Review Article
Bladder Augmentation Surgery in Prospective Renal Transplant Recipients - A Nephrologist Perspective
Sufi M. Suhail*
Department of Renal Medicine, Singapore General Hospital, Singapore
*Corresponding author: Sufi M. Suhail, Department of Renal Medicine, Singapore General Hospital, DUKE-NUS Graduate Medical School, 169857, 20 College Road, Singapore
Published: 29 Dec, 2017
Cite this article as: Suhail SM. Bladder Augmentation
Surgery in Prospective Renal
Transplant Recipients - A Nephrologist
Perspective. Clin Surg. 2017; 2: 1847.
Abstract
Extrapolating success of Bladder Augmentation Surgery (BAS) in pediatric renal transplant
population to adult renal transplantation program could be a challenging action; but it would open up
an option for adult end stage renal failure patients resulting from lower urinary tract abnormalities,
who are otherwise contraindicated from transplant surgery. Currently a platform of BAS has been
developing as predicted by a significant number of papers based on this innovative and courageous
maneuver, that are being published in current renal transplant and related literature.
The definition of BAS in the context of renal allograft, and characterization in adult renal transplant
are yet to be précised in terms of indications, selection of surgical technique and transplant subjects,
and defining post-transplant outcome in short term and long term complications, graft function
and survival in addition to its’ socioeconomic impact. The methodology of BAS is nonetheless not
more complex than that of other sophisticated urological surgical procedures as practiced in related
urological issues. The complexities associated with BAS may be the major litigating factor though,
the success of BAS in pediatric transplant with its time tested relevance, could be a motivation to
practice this challenging procedure in otherwise contraindicated adult renal transplant. Moreover,
the need for a centralized guideline is also felt in recent years as more and more interests have been
being shown worldwide. In this context current status of BAS in adult renal allograft surgery needs
to be defined and would be of significant importance in clinical transplantation. This review aims to
bring the essence of BAS in adult renal transplantation to the renal physicians in a legible format.
Keywords: Bladder augmentation surgery; Renal Transplant; Nephrologist
Introduction
Although Bladder Augmentation Surgery (BAS)–known as urinary Bladder Cystoplasty
(BC) - in adult endstage renal failure patients going for elective renal transplant (RTx) is virtually
uncommon and rarely practiced currently, a nephrologist would be in a remarkably unfamiliar
zone dealing with such cases [1]. It would be of interest to the nephrologist’s perspective to get a
renewed acquaintance in that subject. The aim of this review is mainly to focus on such unfamiliar
and hitherto unrecognized situation post renal transplant. Bladder augmentation surgery or bladder
cystoplasty is done mainly to reconstruct a structurally or functionally reduced bladder volume
either due to congenital or due to acquired bladder defects [2]. It is common in pediatric urology
and non-transplant adult urological surgery. In pediatric renal transplantation bladder cystoplasty
is done in End Stage Renal Failure (ESRF) as a result of congenital urogenital malformation with
obstructive uropathy including neurogenic bladder [3]. The cystoplasty is accomplished either
as Enterocystoplasty (EC), where a patch of small intestine is auto-grafted to the bladder, or as
Ureterocystoplasty (UC), where the native ureter of a non-functional endstage kidney is used to
increase the size of the contracted urinary bladder. Both types of surgery have its own merits and
demerits.
However, the issues in terms of structural and metabolic complications in the long run may be
notably compromising the overall outcome. This needs to be understood by the nephrologist as well
as the receiving patients. Therefore a renewed understanding of the relatively unfamiliar subject
from the nephrologist’s perspectives is of paramount importance.
Indication of Bladder Augmentation Surgery
A brief review of the indications of BAS can be stratified in pediatric group and adult patients.
In both age groups BAS has indications in non-transplant conditions and transplant surgery (Figure
1 and Table 1).
Indication of BAS for pediatric non-transplant
Indication for BAS for non-transplant related conditions is to
create a low pressure but high volume urine reservoir. This permits
a notably improved continence and voiding, at the same time helps
to maintain function of upper urinary tract including integrity of
kidney. This helps preserving good renal function. The situations
where the BAS is required are congenital Vesico-Ureteric Reflux
(VUR), exstrophy of bladder, epispadias, hypospadiasis, posterior
urethral valve and congenital neurogenic bladder. In these conditions
EC is done mostly, by harvesting a segment of small intestine. This
allows fairly adequate amount of surface area with mucosal integrity
[4,5].
