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Treatment of bladder dysfunction in children with end-stage renal disease
M W Burns1, S L Watkins, M E Mitchell
1Department of Surgery, Children's Hospital and Medical Center, Seattle, WA 98105.
Insights
Pediatric renal transplant patients often need bladder reconstruction before transplantation. Augmenting the bladder improves function, leading to infection-free outcomes and successful kidney transplants in children.
Area of Science:
- Pediatric Urology
- Nephrology
- Transplantation Surgery
Background:
- Pediatric renal transplant management differs significantly from adults.
- Obstructive uropathy and bladder dysfunction are common in children with end-stage renal disease (ESRD).
- Small-capacity, poorly compliant bladders pose challenges for successful renal transplantation.
Purpose of the Study:
- To evaluate the efficacy of pre-transplant bladder augmentation in pediatric renal transplant recipients.
- To assess the impact of restoring bladder compliance and improving emptying on transplant outcomes.
- To recommend a management strategy for pediatric patients with ESRD requiring renal transplantation.
Main Methods:
- Retrospective review of pediatric renal transplant cases since 1985.
- Identification of patients with obstructive uropathy/dysplasia and bladder dysfunction.
- Pre-transplant bladder augmentation (e.g., gastrocystoplasty) followed by ureteral reimplantation.
- Postoperative monitoring of bladder function using voiding cystourethrography (VCUG) and urodynamics.
- Assessment of allograft function and complication rates.
Main Results:
- Of 50 pediatric renal transplants, 13 (26%) had obstructive uropathy/dysplasia.
- Five children presented with small-capacity, poorly compliant bladders.
- Children undergoing bladder augmentation and subsequent transplantation into the reconstructed bladder were infection-free.
- All patients demonstrated successful voiding per urethra and maintained functioning allografts.
Conclusions:
- Urological reconstruction, including bladder augmentation, is recommended prior to renal transplantation in select pediatric patients.
- Transplanting into a reconstructed, compliant bladder improves functional outcomes and reduces complications.
- Comprehensive follow-up, including urodynamic assessment, is crucial for long-term success.
Abstract:
The appropriate management of the urinary bladder in patients requiring a renal transplant is significantly different in children than in adults. The etiology of end-stage renal disease (ESRD) in 13 of 50 children (26%) transplanted since 1985 was obstructive uropathy/dysplasia. Five of these children had small-capacity, poorly compliant bladders. Our current approach is to restore bladder compliance, improve emptying, and transplant into the restored bladder rather than divert. Pretransplant gastrocystoplasty was performed in three children and the donor ureter was implanted into the augmented bladder. One child awaits transplantation following his bladder augmentation. Bladder function is followed postoperatively by voiding cystourethrography (VCUG) and urodynamics. All of the children who have received transplants into augmented bladders are infection-free, voiding per urethra, and have functioning allografts. We recommend: (1) an initial VCUG in all children; (2) complete urodynamics, if appropriate; (3) urological reconstruction to include augmentation prior to transplantation; (4) transplantation into the reconstructed bladder; and (5) comprehensive follow-up including regular urodynamic assessment.