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Cystitis cystica is a benign proliferative bladder disorder caused by chronic irritation, occasionally mimicking neoplasia. Obstruction at the bladder neck or vesicoureteric junctions may lead to bilateral hydroureteronephrosis and ESRD. While TURBT and DJ stenting are the mainstays of management, recurrent obstruction and infection can complicate outcomes. Renal transplantation in this setting is rarely reported due to risks of recurrent UTIs, recurrence under immunosuppression, and potential malignant transformation.
AIM
To describe a rare case of successful living related renal transplantation in a patient with ESRD secondary to cystitis cystica et glandularis , with two year follow up demonstrating sustained graft function and absence of lesion recurrence
CASE PRESENTATION
A 34-year-old male with a history of TURBT and bladder neck resection performed elsewhere three months prior for biopsy-proven cystitis cystica presented with progressive renal dysfunction at creatinine of 4 mg/dL. MR urography revealed a polypoidal bladder neck mass involving bilateral vesicoureteric junctions with gross hydroureteronephrosis. DJ stenting failed, necessitating an anterograde stent.
His course was complicated by recurrent urosepsis requiring IV antibiotics and repeated DJ stent exchanges, ultimately progressing to end-stage renal disease requiring maintenance hemodialysis, which continued for 1.5 years.
After discussing transplant options and the risks of post-transplant infection and disease recurrence, a decision was made to proceed with transplantation. Due to recurrent infection risk from poorly functioning hydronephrotic kidneys, bilateral pre-transplant nephrectomy was performed. Bladder evaluation showed adequate capacity, and cystoscopic biopsy near the trigone/right VUJ was consistent with cystitis glandularis without dysplasia or malignancy.
The patient underwent a living-related renal transplant from his cousin sister after negative Flowcytometry crossmatch and PRA, using standard surgical technique, induction with very low-dose thymoglobulin, and triple-drug immunosuppression. Postoperatively, he had prompt diuresis, with creatinine normalizing by day 1, and an uneventful recovery. Serial urine cultures remained sterile. Subsequent ultrasonography and cystoscopy at 6 months and 2 years post-transplant showed no recurrence, with a healthy neo ureteric orifice.
At two years of follow-up, he maintains stable graft function, remains on tacrolimus, mycophenolate, and steroids, with no evidence of recurrent bladder pathology, graft dysfunction, or urinary tract infection.
DISCUSSION
This case underscores key considerations in managing cystitis cystica progressing to ESRD. Chronic bladder neck and VUJ obstruction can cause progressive hydronephrosis and renal injury, as seen in our patient, who required long-term hemodialysis despite TURBT and stenting, complicated by recurrent infections and urosepsis.
Pre-Transplant Optimization: Bilateral nephrectomy was necessary to remove poorly functioning, infected kidneys. Pre-transplant bladder evaluation confirmed adequate capacity and absence of malignancy, supporting safe transplantation under immunosuppression.
Transplant Feasibility: Living-related renal transplantation was successfully performed with standard technique and triple immunosuppression, achieving excellent early graft function. Perioperative infection prophylaxis and monitoring were critical given prior urinary pathology. It emphasizes the importance of multidisciplinary collaboration between nephrology and urology teams to achieve favorable outcomes.
Long-Term Outcomes: At two-year follow-up, graft function remains stable with no recurrence of cystitis cystica or urinary tract infections, highlighting that with thorough evaluation, optimization of immunosuppression, and vigilant care, renal transplantation is feasible and safe in selected patients.
Renal transplantation in cystitis cystica is rarely reported but is feasible with meticulous preoperative assessment, infection control ,counseling and vigilant follow-up. To the best of current knowledge, this stands as only the second reported case globally , contributing to the limited evidence that this diagnosis should not exclude patients from potentially life -saving renal transplantation. Careful follow up ensures excellent long term graft function and prevents lesion recurrence.