Indication of BAS for pediatric renal transplantation
In pediatric renal transplantation, BAS has opened up the
scope of transplantation in ESRF caused by congenital neurogenic
bladder and congenital urinary abnormalities leading to obstructive
uropathy. Not until a few decades ago, transplantation was denied in
such situations [6,7].
Indication of BAS for adult non-transplant
In adult non-transplant situations BAS remains a viable option
in both neurogenic and non-neurogenic bladder dysfunction where
conservative approach, pharmacological therapy and minimally
invasive surgeries have failed to show adequate response, and have
been shown to be unsuccessful and exhaustive [8]. Non-neurogenic
bladder is associated with infective and inflammatory disorders
of bladder. These include, interstitial cystitis, schistosomiasis,
tuberculous cystitis, interstitial cystitis/bladder pain syndrome, post
radiation cystitis and cystitis associated with systemic or intravesical
chemotherapy [9,10]. In these conditions enterocystoplasty is done
instead of ureterocystoplasty to maintain an intact upper urinary tract.
The non-transplant related BAS for neurogenic bladder refractory to
treatment is resorted to conditions associated to spinal cord injury
and spinal cord diseases including multiple sclerosis. Patients with
detrusor muscle over activity, who fails conservative measures with
anticholinergic medications, trial of intravesical botulinum toxin and
sacral neuromodulation, are considered for BAS with EC [11,12].
Indication of BAS in adult renal transplant patient for nontransplant
reasons
BAS for adult renal transplanted patients is more confined to a
fewer conditions including neurogenic and non-neurogenic bladder.
In a smaller proportion of adults, lower urinary tract structural
abnormalities causes ESRF that requires consideration for BAS
before renal transplantation. These groups of patient have had their
bladder abnormalities as mentioned above in childhood. But their
Chronic Kidney Disease (CKD) had reached ESRF requiring renal
replacement therapy in adult life. In one study less than 0.5% (24 out
of 1406 transplant) of adult transplant population had undergone
BAS with EC before renal transplant surgery with a mean interval of
9.2 (6.5-17) months between BAS and RTx [13].
Indication for BAS in adults for transplant related reason
Adults do not require BAS post renal transplant commonly, as
most transplants are done within reasonable time lapse after reaching
ESRF in most cases of living donor related renal transplant patients.
In disease donor related renal transplant we did not encounter any
requirement for BAS post-transplant in our center. However, the
occurrences of dysfunctional bladder after prolonged anuric state
during dialysis requiring period of ESRF (more than 2 years) could
pose a significant risk for post-transplant urinary retention. This is
due to disuse atrophy of detrusor muscle of the bladder wall from
prolonged anuria. When bladder outlet obstruction is excluded and
evaluation reveals the bladder not reparable or usable with acceptable
results, BAS with UC could be considered [14].
Figure 1
Figure 1
Algorithm for indication of bladder augmentation surgery in renal transplantation.
BAS: Bladder Augmentation Surgery; ESRF: End-Stage Renal Failure; UC: Uretero-Cystoplasty; EC: Entero-Cystoplasty.
Table 1
Table 1
Causes of ESRF requiring BAS related to non-transplant conditions, and related to renal transplantation.
Adaptation of Inactive Bladder
Urinary retention in the bladder is defined as persistence of urinary retention requiring Intermittent Catheterization (ISC) or Indwelling Urinary Catheter (IUC) for more than 2 months [14]. This period of 2 months is considered as post-transplant adaptation for bladder atonia when other causes of urinary retention is excluded by pre-transplant bladder evaluation for cases that are considered BAS.
Urodynamic Evaluation before Renal Transplant
Who will require urological evaluation pre-transplant?
As transplant patients are continually growing in numbers,
and as getting renal donors is increasingly becoming difficult,
these together with the consequent prolong waiting time, the state
of anuric condition in ESRF patients on dialysis, is also exceeding
the limit of 2 years in many situations. As a consequent, the risk of
bladder dysfunction from disuse related bladder atrophy pose a risk
of subsequent urinary retention post-transplant [14,15]. Along with
it the age of the prospective transplant recipients is also increasing
posing the risk of developing prostatic hypertrophy in male and
Uterovaginal prolapse in female. The likelihood of having an
associated cause of neurogenic bladder in case of diabetic neuropathy
or residual vesicoureteric reflux in adult needs to be excluded.
