The global prevalence of end-stage renal failure is on the rise and renal transplantation is a cost-effective option of renal replacement therapy. Renal failure has diverse causes, often accompanied by lower urinary tract pathology. This case study highlights the importance of identifying and addressing bladder pathology to ensure safe transplantation.

 

A 45-year-old man with systemic lupus erythematosus and lupus nephritis, who had been anuric and on haemodialysis for 20 years, underwent a cadaveric renal transplantation. The surgery revealed a small bladder capacity, and he underwent standard Lich Gregoir uretero-neocystostomy over a ureteral stent. His post-operative course was complicated by a urinoma due to an anastomotic leak, managed conservatively with prolonged bladder drainage for 6 weeks, and subsequently resolved. He subsequently developed urosepsis requiring intensive care unit admission and intubation, caused by multidrug-resistant organisms. He underwent multiple graft biopsies showing acute tubular necrosis, severe pyelonephritis, and T cell-mediated rejection. Treatment included high-end antibiotics followed by immunosuppressants, leading to cessation of intermittent haemodialysis and stabilization of creatinine around 200 μmol/L. Two months post-transplantation, he experienced voiding difficulties despite silodosin. Video urodynamic study revealed a poorly compliant bladder with small capacity, detrusor overactivity causing incontinence, vesicoureteric reflux occurring at 150 mls, and a detrusor leak point pressure of >40 cmH2O signifying an unsafe bladder. Additionally, dysfunctional voiding was evident from abnormal urethral pressure profiles showing increased activity during voiding and a staccato uroflow pattern (Figures 1 and 2). Currently, he maintains good urine output on clean intermittent self-catheterization.

Urodynamic studies are not routinely performed in renal transplant patients but are valuable for patients with lower urinary tract symptoms. This case underscores the role of urodynamic studies in evaluating and managing lower urinary tract symptoms in renal transplant candidates, highlighting their importance in optimizing post-transplant outcome.