Low incidence of urinary tract infections following renal transplantation in children with bladder augmentation.

PURPOSE: Children with end-stage renal disease and bladder dysfunction may require augmentation cystoplasty before kidney transplantation. Previous reports have suggested unacceptable urinary tract infection rates in these immunosuppressed patients. We reviewed our experience in this population. MATERIALS AND METHODS: We retrospectively studied patients undergoing augmentation cystoplasty and subsequent renal transplantation by a single surgeon between 1989 and 2007. This cohort was compared with a control group on clean intermittent catheterization who had undergone transplantation without augmentation. Patient demographics, etiology of renal failure, surgical details, surgical/allograft outcomes and occurrence of urinary tract infection were analyzed. RESULTS: The augmented group included 17 patients with a median age at reconstruction of 6.4 years. Stomach was used in 15 patients and colon in 2. Median time between reconstruction and transplantation was 1.2 years. Median followup after transplantation was 7.7 years. The control group included 17 patients with a median age at transplantation of 10.9 years. Median followup in the controls was 6.1 years. All ureteral reimplantations were antirefluxing. Patients on clean intermittent catheterization were maintained on oral antibiotic suppression and/or gentamicin bladder irrigations. In the augmented group 35 episodes of urinary tract infection were noted, and the number of documented infections per patient-year of followup was 0.22, compared to 32 episodes of urinary tract infection and 0.28 infections per patient-year of followup in the controls. No allograft was lost to infectious complications. CONCLUSIONS: In our series there was no increase in urinary tract infection rate following renal transplantation in patients with augmented bladders compared to controls. This finding may be due to the use of gastric augmentation, antirefluxing reimplantation and gentamicin irrigations.

Use of customized MIC-KEY gastrostomy button for management of MACE stomal complications.

OBJECTIVES: Severe bowel dysfunction often accompanies neurogenic bladder, and Malone antegrade continence enema procedures can lead to improvement in the quality of life for these patients. The most commonly reported complication has been stomal stenosis of the conduit. We report our experience with the use of the MIC-KEY gastrostomy button for the management of this complication. METHODS: A retrospective cohort study of 53 consecutive children who had undergone the Malone antegrade continence enema (ACE) procedure from 2000 to 2006 was performed. The records of patients with stomal complications were assessed for presentation, management, and outcomes. RESULTS: We identified 20 patients (38%) with stomal stenosis. Stomal dilation and stenting alone was successful in 4 patients, and stomal revision was necessary in 16 (30%). Six children required placement of the MIC-KEY gastrostomy button into the ACE stoma for recurrent stomal stenosis (n = 5) or a buried stoma (n = 1). All patients were successfully treated with placement of a MIC-KEY button to continue their bowel irrigation. The size of the button was determined by the endoscopic assessment of the length and width of the ACE stoma and was custom made by the manufacturer. The average time that the button was in place was 26 months, and it was generally changed every 3 months. CONCLUSIONS: In the rare subset of patients with recurrent stomal stenosis or a buried stoma, the MIC-KEY gastrostomy button was found to be a practical and easy method for the management of these conditions and to preserve the ACE conduit.

Safety of gentamicin bladder irrigations in complex urological cases.

PURPOSE: Recurrent urinary tract infections are common in complex pediatric urological cases, particularly those requiring clean intermittent catheterization. At our institution gentamicin bladder irrigations have been used for antimicrobial prophylaxis and to treat symptomatic bacteriuria, particularly when the infection does not involve the upper urinary tract. The purpose of this study was to assess the safety of this therapy. MATERIALS AND METHODS: A retrospective study was performed of all children treated with gentamicin bladder irrigations from 1999 to 2004. The dose was 14 mg gentamicin in 30 ml saline instilled via catheter once or twice daily. Serum creatinine and random gentamicin levels were obtained according to a protocol based on risk of gentamicin toxicity. Patient demographics, laboratory results and outcomes were abstracted from the medical records. RESULTS: A total of 80 patients (38 males and 42 females) were identified. Median patient age was 10 years and median duration of treatment was 90 days. No patient had detectable serum gentamicin levels greater than 0.4 mg/dl. Small increases in serum creatinine were seen in 3 patients, all of whom had chronic renal insufficiency. A total of 21 patients (26%) had breakthrough UTIs, of which 5 (24%) were gentamicin resistant. No adverse events were documented. CONCLUSIONS: Gentamicin bladder irrigations are a helpful adjunct in the management of complex pediatric urological cases involving recurrent symptomatic bacteriuria. We no longer require intensive laboratory monitoring of low risk patients at our institution.

