Kidney transplantation: Changing lives, one kidney at a time
Chaired by Dr. Alberto Breda (ES) and Prof. John Heesakkers (NL), day one of EAU23 started with a highly informative Plenary Session on the functional aspects of kidney transplantation (KT). In a series of state-of-the-art lectures and debates, the session began with a review of the options of transplantation in crippled bladder patients, followed by an in-depth analysis on bladder function and lower urinary tract symptoms (LUTS) after a renal transplant, pelvic surgery in patients who had renal transplantation, and an insightful debate between leading experts on pre-surgery urological KT patient evaluations.
In Prof. Fiona Burkhard’s (CH) presentation “Transplantation in a bladder cripple: What are the options?”, she stated that many of the patients are young and want more options for treatment. “End-stage renal disease (ESRD) is caused by lower urinary tract disease (in 6% of patients with a kidney transplant), and congenital anomalies of the lower urinary tract in 20% of paediatric patients and 15% in adults. Rates of transplantation in lower urinary tract reconstruction are 0.4-2.5%.”
“The goal for reconstruction is to preserve kidney function after KT, achieve unobstructive drainage and patient normality: voiding function and continence, sexual function, body image and reproductive function.” According to Prof. Burkhard, options for crippled bladder patients include urostoma (colon, ileum), augmentation enterocystoplasty (also known as ‘clam enterocystoplasty’), orthotopic bladder substitute and continent catheterisable reservoir.
Metabolic acidosis is one of several complications that could be experienced with enlarging the bladder. “The symptoms of acidosis include weakness/fatigue, a greyish appearance, loss of appetite, stomach burning, nausea and vomiting.” A venous blood gas analysis can be performed to confirm diagnosis. The other complications included chronic bacteriuria, urinary tract infection (50-70%), pyelonephritis (13%) and stones (20-50%).
In summary, Prof. Burkhard stated that KT in urinary diversion is rare (less than 1%), graft survival is comparable between continent and incontinent diversion, diversion prior to transplantation (months) seems preferable and infections are common but do not affect graft survival.
Dr. Javier Sanchez Macias (ES) presented the lecture “Bladder function and LUTS after renal transplant”, whereby he provided information on post-operative lower urinary disorders including absence of bladder, low capacity bladder and neurogenetic bladder. “The implementation of new minimally-invasive technologies for the management of patients with LUTS will in the future oblige their daily use in transplant patients. New studies will be necessary to determine whether Rezūm, Aquablation or transurethral HIFU techniques will replace endoscopic enucleation and TURP”, stated Dr. Sanchez Macias.
Proceeding his presentation, Dr. Sanchez Macias was awarded the Confederation Americana de Urologia (CAU) Lecturer prize for EAU23.
In his lecture “Pelvic surgery in patients with a renal transplant: Do’s and don’ts”, Prof. Francisco Burgos Revilla (ES) outlined laparoscopic and ultrasonographic anatomy of the pelvis in KT recipients, resolution of KT surgical complications, pelvic oncological surgery and the implications for the graft and limitations, as well as treatment of functional pathology involving the pelvis. He stressed that “Surgery in the pelvic space is confronted with the presence of a kidney in the iliac fossa. Any pelvic surgery for a potential kidney transplant recipient may compromise a future implantation”.
Lively debates followed between Dr. Oscar Rodriguez Faba (ES) and Dr. Romain Boissier (FR) on the topic of “Urological evaluation of the recipient before kidney transplant should be obligatory”. Dr. Rodriguez stressed that a proper urological evaluation of a KT patient is necessary. “Urological complications comprise the second most common adverse event after KT. Pre-transplant targeted urological evaluation allows for optimisation of the urinary tract accepting the graft.” He suggested that the urological evaluation should include the need for native nephrectomy; suitability and functionality of a compliant and continent urinary reservoir; urological symptoms; and screening and treatment of genitourinary malignancies. The importance of a CT scan was deliberated in the post-debate discussions.
Other presentations in this Plenary Session included living donor nephrectomy, kidney transplantation in the octogenarians, techniques and results of paediatric kidney transplantation, as well as the long-term effects on LUT behaviour of renal transplantation in children. To (re)watch the full presentations, please go to EAU On Demand on the Virtual Platform.