888 TRANSPLANTATION INTO LONG-TERM DEFUNCTIONALIZED BLADDER

Streem, S. B.: Long-term results of renal transplantation into the valve bladder. J. Urol., 151: 1500, 1994.

14. Flechner, S. M., Conley, S. B., Brewer, E. D., Benson, G. S. and Comere, J. N., Jr.: Intermittent clean catheterization: an al- ternative to diversion in continent transplant recipients with lower urinary tract dysfunction. J . Urol., 130 878, 1983.

EDITORIAL COMMENT

The authors demonstrate that carefully selected patients with end stage renal disease can undergo successful transplantation with urinary drainage into a long-term defunctionalized bladder. They stress that bladder function and continence should be confirmed preoperatively by bladder cycling. No patient underwent bladder augmentation. Four patients have a bladder capacity of 350 cc or less. Although these patients have excellent long-term renal func- tion, some may have high intravesical pressure with a small, poorly compliant bladder, which may be detrimental to allograft function. The patient with a small bladder capacity preoperatively should be counseled that he or she will have to void or perform self- catheterization frequently in the postoperative period. The major criticism of this study is the failure to document adequate bladder compliance, which should be monitored by cystometrography. Blad- der augmentation should be performed if intravesical pressures are persistently elevated.

The benefits of preoperative bladder cycling with an indwelling suprapubic catheter are not clearly demonstrated by this study. I agree that intermittent instillation of an antibiotic imgant is a good way to assess urinary continence during ambulation, and also to

evaluate the ability to perform intermittent catheterization of the bladder preoperatively. However, the authors have not documented changes in bladder function after cycling with increasing volumes of imgation.

H. Albin Gritsch Department of Urology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

REPLY BY AUTHORS

Post-transplant urodynamic studies done approximately 3 months after surgery were not routinely repeated since the patients were asymptomatic. Bladder compliance increased after transplantation as bladder capacity increased (table 2 in article). In addition, no patient voided with detrusor pressure greater than 70 cm. water. There was stable long-term allograft function for up to 10 years without evidence of hydronephrosis due to bladder noncompliance. These findings support our recommendation that potential recipi- ents with a defunctionalized bladder can safely undergo transplan- tation when capacity greater than 100 cc and voiding pressure less than 100 cm. water are demonstrated during bladder rehabilitation.

Since 1963 more than 1,900 renal transplants have been per- formed at our clinic, including hundreds in patients with anuria and defunctionalized bladders. No patient has undergone bladder aug- mentation for the purpose of transplantation. Currently there are a number of children with bladder augmentation and renal insuffi- ciency who may undergo transplantation in the future.