The Outcome of Pre-transplant Bladder Cycling in Patients With Defunctionalized Bladder
Phase: NA
Conditions: Bladder Cycling, Defunctionalized Bladder
Sponsor: Ain Shams University

 
MasterDegreeThesis/MFA/ISRO/FacultyOfMedicine/ASU 
 
 
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The outcome of bladder cycling prior to renal 
transplantation in patients with 
defunctionalized bladder 
 
PROTOCOL OF A THESIS FOR PARTIAL FULFILLMENT OF DOCTORATE 
DEGREE IN UROLOGY 
BY 
Postgraduate Student: 
Mohamed Shaker Abd El-Aziz 
M.B.B.Ch., Faculty of Medicine – Ain Shams University 
Master degree of Urology, Ain Shams University 
Under Supervision of  
Prof. Dr. Mohamed Esmat Abo Ghareeb. 
Professor of Urology 
Urology Department, Ain Shams University 
Dr. Mohamed Kandil Abd El Fatah. 
Lecturer of Urology 
Urology Department, Ain Shams University 
 
Faculty of Medicine  
Ain Shams University  
Cairo-Egypt   

 
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2022 
     
 
 
 
 
 
 
1-What is already known on this subject? AND 
What does this study add? 
         Kidney transplantation still remains the best treatment for end-stage 
renal disease (ESRD). Indeed, increasing numbers of patients are referred 
for transplantation, but there has been no concomitant increase in the 
supply of kidneys from the traditional donor pool. Many potential recipients 
awaiting transplantation, therefore must undergo dialysis for a long time. 
Regarding the detrimental effect of long-term dialysis associated with 
oliguria or anuria on the lower urinary tract, and especially in bladder, the 
interruption of physiological cycle of storage and voiding brings to a 
situation called Defunctionalized Bladder (DB) in which the bladder capacity 
became smaller in size. (Errando et al 2018). 
 In this study we will evaluate the outcome of renal transplantation into a 
defunctionalized bladder by pre-transplant programmed bladder cycling. 
 
2.AIM / OBJECTIVES 
The aim of this study is to evaluate the anatomical and 
physiological benefit of programmed bladder cycling prior to 
renal transplantation in patients with defunctionalized urinary 
bladder.  
 
 

 
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3.INTRODUCTION/ REVIEW  
         
          Despite medicine has been experiencing several and constant 
improvements in these years, kidney transplantation (KT) still remains 
the best treatment for end-stage renal disease (ESRD). In the recent 
years, we’re witnessing a constant growth of the patients’ waiting-list for 
renal transplant, due either to the lack of kidney donors and to the rise in 
ESRD incidence and prevalence. ( Aytekin et al 2020) 
 
Some patients are able to benefit from a related living organ donor and 
pre-emptive or early KT, but most will need renal replacement therapy 
(haemodialysis or peritoneal dialysis) for a long time. The natural 
consequence of this situation is that patients affected from ESRD have to 
stay in dialysis for longer periods, thus often developing oliguria or 
anuria. ( Bendorf  et al 2013) 
 
 The amount of diuresis in ESRD patients differs significantly; from 
volumes that can be defined as “normal” to “zero” mL (diuresis of 1500 
mL or more/day can be considered normal). As a result, many patients 
will not regularly use their lower urinary tract (LUT) during the 
transplant waiting period which in some cases may be long. Indeed, this 
inactivity of the LUT brings over time to a condition of small bladder, 
with even less of 100 mL of maximum bladder capacity, due to atrophy 
and fibrosis. ( Girerd et al 2018) 
 
Current evidences show that preemptive renal transplant, or after 
a limited dialysis period, provide better graft survival rate, lesser 
complication rates and reduce metabolic impairment when 

 
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compared to those who experienced long-term dialysis, especially 
in children. A period greater than 6 months of dialysis is 
associated with worst outcomes. ( Neves et al 2018). 
 
 Regarding the detrimental effect of long-term dialysis on the 
LUT, and especially in bladder, the interruption of physiological 
cycle of storage and voiding brings to a situation called 
Defunctionalized Bladder (DB). A standard definition of DB does 
not exist, however a common definition used by Errando et al., 
identify a DB when bladder output is less than 300 mL/24 h. 
Other definitions exist, however they differs greatly and due to 
their heterogeneity a general consensus on DB still lacks. 
(Errando et al 2018). 
 
 
 
 
 
4.METHODOLOGY: 
Patients and Methods/ Subjects and Methods/ Material and Methods 
 
Type of study: prospective cohort study. 
 
Study setting: department of urology, Faculty of medicine, Ain shams university 
hospitals. 
 
Study period: 18 months 
 
Study population: Egyptian patients attending Ain Shams University hospitals who 
are prepared for renal transplantation.                                 
Inclusion criteria:  
1-Age: 16 years and older. 
2-ESRD patients maintained on hemodialysis for more than 12 months. 
3-Have oliguria or anuria 

 
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4-reduced bladder capacity (less than 100 ml) assessed by cystogram. 
 