Urological evaluation
A plain Ultrasound Scan (US) of urinary bladder and prostate are
simple noninvasive investigations that will exclude enlarged prostate
and atrophied bladder. Presence of residual urine volume in an anuric
patient could be non-significant and merely represents bladder sweet
[12,16]. Urodynamic study including voiding cystourogram in
pre-transplant state has no role in anuric ESRF patients. However,
post-transplant persistent anuria (more than 2 months) would be
benefitted to evaluate the bladder action and post-voidal volume.
In addition to delineating possible Vesico-Ureteric Reflux (VUR),
it confirms degree of bladder atonia and requirement for BAS. In
addition, urethrocystoscopy and urethrocystography may contribute
to the objective findings of US and urodynamic study [17].
Frequency of BAS in Renal Transplant
In setting of pediatric transplant, where ESRF is commonly related to congenital urological issues, BAS is considered a better option than ileac conduit urinary diversion in transplant recipient [6,7]. In these situations BAS is done before, after or at the time of transplant depending on the individual scenario. The complications related to graft survival and urinary tract infection between each procedure does not differ significantly [18,19]. In adult setting, BAS is only considered when the ESRF was the result of same congenital abnormalities as mentioned above, where the requirement of dialysis occurred in adulthood. In other cases of ESRF from adult origin, the requirement of BAS is less than 0.5% in a large cohort of adult renal transplant [13]. The incidence of BAS in adults is a rarity in transplant literature.
Figure 2
Figure 2
(A) Bivalving of urinary bladder, (B) Stitching of detubularized
patch of ileum to the cut bladder.
Figure 3
Surgical Techniques
Native dilated ureter is used for BAS as Uretero Cystoplasty
(UC) as the native kidneys are nonfunctional rendering native ureter
unused, thus making it available when there is ureteromegally. This
procedure is much more acceptable than other alternatives like
ileac conduit as that is associated with higher incidence of urinary
tract infection and electrolyte and acid-base related metabolic
abnormalities [10,20-22]. Therefore urological evaluation before
prospective renal transplant recipients requiring BAS is required to confirm dilated ureter availability for UC. If the ureter is not dilated
UC may not be surgically possible and enterocystoplasty with a
segment of small intestine needs to be considered.
BAS technique for enterocystoplasty
In enterocystoplasty, asegment of bowel is used. A detubularized
patch of ileum is taken from near ileocecal part and anastomosed
with bladder that has been cut in a bivalve fashion to accommodate
the bowel segment (Figure 2).
BAS technique for ureterocystoplasty
In ureterocystoplasty, a detubularized part of the dilated ureter
is stitched to the bivalved bladder (Figure 3). Dilated ureters are
mobilized and opened on their anterolateral surface from 3 cm of
Uretero-Vesical Junction (UVJ). The bladder is opened in the midline
and bivalved. The medial edges of ureters are then sutured to each
other and the lateral edges were sutured to the bivalved bladder
halves. Resulting in a dome shaped bladder [23].
Table 2
Table 2
Comparative complications of BAS and post-transplant complications, graft function and survival.
Outcome of BAS in Renal Transplant
Graft survival and patient survival
One longitudinal study compared the outcome of EC and UC in
renal transplant population over a period of 20 years and compared
them with transplant patients with normal bladder. The mean follow
up period was 5 years post-transplant (n-1406 with BAS done in 24
patients) [13]. Demographic were identical in the three groups. There
was no significant difference in graft survival or patient survival at 1
year. However, 5 year graft and patient survival were non-significantly
lower in both EC and UC group as compared to normal bladder
group (Table 2).
Infective complications
Pyelonephritis requiring hospitalization of recipients occurred 23
times in EC group and six in UC group. However, 2 patients with
normal bladder had Pyelonephritis. These differences were significant
between EC and UC group (p=0.025) and EC and normal bladder
group (p< 0.001), but not between UC and normal group (p=0.31).
That indicated that UC, when possible in cases of obstructive uropathy
could be better option than EC [13].
Long-Term Complication of BAS in Renal Transplant
Graft related
There were no significant differences among the three study
groups in terms of follow-up period, and mean serum creatinine
level [13]. However in pediatric population, long term complications
include recurrent urinary tract infections. This is particularly
prevalent in cases of non-compliance to the clean intermittent selfcatheterization
for voiding and or the presence of associated Vesico-
Ureteric Reflux [1].
