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

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(1)Renal Transplant Accepted after revision: February 2, 1999. Eur Urol 1999;36:450–453. The Use of Long-Term Defunctionalized Bladder in Renal Transplantation: Is It Safe? X. Martin R. Aboutaieb S. Soliman A. El Essawy M. Dawahra N. Lefrancois Service d’Urologie et Chirurgie de la Transplantation, Hôpital Édouard-Herriot, Lyon, France. Abstract 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 pyeloureteral anastomosis using the recipient’s native ureter (4 patients). The amount of residual urine was insignificant (! 100 cm3) 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. ABC. © 1999 S. Karger AG, Basel 0302–2838/99/0365–0450$17.50/0. Fax + 41 61 306 12 34 E-Mail karger@karger.ch www.karger.com. Accessible online at: http://BioMedNet.com/karger. 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 cm3) 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.. Introduction. Ureteral reimplantation in kidney transplantation is usually performed using an anterior extravesical technique according to the principles of Lich and Gregoire [see 1], because of its simplicity and the low rate of com-. Prof. Xavier Martin Service d’Urologie et Chirurgie de la Transplantation Hôpital Édouard-Herriot, Pavillon V, Place d’Arsonval F–69437 Lyon Cedex 03 (France) Tel. +33 472110570, Fax +33 472110582, E-Mail ssoliman@soficom.com.eg. Downloaded by: King's College London 137.73.144.138 - 12/2/2017 11:28:15 AM. Key Words Kidney transplantation W Defunctionalized bladder W Ureterovesical anastomosis.

(2) Patients and Methods Patients Between 1990 and 1994, 20 patients who were on dialysis for more than 15 years underwent renal transplantation (group I): 12 men with a mean age of 41.6 (range 26–57) years and 8 women with a mean age of 48.9 (range 35–59) years. We compared these patients with another group of 20 patients transplanted at the same time, but whose duration of dialysis was less than 5 years (group II): 16 men with a mean age of 42.4 (range 26–58) years and 4 women with a mean age of 55.75 (range 53–58) years. None of the patients in either group had renal failure due to urological causes. Pre-operative evaluation of the bladder capacity in the 40 patients was done by ultrasound, retrograde cystography and bladder catheterization. Surgical Technique In 13 patients of group I, the ureterovesical anastomosis was carried out by non-stented extravesical approach, according to the principles of Lich and Gregoire [see 1]. As this technique was not possible in the other 7 cases, due to surgical difficulties like adherent mucosa, the ureteral reimplantation was converted to Politano-Leadbetter ureteroneocystostomy in 3 cases and pyelo-ureteral anastomosis (using the recipient’s native ureter) in 4 cases. In group II, the ureteroneocystostomy was done using the non-stented extravesical approach in all kidneys except one with a duplex ureter in which the PolitanoLeadbetter technique was applied (table 1).. Results. The two groups were comparable with regard to number, age, renal allograft source and post-transplantation immunosuppressive treatment. Pretransplant bladder capacity evaluation showed a significant difference between the two groups (p ! 0.001). Group I showed a mean bladder capacity of 150 (range 30–500) cm3, while in group II the mean bladder capacity was 300 (range 250–500 cm3).. Defunctionalized Bladder in Renal Transplantation. Table 1. Techniques of ureteral reimplantation. Ureteral reimplantation techniques. Group I (n = 20). Group II (n = 20). Extravesical Politano-Leadbetter Pyelo-ureteral. 13 3 4. 19 1 –. Only 2 patients in group I had residual urine after micturition (!100 cm3). Vesico-ureteral reflux was also observed in 4 patients of group I (grades I–III). The mean postoperative bladder catheterization period was 7.8 days in group I and 4.2 days in group II. There were differences in the postoperative complications between the two groups. Postoperative urinary tract infections were observed in 9 cases of group I and in 4 cases of group II (probably due to the longer period of postoperative catheterization in group I). There were no surgical complications in patients of group II, while there were 6 patients with surgical complications in group I. These 6 cases were among those patients in whom extravesical technique was not possible due to surgical difficulties, and thus we were obliged to use other anastomotic techniques. It should be noted that these 6 cases had the lowest bladder capacity (30–150 cm3). There was a significant difference in the bladder capacity between these 6 cases and the rest of the patients in group I (p ! 0.01). The complications were: stenosis after a pyelo-ureteral anastomosis (1 case), stenosis after a ureterovesical anastomosis with Politano-Leadbetter technique (1 case), 3 cases of urinary fistulae (1 with Politano-Leadbetter ureterovesical anastomosis and 2 cases with pyelo-ureteral anastomosis) and 1 case with vesico-ureteral reflux (table 2). The fistulae observed with the pyelo-ureteral technique were not at the site of the pyelo-ureteral anastomosis but at the level of the bladder where the first attempt of bladder dissection was performed. Graft losses were comparable between the two groups. There were three graft losses in group I after a mean of 79.5 (range 5–138) days and two graft losses in group II after a mean of 345 (range 180–510) days. The causes of graft losses were cellular rejection in 4 cases and a vascular cause in 1 case, with no losses due to surgical complications. After a mean follow-up period of 3 years, all bladders with a low capacity in group I had a mean capacity of 250 cm3 and a normal voiding function.. Eur Urol 1999;36:450–453. 451. Downloaded by: King's College London 137.73.144.138 - 12/2/2017 11:28:15 AM. plications. This technique is usually easy in bladders of normal capacity. The mucosa can usually be dissected easily, and an antireflux procedure can be performed. When mucosal dissection is difficult with the extravesical approach, a transvesical approach or pyelo-ureteral anastomosis can be used. Patients with a long history of dialysis often develop small defunctionalized bladders. After transplantation, such bladders usually recover a good function [2]. However, at the time of transplantation, difficulties may appear, and ureteral reimplantation, whatever the technique is, can be hazardous, leading to complications. In this study, we have compared surgical complications of ureteral reimplantation in patients with longterm defunctionalized bladders and in patients with short-term defunctionalized bladders..

