Preparation of the children with persistent pathology of the urinary tract to the kidney transplantation
Article published in Urologia Polska 2008/61/Supl. 1.

authors

Piotr Gastoł, Lidia Skobejko-Włodarska, Jacek Rubik, Piotr Kaliciński, Ryszard Grenda, Małgorzata Baka-Ostrowska

Klinika Urologii Dziecięcej, Instytut „Pomnik – CZD” w Warszawie
Klinika Chirurgii Dziecięcej i Transplantacji Narządów, Instytut „Pomnik – CZD” w Warszawie
Klinika Nefrologii, Transplantacji Nerek i Nadciśnienia Tętniczego, Instytut „Pomnik – CZD” w Warszawie

summary

Introduction.

Kidney transplantation (KTx) is the best method of the treatment in the end stage renal disease (ESRD). Children with persistent uropathy were disqualified from registration in the waiting list till now.

Objectives.

Methods and possibilities of the preparation of the children with uropathy to the KTx are presented in this paper.

Materials and methods.

40 children with ERSD, who did not enter waiting list to KTx because of persistent pathology of the urinary tract are presented. There were 19 boys after posterior urethral valves (puv), 10 children with reflux nephropathy, 6 with neurogenic bladder, two with prune belly syndrome, one with persistent urogenital sinus, one with congenital urethral atresia, and one with hypospadias. Cystography and urodynamic study were done in these patients. In group of 19 boys after puv, in one case ureterocutaneostomy was still opened, and in 3 vesico-ureteral reflux (VUR) was observed. In urodynamic study, high voiding pressure was observed in 7 patients, small bladder with high voiding pressure in 4, poor compliance of the detrusor muscle in 4, and normal bladder function in 4. In group of 10 children with reflux nephropathy,

in 7 persistent VUR was observed. In urodynamic study, small bladder with high voiding pressure was stated in 3 patients, unstable bladder in 1, small bladder in 2, and normal bladder function in 4. In group of 6 children with neurogenic bladder, in 3 cases poor compliance of the detrusor was stated in the urodynamic study, in 2 small bladder, and in 1 atonic bladder. Bilateral VUR V° and huge bladder with low pressure was diagnosed in both boys with prune belly syndrome. Small bladder in urodynamic study was observed in child with persistent urogenital sinus and in boy with congenital urethral atresia. High voiding pressure because of the urethral stenosis was stated in boy after hypospadias repair.

Results.

In group of 7 boys with high voiding pressure after puv, in 3 remnant valves were incised, in 2 remnant valves were incised and α-blocker agent was applied, and in 2 α-blocker was only used. After treatment all these patients entered waiting list to KTx – 3 are after transplantation, and 4 are still waiting. Among 4 boys with small bladder, in 2 cases transurethral incision (TUI) of the valves was done, in one ditropan and α-blocker therapy was used, and in one mechanical enlargement of the bladder was tried. This experiment was unsuccessful and patient was qualified to KTx with ileal conduit m. Bricker. After pharmacotherapy in one patient and TUI in one of two bladder capacity enlarged

and boys entered waiting list. In second patient after TUI bladder capacity was small and he was qualified to KTx with ileal conduit m. Bricker. Among 4 patients with poor compliance of the detrusor muscle in one TUI was done, in second ditropan and α-blocker therapy was used – after treatment these patients entered waiting list to KTx. Another two with poor compliance were qualified to KTx with ileal conduit m. Bricker at one stage. In group of 4 patients with normal bladder function, in one ureterocutaneostomy was closed, in other 3 endoscopic correction of the vesico-ureteral reflux was performed – these patients are waiting for KTx. Three children with reflux nephropathy and with small bladder with high

voiding pressure were qualified to KTx with ileal conduit m. Bricker (one with nephrectomy in the same procedure). Patient with unstable bladder after ditropan and α-blocker therapy entered waiting list to KTx. Children with normal bladder function and small bladder were qualified to KTx after: endoscopic therapy (4 children), nephroureterectomy (1 child). In one case nephroureterectomy was done during KTx, in another ureter was ligated leaving nonfunctional kidney. In 2 children with neurogenic bladder colocystoplasty with Mitroffanof was done and they are waiting for KTx. Three patients were qualified to KTx with ileal conduit m. Bricker. Child with atonic bladder waits for KTx to the bladder. In boys

with prune belly syndrome nephroureterectomy on one side was done. These patients were qualified to KTx with nephroureterectomy on the other side during the same procedure. Child with persistent urogenital sinus and small bladder was qualified to KTx with ileal conduit m. Bricker. In a boy with congenital urethral atresia, ureterocystoplasty was done with vesicostomy, and KTx to this reservoir was performed. In boy with very narrow urethra after hypospadias repair meatotomy was done, and after that he was qualified to KTx.

Conclusions.

1. Main pathologies of the urinary tract make KTx impossible are: posterior urethral valves, reflux nephropathy and neurogenic bladder. 2. Cystography and urodynamic study are the basic study in registration in the waiting list to KTx. 3. Complete destruction of the subvesical obstruction, pharmacotherapy of the vesical dysfunction and antireflux therapy allows KTx to the own bladder. 4. In case of impossibility to achieve a good bladder function children should be qualified to KTx with ileal

conduit m. Bricker or with continent urinary diversion.