The necessity of voiding cystourethrogram for the evaluation of recipient candidates in adult renal transplantation

Objective. While international guidelines necessitate Voiding Cystourethrogram (VCUG) for pediatric patients, it is unnecessary for the evaluation of adult patients without urological disorders as renal transplant candidates. The objective of this study was to evaluate the results of adult candidates who underwent VCUG before transplantation and to demonstrate the necessity for this imaging. Methods. A retrospective study of the data of 1265 adult candidates who underwent VCUG before transplantation at our center, was undertaken. VUR, the presence of Postvoiding residual urine (PVR) (>100 ml), Low bladder capacity (LBC) (<100 ml), and urethral pathologies were evaluated with VCUG. Results. The mean age was 42.3 ± 1.3. The mean dialysis period was 27.8 ± 4.2 months. According to the VCUG results, 19.2% of the patients had pathological findings. On the other hand, the rate of urological disorders was only 5.1%, according to end-stage renal disease (ESRD) etiologies. VCUG outcomes indicated bilateral high-grade reflux in native kidneys in 4.4% (n = 56) of the candidates, unilateral high-grade reflux in 4.1% (n = 52), bilateral low grade reflux in 2.1% (n = 26), unilateral low-grade reflux in 2.4% (n = 30), and reflux in rejected transplanted kidney in 2.3% (n = 29). In addition, significant LBC was noted in 4.8% (n = 61), significant PVR in 1.1% (n = 14), and urethral stricture in 0.5% (n = 6) of the candidates. Conclusion. VCUG should be considered as a part of routine evaluation in adult renal transplant recipient candidates as well as in pediatric candidates, even if their ESRD etiologies are not due to urological disorders.

renal transplantation, transplant candidates, vesicoureteral reflux, voiding cystourethrogram

1. Tonelli M, Wiebe N, Knoll G et al. Systematic Review: Kidney Transplantation Compared With Dialysis in Clinically Relevant Outcomes. Am J Transplant. 2011; 11 (10): 2093–2109. doi: 10.1111/j.1600-6143.2011.03686.x.

2. Dodson JL, Jerry-Fluker J V, Ng DK et al. Urological disorders in chronic kidney disease in children cohort: clinical characteristics and estimation of glomerular filtration rate. J Urol. 2011; 186 (4): 1460–1466. doi: 10.1016/j.juro.2011.05.059.

3. Power RE, Hickey DP, Little DM. Urological evaluation prior to renal transplantation. Transplant Proc. 2004; 36 (10): 2962–2967. doi: 10.1016/j.transproceed.2004.11.006.

4. Karam G, Kälble T, Alcaraz A et al. Guidelines on renal transplantation. Eur Assoc Urol. 2014; 23. doi: 10.1056/NEJM199408113310606.

5. Benavente RC, Dorado CQ, Martin LL, Rodriguez CS, Gonima PC, Enguita CG. The candidate for renal transplantation work up: Medical, urological and oncological evaluation. Arch Esp Urol. 2011; 64 (5): 441–460.

6. Williams G, Fletcher JT, Alexander SI, Craig JC. Vesicoureteral Reflux. J Am Soc Nephrol. 2008; 19 (5): 847– 862. doi: 10.1681/ASN.2007020245.

7. Shandera K, Sago A, Angstadt J, Peretsman S, Jaffers G. An assessment of the need for the voiding cystourethrogram for urologic screening prior to renal transplantation. Clin Transplant. 1993; 7 (4): 299–301. http://www.ncbi.nlm.nih.gov/pubmed/10146299. Accessed November 11, 2018.

8. Glazier DB, Whang MI, Geffner SR et al. Evaluation of voiding cystourethrography prior to renal transplantation. Transplantation. 1996; 62 (12): 1762–1765. http://www.ncbi.nlm.nih.gov/pubmed/8990358. Accessed November 11, 2018.

9. Kabler RL, Cerny JC. Pre-transplant urologic investigation and treatment of end stage renal disease. J Urol. 1983; 129 (3): 475–478. http://www.ncbi.nlm.nih.gov/pubmed/6339746. Accessed November 11, 2018.

10. Tsunoyama K, Ishida H, Omoto K, Shimizu T, Shirakawa H, Tanabe K. Bladder function of end-stage renal disease patients. Int J Urol. 2010; 17 (9): 791–795. doi: 10.1111/j.1442-2042.2010.02579.x.

