Early transplantation into a vesicostomy: a safe approach for managing patients with severe obstructive lesions who are not candidates for bladder augmentation

摘要

IntroductionManagement of severe antenatally detected oligohydramnios with and without obstruction is improving with the result that more fetuses are surviving with early renal failure. Significant advances have occurred in all specialties involved in the management of these patients. All these specialties working together have resulted in the survival of more patients born with renal failure. ObjectiveThe aim of this study is to highlight the medical advances in antenatal management of fetal oligohydramnios and pulmonary hypoplasia and to demonstrate that transplantation into a diverted urinary system is safe and leads to good outcomes. Study designA case series of five patients were presented who, at the study center's respective facilities, recently underwent renal transplantation into bladders drained by cutaneous vesicostomy after extensive bladder evaluation and whose clinical cases highlight the aim of this study. ResultsA total of 5 patients were reviewed. Renal failure was caused by posterior urethral valves in four patients, and in one patient Eagle-Barrett syndrome. One patient received an amnio-infusion and attempted antenatal bladder shunt. One patient was ventilator dependent until 24 months, and required a tracheostomy, while two patients were ventilator dependent for the first few months of life. Three of five patients were dialysis dependent. Patient age at transplantation ranged from 20 to 61 months. All patients were poorly compliant pre-transplant and had bladder capacities ranging from 10 mL to 72 mL. Months since follow-up ranged from 3 to 64 months. Creatinine levels prior to transplant ranged from 1.9 to 5.6. During the follow up period, this range decreased to 0.13 to 0.53. Two of five patients had UTI episodes since transplantation. Patient A showed Banff Type 1A acute T-cell mediated rejected approximately two months after transplant, but subsequent biopsies have been negative for rejection. Patient A also required a vesicostomy revision approximately two months after transplant and balloon dilation of UVJ anastomosis three months after transplant. DiscussionVesicostomy is an especially attractive option to manage children with small bladders to accommodate the high urinary output that occurs after transplantation in infants who require an adult kidney. Recent advances in antenatal management such as amnioinfusion for oligohydramnios have made significant impacts in pulmonary and renal management of this patient population over recent years. ConclusionThis report provides further support for the use of vesicostomy as an option for surgical management of patients with renal failure with oligohydramnios and severe obstructive lesions identified antenatally. It also indicates the need to update the criteria for antenatal management of oligohydramnios in obstructive and anephric patients.CriteriaABCDECause of renal failurePosterior urethral valvesEagle-Barrett syndromePosterior urethral valvesPosterior urethral valvesPosterior urethral valvesAntenatal interventionsAmnioinfusions; attempted bladder shuntNoneNoneNoneNonePulmonary hypoplasia/ventilator dependencyYes, ventilator dependence until 24 months, requiring tracheostomyVentilator dependence for the first few months of lifeNoneYes, ventilator dependence for first few months of lifeNoneDialysis dependencyYes, was on peritoneal dialysis until transplantationNoNoYes, peritoneal dialysisYes, peritoneal dialysisAge at transplantation to diverted vesicostomy20 months24 months26 months46 months61 monthsPretransplant bladder capacity and compliance30?ml; poorly compliant45?ml; poorly compliant10?ml; poorly compliant72?ml; poorly compliant26?ml; poor complianceFollow-up in months since transplantation12 months12 months3 months16 months64 monthsCreatinine before transplantation3.6–5.62.2–3.31.9–2.84.083.2–3.7Creatinine range during follow-up period0.17–0.360.13–0.380.17–0.340.350.30–0.53Episodes of UTI since transplantationYes, multipleNoneYes,E