End-Stage Renal Disease and Bladder Dysfunction: Algorithm for Renal Transplantation W.C. Nahas, E. Mazzucchi, I. Antonopoulos, F.T.E. Denes, E. David-Neto, L.E. Ianhez, and S. Arap T HE BLADDER properties of urinary storage in a low-pressure regimen and regular emptying with no residual urine are very important for the preservation of the upper urinary tract. If the pressure inside the reservoir is high or it can’t be adequately emptied, the kidney will be jeopardized and the renal function impaired. These patients were considered poor candidates for kidney transplant (K Tx). In the last 15 years, with the acceptance of clean intermittent bladder catheterization (CIC) even for trans- planted patients, a better knowledge of the bladder physi- ology, and the use of intestinal segments for reconstruction of the bladder, this group of patients now has the opportu- nity for renal transplantation. 1–3 The aim of this study was to propose an algorithm for patients with ESRD and contracted, inelastic, poorly com- pliant bladder or urinary diversion, who need to be submit- ted to a renal transplantation. MATERIAL Records from 29 patients with bladder dysfunction or urinary diversion who underwent 30 transplants (Tx) between 1987 and 1999 were reviewed. Mean age was 24 years (6 to 46 years); 11 were female, and 18 were male. The etiology of the bladder dysfunction was neurogenic bladder (10 patients), reflux (seven patients), posterior urethral valve (five patients), tuberculosis (four patients), a complex urological anomaly (two patients), and interstitial cystitis (one patient). Initial study included cystography, ultrasound, uro- dynamic evaluation, and loopogram. Patients with bladder dysfunction and poor bladder capacity (,100 mL) were submitted to bladder cycling; after improvement of bladder capacity, a urodynamic evaluation was done. Twenty-four patients with poor bladder compliance were sub- mitted to bladder enlargement. In six patients their own urinary tract (ureter and/or pelvis) was initially used. Three of them were successful; in three others, who had been previously submitted to a ureteric reimplantation, the augmentation failed and they were submitted to a second enlargement with an intestinal segment. In the total, 21 bladders were augmented with an intestinal segment (ileum, 14 patients; sigmoid, five patients; ileocecum, one patient; ileum 1 sigmoid 1 patient), including the three initially enlarged with the ureter. A detubularized bowel segment was utilized in all patients enlarged after 1987; two cases treated before that were submitted to a nondetubularized ileocystoplasty and a sigmoidocystoplasty. The bladder enlargement was performed before transplantation in all patients except two. The abnormal bladder function was not recognized in one and the other developed interstitial cystitis after KTx. Two patients presented a complex urological anomaly: one had a cystectomy done 18 years before and was maintained with an external incontinent ileal conduit (Bricker), and another with a bilateral ectopic ureterocele and a dwarf bladder was submitted to an external urinary continent reservoir with a Mitrofanoff proce- dure. They were considered candidates for K Tx into a urinary reservoir. Three patients with urinary diversion, one Bricker and two cutaneous ureterostomies, had their bladder refunctionalized. The bladder developed a good capacity and the compliance was con- sidered adequate. They were prepared for the transplant with a refunctionalized bladder. The kidney was placed extraperitoneally in the iliac fossa in a classic way and, whenever possible, the ureter was implanted into the bladder with an antireflux procedure. The transplant was performed at least 10 to 12 weeks after the urinary reconstruction. Twenty-one had received a kidney from a living donor and eight from a cadaveric donor. The ureter was implanted into the bladder in 15 patients; into the bowel segment in five patients, and anastomosed with the native ureter in two patients. A Foley catheter was maintained for a minimum of 10 days in all enlarged patients. RESULTS Bladder capacity and compliance in all augmented patients were markedly improved, except in three initially submitted to ureterocystoplasty who were reoperated on and submit- ted to a second enlargement with an intestinal segment (ileum, two patients; colon, one patient) with good evolu- tion. The follow-up ranged from 1 to 101 months (m 5 38). All patients with neurogenic bladder except one, and an additional one because of a posterior urethral valve use CIC to empty their bladder and are on prophylactic antibiotic therapy. The actuarial renal allograft survival was 92%, 87%, and 78% at 12, 36, and 60 months, respectively, and the mean creatinine level was 1.4 (0.7 to 2.4). One patient in the group, submitted to an enterocystoplasty, has received a second transplant; the first was lost after 39 months due to From the Division of Urology, University of Sao Paulo School of Medicine Hospital, Sao Paulo, Brazil. Address reprint requests to Dr William C. Nahas, R. Fernandes de Abreu, 288, ap 61, 04543-070 Sao Paulo, Brazil. 0041-1345/01/$–see front matter © 2001 by Elsevier Science Inc. PII S0041-1345(01)02281-3 655 Avenue of the Americas, New York, NY 10010 2984 Transplantation Proceedings, 33, 2984–2985 (2001)