Renal transplantation in the valve bladder: is bladder augmentation always necessary?

Abstract

Purpose In patients with a fibrotic bladder secondary to posterior urethral valves (“valve bladder”), pre-emptive bladder augmentation is generally recommended in order to preserve graft function. We report our preliminary experience in children with renal transplantation in valve bladders without a preliminary augmentation. Material and methods Out of 151 pediatric candidates for renal transplantation, 15 presented with a valve bladder and were considered candidates for bladder augmentation. In 10 patients the bladder augmentation was performed prior to renal transplantation. In the remaining 5 patients with oligo/anuria the decision for the bladder augmentation was postponed to the post-transplant period. Serum creatinine, urinary ultrasound, voiding diary were re-evaluated at 1,2,3,4 and 6 months and urodynamics at 6 months follow-up. Results Out of the 5 patients, in two grafts a ureterostomy was performed. The other 3 patients had a graft ureteral reimplantation associated with a transient suprapubic catheter which allowed for frequent bladder emptying and overnight bladder drainage for 2 months. At follow-up the 3 patients had normal renal function with an absence of hydronephrosis. At 6 months bladder capacity improved from av.40% of expected capacity for age (range 30 to 65%) to av.95% (range 90 to 120%), with end filling bladder pressure Conclusions In oligo/anuric valve bladder patients it can be hard to decide whether a poorly compliant bladder is due to fibrosis or to defunctionalisation. Bladder cycling before transplantation is not always tolerated. Furthermore, pre-emptive bladder augmentation can be performed several months before transplantation. We think in selected cases bladder augmentation can be avoided before transplantation, and once the normal diuresis is restored the native bladder can show significant improvement in capacity and compliance. Frequent monitoring of graft function and bladder function is mandatory.