is a common procedure performed to manage a variety of lower urinary tract pathologies. The purpose of this article is to review the complications associated with the bladder left in situ and to relate this to the female patient. Complications related to the defunctionalized bladder include pyocystis, hemorrhage, pain/spasm and neoplastic transformation. The defunctionalized bladder also has implications for sexual function, pregnancy and undiversion. The risk factors for complications are chronic infection, inadequate drain-age, interstitial cystitis and previous irradiation. The incidence of neoplastic change in the defunctionalized bladder is low, but long-term follow-up is advised, as carcinoma could develop many decades after diversion. Sexual function following urinary diversion is better preserved when the bladder is retained.     

Nursing Care of the Patient With Neurogenic Bladder After Kidney Transplantation: A Case Report

ObjectiveUrologic complications are among the most common complications after kidney transplantation. These complications are urinary retention, hematuria, hemorrhage, urinary leakage, vesicoureteral reflux, pyelonephritis, and nephrolithiasis. Although neurogenic bladder is one of the indications for kidney transplantation, it is not considered in the literature to be an expected complication after transplantation. In this case, we discuss the nursing care of a patient who underwent kidney transplantation from a living donor and developed neurogenic bladder.Case reportA 60-year-old woman underwent kidney transplantation from a living donor, and neurogenic bladder developed in the patient 1 year after kidney transplantation. Clear intermittent catheterization treatment was administered for the kidney transplant recipient with neurogenic bladder. Clear intermittent catheterization treatment was stopped in the patient who had frequent urinary tract infections and, alternatively, sacral neuromodulation treatment was administered to the patient.ConclusionsThe nursing care of a patient with neurogenic bladder after kidney transplantation aims to prevent excessive bladder distension, infection, stone formation, vesicoureteral reflux, renal failure, urinary tract damage, and incontinence, and to ensure regular and complete discharge of the bladder. The most common treatment modalities for these objectives are permanent or intermittent catheterization, sacral neuromodulation, and medical therapy. In the care of the patient with neurogenic bladder after kidney transplantation, nurses should provide appropriate care related to treatment options and bladder training, plan urination schedules of the patient, and monitor for possible complications.     

Disappearance of hepatitis B virus core deletion mutants and successful combined kidney/liver transplantation in a patient treated with lamivudine

Hepatitis B virus (HBV) core deletion variants with enhanced viral replication are associated with rapid deterioration of liver function in renal allograft recipients. Antiviral agents such as famciclovir and lamivudine offer new treatment strategies for these patients. Appearance, accumulation and persistence of HBV core deletion mutants were closely monitored in a kidney transplant recipient with liver cirrhosis before and after initiation of antiviral treatment. Under treatment with famciclovir HBV DNA concentration decreased by 50 %, HBV mutants persisted. After replacement of famciclovir by lamivudine HBV replication was reduced below the detection limit. Lamivudine was well tolerated and liver function improved. After successful combined kidney/liver transplantation the patient became HBsAg and HBV DNA (detected by PCR) negative under continuous hyperimmune globulin and lamivudine treatment. Antiviral therapy with lamivudine may be useful in treatment of progressive liver disease associated with HBV core deletion mutants in renal allograft recipients and may enable successful liver transplantation. Received: 12 June 1998 Received after revision: 16 October 1998 Accepted: 10 November 1998     

Native pyeloureterostomy after kidney transplantation: experience in 48 cases

Necrosis and stenosis of the ureter are severe complications after kidney transplantation and occur with mean incidence of 2,9–13,4 %. Several surgical techniques like simple nephrostomy or complex urinary tract reconstruction have been applied for repair. In this study, our experience with native pyeloureterostomy (NPUS) using the native ureter is presented. Between March 1978 and June 1996, 2592 kidney transplantations were performed in our institution. In 48 patients (1,9 %), secondary urinary tract reconstruction by NPUS was necessary. These patients were evaluated retrospectively by review of the case notes. At the time of operation the mean age was 45 ± 14 years. Indications for NPUS were distal ureteral stenosis (n = 29), necrosis (n = 17), bleeding (n = 1) or iatrogenic lesion of the ureter (n = 1). The mean time period between transplantation and urinary tract reconstruction was 20 ± 23 days (range: 1–90 days) for necrosis and 404 ± 637 days (range: 14–2385 days) for stenosis. A pyeloureterostomy was technically feasible in all patients using the recipient's ipsilateral ureter. In 40 out of 48 patients the graft developed a normal function postoperatively (follow up: 39 ± 48 months). A graft nephrectomy was necessary only in one patient, because of complete pyelonnecrosis 6 days after NPUS. Two grafts were lost due to acute rejection. Data of five patients were not available > 15 years after successful reconstruction. We can conclude that NPUS is a safe and simple rescue technique for the treatment of distal ureteral complications after kidney transplantation. Therefore, this technique should be the therapy of choice when secondary reconstruction by re-ureteroneocystostomy is not possible. Received: 29 November 1999/Revised: 9 March 2000/Accepted: 27 May 2000     