Lower urinary tract reconstruction is safe and effective in children with end stage renal disease.

PURPOSE: Congenital urinary tract anomalies with bladder dysfunction pose a formidable management challenge in children with end stage renal disease (ESRD). We report a series of patients with ESRD who underwent lower urinary tract reconstruction to assess the results and surgical complications. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients with ESRD who underwent urinary reconstruction. The etiology for renal failure included posterior urethral valves, cloacal anomalies, VATER syndrome and reflux nephropathy. RESULTS: From 1989 to 2000, 20 patients were identified. Median patient age at time of reconstruction was 4.5 years and median followup was 7.3 years. Pre-transplant augmentation cystoplasty was performed in 14 patients (70%) and continent reconstruction without bladder augmentation was performed in 6 patients. Subsequent renal transplant was performed in 19 patients (15 with a living related donor). Overall patient survival was 95%. There was 1 death in the immediate post-transplant period secondary to cerebral edema thought to be due to a precipitous decrease in blood urea nitrogen. The overall graft survival rate is 82%. No patients lost grafts due to infection or technical complications. All patients have stable upper tracts, and mean creatinine is 1.2 mg/dl. Three patients required major surgery due to complications of the reconstruction and 2 treated with gastrocystoplasty had severe hematuria while anuric before transplantation. All patients are continent of urine. CONCLUSIONS: Our long-term data confirm that severe bladder dysfunction can be managed safely and effectively with continent urinary reconstruction in children with ESRD.

Gastrocystoplasty: long-term followup.

PURPOSE: The use of stomach has become controversial in pediatric lower urinary tract reconstruction. Recent series have reported a high incidence of hematuria-dysuria syndrome and metabolic abnormalities, which has prompted a significant decrease in its use at our institution during the last 5 years. MATERIALS AND METHODS: We retrospectively reviewed the medical records of children who underwent urinary reconstruction with gastrocystoplasty. Patients were excluded from consideration if they had less than 5 years of followup. RESULTS: From 1989 to 1997, 18 males and 26 females were identified. Median patient age at time of reconstruction was 4.5 years and median followup was 9.8 years. Urinary continence was present in 89% of cases, and upper tract dilatation was stable or improved in 91%. No patient had chronic metabolic alkalosis. Major surgery was required for complications of the gastrocystoplasty in 6 cases, including patch contraction and ureteral obstruction necessitating excision in 1. Two patients had severe hematuria while anuric from renal failure which was managed conservatively with bladder cycling and H2 blockers. Symptoms resolved completely after renal transplantation in both cases. Febrile urinary tract infection occurred in 20% of cases and asymptomatic bacteriuria was present in 36%. CONCLUSIONS: The use of stomach segments in pediatric urinary reconstruction can be beneficial in patients with chronic renal insufficiency, metabolic acidosis or short gut syndrome. Despite negative reports concerning serious complications of gastrocystoplasty, our long-term data confirm that it remains an important option in our reconstruction armamentarium.

Successful renal transplantation in children with posterior urethral valves.

PURPOSE: The treatment of children with posterior urethral valve (PUV) and end-stage renal disease can be challenging. Some series have had poor outcomes after renal transplantation with an increased risk of graft dysfunction and urinary tract infections. We present our experience with a pediatric population and compare it to all the other pediatric renal transplants done at our institution. MATERIALS AND METHODS: We identified 10 patients with PUV who underwent a total of 13 renal transplants between 1990 and 2000. The comparison group included 120 transplants done in 95 patients during the same period. Cumulative allograft survival and function were recorded. RESULTS: Overall patient survival in the PUV group was 100%. Mean age at transplant in the PUV group was 10.0 years and mean followup was 3.9 years. Six patients underwent high proximal urinary tract diversion, while the remainder had primary transurethral valve ablation. Three patients had bladder augmentation before transplantation. Cumulative allograft survival in the PUV group at 1 and 5 years was 85% and 64%, respectively. Of the 10 patients 9 currently have functioning living related donor transplants. One patient lost 3 cadaveric donor transplants to chronic rejection. No patients lost grafts due to infection or bladder dysfunction. Mean serum creatinine of the functioning grafts was 1.1 mg/dl. CONCLUSIONS: Renal transplantation can be performed safely and effectively in patients with PUV, including those who have undergone previous proximal urinary tract diversion. Preoperative bladder management and continued monitoring of bladder and kidney function postoperatively are paramount in the preservation of allograft function.