Other long term complications include urinary stones, perforation,
need for intermittent self-catheterization and malignancy. These are
particularly prevalent in EC rather than UC. Bladder stone has been
reported to be around 40% mainly due to stasis of urine in atonic
bladder. Increased excretion of calcium in urine, as explained below,
also contributes to urinary calculi. Most of the malignancy happened
after a prolonged latent period and mostly are adenocarcinoma [24].
Routine cystoscopy has been recommended yearly after a 10 years of
BAS [24].
Metabolic systemic complication
As intestinal epithelium is not customized to urine in physiology,
metabolic abnormalities with electrolyte and acid-base disorder may
complicate the long term morbidity. Hyperchloremic metabolic
acidosis can occur as a result of absorption of urinary ammonium
with its chloride salt, and secretion of sodium bicarbonate by the
intestinal epithelium in EC. This resembles Type 1 Renal Tubular
Acidosis (RTA) [25,26].
Chronic acidosis results in osteoporosis because of increased
bone resorption. This leads to growth retardation in children and also
causes renal stone production because of increased urinary excretion
of calcium salts [27].
Long term complications in adults
We reviewed three studies of adult BAS with long-term follow
up. The infective complications, requirement of ISC, urinary stone,
malignancy and metabolic complications were similar to those of
pediatric BAS. The graft function and survival were not affected by
BAS [28,2,13].
Current Prospective of BAS in Adult Transplantation
Perspective of nephrologist
While children with congenital urinary abnormalities with ESRF
were denied renal transplantation in the past, BAS has made that
possible with good graft and patient outcome in the current decade
[1]. Extrapolating the success in pediatric population, adults with
structural urological abnormalities with ESRF could potentially
become candidate for potential renal transplantation with BAS bringing in the hope [13]. In this perspective, the nephrologists
have a role in selection and optimization of the potential transplant
recipient, and organizing the urological procedure for BAS either
pre-transplant or post-transplant. These include urological studies
including CT KUB to delineate the lower urinary tract status, and the
urodynamic study to identify the functional integrity and capacity of
the urinary bladder. A referral to urologist for these processes could be
initiated once the nephrologist is sufficiently confident of the prospect
of BAS, and the potential recipient is clearly accepting the procedure
and outcome. In adults ESRF, whether due to urological disorders of
lower urinary tract initiated in childhood as congenital anomalies or
due to lower urinary tract obstruction with megaloureter leading to
ESRF, BAS could potentially make renal transplant a viable option
that is thought to be a challenge until now.
The issue of bladder atonia from prolonged inactivity of many
years from non-functional kidneys in patient son dialysis needs
nephrologist’s consideration of adaptation period of urinary retention
requiring intermittent catheterization or indwelling urinary catheter
for 2 months [14]. This period of 2 months is considered as posttransplant
adaptation for bladder atonia recovery. In this situation,
urological evaluation is needed to exclude other causes of urinary
retention before considering BAS.
Perspective of urologist
Perspectives of allograft recipient
As mentioned above, the apparent contraindication for
transplantation in ESRF due to congenital lower urinary tract
abnormalities and neurogenic bladder may be obviated with a
renewed prospect of BAS [1]. In addition, newly transplanted patients
with prolonged and unresolving bladder atonia post-transplant as
explained earlier requiring persistent IDC or ISC, could also become
potential candidates for BAS [14]. In this field of prospective BAS,
patients need to be educated regarding the need, risk assessment,
patients’ practice requirements, short term and long-term
complications in the post-transplant period. Motivation of patient
needs to be assessed by clinical psychologist, and impact of cost to be
evaluated by medical social service personnel. Informed consent from
the patient and their care givers needs to be documented to avoid
future legal mitigations.
Conclusion
BAS in adult renal transplantation, unlike that of pediatric transplantation, would be a change maker procedure for prospective renal transplant recipients for whom transplant would be hitherto remained a contraindication. For recipients with prolonged posttransplant bladder atonia requiring graft-lifelong IDC or ISC, with risks of recurrent UTI and graft dysfunction, BAS could pose a reasonable remedy. This field would generate interest in the renal transplant community substantially.
Acknowledgment
The author acknowledges the contribution of all relevant personnel and authors of the reference materials used in the making of this review paper.
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