An Unexpected Intraoperative Finding of Bladder Neck Contracture During Kidney Transplant: What to Do? A Novel Case with a Clear Strategy

Introduction: Bladder neck contracture (BNC) is a relative contraindication for renal transplantation. It is one of the rare but most feared complications of urological procedures, including transurethral resection of the prostate (TURP) and renal transplantation (RT). The etiology remains unclear, but multiple triggers have been implicated. We present a challenging case where bladder neck contracture was diagnosed during the transplant in a patient with previous TURP. This did not interfere with the transplant and was subsequently treated successfully resulting in normal voiding post-transplant. Case Description: A 70-year-old African American male with a medical history notable for TURP in 2016 and an Orthotopic Liver Transplant in 2019 was admitted for renal transplantation. During routine pre-transplant recipient evaluation, no signs or symptoms of obstructive uropathy were reported. At the time of the kidney transplant, Urology was consulted in the OR due to difficulty passing a Foley’s catheter. Cystogram and cystourethroscopy revealed a dense BNC, likely from a prior TURP. After discussion with the family and collaboration between transplant surgery and urology, a suprapubic catheter was placed, and the patient underwent renal transplantation. Three months later, after reporting the ability to void, the patient was re-evaluated. Cystourethroscopy and BNC incision were performed, and a Foley catheter was placed. The suprapubic catheter was clamped progressively and subsequently removed 3 weeks later. The patient was able to urinate normally and remained asymptomatic. Discussion: Bladder neck contracture (BNC) can present unexpectedly during renal transplant surgery, with urological issues often undiagnosed in dialysis patients due to low urine output. We suggest pre-transplant urological evaluation for select patients at risk of BNC to avoid it being labeled as a contraindication and consider a suprapubic catheter as a bridge to transplant. Our case highlights the value of a systematic, stepwise approach with shared decision-making, ensuring successful renal transplantation without organ refusal.