Conservative management of hostile bladders with intravesical botulinum toxin for successful renal transplantation

Abstract

Introduction: Renal transplant is the most desired and cost-effective therapy for patients with end stage renal disease. While a lower urinary tract cause of end-stage renal disease (ESRD) is not an absolute contraindication to renal transplantation, appropriate vesical storage and drainage is imperative for survival and function of the graft. It is crucial to address and resolve any urological causes of renal failure prior to transplantation to prevent subsequent graft failure. Most patients can be managed with conservative measures such as intermittent self-catheterization, but select cases may require more aggressive intervention including bladder augmentation or urinary diversion to address a hostile bladder environment prior to transplantation. To our knowledge, this is the first report of a poorly compliant bladder noted during pre-transplant evaluation that was managed conservatively with intravesical botulinum injections leading to a successful transplantation.

Conclusion: We found through our experience that intravesical botulinum injections offers a conservative approach to increase bladder compliance and lower storage pressures thereby permitting safe renal transplantation. This management strategy can be employed in carefully selected patients who have failed oral anticholinergics and CIC, and wish to avoid bladder augmentation and urinary diversion. Careful follow-up is necessary to detect changes in urinary symptoms and bladder parameters, which may be a sign of possible botulinum failure necessitating the need to revisit more aggressive management options.