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1. KIDNEY TRANSPLANTATION IN ABNORMAL BLADDER Dr Krishan Suyal

2. 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.

3. 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.

4. o 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 1- neuropathy, 2- bladder outlet obstruction (posterior urethral valve, urethral stricture), 3- acquired voiding dysfunction (Hinman syndrome), 4- acquired bladder disease (interstitial cystitis, post- radiotherapy changes, fibrosis from intravesical chemotherapy), 5- perivesicular scar (pelvic hematoma, prior ipsilateral transplant) and 6- augmented bladders.

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

8. Urologic evaluation includes 1 a history for urologic disease and operations on the urinary tract; 2 a physical examination including the location of scars, abdominal catheters, and stomas that may interfere with transplantation; 3 urinalysis; 4 urine or bladder wash culturing; and 5 ultrasonography of the abdomen and pelvis to include a postvoid bladder image.

9. 6 Urodynamic testing aims to assess bladder capacity, compliance, and emptying, as well as sphincter function. Indications for urodynamic studies(UDS) include 1. a known neuropathic bladder, 2. prior severe posterior urethral valves 3. 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. AUGMENTATION TYPES 1- Autoaugmentation 2-conventional Enterocystoplasty 3- Gastrocystoplasty 4- Ureterocystoplasty 5- Seromuscular Enterocystoplasty

16. Ureterocystoplasty 1. Patients without reflux – Success directly related to pre-op diameter of ureter (> 1.5 cm with good results). 2. Patients with reflux – - Preoperative urodynamics predictive of success when good compliance noted (including refluxing ureter), but further big increases in capacity and compliance post- op not noted. - Poor success if pre-op urodynamics with poor compliance (including refluxing ureter) nearly all patients requiring re augmentation1

17. Autoaugmentation

18. AUTOAUGMENTATION Cartwright and Snow 17 patients - average age 10 years All with spinal dysraphism Mean f/u 75 months 71% clinical failures Upper tract deterioration Persistent incontinence 93% urodynamic failures

19. AUTOAUGMENTATION Cartwright and Snow 1/3 increased capacity 2/3 improved compliance 23% required secondary augment Trends - Good results Near normal capacity but poor compliance Trends - Poor results Bladder Exstrophy Multiple prior bladder operations

20. Seromuscular Enterocystoplasty

21. PRETRANSPLANT ISSUES

22. 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.

23. HYPERTONICITY Managed with medication as a 1st line therapy , - anticholinergics, and with augmentation as 2nd line . 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.

24. CIC/CISC ( Lapides ) Use of CIC in managing abnormal bladder- a truly revolutionary lifesaver . o safe and effective for patients with a poor flow rate who fail to empty the bladder. o 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.

25. 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.

26. CSIC CATHETERS

27. Sizes range from 6 to 12 Fr for children and 14 to 22 Fr for adults. Catheters with lengths of approx. 1 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).

28. 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.

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

30. PRETRANSPLANT NEPHRECTOMY o Seldom required nowadays. INDICATIONS

31. PERITRANSPLANT MANAGEMENT

32. TRANSPLANT IN URETEROSTOMY o A preexisting n at i v e cutaneous ureterostomy m ay serve as a c o n d u i t for graft ureteral dr ai n a g e in select patients with e x cel l en t l ong-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.

33. 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.

34. TRANSPLANT IN AUGMENTED BLADDER o 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.

35. 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.

36. TRANSPLANT IN CONTINENT RESERVOIR Transplantation into continent urinary diversion - Kock, Mainz and Indiana pouch . 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.

37. P OST OPERATIVE 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.

38. 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 .

39. 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.

40. 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.

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

42. THANK YOU !!!