Response of the fetal sheep bladder to urinary diversion

PURPOSE: In adults urinary diversion results in bladder atrophy and a rapid decrease in contractile function. Little is known about the effects of urinary diversion on bladder development. In this regard we characterized the responses of fetal sheep bladder strips obtained from animals that underwent urinary diversion. MATERIALS AND METHODS: Urinary diversion was performed on fetal sheep after 90 days of gestation (term 147 days) and bladder tissue was obtained 2 weeks later. Contractile and relaxant responses of full-thickness bladder strips were tested. RESULTS: Bladders from fetal sheep subjected to urinary diversion weighed significantly less than control fetal bladders. Histological studies demonstrated marked connective tissue infiltration and the reorganization of smooth muscle elements. Carbachol stimulated a tonic contraction, while field stimulation administered during the tonic contraction elicited a phasic relaxation or a biphasic response, consisting of an initial relaxation and then a phasic contraction in control and diverted bladders. Contractile responses of defunctionalized strips to carbachol were significantly less than those of control bladder strips. Contractile responses of defunctionalized bladder strips to field stimulation at 1 Hz. were significantly greater than those of control strips. Responses of the 2 sets of fetal bladder strips to higher frequencies were similar, as were the contractile responses to adenosine triphosphate and KCl. Field stimulated relaxations in the presence of carbachol stimulated contraction of defunctionalized bladder strips were significantly greater than those of control strips, while the relaxant responses of each set of fetal bladder strips to isoproterenol and nitroprusside were similar. CONCLUSIONS: Urinary diversion in normal fetal sheep resulted in marked structural changes, reduced carbachol stimulation and increased field stimulation relaxation.     

Outcome of renal transplantation after urinary diversion and enterocystoplasty: a retrospective, controlled study

A total of 17 patients with intestinal urinary diversion of enterocystoplasty underwent renal transplantation between 1970 and 1988. Patient age ranged from 4 to 35 years (mean age 20 years). The patients were divided into 2 groups. In group 1 (10 patients, 2 of whom required retransplantation) the ureter of the transplanted kidney was implanted into an ileal (7) or colonic (1) conduit or enterocystoplasty (2). In group 2 (7 patients, 1 of whom required a second transplant) the diversion was taken down and the transplanted ureter was implanted into the defunctionalized bladder. There were 14 living related and 6 cadaveric kidneys transplanted. Graft survival rates were 58 and 87% in groups 1 and 2, respectively, with an over-all rate of 70% (14 of 20 kidneys). There was no statistical difference in the graft survival rate between the 2 groups. The complications in group 1 included ureteroileal anastomotic leak (3 patients), ureteroileal stenosis (1), calculus formation (1), urosepsis (1), hyperchloremic metabolic acidosis (1), and wound infection and dehiscence (1). There were no complications in group 2. Renal transplantation into a pre-existing urinary intestinal conduit or augmented bladder does not statistically adversely affect patient or graft survival. However, the complication rate is much higher when the ureter is implanted into an intestinal segment. Therefore, it is preferable whenever possible to implant the ureter into the native bladder.     

Postoperative adaptation of urinary bladder to variable volume of urine in the initial period following kidney transplantation

OBJECTIVES: Postoperative adaptation of urinary bladder is a process involving all patients after kidney transplantation that is facilitated by improve surgical techniques and new perioperative protocols. METHODS: The study enrolled 102 kidney transplant recipients whose transplantations were performed between 2000 and 2002. The function of urinary bladder was examined: on the day of operation and 2, 4, 8, 12, 16, and 24 weeks following operation. Patients were assessed with respect to bladder adaptation in relation to the period of dialysis. RESULTS: In patients undergoing dialysis up to 24 months, the maximum speed of flow increased from the 2nd week postoperation and regained normal values after 12 weeks. Volume of micturition, cystometric volume, and compliance regained proper values after 24 weeks of observation. CONCLUSION: The findings confirm that adaptation of the bladder is faster among patients who have had dialysis for longer than 12 months. The most useful, economical, and noninvasive assessment of bladder function was obtained with uroflowmetry in combination with daily bladder diary.     

