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      Kidney transplantation in abnormal bladder

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          Abstract

          Structural urologic abnormalities resulting in dysfunctional lower urinary tract leading to end stage renal disease may constitute 15% patients in the adult population and up to 20-30% in the pediatric population. A patient with an abnormal bladder, who is approaching end stage renal disease, needs careful evaluation of the lower urinary tract to plan the most satisfactory technical approach to the transplant procedure. Past experience of different authors can give an insight into the management and outcome of these patients. This review revisits the current literature available on transplantation in abnormal bladder and summarizes the clinical approach towards handling this group of difficult transplant patients. We add on our experience as we discuss the various issues. The outcome of renal transplant in abnormal bladder is not adversely affected when done in a reconstructed bladder. Correct preoperative evaluation, certain technical modification during transplant and postoperative care is mandatory to avoid complications. Knowledge of the abnormal bladder should allow successful transplantation with good outcome.

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          Most cited references 48

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          Prognostic value of urodynamic testing in myelodysplastic patients.

          We herein describe the clinical progress of 42 myelodysplastic patients studied urodynamically and followed for a mean of 7.1 years. Urodynamic evaluation included urethral pressure profilometry, simultaneous determination of urethral pressure, intravesical pressure and external anal or external urethral sphincter electromyography with fluoroscopic voiding cystourethrography. Assessment of urethral function showed 36 patients (86 per cent) with an open vesical outlet and nonfunctional proximal urethral. Cystometrography revealed that 7 of 42 patients (17 per cent) had reflex detrusor activity: 4 with coordinated micturition and 3 with detrusor-sphincter dyssynergia. Thirty-five patients (83 per cent) had areflexic detrusor dysfunction: 5 with atomic detrusor response and 30 with a progressive increase in pressure with increasing volume. The intravesical pressure at the time of urethral leakage was 40 cm. water or less in 20 patients and at pressures greater than this value in 22 patients. No patient in the low pressure group had vesicoureteral reflux and only 2 showed ureteral dilatation on excretory urography. In contrast, of the patients in the higher pressure group 15 (68 per cent) showed vesicoureteral reflux and 18 (81 per cent) showed ureteral dilatation on excretory urography. Thus, a striking relationship between the urethral closure pressure and intravesical pressure at the time of urethral leakage and the clinical course in this group of myelodysplastic patients is demonstrated. Every patient with a normally closed vesical outlet was continent on intermittent catheterization and an anticholinergic agent, while only 60 per cent of patients with open bladder outlets similarly treated achieved good urinary control and none was dry. An artificial sphincter device would seem to be a reasonable method to achieve urinary control in the latter patients but the detrusor response to filling also must be considered. Detrusor hypertonia should be controlled or controllable before a sphincter augmenting device can be used safely. Treatment options for patients with high urethral closure pressures include intermittent catheterization and anticholinergic medications or a sphincter ablative procedure to decrease the outlet resistance combined with anticholinergic therapy and implantation of an artificial sphincter. However, only longer followup will determine if these therapeutic regimens will prevent upper urinary tract deterioration.
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            Renal transplantation following renal failure due to urological disorders.

            Renal allograft outcome, during an 8 year period (1985-1992), has been assessed in 56 renal transplants performed in 55 patients who had end-stage renal failure as a consequence of urological abnormalities. The abnormalities were: primary vesicoureteric reflux (VUR) or renal dysplasia (26 patients); posterior urethral valves (PUV) (15); neuropathic bladders (6); vesico-ureteric tuberculosis (5); bladder exstrophy (3); and prune belly syndrome (1). Six patients had augmented bladders, and eight transplants were performed in seven patients with urinary diversions. Overall, 1 and 5 year actuarial graft survival was 89 and 66%, with mean creatinine of 154 micromol/l +/- 11 (SE) and 145 +/- 9 respectively. Patients with abnormal bladders or conduits (n = 28) had worse graft function than those with normal bladders (n = 28) although graft survival was not significantly different in the two groups at 1 and 5 years: 93 and 75% with normal bladders vs 86 and 57% with abnormal systems. Symptomatic urinary tract infections were common in the first 3 months after transplantation (63%); fever and systemic symptoms occurred in 39% with normal bladders and 59% with abnormal bladders. Urinary tract infection directly contributed to graft loss in six patients with abnormal bladders, but had no consequences in those with normal bladders. Abnormal bladders must be assessed urodynamically before transplantation, and after transplantation adequacy of urinary drainage must be re-assessed frequently. Prophylactic antibiotics are now given for the first 6 months and urinary tract infections must be treated promptly. With these measures, good results, similar to those of patients without urological problems, can be obtained.
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              Clinical and urodynamic evaluation after ureterocystoplasty and kidney transplantation.

              We assessed clinical and surgical results in renal transplantation candidates with voiding dysfunction and end stage renal disease who underwent bladder augmentation. We analyzed 8 patients 3 to 30 years old with dilated ureters, voiding dysfunction and end stage renal disease who underwent renal transplantation following bladder augmentation from 1995 to 2003. The etiology of bladder dysfunction was neurogenic bladder in 3 patients, posterior urethral valves in 3 and vesicoureteral reflux in 2. All cases were assessed by ultrasonography, voiding cystourethrography and urodynamic studies. Mean followup was 50 months (range 4 to 93). Previous urodynamic evaluation revealed a bladder capacity of 75 to 294 ml (mean +/- SD 167.38 +/- 77.32) and an intravesical pressure of 28 to 100 mm H2O (mean 51.25 +/- 22.17). Urodynamic study after augmentation and kidney transplantation showed a bladder capacity of 191 to 400 ml (mean 335.25 +/- 99.01) and an intravesical pressure of 15 to 35 mm H2O (mean 28 +/- 9.45). Mean serum creatinine was 1.65 mg/dl (range 0.8 to 2.5). All patients remained continent. Three patients with neurogenic bladder empty the bladder by clean intermittent catheterization and the others empty by the Valsalva maneuver. None of the grafts were lost and the most common complication was asymptomatic urinary tract infection. Bladder augmentation is a well-known procedure for low capacity and poorly compliant bladders even in candidates for a renal transplant. Ureterocystoplasty combines the benefits common to all enterocystoplasties without adding to complications or risks.
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                Author and article information

                Journal
                Indian J Urol
                IJU
                Indian Journal of Urology : IJU : Journal of the Urological Society of India
                Medknow Publications (India )
                0970-1591
                1998-3824
                Jul-Sep 2007
                : 23
                : 3
                : 299-304
                Affiliations
                Department of Urology and Nephrology, Muljibhai Patel Society for Research in Nephrourology, Muljibhai Patel Urological Hospital, Nadiad - 387 001, Gujarat, India
                Author notes
                For Correspondence: Dr Mahesh Desai, Department of Urology, Muljibhai Patel Urological Hospital, Nadiad - 387 001, Gujarat, India. E-mail: mrdesai@ 123456mpuh.org
                Article
                IJU-23-299
                10.4103/0970-1591.33728
                2721610
                19718334
                © Indian Journal of Urology

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Symposium

                Urology

                transplantation, augmentation, abnormal bladder

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