(3) complications with different techniques of ureteral reimplantation. Postoperative surgical complications. Stenosis Urinary fistula Vesico-ureteral reflux. Discussion. In 1974, Tanagho [3] reported that defunctionalization of a normal bladder does not limit its ability to recover, which was further confirmed in subsequent studies [4, 5]. In adults, a contracted bladder, if due primarily to prolonged defunctionalization, should also improve with restoration of the urinary flow [2]. Serrano et al. [2] reported that bladders can be successfully restored after 26 years of defunctionalization. However, there may be instances in which chronic inflammation or previous surgery may cause extreme fibrosis leading to impaired bladder recovery, including chronic tuberculosis or schistosomiasis. In these particular cases bladder augmentation has a place [2]. The compatibility of intestinal diversions and bladder augmentations has been often documented [6, 7]. It appears that urological complications are more common in patients with intestinal segments, and thus pretransplant bladder augmentation should be reserved only for patients likely to have a bladder with a poor compliance after transplantation [8]. Gonzalez [8] also stated that pretransplant bladder augmentation should be restricted to the treatment of urinary incontinence or decreases in compliance with proved adverse effect on the upper tracts. In this study patients with small defunctionalized bladders were accepted for transplantation, as we believe that pretransplant bladder augmentation should be restricted only to fibrotic bladders with very poor compliance. Although small defunctionalized bladders will usually recover after transplantation, sometimes the surgical procedure for ureterovesical anastomosis is difficult, and morbidity may happen as a consequence. As most transplant centers, we prefer to use the extravesical ureteroneocystostomy technique derived from the principles of Lich and Gregoire [see 1]. It has been proven to be reproducible, and the morbidity is usually lower than when other techniques are used [9, 10]. On the other hand, when the dissection of the mucosa is not possible from outside, we usually use the classical Politano-Leadbetter technique. Another option is. 452. Eur Urol 1999;36:450–453. Group I. Group II. (6/20 patients). (0/20 patients). extravesical PolitanoLeadbetter (0/13) (3/3). pyelo-ureteral (3/4). extravesical PolitanoLeadbetter (0/19) (0/1). – – –. 1 2 –. – – –. 1 1 1. – – –. to use the recipient’s own ureter and perform a pyelo-ureteral anastomosis. The use of these two latter techniques has been associated with an increased rate of morbidity in our patients of group I, probably because in these patients a first attempt to dissect the bladder mucosa was performed. We, therefore, advocate in case of a small bladder not to try the classical ureteroneocystostomy but to perform as a first choice a pyelo-ureteral anastomosis. In order to lower the morbidity of transplantation in these patients with small defunctionalized bladders, we have evaluated, since 1994, 2 patients with a bladder capacity !50 cm3. A suprapubic catheter was placed under local anasthesia, and the patient was asked to inject three times per day normal saline into the bladder. The continence was tested, and micturition was then performed. An increase of the bladder capacity from 50 to 150 cm3 was achieved in the 2 patients within 6–8 weeks. The catheter was then removed, and the patient was considered ready for the transplantation. Since that time 1 patient has been transplanted with no technical problems. At surgery, the bladder capacity was sufficient to perform good submucosal dissection with good results. The other patient is still waiting. So we think that this technique is more practical for living-donor transplant, whose operation and rehabilitation can be planned. It was mentioned by Serrano et al. [2] that continuous bladder cycling before transplantation remains the best way to rehabilitate, artificially, the prolonged defunctionalized bladder. In conclusion, we think that small defunctionalized bladders can be used in kidney transplantation, but the immediate risk of surgical complications is increased. They usually recover normal capacity and function after transplantation. Rehabilitation via continuous bladder cycling in a small, low-compliant prolonged defunctionalized bladder could be of value in performing ureteroneocystostomy with less difficulties and, therefore, probably less complications. This technique could also be more practical for living-donor transplant, whose operation and rehabilitation can be planned.. Martin/Aboutaieb/Soliman/El Essawy/ Dawahra/Lefrancois Downloaded by: King's College London 137.73.144.138 - 12/2/2017 11:28:15 AM. Table 2. Postoperative surgical.

