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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2013  |  Volume : 24  |  Issue : 3  |  Page : 602-604
Bilateral ureterocystoplasty: A new technique for augmentation of bladder in transplant patients


The Nephro-urology and Kidney Transplantation Center, Urmia University of Medical Sciences, Urmia, Iran

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Date of Web Publication24-Apr-2013
 

How to cite this article:
Bartani Z, Taghizade AA. Bilateral ureterocystoplasty: A new technique for augmentation of bladder in transplant patients. Saudi J Kidney Dis Transpl 2013;24:602-4

How to cite this URL:
Bartani Z, Taghizade AA. Bilateral ureterocystoplasty: A new technique for augmentation of bladder in transplant patients. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2020 May 29];24:602-4. Available from: http://www.sjkdt.org/text.asp?2013/24/3/602/111084
To the Editor,

Augmentation cystoplasty is indicated in pa­tients with neurogenic bladder in whom con­servative therapy has failed. [1] Several tissues can be used for augmentation. An ideal tissue for increasing capacity and improving com­pliance should have transitional epithelium that is relatively impermeable and will avoid the occurrence of metabolic changes. Such an alternative procedure is ureterocystoplasty.

We report here about a 17-year-old male kidney transplant patient with bilateral grade IV vesicoureteral reflux and features resem­bling a neurogenic bladder, who underwent ureterocystoplasty. He was transplanted after nine months on dialysis with a kidney from his brother. He remained well during post-trans­plantation for several weeks, but developed two episodes of pyelonephritis needing admis­sion. Urodynamic studies confirmed the diag­nosis of neurogenic bladder with low compliance [Figure 1]A.
Figure 1: A) Cystography before surgery, B) cytography after surgery.

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Here, we faced a special scenario of a kidney transplanted patient with neurogenic bladder and bilateral chronic pyelonephritis. Thus, he was a candidate for bilateral nephrectomy and obviously needed augmentation cystoplasty to save the transplant. As the ureters were mode­rately dilated, we planned to use both of them (bilateral ureterocystoplasty) for ureterocystoplasty in order to effectively enhance the bladder volume and compliance.

The operation started with a midline incision and entering peritoneal cavity. Both kidneys were quite small and both ureters were mode­rately dilated and were full of pus. First, bila­teral simple nephrectomy was performed. Then both dilated ureters were mobilized and opened on their anterolateral surface to 3 cm of uretero-vesical junction (UVJ) [Figure 2]A. The blad­der was opened in the midline and bivalved. The medial edges of ureters were then sutured to each other and the lateral edges were su­tured to the bivalved bladder halves. The final result was almost a dome-shaped bladder [Figure 2]B. Suprapubic catheter was inserted through the native bladder wall, and a Foley's catheter was inserted per urethra.
Figure 2: A) Both ureters opened anterolaterally; B) final aspect.

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After three weeks from the time of surgery, the urethral catheter was removed following a cystography [Figure 1]B. Short-term follow-up of the patient showed good bladder capacity with no leakage, and he was put on clean inter­mittent catheterization (CIC). Further follow-up after four months revealed that patient was continent and had no post-void residual urine (PVR).

Pharmacological manipulation and CIC are major advances in management of vesicoureteric reflux, but surgery for bladder augmen­tation is often necessary. [1] There are well-recog­nized long-term complications associated with the use of gastrointestinal segments. [2],[3] There­fore, augmentation cystoplasty is still the best surgical method for correcting storage and emptying problems of the bladder. In patients with massive reflux to the ureter, which is draining poorly, it is reasonable to use the ureteral tissue to augment the bladder. Although a refluxing ureter is generally considered more suitable, the obstructed mega-ureter may also be used successfully. [4] This procedure avoids the known risks of gastrointestinal segments and will result in less metabolic changes due to the presence of transitional epithelium in the ureter similar to that present in the bladder and also eliminates the tubular ureter as a source of infection. [4],[5],[6],[7]

Further follow-up is needed in this patient to confirm its long-term efficacy and safety. However, we feel that this could be considered as a new surgical method in patients needing cystoplasty and having dilated ureters, espe­cially if they are transplant candidates.

 
   References Top

1.Synder HM. Principles of pediatric urinary reconstruction: A synthesis. In: Gillenwater JY, Grayhack JJ, Howards JJ, et al, eds. Adult and Pediatric Urology. Chicago: Year Book Medical Publishers; 1987. p. 1726-81.  Back to cited text no. 1
    
2.Rink RC, Mitchell ME. Physiology of lower urinary obstruction. Urol Clin North Am 1990; 17:329-34.  Back to cited text no. 2
    
3.Khoury JM, Webster GD. Evaluation of augmentation cystoplasty for severe neuro­pathic bladder using the hostility score. Dev Med Child Neurol 1992;34:441-7.  Back to cited text no. 3
    
4.Goldwasser B, Webster GD. Augmentation and substitution enterocystoplasty. J Urol 1986; 135:215-24.  Back to cited text no. 4
    
5.Adams MC, Mitchell ME, Rink RC. Gastrocystoplasty: An alternative solution to the pro­blem of urological reconstruction in the severely compromised patient. J Urol 1988;140 (5 Pt 2):1152-6.  Back to cited text no. 5
    
6.McDougal WS. Metabolic complications of urinary intestinal diversion. J Urol 1992;147: 1199-208.  Back to cited text no. 6
    
7.Mahan JD, Mentser MI, Koff SA. Complications of intestinal augmentation and substitution cystoplasty. Pediatr Nephrol 1994;8;550-7.  Back to cited text no. 7
    

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Correspondence Address:
Zohreh Bartani
The Nephro-urology and Kidney Transplantation Center, Urmia University of Medical Sciences, Urmia
Iran
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DOI: 10.4103/1319-2442.111084

PMID: 23640646

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