Surgical complications of renal transplant: experience of a tertiary case Urology institute in Pakistan

Objective: To evaluate the surgical complications of renal transplantation in adult end stage renal disease patients

Study Design: Retrospective observational study

Place and Duration of Study: Armed Forces Institute of Urology [AFIU] Rawalpindi, from Apr 2009 to Apr 2014

Material and Methods: Frequency of the surgical complications of renal transplant was assessed in 105 adults with end stage renal disease subjected to renal transplantation at Armed Forces institute of Urology Rawalpindi, from Apr 2009 to Apr 2014

Results: Total 105 adults were included in the study with the median age of 38 years; [ranging from 18 to 61 years]. There were 88 [83.8 percent] male and 17 [16.2 percent] female patients. All were live related transplants. Vascular complications were the most common [6.66 percent] followed by urological complications [2.85 percent]. Graft loss occurred in 3.8 percent and surgical mortality was 0.95 percent

Conclusion: Vascular complications after renal transplantation need prompt detection and remedial steps to avoid graft loss. Urological complications, on the other hand, increases morbidity, often needs corrective radiological or surgical intervention, but rarely leads to graft loss

effective technique of obturator nerve block to prevent adductor reflex during transurethral resection of bladder tumor

Objective: To observe the efficacy of blind obturator nerve block by Labat technique for prevention of obturator jerk during transurethral resection of bladder tumor performed under spinal anesthesia

Study Design: Descriptive Study

Material and Methods: This was a single center based study conducted at tertiary care military hospital for a period of thirty months. Fifty five patients were recruited in the study, after identifying the location of bladder growth in the lateral wall on ultrasound USG and confirming its exact site on cystoscopic examination. Those eliciting obturator jerk during transurethral resection of bladder tumor [TURBT] were included and ONB was performed using 2% lidocaine via blind technique of Labat. TURBT was restarted and presence of obturator jerk was recorded if evoked [primary outcome]

Results: Median age was 67.3 +/- 8 years with majority [72.7%] in the age group between 61 to 80 years. Male female ratio was 7:1. Fifty [90%] patients presented with solitary growth. Mean operating time was 28.8 +/- 12 minutes. ONB was successful in 52 [94.54%] of the cases while failure in 3 [5.45%] resulted in conversion to general anesthesia for the completion of TURBT

Conclusion: Blind obturator nerve block [ONB] by using Labat technique for obturator nerve block has proven to be simple, reliable and easily replicable in any set up and it does not require any time consuming steps or sophisticated equipment

Complications of percutaneous nephrolithotomy single center experience of 103 cases

Objective: To present our complications of percutaneous nephrolithotomy [PCNL] during initial one year using modified Calvien system

Study Design: Observational prospective cohort

Place and Duration of Study: Armed Forces Institute of Urology [AFIU] Rawalpindi from 1[st] January 2014 to 31[st] December 2014

Material and Methods: The study was conducted at AFIU, Rawalpindi from 1[st] January 2014 to 31[st] August 2014. All of the consecutive 103 patients who underwent PCNL were included. Single-stage PCNL was performed in all the cases under general anesthesia. Pneumatic and ultrasound probes [alone or in combination] were used to fragment the calculi. Stone fragments were removed using graspers. A 16 Fr Foley catheter was used as nehrostomy tube. It was clamped on the first postoperative day. Foley catheter and ureteric stent was removed one day later. Intravenous antibiotics were given during admission period, i.e. 3-5 days. The complications were classified according to modified Clavien system. The data was analysed using the Statistical Package for the Social Sciences [SPSS] version 16

Results: Sixty nine [67%] patients were males and thirty four [33%] were females. Their ages ranged from 7 years to 81 years with mean age 41.7 +/- 16.34 years. PCNL was performed on right side in 48 [46.6%] cases while 55 [53.4%] underwent PCNL on left side. Overall complication rate was 21.35%. Grade 1 complications in 7.7%, grade 2 in 7.8%, grade 3a in 2.8% and grade 4a complications in 2.9% were seen

Conclusion: PCNL is associated with low incidence of major complications even in the hands of beginners when carefully performed

