CHAPTER 87: Preparation of the Abnormal Bladder for Pediatric Renal Transplant

INTRODUCTION

The purpose of this chapter is to discuss the work up and evaluation of the recipient bladder and to discuss how to optimize the native bladder. Many children needing renal transplantation will have renal failure secondary to lower urinary tract disease such as posterior urethral valves, neurogenic bladder from spina bifida, or other genitourinary anomalies such as Vesicoureteral Reflux, bilateral ectopic ureters, etc. There are several goals the transplant team needs to have to allow the recipient patient to have an adequate bladder reservoir for renal transplantation.

GOALS OF PREPARING THE BLADDER FOR TRANSPLANT

1. Allow for unobstructed drainage of urine into the bladder reservoir

2. Provide a low-pressure storage reservoir (pressure <30 cm H₂O)

3. Allow for volitional emptying of the reservoir while staying continent (dry for 3 hours)

   1. Normal voiding (Figure 87-1)

   2. Intermittent catheterization via the native urethra

   3. Intermittent catheterization via a continent catheterizable channel (Mitrofanoff)

4. Prevention of urinary tract infections (UTIs) and stones

PRE-TRANSPLANT ASSESSMENT OF THE BLADDER

Assessment For All Transplant Candidates

• Detailed history including

  • History of UTIs

  • Incontinence

  • Congenital abnormalities

  • Voiding diary

• Renal-bladder ultrasound

  • Bladder wall, ureteronephrosis, hydronephrosis

• Post void residual (PVR)

Detailed Assessment of the Abnormal Bladder

• Examples of “abnormal” bladders:

  • Neurogenic bladder (Figure 87-2)

  • Non-neurogenic bladder

  • Ectopic ureters

  • Vesicoureteral reflux

  • Radiation

  • Exstrophy

• VCUG (Figure 87-3)

  • Assess bladder anatomy-appearance, capacity, status of urethra, presence and grade of reflux (Figure 87-4)

  • Urodynamics (If video urodynamics are available, then VCUG is not needed) (see Figure 87-5 and Table 87-1)