 
Exclusion criteria:  
1- Previous bladder or pelvic surgery or procedure having affected the bladder 
function. 
2- Neurogenic bladder dysfunction. 
3-Patients with history of lower urinary tract symptoms before developing renal 
failure. 
4-Those with lower urinary tract disease resulting in renal failure. 
 
Sampling method: prospective cohort study. 
 
Sample size: the study main objective is to describe various parameters related to 
bladder functionality in renal transplanted cases with defunctionalized bladder 
when treated with pre-transplant bladder cycling and due to limited data available, 
estimation of sample size will be based on effect size. A sample size of at least 20 
cases achieves a power of 80% to detect a large effect size of 0.7 comparing pre- 
and post- cystometric capacity using paired t-test with level of significance of 0.05. 
 
Ethical Considerations:  
The study will be presented for approval from the ethical committee of the Faculty 
of medicine, Ain shams university.  
- Informed written consent will be taken before recruitment in the study after 
explaining the purpose and procedures of the study.  
- The privacy of participants and confidentiality of data will be guaranteed during 
the various phases of the study.  
- Any participant does not have to take part in this research if he or she wanted, they 
may stop participating at any time. 
 
Study procedures: 
Preoperative evaluation:  
 1-History including medical history, surgical history, drug history and history 
of a voiding diary that documents urinary continence, voided volumes and 
times of voiding.  
2-Detailed physical examination with special attention to abdominal scars, 
stomas and catheter. 
3- Laboratory investigations:  

 
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Urine analysis, urine culture (mid-stream) and sensitivity, blood urea, creatinine 
levels, complete blood counts, liver function tests (ALT, AST) and coagulation 
profile. 
4) Radiological investigations:  
As pelvi-abdominal ultrasound and ascending cystogram in order to confirm the 
diagnosis of reduced bladder capacity. 
5) Cystometry. 
 
-Bladder recycling will be done by the patient after proper education. It will be 
started by the instillation of the sterile water in the bladder in amount equal to the 
estimated bladder capacity. Then the amount will be gradually increased till the 
patient can withstand filling the bladder with 250 cc of sterile saline for 2 hours. 
Any associated complications will be reported and the time needed to reach the due 
bladder capacity will be recorded. 
-Ascending cystogram will be done after bladder recycling. 
 
Intraoperative: The procedure of renal transplantation will be carried out 
according to the hospital protocol and the ureteroneocystostomy will be 
done by a stented Leich Gregoir technique. 
 
Postoperative evaluation:  
Assuming that the bladder will regain its activity and full capacity after 8 weeks of 
transplantation, all patients will be assessed 3 months after transplantation by the 
following: 
1. IPSS questionnaire in order to evaluate the lower urinary tract symptoms. 
2. Ascending cystogram. 
3. Pelvi-abdominal ultrasound with pre and post voiding residual urine 
assessment. 
4. Renal graft function. 
And after 6 months of transplantation by: 
1- IPSS questionnaire. 
2- Pre and post voiding pelvi-abdominal ultrasound. 
Statistical Analysis Method  
Data will be collected, tabulated and will be subjected to adequate statistical 
analysis including mean and standard deviations and will discussed. 
 
 

 
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Contents: 
 
1) Introduction. 
2) Aim of the study. 
3) Review of literature.  
a. End stage renal disease 
b. Defunctionlized bladder. 
c. Clinical and urodynamics characteristics of DF. 
     d. Renal transplantation. 
4) Patients and methods. 
5) Results. 
6) Discussion. 
7) Summary. 
8) Conclusion. 
9) References. 
    10) Arabic Summary. 

 
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5.REFERENCES  
 
 
  1. Aytekin S, Dinc B, Ertug Z, Hadimioglu N, Aytekin EC. 
Perioperative comparison of preemptive and non-preemptive 
renal transplant recipients. Turkish J Anaesthesiol Reanim. 
2020;48(2):102–7. 
 2. Bendorf A, Pussell BA, Kelly PJ, Kerridge IH. 
Socioeconomic, demographic and policy comparisons of 
living and deceased kidney transplantation rates across 53 
countries. Nephrology (Carlton). 2013;18(9):633–40. 
 3. Errando, C., Batista, J. E., Caparros, J., Arano, P., 
Villavicencio, H. Is bladder cycling useful in the urodynamic 
evaluation previous to renal transplantation?. Urol Int. 2015; 
74: 341-5. 
 4. Girerd S, Girerd N, Duarte K, Giral M, Legendre 
C,Mourad G, et al. Preemptive second kidney transplantation 
is associated with better graft survival compared with non-
preemptive second transplantation: a multicenter French 
2000-2014 cohort study. Transpl Int. 2018;31(4):408–23.. 
5. Neves Neto JF, Palomino Z, Mizuno Watanabe IK, Aguiar 
WF, Medina-Pestana JO, Soler R. Pretransplant 
defunctionalized bladder-overrated condition? Neurourol 
Urodyn. 2018;37(5):1559–66.