Comparison of HO:YAG laser and pneumatic lithotripsy in the treatment of proximal ureteral stones

Objective: To evaluate the effectiveness and safety of treatment for proximal ureteral stones with pneumatic lithotripsy compared to holmium: yttrium-aluminum-garnet [HO: YAG] laser therapy

Study Design: Randomized control study

Place and Duration of Study: Armed Forces Institute of Urology, Rawalpindi from Sep 2014 to Mar 2015

Material and Methods: This randomized control trial was conducted at Armed Forces institute of Urology Rawalpindi. A total of 73 patients who underwent treatment between Sep 2014 and Mar 2015 were included in the study. Of the patients, 37 had pneumatic lithotripsy [PL group] and 36 had ureteroscopic HO: YAG laser lithotripsy [LL group] using rigid 8 Fr-ureteroscope for the fragmentation of the ureteric stones. Patients were evaluated for stone clearance after 3 weeks, with X-ray KUB, ultrasound and plan CT KUB [where indicated]. All the data were recorded in a proforma and analyzed in SPSS version 11

Results: There was a difference between the two groups according to overall stone clearance rate 83.8% for PL group vs. 86.5% for LL group. Proximal stone migration was seen in 16.2% of cases in PL group while in only 5.5% of cases in LL group. The overall complication rate was 35.1% in PL group while 30.5% in LL group. The mean procedure time was 28.8 +/- 4.5 minutes for PL group while it was 35.5 +/- 8.6 minutes for LL group

Conclusion: The pneumatic and holmium: yttrium-aluminum-garnet laser lithotripsy both are established choices for treatment of ureteral stone but in terms of stone clearance rate and decrease incidence of proximal stone migration HO: YAG lithotripsy is better than pneumatic lithotripsy

Intra-intestinal mesh migration presenting with faecal fistula after incisional hernia repair

Ventral hernias are a frequent problem in our society. Incisional hernia is not an infrequent sequel of ventral abdominal hernia repair. Incisional hernias are characterized by breakdown of the scar in the abdominal wall from an incision for any previous operation. This differentiates them from recurrent hernias where a previously done hernia repair operation breaks down. Such repairs are globally done by applying meshes of different sizes and types. Despite all the documented benefits of its use, a number of complications associated with mesh are reported in many studies. This study reports the case of a man operated for an incisional hernia, repaired by a proline mesh. He developed a complication of migrating mesh after 5 years of surgery at LUMHS, Jamshoro. There are very few such mesh complications reported in the literature

Preliminary assessment of phytochemical contents and antioxidant properties of Pistacia integerrima fruit

Present study was focused on the evaluation of preliminary phytochemical screening and antioxidant properties in hydrophilic and lipophilic solvents extracts of Pistacia integerrima fruit, collected from Lesser Himalayas-Pakistan. Ethnobotanical data were collected through semi-structured interviews. Standard analytical methods were followed to estimate the proximate composition of nutrients, trace metals and phytochemical contents including phenolics, flavonoids, flavonols and ascorbic acid. The free radical scavenging activities of aqueous and acetone extracts were carried out against 2, 2-diphenyl-l-picrylhydrazyl, hydroxyl radical, hydrogen peroxide radical, ferrous ion chelation, ferric ion reduction, and phosphomolybdenium complex assay. Comparatively highest value of cultural importance index was determined for Margalla hills than other study sites. Crude fibers contents [33.65%] were found highest among nutrients, while in minerals utmost level was measured for K [947.3mg/kg, FW], followed by Ca, Mg, Na and Fe. Acetone extract exhibited highest total phenolics contents [113.7mg GAE/100g, FW] and antioxidant potential for ferric ion reduction [107.3microM GAE/l00g, FW], phosphomolybdenum complex assay [99.32micro,M AAE/100g, FW] and DPPH radical scavenging [91.89%]. Fruit of P. integerrima was found an excellent source of nutrients, minerals and antioxidants. Crude extracts exhibited noteworthy potential against free radicals and could be of immense significance in the prevention of different diseases related to free radicals. Present data could be an effectual tool for propagation programs intended to enhance the antioxidant and other phytochemical components in foods

Treatment of mycosis fungoides with total skin electron beam therapy using modified stanford technique

