USE OF THE DONOR BLADDER TRIGONE TO FACILITATE PEDIATRIC EN-BLOC KIDNEY TRANSPLANTATION

PEDIATRICS

S.M. Flechner, I. Saad, H.Y. Tiong, J. Rabets, V. Krishnamurthi
Glickman Urological And Kidney Institute, Cleveland Clinic Foundation, Cleveland/UNITED STATES OF AMERICA

Body: Introduction: We describe the use of the donor bladder trigone, which incorporates both ureters, to facilitate pediatric en-bloc transplantation into the adult recipient bladder. The potentialadvantages of this technique are avoiding the anastomoses of these small ureters into the bladder, and the potential creation of an anti-refluxing system.

Methods: The pediatric en bloc kidneys were transplanted to the recipient right iliac artery and vein end-to-side using the donor aorta and vena cava. A patch of bladder trigone 3 x 2 cm wasfashioned to include both ureteral orifices. In the female donor the trigone had to be separated from the anterior vaginal wall. A linear 4 cm incision was made in the anterior surface of the bladderat a point that provided a gentle curve to the ureters. The bladder patch was secured with a single layer of 3-0 interrupted PDS sutures after 4.7F x 14cm double J ureteral stents were advanced fromthe bladder to the renal pelvis of either kidney. A Foley catheter was left for two weeks, and removed after a cystogram confirmed healing of the bladder. The ureteral stents were removedcystoscopically 8 weeks after transplant.

Results: Recipients were given basiliximab induction, followed by tacrolimus, mycophenolate mofetil and low dose steroids. There were no cases of DGF or acute rejection. The two transplants from malepediatric donors healed and resulted in non-refluxing systems. The recipient of the female pediatric donor developed a pelvis abscess that grew S. epidermidis, a urine leak, and the patch had to berevised after 6 weeks.

Recipient Age/Gender	Cause ESRD	Time on Dialysis	Pre Tx Urine/24h	Pedi-Donor Age/Gender	Surgical Complication	UV Reflux	SCr mg/dL
24 yo Male	FSGS/Htn	8 yrs	Anuric	13 Month Male	No	No	1.2 at 12 mo
37 yo Female	Interstitial Nephritis	5 yrs	300 cc	21 Month Male	No	No	1.0 at 10 mo
49 yo Female	Polycystic	Pre- emptive	2000 cc	23 Month Female	Yes	No	1.2 at 9 mo

Conclusions: The use of the donor bladder trigone to facilitate pediatric en bloc kidney transplantation is especially helpful in recipients with small-defunctionalized bladders. The techniquedescribed provides for a well vascularized bladder segment, and the resultant transplant urinary tract can be maintained without vesico-ureteral reflux. However, the use of a female pediatric donorfor this procedure may be a special circumstance requiring increased attention to sterilize the small donor introitus. Removal of the anterior vaginal wall from the donor trigone in the pediatricfemale, may also compromise its blood supply.

Disclosure: All authors have declared no conflicts of interest.