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Long-term outcomes in children with renal transplants into vesicostomy
Shannon Cannon, MD1, Ashley W. Johnston, MD2, Rosalia Misseri, MD3, Neil J. Paloian, MD1, Mark P. Cain, MD4, Walid A. Farhat, MD1.
1University of Wisconsin, Madison, WI, USA, 2Indiana University School of Medicine, Indianapolis, IN, USA, 3Indiana University, Indianapolis, IN, USA, 4Seattle Children's Hospital, Seattle, WA, USA.

Background: Advances in early detection and intervention for obstructive uropathy have resulted in improved perinatal survival and candidacy for renal transplant. Previous reports demonstrate that transplantation into a bladder drained by cutaneous vesicostomy is safe. We aimed to examine long-term outcomes and fate of the bladder in our cohort of patients who underwent vesicostomy before or in conjunction with renal transplantation for obstructive uropathy. Methods: We performed a retrospective chart review identifying pediatric patients (<18 years old) who underwent vesicostomy creation prior to or at the time of renal transplantation at 2 tertiary academic centers. We recorded ages at vesicostomy creation and transplantation, etiology of renal failure (diagnosis), transplantation type, serum creatinine values pre- and post- transplantation, as well as the fate of the bladder at last follow-up. We furthermore examined the rates of complication including urinary tract infections (UTI) and graft rejection. Descriptive analyses were performed.
Results: A total of 7 patients were identified with the majority being male (6/7, 86%). Cohort characteristics are shown in Table 1. Mean follow-up post-transplantation was 45 months (SD 23 months). Median age at time of vesicostomy was 4.8 months (IQR 21.2 months) and mean age at time of renal transplantation was 38 months (SD 17 months); three (42%) underwent concomitant renal transplantation and vesicostomy creation. The most common underlying diagnosis was posterior urethral valves (3/7, 43%). Other diagnoses included Eagle-Barrett Syndrome (2/7, 29%), membranous urethral obstruction (1/7, 14%), and cloacal anomaly (1/7, 14%). The majority received a living related graft (5/7, 71%). Bladder capacity was reduced on cystometrogram prior to transplantation (median 45 mL [IQR 113 ml], mean actual:expected ratio 0.64).
Mean serum creatinine values decreased from 3.86 mg/dL (SD 1.57 mg/dL) pre-transplantation to 0.21 mg/dL (SD 0.04 mg/dL) post-transplantation. Nearly all (6/7, 86%) went on to vesicostomy closure. Additional surgical revisions to bladder management occurred in 57% (4/7), specifically appendicovesicostomy (3/7, 43%), ureteral bladder augment (1/7, 14%), and ileovesicostomy (1/7, 14%). On most recent follow-up, serum creatinine remained low (mean 0.62 mg/dL [SD 0.21 mg/dL]). While UTI post-transplantation was common (4/6, 67%), graft rejection was rare (1/7, 14%).
Conclusions: We present the largest cohort of pediatric patients with renal transplantation into a bladder diversion with a cutaneous vesicostomy, demonstrating good outcomes for nearly 5 years after transplantation. All patients continued to have preserved renal function and minimal graft rejection over the study period. Our findings suggest that renal transplantation into a vesicostomy is safe and could be considered for patients with significantly decreased bladder capacity and/or very poor compliance. Definitive bladder management such as vesicostomy closure, diversion or augmentation can be performed when appropriate based on patient health status and when timing is optimal.

IDFollow-up Post-transplant (months)Age at Vesicostomy (months)Age at Transplant (months)Pre-transplant Creatinine(mg/dL)Post-transplant Creatinine (mg/dL)Vesicostomy ClosureBladder Surgery after Vesicostomy Closure
4*0.350.86.6*Yes*Recent transplant
5530.835.64.30.7YesAPV; Ureteral bladder augment
All45.1(SD 23.2)4.7(IQR = 20.9)35.4(SD 17.0)3.86(SD 1.57)0.61(SD 0.21)6/7 closed

APV= Appendicovesicostomy

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