A retrospective review of three patients with mycosis fungoides treated with total skin electron beam therapy, from the year 2007 to 2009, at the Oncology department, Ziauddin University Hospital

Diagnostic evaluation of fine needle aspiration biopsy in lung cancer

To evaluate the yield of Fine Needle Aspiration Cytology [FANC] in suspected lung cancer. Observational study. This study was conducted at the Department of Pulmonology, Bolan Medical College Quetta from Jan 2009 to Aug 2009. Thirty Cases both male and female were included in the study. The lesion was localized with recent PA and Lateral Chest X-Rays and ultra sound. A 22 guage needle was attached to 10cc syringe. The needle was introduced into the lesion under local anaesthesia. On reaching the mass slight suction was applied and few in and out movements were made, the needle was taken out and 3-4 slides were made of the aspirate, fixed immediately with alcohol. Among thirty cases, malignancy was proved in 21 cases while in 3 cases FNAC was positive for malignancy but no call type was revealed. In six cases malignancy was not found. Among proven 21 cases 14 had squamaus call carcinoma, 6 had Adeno carcinoma and one had small call carcinoma. FNAC of the peripheral lung lesions is a safe, quick and reliable method of establishing diagnosis of lung cancers where bronchoscopic help is not available or the tumor is not with in reach of bronchoscope

Post laparoscopic cholecystectomy exploration: an audit

This study was conducted to analyse the different causes and factors for exploration and their management after laparoscopic cholecystectomy in 1000 cases of cholelithiasis. This is a prospective study conducted in the department of surgery Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan, from January 2003 to December 2010. Thousand cases of cholelithiasis were operated for laparoscopic cholecystectomy in eight years and were observed for their recovery and complications postoperatively. Those patients who developed major problems were assessed clinically and by different investigations like LFT, Ultrasound, CT scan and HIDA scan to find out the cause. They were operated once absolute indication of exploration was made. All patients were included in study after getting informed consent for first operation as well as for Re-do surgery if any one required exploration. Out of 1000 cases, 58 patients [5.8%] developed unidentified complications during laparoscopic cholecystectomy who required surgery for one or other reason. The problems which required exploration were bleeding in 2.2%, biliary leak in 1.9% and obstructive jaundice in 1.0% of cases as main reasons. The cases were managed by various open surgical procedures depending upon the pathology found on exploration. Laparoscopic cholecystectomy though proved as gold standard for cholelithiasis but still is not free of complications and can land up into major problems for patients who had either difficult cholecystectomy or over looked congenital anomalies of biliary tree

Allergic bronchopulmonary aspergillosis and bronchial asthma, a forgotten partners

To evaluate the incidence of ABPA [Allergic Broncho Pulmanary Aspergillosis] in Asthma. Observational Study. This study was conducted at Pulmonology Department, Bolan Medical College Quetta from 2005-2010. Forty Cases both male and female were included in this study. A detailed medical history, complete physical examination, recent posteroanteral and lateral chest X.Ray were obtained. Where ever possible previous X-Ray chest were also obtained for comparison and to see the fleeting shadows. Laboratory help included absolute eosinophil count, total serum IgE, Sputum for fungal hyphae and spirometry. Among forty [40] cases 90% were asthmatics between 11-40 years of age. In 92% of cases the radiological findings were fleeting in nature. 70% were misdiagnosed and treated as pulmonary tuberculosis. All 40 case had raised [70.5 x 10[9] perlitre] absolute eosinophil count in peripheral blood. Sputum eosinophilia was detected in 77% of cases and fungal hyphae were isolated in 47% cases bronchospy and serum IgE levels were also abnormal but performed in only 25% cases. ABPA must be considered in asthma patients having unexplained, fleeting or persistent chest radiographic shadows

Brachiobasilic fistula with anterior transposition, a workable solution in difficult clinical situations