Reconstruction of necrotic kidney graft pelvis with a vascularized small bowel patch

Complete necrosis of the pelvis in a transplanted kidney is a rare but particularly severe complication that generally requires removal of the graft. Here, the case of a patient is reported in whom complete necrosis of the ureter and the pelvis occurred a few days after transplantation, while kidney function was excellent. After resection of all necrotic tissue, reconstruction of the pelvis was performed with a vascularized small bowel patch fixed to the renal parenchyma at the border of the intrarenal pelvis. The native ureter was then anastomosed to this reconstructed pelvis. Although the patient suffered from recurrent urinary tract infections in the early postoperative phase, he is now well, with normal kidney graft function and unimpaired urine flow through the reconstructed urinary tract, 18 months after transplantation. This report demonstrates that successful surgical reconstruction after complete necrosis of the renal pelvis in a grafted kidney can be achieved, although the long-term outcome of this graft-saving technique remains to be seen. Received: 15 November 1999 Revised: 31 March 2000 Accepted: 15 November 2000     

Significance of urodynamic assessment of lower urinary tract in dialysis patients before renal transplantation

INTRODUCTION: Some dialyzed patients suffer from lower urinary tract (LUT) anatomic and functional disturbances. Complete LUT assessment should be performed to decide whether they can be included on the waiting list, because such disorders, if not diagnosed and properly treated before transplant, may lead to graft loss. PATIENTS AND METHODS: Based on data in the medical records of 4170 dialysis patients, 535 were selected for further investigation: 265 patients after undergoing urethrocystography or urethrocystoscopy, were included on the waiting list for transplantation and 145 patients underwent nephroureterectomy owing to reflux, nephrolithiasis, polycystic renal disease, or hydronephrosis. Five patients with urethral or bladder neck stricture underwent urethral dilation or bladder neck incision. These patients were also ultimately listed for transplantation. Twenty-two patients, with serious LUT disease were qualified for kidney transplantation after extra-anatomic urine outflow. Ninety-eight patients underwent a urodynamic study (URD) to assess LUT disturbances. RESULTS: Of 535 studied patients, 460 (86%), including those who underwent surgical or pharmacologic treatment, were ultimately listed for kidney transplantation. Out of 98 patients who underwent a URD, 45 (46%) were included for kidney transplantation, and 47 for transplantation with atypical urinary outflow. Six patients were excluded from transplantation owing to refusal of investigations or serious contraindications. CONCLUSIONS: All potential kidney recipients should undergo proper evaluation of the LUT before being qualified for kidney transplantation. This study allows selection of patients who should undergo surgical and/or pharmacologic treatment before transplantation.     

A case report: occurrence of bladder carcinoma in the defunctionalised bladder in a patient after operation of left ureteral carcinoma]

An eighty year-old woman was diagnosed as left ureteral carcinoma and right dysfunctional kidney in 1984. Left partial ureterectomy, partial cystectomy, and left ureterocutaneostomy were performed and her bladder was left behind after the operation. In 1990 (72 months after the operation), she was aware of bleeding from the urethra. A bladder wash was performed, demonstrating malignant cells on cytological examination, and cystoscopy revealed a papillary tumor in the defunctionalized bladder. Total cystectomy was performed and the histological findings of the surgical specimen showed transitional cell carcinoma, grade 2, pTaNoMo. This case shows the need for periodic examinations of the defunctionalized bladder, because renal pelvic and ureteral carcinoma tends to recur in the bladder within two years after operation and because tumors rarely developed in the defunctionalized bladder.     

Acute renal failure due to obstruction in Burkitt lymphoma

 Acute renal failure in Burkitt lymphoma is commonly the result of tumor lysis syndrome. We present a 15-year-old boy who developed hypertension, seizures, and acute renal failure due to extrinsic compression of the bladder and ureters by a large retrovesical Burkitt lymphoma. The causes of acute renal failure in Burkitt lymphoma and the incidence of acute urinary obstruction in this disease are reviewed. Received: 18 May 1998 / Revised: 30 June 1998 / Accepted: 1 July 1998     

The Boari bladder flap: an effective continent stoma for the high‐compliance neurogenic bladder

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To determine if a continent urinary stoma can be created effectively using a Boari bladder flap (BBF) technique.

PATIENTS AND METHODS

Selected patients (15, eight women and seven men) with a neurogenic bladder and a bladder compliance of >20 mL/cmH₂O had a procedure to create a BBF continent urinary stoma. The technique consisted of tubularising a trapezoidal, full‐thickness detrusor flap 10 cm long, 5–6 cm wide at the base and 2 cm at the tip, over a 12 F catheter, and plication of detrusor muscle around the stomal base. Outcomes after surgery were assessed by reviewing stomal continence, stomal patency, and stability of the upper urinary tract.

RESULTS

Ten BBF procedures were performed using native detrusor muscle, four with enterocystoplasty tissue and one in a defunctionalized bladder. Over a mean follow‐up of 13 months, 11 patients had functioning stomas and 10 of these reported complete stomal continence. The mean change in serum creatinine level from the preoperative baseline for all patients was 0.1 mg/dL. The odds ratio for procedural failure, defined as a stoma unusable for self‐catheterization, was 7.5 (P = 0.04) when the BBF was created from augmented or defunctionalized bladder tissue, compared to native high‐compliance detrusor.

CONCLUSION

A BBF can be used to create a viable, functional stoma in the high‐compliance neurogenic bladder, although the rate of stomal complications is high when the BBF is created from enterocystoplasty tissue.