(4) References. Defunctionalized Bladder in Renal Transplantation. 5 Ross JH, Kay R, Novick AC, Hayes JM, Hodge EE, Streem SB: Long-term results of renal transplantation into the valve bladder. J Urol 1994;151:1500–1504. 6 Nguyen DH, Reinberg Y, Gonzalez R, Fryd D, Najarian JS: Outcome of renal transplantation after urinary diversion and enterocystoplasty: A retrospective, controlled study. J Urol 1990; 144:1349–1351. 7 Sheldon CA, Gonzalez R, Burns MW, Gilbert A, Buson H, Mitchell ME: Renal transplantation into the dysfunctional bladder: The role of adjunctive bladder reconstruction. J Urol 1994;152:972–975.. Eur Urol 1999;36:450–453. 8 Gonzalez R: Editorial: Renal transplantation into abnormal bladders. J Urol 1997;158:895– 896. 9 Butterworth PC, Horsburgh T, Veitch PS, Bell PRF, Nicholson ML: Urological complications in renal transplantation: Impact of a change of technique. Br J Urol 1997;79:499–502. 10 Thrasher JB, Temple DR, Spees EK: Extravesical versus Leadbetter-Politano ureteroneocystostomy: A comparison of urological complications in 320 renal transplants. J Urol 1990;144: 1105–1109.. 453. Downloaded by: King's College London 137.73.144.138 - 12/2/2017 11:28:15 AM. 1 Hinman FJR: Atlas of Urologic Surgery. Philadelphia, Saunders, 1989, vol II, sect 15, pp 637–649. 2 Serrano DP, Flechner SM, Modlin CS, Wyner LM, Novick AC: Transplantation into the longterm defunctionalized bladder. J Urol 1996; 156:885–888. 3 Tanagho EA: Congenitally obstructed bladders: Fate after prolonged defunctionalization. J Urol 1974;111:102–109. 4 Firlit CF: Use of defunctionalized bladders in pediatric renal transplantation. J Urol 1976; 116:634–637..

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