This study was undertaken to assess the role of brachio-basilic fistulae with anterior transposition in patients with unsuitable veins for formation of conventional AV fistulae or after failure of multiple fistulae. Descriptive study. Armed Forces Institute of Urology and Military Hospital Rawalpindi, from November 2007 to October 2009. Patients of CKD with unsuitable veins for the formation of conventional AV fistula and those with failed Radiocephalic and Brachiocephalic fistulae in whom Brachio-basilic fistula was formed, were included in the study. Patients unfit for general anesthesia and those with upper arm Prosthetic grafts were excluded. The patients were interviewed, examined with particular attention to vascular access and a complete data about their hemodialysis and previous vascular access was collected. Transposed Brachio-basilic fistulae were created in 38 patients of End Stage Renal Disease [ESRD] during study period; out of which 1 patient was lost during followup and the rest 37 were followed prospectively. The median duration of follow-up was 13.56 months [SD +6.03] with a range of 3 to 23 months. In 92% of cases transposed Brachio-basilic fistula was created after failure of one or more conventional fistulae. Complications were noted in 16.2% cases which included primary failure, wound infection, arm swelling and distal ischemia as a result of steal phenomena [Table]. Three patients died during this period. Life of fistulae ranged from primary failure to as long as 23 months. Transposed brachio-basilic fistula is a viable option for patients who do not have suitable vasculature for formation of conventional fistula but especially for those after failure of fistulae at other sites

Ethnobotanical survey of Lora valley district Abbottabad [Khyber Pakhtunkhwa], Pakistan

The present paper is based on an ethnobotanical research project conducted in Lora Valley and its allied areas. District Abbottabad [Khyber Pakhtunkhwa] Pakistan. The inhabitants of the area used plant species for various purposes such as health care, food, fodder, fuel and shelter. A total of 57 plant species belonging to 35 families were recorded for their ehtnobotanical uses. The ethnomedicinal inventory was developed by botanical name, family name, local name, flowering period, conservation status, part used, and ethnobotanical uses. Plant specimens were collected, identified, preserved, mounted and vouchers were deposited in the Department of Plant Sciences, Quaid-i-Azam University Islamabad, for future reference

Frequency, causes and outcome of placenta praevia

The objective of the study was to identify and target preventive interventions among women at increased risk of placenta praevia. This is a Descriptive study. All the case records of women with the diagnosis of pregnancy with placenta praevia were reviewed. The frequency of placenta praevia was 1.45% or 1:69 deliveries complicating a singleton pregnancy. Diagnosis of placenta praevia was confirmed by complete history, examination and finally the ultra sound examination, the course of events during antenatal period, their mode of delivery and fetal outcome of all such patients were assessed. Special attention was paid to the past history of dilatation and curettage, previous LSCS and or other forms of uterine surgical procedures. There were 7082 deliveries during the study period. Out of which 103 patients had placenta praevia. The frequency of placenta praevia was found to be 1.45% or 1:69 deliveries. The maximum No. of patients 38 [36.89%] had placenta praevia type III. Highest percentage of the patients with placenta praevia were between 30-35 years. 40 [38.83%] gave history of one or more Gynecological/Obstetrical procedures before the present pregnancy. Incidence of placenta praevia was significantly higher in patients with previous Caesarean Section i.e 15 [15.15%] had previous one or more LSCS. While 18 [17.4%] had history of previous curettage/induced abortion. The poor socioeconomic status illiteracy early marriages, multiparity, long distances from the referral centers, lack of proper health care facilities at the primary and secondary health care centers predisposed the patients in our area to increased incidence and complications of placenta praevia

Vesico-vaginal fistula: interposition flap, a key to success

Vesico-vaginal Fistula [VVF] is an abnormal communication between bladder and vagina that causes continuous discharge of urine into vaginal vault. The objective of this study is to describe current trends of aetiology and repair of Vesico-vaginal Fistulae. This is a Descriptive Study, conducted at Armed Forces Institute of Urology, Rawalpindi and Combined Military Hospital, Kharian between May 2001 and May 2007. All patients diagnosed as cases of vesico-vaginal fistulae were included in the study. Their demographic profile and repair success was determined. A total of 86 patients were included in the study. The mean age of the patients was 35.5 years [range 25-46]. Total abdominal hysterectomy was the most common cause [53% of the cases] followed by obstetric causes [43.92% of the cases]. Success rate of the surgery in the study was 97.5%. The common causes of vesico-vaginal fistula in this study were total abdominal hysterectomy and obstetric causes. The success rate was high, yet the attempt should be made to prevent this socially distressing condition

