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Table of Contents
COMMENTARY
Year : 2020  |  Volume : 14  |  Issue : 3  |  Page : 202-203

Voiding cystourethrogram in adult pretransplant evaluation – Will it make a difference?


1 Department of Nephrology, Asian Institute of Nephrology and Urology, Hyderabad, Telangana, India
2 Department of Urology, Asian Institute of Nephrology and Urology, Hyderabad, Telangana, India

Date of Submission01-Apr-2020
Date of Acceptance31-May-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Srikanth Gundlapalli
Asian Institute of Nephrology and Urology, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_23_20

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How to cite this article:
Gundlapalli S, Pandya S, Bendigeri T. Voiding cystourethrogram in adult pretransplant evaluation – Will it make a difference?. Indian J Transplant 2020;14:202-3

How to cite this URL:
Gundlapalli S, Pandya S, Bendigeri T. Voiding cystourethrogram in adult pretransplant evaluation – Will it make a difference?. Indian J Transplant [serial online] 2020 [cited 2020 Nov 1];14:202-3. Available from: https://www.ijtonline.in/text.asp?2020/14/3/202/296883



Urologic disorders contribute small percentage of end-stage renal disease in adults as per literature.[1],[2] Epidemiological data describe chronic interstitial nephritis as the third most important cause of chronic kidney disease.[3] It is possible that some of these could be adolescents and young adults presenting with end-stage renal disease secondary to an undiagnosed pediatric kidney disease. In addition, elderly male population with bladder outlet obstruction and female population with functional anomalies of the bladder may remain undiagnosed on dialysis due to oliguria.[4] Both these groups of population are under the additional risk of urinary tract infections complicating posttransplant period. Diagnosing these disorders could help us plan electively to mitigate the risk.

The workup directed at bladder problems is part of routine pretransplant protocol, however recommendations for workup of patients with medical history of urologic disease, recurrent urinary tract infections, and prolonged anuria exist.[1],[5]

Voiding cystourethrogram (VCUG) provides both anatomical and early functional assessment of the bladder and helps in deciding the necessity of a more detailed testing such as urodynamic studies. However, VCUG is not a gold standard in screening for all lower tract anomalies. The reliability of VCUG in grading the reflux disease is questionable with wrong interpretations in up to 22% of the cases.[6] Prolonged oligoanuria leads to detrusor contracture which may improve later. Hence, mere demonstration of low bladder capacity does not preclude safe transplantation.[7] Predicting normalization of bladder capacity and compliance post transplantation can be accomplished by “bladder cycling.”[8] Information on the dynamic bladder pressures and flow measurements is not elicitable in this test. Infection if precipitated by VCUG may defer the transplantation, adding unnecessary costs and complications.

Although some studies vouch for VCUG in pretransplant evaluation, interestingly, literature has been equivocal in recommending this test as a routine. Reports of lower tract anomalies in literature range from as low as 2.5%[4] without any significant clinical consequence to as high as 49.5%[9] with significant risks. Even the studies which reported a significant incidence of abnormalities on VCUG did not report any requirement of surgical correction pre transplant.[5]

Prolonged waiting times of deceased donor transplantation may alter the dynamics of the lower tract, leading to significant abnormalities on urologic assessment. Whether this transforms into a clinically significant problem post transplantation is unclear. At this juncture, a rational approach would be a thorough assessment for childhood history, voiding problems prior to the oliguric phase, and recurrent urinary infections to estimate a pretest probability for lower tract anomaly. This can guide the further invasive testing.



 
  References Top

1.
Power RE, Hickey DP, Little DM. Urological evaluation prior to renal transplantation. Transplant Proc 2004;36:2962-7.  Back to cited text no. 1
    
2.
Hatch DA. Kidney transplantation in patients with an abnormal lower urinary tract. Urol Clin North Am 1994;21:311-20.  Back to cited text no. 2
    
3.
Sharma M, Doley P, Das HJ. Etiological profile of chronic kidney disease: A single-center retrospective hospital-based study. Saudi J Kidney Dis Transpl 2018;29:409-13.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Glazier DB, Whang MI, Geffner SR, Lyman NW, Friedman GS, Viscuso R, et al. Evaluation of voiding cystourethrography prior to renal transplantation. Transplantation 1996;62:1762-5.  Back to cited text no. 4
    
5.
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;7:299-301.  Back to cited text no. 5
    
6.
Jequier S, Jequier JC. Reliability of voiding cystourethrography to detect reflux. AJR Am J Roentgenol 1989;153:807-10.  Back to cited text no. 6
    
7.
Serrano DP, Flechner SM, Modlin CS, Wyner LM, Novick AC. Transplantation into the long-term defunctionalized bladder. J Urol 1996;156:885-8.  Back to cited text no. 7
    
8.
Errando C, Batista JE, Caparros J, Araño P, Villavicencio H. Is bladder cycling useful in the urodynamic evaluation previous to renal transplantation? Urol Int 2005;74:341-5.  Back to cited text no. 8
    
9.
Lai S, Pastore S, Piloni L, Mangiulli M, Esposito Y, Pierella F, et al. Chronic kidney disease and urological disorders: Systematic use of uroflowmetry in nephropathic patients. Clin Kidney J 2019;12:414-9.  Back to cited text no. 9
    




 

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