1 Urology Journal UNRC/IUA Vol. 1, 1-4 Winter 2004 Printed in IRAN Kidney Transplantation A Comparison of Augmentation Cystoplasty Before and After Renal Transplantation with the Control Group BASIRI A*, SIMFOROOSH N, KHODDAM R, HOSEINI MOGHADDAM MM, SHAYANI NASAB H Urology and Nephrology Research Center, Shahid Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran ABSTRACT Purpose: We compared two surgical methods of augmentation cystoplasty (AC), before and after renal transplantation, and the outcomes of both methods with trans- plant patients with normal bladder function. Materials and Methods: 1520 kidney transplantations were performed at Shahid Labbafinejad Center between March 1988 and February 2002 of which 36 cases was accompanied with AC. In 20 patients (group A) AC was performed before transplan- tation. This group consisted of 14 males and 6 females with a mean age of 26.1 (13- 39) at the time of transplantation. Sixteen patients consisting of 11 males and 5 females (mean age 27.3, 12-44) underwent AC after transplantation. Eventually 40 transplant patients with normal bladder function were assigned in the control group including 18 males and 22 females with a mean age of 31.2 (11-55) (group C). Results: Normal graft function was achieved in 16, 13, and 33 patients of groups A, B, and C respectively over the mean follow-up of 70, 59, and 76 months (p<0.7). Mean serum creatinine during the follow-up was 1.48±0.4, 1.7±1, and 1.4±0.55 for groups A, B, and C respectively. 9, 12, and 17 patients (26, 64, and 34 cases) with UTI requiring hospital admission were observed in the 3 groups respectively. The incident of UTI and the resultant hospitalization in group B was more than the one in group C (p<0.03), but it did not differ significantly from group A to group C. Conclusion: AC is a safe and effective method to improve the lower urinary sys- tem function and with the exception of increased risk of UTI following AC after transplantation (group B), there is no considerable difference in the complication rates between AC before and after renal transplantation. As a result, we can perform AC before or after kidney transplantation in patients with dysfunctional lower uri- nary tract system up to their specific conditions. KEY WORDS: augmentation cystoplasty, renal transplantation, dysfunctional bladder Accepted for publication A COMPARISON OF AUGMENTATION CYSTOPLASTY BEFORE AND AFTER RENAL TRANSPLANTATION WITH THE CONTROL GROUP INTRODUCTION The idea of kidney transplantation of patients with reconstructed bladder is fairly new. In 1966 Kelly and colleagues introduced kidney trans- plantation in a patient with dysfunctional blad- der who had undergone ileal conduit.(1) In 1982 Marshall performed pyeloileocecocystoplasty suc- cessfully in a patient with transplanted kidney hydronephrosis due to dysfunctional bladder.(2) Since then a number of studies has been pub- lished reporting successful AC in renal trans- plant patients(3, 4), but these few studies has been done with very small sample sizes and short term follow-ups. It is of controversy whether to perform AC before or after the transplant proce- dure and the appropriate time of AC in associa- tion with transplantation is not defined yet. MATERIALS AND METHODS 1520 kidney transplant was performed at Shahid Labbafinejad Center between March 1988 and February 2002. 20 patients with dysfunction- al lower urinary tract system not responded to conservative therapies had undergone AC during these years and afterwards they received trans- planted kidney due to ESRD. The GI segments used in reconstruction were ileum in 15, sigmoid colon in 1, and gaster in 4 cases. These patients (group A) included 14 males and 6 females. Mean age was 26.1 (13-39) at the time of transplanta- tion. Mean interval between transplantation and AC was 33.4 (6-52) months. Group B consisted of 16 ESRD patients (11males and 5 females, mean age 27.3, 12-44) suffering from dysfunctional bladder in whom transplantation was performed and AC served as the next step. The GI segments used were ileum in 13, sigmoid colon in 2, and gaster in 1 cases. Mean interval between