11. Zachoval R, Borovicka V, Marada T et al. The Effects of Diuresis, Duration of Dialysis and Age on Lower Urinary Tract Function in Urologically Healthy Male Patients on the Waiting List for Kidney Transplant. Urol J. 2018; 15 (2): 49–54. doi: 10.22037/uj.v0i0.3888.

12. Inoue T, Satoh S, Saito M et al. Correlations Between Pretransplant Dialysis Duration, Bladder Capacity, and Prevalence of Vesicoureteral Reflux to the Graft. Transplantation. 2011; 92 (3): 311–315. doi: 10.1097/TP.0b013e318223d7d6.

13. Chun JM, Jung GO, Park JB et al. Renal Transplantation in Patients With a Small Bladder. Transplant Proc. 2008; 40 (7): 2333–2335. doi: 10.1016/j.transproceed.2008.06.028.

14. Inoue T, Satoh S, Saito M et al. Correlations Between Pretransplant Dialysis Duration, Bladder Capacity, and Prevalence of Vesicoureteral Reflux to the Graft. Transplantation. 2011; 92 (3): 311–315. doi: 10.1097/TP.0b013e318223d7d6.

15. Kashi SH, Wynne KS, Sadek SA, Lodge JP. An evaluation of vesical urodynamics before renal transplantation and its effect on renal allograft function and survival. Transplantation. 1994; 57 (10): 1455–1457. http://www.ncbi.nlm.nih.gov/pubmed/8197607. Accessed November 12, 2018.

16. Song M, Park J, Kim YH et al. Bladder capacity in kidney transplant patients with end-stage renal disease. Int Urol Nephrol. 2015; 47 (1): 101–106. doi: 10.1007/s11255-014-0848-1.

17. Parmaksız E. Predictors of vesicourethral reflux in pretransplant evaluation of end-stage renal disease patients. South Clin Istanbul Eurasia. 2018; 29 (3): 176–179. doi: 10.14744/scie.2018.63935.

18. Knoll G, Cockfield S, Blydt-Hansen T et al. Canadian Society of Transplantation: consensus guidelines on eligibility for kidney transplantation. Can Med Assoc J. 2005; 173 (10): S1–S25. doi: 10.1503/cmaj.1041588.

19. Zermann DH. Disorders of micturition. In: Diseases of the Kidney, 7th Ed. Philadelphia: Lippincott-Williams and Wilkins, 2001. Vol. 1: 663–694.

20. Kim B-R, Lim JH, Lee SA et al. The Relation between Postvoid Residual and Occurrence of Urinary Tract Infection after Stroke in Rehabilitation Unit. Ann Rehabil Med. 2012; 36 (2): 248. doi: 10.5535/arm.2012.36.2.248.

21. Dromerick AW, Edwards DF. Relation of postvoid residual to urinary tract infection during stroke rehabilitation. Arch Phys Med Rehabil. 2003; 84 (9): 1369–1372. http://www.ncbi.nlm.nih.gov/pubmed/13680576. Accessed November 10, 2018.

22. Sarier M, Demir M, Goktas S et al. Results of Real-time Multiplex Polymerase Chain Reaction Assay in Renal Transplant Recipients With Sterile Pyuria. Transplant Proc. 2017; 49 (6): 1307–1311. doi: 10.1016/j.transproceed.2017.02.051.

23. Sarier M, Duman I, Demir M, Yuksel Y, Emek M, Kukul E. The outcomes of transurethral incision/resection of the prostate (TUIP/TURP) performed early after renal transplantation. Turkish J Urol. 2018; 44 (2): 172–177. doi: 10.5152/tud.2018.98404.

24. Shenasky JH. Renal transplantation in patients with urologic abnormalities. J Urol. 1976; 115 (5): 490–493. http://www.ncbi.nlm.nih.gov/pubmed/775135. Accessed March 15, 2017.

25. Martin X, Aboutaieb R, Soliman S, el Essawy A, Dawahra M, Lefrancois N. The use of long-term defunctionalized bladder in renal transplantation: is it safe? Eur Urol. 1999; 36 (5): 450–453. doi: 10.1159/000020029.

26. Onay ÖS, Agras PI, Bayrakci US, Cengiz N, Erçoban HS, Melek E, Uslu Y. Urinary tract infections following voiding cystouretrography in children. Turk Arch Ped 2008. 2008; (43): 14–16.

27. Rachmiel M, Aladjem M, Starinsky R, Strauss S, Villa Y, Goldman M. Symptomatic urinary tract infections following voiding cystourethrography. Pediatr Nephrol. 2005; 20 (10): 1449–1452. doi: 10.1007/s00467-005-1942-5.