Pre-transplant bladder rehabilitation in patients with abnormal lower urinary tracts

A retrospective experience with preoperative lower tract evaluation, bladder rehabilitation and transplant outcome in patients with major abnormalities of the lower urinary tract is presented. From more than 1000 renal transplants during a 23-year period, 11 patients required either augmentation cystoplasty (7 cases) or supravesical conduit diversion (4 cases) in preparation for transplantation. The causes of bladder abnormality were neurogenic, dysfunctional voiding, posterior urethral valves, congenital atresia, and acquired contracture in 4, 3, 2, 1 and 1 cases respectively. Lower tract evaluation began with voiding history and voiding cystourethrogram. Patients with incontinence or near zero bladder capacity were managed with supravesical diversion. Continent patients were studied further with serial cystometrograms via percutaneous suprapubic catheters during trials of bladder cycling to study bladder compliance. Continent patients with abnormally high bladder pressure (greater than 75 cm water) and/or low bladder capacity (less than 100 ml) underwent augmentation cystoplasty with intestinal segments. To date, 10 renal transplants have been performed in 8 patients with a cumulative graft survival of 70%, with follow-up of 13 months to 3 1/2 yr. Two patients with bladder augmentation are awaiting transplantation. The final patient died of suspected pulmonary embolus following bladder augmentation and subsequent development of a bowel obstruction. Additional morbidity consisted of 8 episodes of urinary infection in 6 patients and 1 case of bleeding at the augmentation cystoplasty suture line. These results suggest that, with careful lower tract evaluation, patients with major bladder abnormalities may safely undergo renal transplantation into a rehabilitated bladder in most cases, or into a supravesical conduit when necessary, and can achieve satisfactory graft survival and low morbidity. A prospective plan for pre-transplant lower tract evaluation is offered.