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Outcomes with bladder cycling in pediatric renal transplantation
Anneliese Fisher, BS, Joseph Randall, MD, Ioana Fugaru, MD, Mac, Pramod Reddy, MD, Eugene Minevich, MD, W. Robert DeFoor, MD, MPH, Michael Daugherty, MD, MHI, Alex Bondoc, MD, Charles Varnell, MD, MS, David Hooper, MD, Cassie Hulme, PhD, MPH, Brian VanderBrink, MD, Andrew Strine, MD, MPH.
Cincinnati Children's, Cincinnati, OH, USA.
BACKGROUND: Safe bladder storage is important for preservation of renal allograft function in children with a small, poorly compliant, and/or defunctionalized bladder undergoing renal transplantation. Urinary diversion or bladder augmentation may be required but carry significant long-term morbidity. Intermittent bladder cycling has been proposed to improve the bladder storage characteristics in children undergoing renal transplantation.
METHODS: We performed a single-center retrospective cohort study of children who underwent bladder cycling with renal transplantation between 2009 - 2025. The primary outcome was the change in the percentage of age- or weight-based expected bladder capacity (EBC) determined by cystogram or urodynamics. Secondary outcomes were need for cutaneous vesicostomy, bladder augmentation, and renal allograft loss requiring dialysis.
RESULTS: A total of 32 children were identified during the study period. Median age at initiation of bladder cycling was 2.39 years (IQR 1.89—3.80), and 75% were male. Posterior urethral valves/urethral atresia (congenital obstructive uropathy) was the most common diagnoses (56.2%). Bladder cycling was initiated prior to transplant in 29/32 children (90.6%) and after transplant in 3/32 children (9.4%) who underwent primary cutaneous transplant ureterostomy. Bladder cycling was performed via ureteral catheterization in 17/32 (53.1%), suprapubic catheter in 14/32 (43.8%), and ureteral Mitrofanoff in 1/32 (3.1%). Median duration of bladder cycling was 7.9 months (IQR 2.2—11.5). In 27 children with documented pre- and post-cycling bladder capacities, median bladder capacity increased from 33% EBC (IQR 20.6—56.2) to 62.4% EBC (IQR 42.8—91.4). Bladder capacity improved in 25/27 children (92.6%). Vesicoureteral reflux (VUR) was present in 21/30 children (70.0%), including bilateral VUR in 15/21 (71.4%) and grade 4-5 VUR in 8/21 (38.1%). Children without VUR demonstrated greater bladder capacity gains (+42.3% EBC) than those with grade 1-3 VUR (+31.2% EBC) and grade 4-5 VUR (+18.8% EBC). Eight of 32 children (25.0%) were anuric at birth. Among the five children with paired pre- and post-cycling measurements, median bladder capacity increased from 28.8% to 68.0% EBC. Following bladder cycling, 28/32 children (87.5%) had not required cutaneous vesicostomy and 31/32 (96.9%) had not required bladder augmentation. Renal allograft loss requiring dialysis occurred in 1/32 children (3.1%).
CONCLUSIONS: Intermittent bladder cycling nearly doubled the bladder capacity in children with a small, poorly compliant, and/or defunctionalized bladder undergoing renal transplantation. Most children did not require cutaneous vesicostomy or bladder augmentation within the follow-up period. Additionally, renal allograft loss requiring dialysis was uncommon. This suggests that bladder cycling may serve as an effective bladder rehabilitation strategy in these challenging cases.
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