Ureteric implantation into the bowel portion of augmented bladders during kidney transplantation: a review of urological complications and outcomes.

Background: In patients with bladder augmentation undergoing kidney transplantation, conventional technique recommends anastomosing the transplanted ureter to the bladder. We report our technique of ureteric implantation into the bowel portion of the enterocystoplasty, and review the urological outcomes of transplantation in these patients.

Methods: Seven patients (mean age: 26 years (range 24-54 years), two females, five deceased donors) with augmented cystoplasty and subsequent kidney transplantation by a single surgeon from 2011 to 2015 were reviewed. Following standard vascular anastomosis and reperfusion of the transplanted kidney, ureteric implantation involved continuous 5/0 polydiaoxanone anastomosis between the spatulated ureter and full thickness bowel portion of the cystoplasty over a 6-Fr double J stent. A second peri-anastomosis layer of bowel plication was performed to prevent reflux using interrupted 3/0 vicryl sutures. Short-term urological and kidney function outcomes were evaluated.

Results: Causes of renal failure included: posterior urethral valve with reflux nephropathy (two patients), bilateral vesicoureteric reflux (two patients), lumbosacral agenesis with neurogenic bladder (one patient), tuberculosis of the urinary tract with post-infective ureteric stricture (one patient), and lupus nephritis (one patient). Bladder reconstruction was performed at median duration of 103 months (35-171 months) before transplantation. Gastrocystoplasty was performed in two patients while colon and/or ileum were used in the remaining six. After transplantation, all reconstructed bladders except one had a Mitrofanoff for clean intermittent self-catheterization, 5-8 times per day. There were no post-operative ureteric/surgical complications. Delayed graft function occurred in three of seven patients. 30-day asymptomatic bacteriuria rate was three out of seven after stent removal. 1-year post-transplantation, patient and graft survival were 100%. Mean serum creatinine was 142.7 (standard deviation: 51.48). Median number of hospital admissions for urinary tract infections was 0.225 (range 0-0.40). Over a median follow-up period of 4 years (2-7 years), one graft failed from acute T-cell-mediated rejection. This patient passed away from cardio-respiratory collapse after a seizure, 35 months post-transplantation. As of June 2018, the other six kidney grafts were functioning. No complications including calculi formation and/or malignancy were reported.

Conclusion: In patients with previously augmented bladders now undergoing kidney transplantation, ureteric implantation into the bowel portion of the cystoplasty appears to be safe.