Ask the Experts - Self-Catheterization After Renal Transplantation?
In a patient with bladder outlet obstruction undergoing renal transplantation, is it safe to advise clean, intermittent self-catheterization postoperatively?

Tapan Sinha, MD

The problem of abnormal bladder capacity, emptying, or both is fairly common in the population of patients with end-stage renal disease (ESRD). In many instances, the bladder dysfunction is the primary, or at least contributory, cause of the renal failure. This is particularly true in pediatric patients; cases of congenital obstruction and bladder dysfunction constitute a significant fraction of the ESRD population in this age group. Other common causes of bladder dysfunction in conjunction with renal failure include (1) neurogenic bladder, related to spinal cord malformation or injury or caused by diabetes, and (2) in the older male population, bladder outlet obstruction caused by prostate disease. Problems with poor bladder capacity or emptying are often masked in the dialysis patient because of anuria or oliguria. The return of normal urine output often unmasks these problems and requires a therapeutic approach.

In our experience at the University of Iowa, the approach to these patients has often included clean intermittent catheterization (CIC), usually performed by the patient. Many of these patients, especially the pediatric patients, undergo augmentation cystoplasty to increase bladder capacity but must perform CIC to empty the reservoir created by this procedure. Although these patients undoubtedly have a higher rate of urinary tract infection, including pyelonephritis, their complication rate is probably not much different from that experienced by similar nontransplant patients not on immunosuppression, and their long-term outcomes seem to be quite good. Their regimen almost always includes long-term anti-infective prophylaxis, typically with trimethoprim-sulfamethoxazole, and use of an antiseptic genitourinary irrigant for catheter preparation. Patients are usually instructed to perform catheterization from once to 4 times daily, depending on bladder capacity. Catheterization is generally performed after voiding, and the frequency of catheterization can be decreased if postvoid residual urine is relatively low, eg, < 100 mL.

These impressions, based on the author's experience, are supported by a number of small series of 5-10 patients each, documenting relatively good outcomes in transplant recipients performing CIC. In one interesting report, a small group of patients performing CIC was observed to have outcomes comparable to a group with surgical urinary diversion prior to transplant. This topic was also reviewed by Hatch.