the two procedures was 27.2 (2-108) months. We assigned 40 transplant patients with nor- mal lower urinary system in group C as the con- trol group. In order to avoid bias, the next 2 patients who underwent transplant just after each case of group A by the same surgeon were assigned. The resultant group included 18 males and 22 females and their mean age was 31.2 (11- 55). Graft function was evaluated by serum creati- nine in this study and the three groups were assessed by measuring mean serum creatinine level, episodes of acute rejection, and episodes of fever due to UTI contributed to hospitalization. In addition, graft loss and mortality in each group were compared with another. Results were analyzed by Chi-square test (Fisher's exact test) and Leven test. Significant P value was identified as p<0.05. RESULTS Mean follow-up was 70 (14-85) months in group A, 59 (22-70) months in group B, and 76 (20-84) months in group C. no significant difference was seen between the mean follow-ups of them (p>0.1). male to female ratio was 14/6 in group A, 11/5 in group B, and 18/22 in group C, indi- cating a difference between groups A and C (p<0.04). mean ages of the three groups were 26.1±9, 27.3±11, and 31.2±8 respectively, without any meaningful differences. Frequency of acute rejection episodes was approximately similar in groups A, B, and C (1.3±1.1, 1.5±0.9, and 1.1±1 respectively). 2.7±2, 3.8±2.1, and 1.2±0.9 episodes of pyelonephritis occurred in the three groups respectively, show- ing a considerable difference between groups B and C (p<0.02), but the differences between groups A and C (p>0.1) and groups A and B (p>0.08) was not significant. Graft loss was seen in 4(20%), 3(18%), and 7(17%) cases respectively, which was not meaningfully different from each group to another (p>0.7). mortality rate was 2 in group A, one during the dialysis and one due to liver disease and cirrhosis. One patient died in group B of urosepsis following cystoplasty and one death occurred in group C while transplant procedure was in process. No statistic difference was seen in the mortality rates of the groups (p>0.07). The mean duration of warm ischemia was 60±14.4 seconds in group A, 78±23 seconds in group B, and 91.9±63 seconds in group C. There was one living related donor transplant in group A while there was no related donor in group B. In group C, 6 patients received kidney from related donors. A significant difference was observed between this group and group B (p<0.03). DISCUSSION 2 A COMPARISON OF AUGMENTATION CYSTOPLASTY BEFORE AND AFTER RENAL TRANSPLANTATION WITH THE CONTROL GROUP Appropriate function of lower urinary system is necessary in order to maintain kidneys intact- ness. Bladder must have a proper volume and a high compliance providing proper reservation and emptying with low pressure. Augmentation cystoplasty is a known method in the treatment of bladder dysfunction when it does not respond to conservative therapies. In 1997 Alfery and coinvestigators reported the outcomes of performing AC prior to renal trans- plantation in 10 children with ESRD. Because of catastrophic complications they recommended performing urinary conduit before transplanta- tion instead of AC.(5) However, our study findings suggest that AC in ESRD patients before or after renal transplantation is safe and complications are tolerable. No definite recommendation about the order of AC and renal transplantation has been yielded up to the present time. In 2000 Power and coworkers retrospectively studied the outcomes of renal transplantation in 10 patients who had previously undergone AC. over a 27 months fol- low-up no mortality was reported and one graft lost. They concluded that renal transplantation in patients who had undergone cystoplasty because of dysfunctional bladder is practicable.(6) Thomolla and colleagues evaluated 8 transplant recipients in a retrospective study of whom 7 had augmented bladder prior to transplantation (group A) and 1 had undergone AC after trans- plantation (group B). In the latter case urinary leakage occurred contributing to additional sur- gery. They stated that in patients with low capac- ity and low compliance bladders not responded to conservative therapies, performing AC preceding renal transplantation in order to provide desir- able bladder reservoir and high compliance is preferred.