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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
PtAge at initiation(years)GenderEtiology of ESRDLifelong renal replacementEstimated urine output dailyPrevious attempt at manual bladder distentionPrevious recommendation for bladder augmentation
12.1MaleBilateral MCDK, Bilateral VURYes<5ccYesYes
22.6MaleCongenital renal dysplasia; WT1 s/p bilateral nephrectomiesYes0NoNo
33.6FemaleBilateral Renal AgenesisYes0YesYes
42.1MaleBilateral Cystic DysplasiaYes<5ccYesYes
53.2MaleBilateral Cystic Dysplasia; Denys-Drash s/p bilateral nephrectomiesYes0YesYes

Table 2: Intraoperative and post-procedure outcomes after enrollment in bladder cycling
PtPlacement of suprapubic tubeBladder volume at first evaluationRequired bladder cyclingAdherence with bladder cycling regimenRenal transplant performedFollow-up time since transplant (months)Lower tract issues after transplant

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