Bladder evaluation in transplant patients: are we overdoing it?
Sujata Patwardhan1,2, Ankit Dr. Vyas1.
1Department of Urology, Seth GS Medical College & KEM Hospital, Mumbai, India; 2Director in Charge, Regional and State organ transplant organization(ROTTO-SOTTO), ROTTO-SOTTO Mumbai, Mumbai, India
Introduction: It is a common practice to perform detailed bladder evaluation(DBE) in patients awaiting transplant surgery, with previous research by some noted authors Yang(1994), Peter(2004), Antoniewicz(2015) supporting this. ESRD patients on maintenance haemodialysis for more than a year eventually become anuric. For their bladder evaluation, it becomes imperative to catheterize and fill the bladder retrogradely. Catheterization thus may need to be done as high as three times, for ultrasonography (USG), micturating cystourethrogram (MCU) and uroflowmetry (UFR). This leads to bacterial colonization in bladder and results in colonisation of the lower tract and a nidus for repeated reinfection. Aim of our study is thus to find out the necessity for detailed bladder evaluation in all patients & how low-capacity poor flow bladders fare post-operatively.
Methods: We studied 80 patients retrospectively for detailed reports on bladder evaluation and their follow up till one year post transplant.
Results: A very high incidence of pyelonephritis (70%) in our post- transplant patients who has undergone DBE. Additionally, some patients are still advised bladder cycling. 85%(68) of patients even with no prior history of lower urinary tract dysfunction (LUTD) or Genitourinary Tuberculosis(GUTB) had a small capacity bladder on USG and /or poor flow pre-operatively. However, in majority (90%) of them, bladder capacity and urine flow normalize as soon as urine production starts. Only a few (7 out of 68) having healthy but low capacity bladder with poor flow required some form of intervention.
Conclusions: Patients who have healthy bladders prior to progressing to ESRD and becoming anuric fare well in post-transplant period as soon as urine production starts even if they are found to have small capacity, low flow in pre-transplant period. DBE in such patients can not only lead to overtreatment, waste resources but also increases infectious complications. Thus, we can omit MCU& UFR in pre transplant evaluation. Only baseline USG to measure bladder capacity and thickness is all that is required. Detailed evaluation reserved only for patients having past-history of LUTD, GUTB, or bladder dysfunction like posterior urethral valves. Thus, by carefully selecting the patient, we minimized the post-transplant pyelonephritis infectious complications to 29%.
Dr. Tukaram Jamale, Professor and Head, Department of Nephrology, Seth GSMC & KEMH All Urology and Nephrology Residents.
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