(7) While McInerney and Mundy described the results of renal transplantation coupled with AC in 8 cases and according to com- plications such as mucous impaction and pyocys- titis (dry cystoplasty) in patients with augment- ed cystoplasty prior to transplantation (group A) and probable injury to the pedicle of intestinal segment in transplantation in this group, they suggested a 3 to 6 months interval transplanta- tion and subsequent AC.(8) Fontaine presented the outcomes of 10 group A and 4 group B recip- ients of cadaveric kidneys over an 8 month fol- low-up in his study. A complication such as dry cystoplasty was rare and he concluded that AC is safe to be done either prior or after renal trans- plantation.(9) Our findings indicated that AC is viable in renal recipients and its complications are accept- able. As no dry cystoplasty was observed in group A, it seems to be a rare condition seen only in anuric and severe oliguric patients. Complications were similar in groups A and B with the exception of more UTI episodes in group B. no meaningful difference in graft func- tion was observed. Eventually, it seems that AC is safe in renal transplant patients and viable either prior or after transplantation. CONCLUSION The decision of when to perform AC in ESRD patients seems to be dependent on the patient condition. For instance, in anuric or severe olig- uric patients it is better to delay AC 3 to 6 months after transplantation, when urinary out- put has improved and immunosuppressive agents has reached the maintenance dose, in order to avoid dry cystoplasty complication. Also in patients with low capacity and low com- pliance bladder in which irreversible fibrosis has not occurred yet, increasing urinary output may raise the bladder volume and a few months fol- low-up is preferred after transplantation as in some cases the improvement of bladder function may dispute the necessity of AC. REFERENCES 1. Kelly WD, et al. Ileal urinary diversion in con- jugation with renal homotransplantations. Lancet 1966; 1: 222. 2. Marshall FF, Smelev JK, Spees EK, Jeffs RD, Burdick JF. The urologic evaluation and man- agement of patients with congenital lower urinary tract anomalies prior to renal trans- plantation. J Urol 1982; 127: 1078. 3. Yamazaki Y, Tanabe K, Ota T, Ito K, Toma H. Renal transplantation into augmented dys- function bladder. Int J Urol 1998 Sep; 5 (5): 423-7. 4. Burns MW, Watkins SL, Mitchell ME, Tapper D. Treatment of bladder dysfunction in chil- 3 A COMPARISON OF AUGMENTATION CYSTOPLASTY BEFORE AND AFTER RENAL TRANSPLANTATION WITH THE CONTROL GROUP dren with end stage renal disease. J Ped Surg 1992; 27: 170. 5. Zaragoza MR, Ritchey ML, Bloom DA, McGuire EJ. Enterocystoplasty in renal transplantation candidates: urodynamic eval- uation and outcome. J Urol 1993; 150: 1463. 6. Barnett MG, Bruskewitz RC, Belzer FO, Sollinger HW, Uehling DT. Ileocystoplasty bladder augmentation and renal transplanta- tion. J Urol 1987; 138. 7. Thomalla JV, Mitchell ME, Leapman SB, Filo RS. Renal transplantation into the dysfunc- tional bladder. J Urol 1989; 141: 265. 8. Sheldon CA, Gonzales R, Burns MW, Gilbert A, Buson H, Mitchell ME. Renal transplanta- tion into the dysfunctional bladder: the role of adjunctive bladder reconstruction. J Urol 1994; 152: 972. 9. McInerney PD, Picramenos D, Koffman CG, Mundy AR. Is cystoplasty a safe alternative to urinary diversion in patients requiring renal transplantation? Eur Urol 1995; 27: 117. 10. Nahas WC, Mazzucchi E, Antonopoulos A, David-Neto E, Ianhez LE, Sabbaga E, Arap S. Kidney transplantation in patients with blad- der augmentation: surgical outcome and uro- dynamic follow-up. Proc 1997; 29: 157. 11. Fontaine E, et al. Renal transplantation in children with aubmentation cystoplasty: long- term results. J Urol 1998 Jun; 159 (6): 2110-3. 12. Power RE, et al. Renal transplantation in patients with augmentation cystoplasty. BJU Int 2000 Jul; 86 (1): 28-31. 4