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Initial results from a feasibility study on a novel approach to bladder cycling prior to transplant: Can we avoid bladder augmentation?
Sameer Mittal, MD, MSc, Aznive Aghababian, BS, Lauren Dinardo, BS, Dana Weiss, MD, Christopher Long, MD, Stephen Zderic, MD, Jason Van Batavia, MD, Douglas Canning, MD.
The Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Background: Controversy exists regarding the management of small, defunctionalized bladders prior to renal transplant (RT). Our hypothesis is that a novel method for bladder cycling would increase bladder volume in preparation for RT.
Methods We retrospectively analyzed patients evaluated from 2014-2019 for clearance during the pre-transplant work-up. We included patients on near life-long renal replacement therapy secondary to primary renal disease or bilateral nephrectomy that presented with small, defunctionalized bladders presumed to be embryologically normal. Bladder Cycling Method: After placement of a suprapubic tube, the bladder was exposed to constant pressure of 20cmH20 by mounting irrigation bags so the meniscus would remain at 20cm above the bladder for the majority of the day. Patients underwent imaging with ultrasound and tube exchange under anesthesia every 2-3 months, with assessment of bladder capacity.
Results: To date, 5 patients have undergone our novel method of bladder cycling. 4/5(80%) of these patients were recommended to undergo bladder augmentation at an outside institution [Table 1]. 4/5 (80%) were successfully able to have a percutaneous cystotomy tube placed into the small capacity bladder [Table 2]. No UTIs or unintended return to OR was noted. Bladder volume increased consistently with duration of cycling and with regimen adherence [Figure 1]. 4/5 patients have undergone successful RT without requiring additional procedures.
Conclusions: Our initial results with a novel method of bladder cycling before RT have encouraging results. Further follow-up and enrollment in this protocol will further elucidate which patients will benefit from this protocol with the aim to avoid unnecessary bladder augmentation.

Table 1: Baseline characteristics of patients enrolled in a novel method for bladder cycling
Pt	Age at initiation(years)	Gender	Etiology of ESRD	Lifelong renal replacement	Estimated urine output daily	Previous attempt at manual bladder distention	Previous recommendation for bladder augmentation
1	2.1	Male	Bilateral MCDK, Bilateral VUR	Yes	<5cc	Yes	Yes
2	2.6	Male	Congenital renal dysplasia; WT1 s/p bilateral nephrectomies	Yes	0	No	No
3	3.6	Female	Bilateral Renal Agenesis	Yes	0	Yes	Yes
4	2.1	Male	Bilateral Cystic Dysplasia	Yes	<5cc	Yes	Yes
5	3.2	Male	Bilateral Cystic Dysplasia; Denys-Drash s/p bilateral nephrectomies	Yes	0	Yes	Yes

Table 2: Intraoperative and post-procedure outcomes after enrollment in bladder cycling
Pt	Placement of suprapubic tube	Bladder volume at first evaluation	Required bladder cycling	Adherence with bladder cycling regimen	Renal transplant performed	Follow-up time since transplant (months)	Lower tract issues after transplant
1	Percutaneous	<5	Yes	Yes	Yes	17.0	None
2	Percutaneous	<5	Yes	Yes	Yes	10.2	None
3	Percutaneous	<5	Yes	No	Pending	-	-
4	Open	<5	Yes	Yes	Yes	56.4	Frequency
5	Percutaneous	8	Yes	Yes	Yes	14.3	None

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