Bladder salvage in children with congenital lower urinary tract malformations undergoing renal transplant
Arianna Mariotto1, Tamas Cserni1, Mahmoud Marei Marei2
1Department of Paediatric Urology, Royal Manchester Children's Hospital, Oxfords Road, Manchester, M139WL, UK.
Insights
A structured bladder optimization program helps identify salvageable bladders in children with Congenital Lower Urinary Tract Malformations (CLUTM) undergoing renal transplant. This approach achieves safe transplantation and native bladder salvage in 57% of cases, preventing unnecessary diversions.
Area of Science:
- Pediatric Nephrology
- Urology
- Transplantation Surgery
Background:
- Congenital Lower Urinary Tract Malformations (CLUTM) increase the risk of post-transplant complications if bladder dysfunction is not addressed.
- Pretransplant assessment can be challenging in patients with prior urinary diversion.
- Low capacity, low compliance, or high-pressure overactive bladders may necessitate transplantation into a diverted or augmented system.
Purpose of the Study:
- To evaluate a structured bladder optimization and assessment program for safe renal transplantation in children with CLUTM.
- To identify potentially salvageable native bladders and prevent unnecessary bladder diversion or augmentation.
- To improve outcomes for pediatric patients with CLUTM undergoing renal transplantation.
Main Methods:
- Retrospective analysis of 130 children undergoing renal transplant between 2007 and 2018.
- Urodynamic studies were performed for all patients with CLUTM.
- Bladder optimization strategies included anticholinergics, Botulinum toxin A (BtA) injections, undiversion, bladder cycling, Clean Intermittent Catheterisation (CIC), and Suprapubic catheter (SPC) placement as indicated.
Main Results:
- Of 35 patients with CLUTM, 20 (57%) received transplants into their native bladders.
- Ten patients initially requiring diversion were successfully optimized for native bladder transplantation.
- 11 patients underwent ileal conduit diversion, and 4 had bladder augmentation; 8 required assistance with bladder drainage.
Conclusions:
- A structured bladder optimization and assessment program enables safe renal transplantation in children with CLUTM.
- This approach achieves a 57% native bladder salvage rate, reducing the need for diversion or augmentation.
- The proposed program facilitates safe transplantation and preserves native bladder function where possible.
Introduction:
Patients with Congenital Lower Urinary Tract Malformations (CLUTM) have increased risk of post-transplant complications if bladder dysfunction is not addressed. Pretransplant assessment may be difficult if urinary diversion has been previously applied. In case of low capacity and/or low compliance and/or high-pressure overactive bladder, transplantation into a diverted or augmented system may be required. We hypothesised that a bladder optimization pathway may help identify potentially salvageable bladders and prevent unnecessary bladder diversion or augmentation. We propose a structured bladder optimisation and assessment programme for safe transplant and native bladder salvage.
Material And Methods:
Data of 130 children who underwent renal transplant between 2007 and 2018 were retrospectively collected and analysed. All patients with CLUTM were assessed by urodynamic study. Bladder optimisation: Low compliance bladders were managed with anticholinergics and/or Botulinum toxin A (BtA) injections. Those who had urinary diversion for their pathology underwent a structured assessment and optimisation process with undiversion/anticholinergics/BtA/bladder cycling/Clean Intermittent Catheterisation (CIC)/Suprapubic catheter (SPC) as indicated. Details of medical and surgical management were collected (Figure 1).
Results:
Between 2007 and 2018, 130 renal transplants were done. Of these, 35 (27%) had associated CLUTM (PUV in 15, neurogenic bladder dysfunction in 16, other pathology in 4) which was managed in our centre. Ten patients needed initial diversion in the form of vesicostomy (2) or ureterostomy (8) to manage primary bladder dysfunction. The median age at transplant was 7.8 years (range 2.5-19.6). After bladder assessment and optimisation, a safe bladder was demonstrated in 5 of 10 with initial diversion leading to transplant into native bladder (without augmentation). Overall, of the 35 patients, 20 (57%) had transplant into native bladder, 11 patients had ileal conduits and 4 had bladder augmentation. Eight required help with drainage: three with CIC, four with Mitrofanoff, and one had reduction cystoplasty.
Conclusion:
With a structured bladder optimisation and assessment programme, safe transplant and 57% native bladder salvage is achievable in children with CLUTM.
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