Clinical spectrum and management of ovarian tumours in young girls upto 20 years of age

Ovarian tumours are one of the common malignancies all over the world affecting all age groups. This study analyses different clinical presentation and management of ovarian tumours in young girls up to 20 years. Patients up to 20 years of age admitted with the diagnosis of ovarian tumour were included. Data collected on a proforma. Variables studied included age, presenting symptoms, investigations, surgical findings, type of surgery, histopathology reports and follow-up. The patients with malignant ovarian tumour were followed by oncologist as well as gynaecologist. Data analysis was done on SPSS. The mean age was 17.27 +/- 2.46 SD years. The common symptoms included abdominal mass, abdominal pain, urinary problems, menstrual irregularities and generalized malaise. All patients were operated after preliminary investigations. Patients were advised to have follow-up post-operatively after 1 month. The follow up was done by oncologist and gynaecologist. Six patients [12.5%] died and 22 [45.83%] were lost to follow up. Ovarian tumours are quite common in young girls. Majority of patients seek medical advice once the disease becomes symptomatic, complicated or advanced disease in the case of malignancy. Histopathology of the tumours revealed that epithelial cell tumour is the commonest tumour in contrast to germ cell tumour as reported by world literature

Presentation and evaluation of renal masses

To find out the various disorders presenting as renal mass to a referral centre for Urology over a 2 year period. A descriptive study. The study was conducted at Armed Forces Institute of Urology Rawalpindi and Combined Military Hospital, Kharian Pakistan from March 2002 through March 2004. A total number of 43 patients who presented as a renal mass or found to have renal mass during the course of investigations and subsequently underwent treatment at the institute were analyzed in the study. Their mode of presentation as various age group distribution and workup, histological break-up, treatment offered and follow-up was recorded. A total number of 43 patients presented as renal mass during the period of study. Seventy four percent of the masses turned out to be renal cell carcinoma and radical nephrectomy was the most common procedure performed [34 patients]. Hematuria was the most common mode of presentation as seen in 32 [74%] patients followed by lumbar pain in 30 [70%] patients. Majority of the lesions was in 46-55 year age group with 33 [77%]. Advances in diagnostic modalities such as CT and MRI will continue to expand the role of preoperative imaging for the diagnosis of renal masses. Surgery remains the mainstay of treatment for the majority of such masses and with increasing detection at an early stage, may possibly improve the cure rate of renal malignancies as well

Primary non-hodgkin's lymphoma of vagina associated with pregnancy

We report a case of non-Hodgkin's lymphoma [NHL] in 23 years old, 36 weeks pregnant female, who presented with a swelling in the vagina. Biopsy of the lesion led to profuse haemorrhage and emergency caesarean-section along with bilateral ligation of internal iliac arteries were required. Recovery was smooth and she was discharged from the hospital on the 5th postoperative day. Histopathology revealed non-Hodgkin's lymphoma, diffuse large B cell type [DLBCL]. Further treatment by medical oncologist led to complete resolution of the tumour at three months

Clinico-pathological profile of patients with breast diseases at university hospital, Jamshoro

To assess various disorders of breast regarding their frequency, presentation, pathology and management at a University Hospital. A descriptive study. Department of Surgery, Liaquat University Hospital Jamshoro - Sindh from January 1999 to December 2003. One hundred and fifty patients with different breast disorders were studied. All cases were assessed clinically by getting history on a predesigned proforma and diagnosis was confirmed with help of relevant investigations. Patients with various breast diseases were included in the study except those who were having either no definite lump or no breast pathology. The treatment given was according to type of lesion in the form of surgery or conservative. Patients with benign breast diseases were assured and followed up after surgical treatment or kept on hormone therapy where as cases with malignant disease were referred to oncologist for cancer registry purpose and chemo-radiotherapy. Among 150 cases, majority was females with female to male ratio of 24:1. All patients presented with breast lump [100%], followed by pain in the lump [53.33%] as main symptoms. Left breast was involved in 53.33% and right breast in 44.66% of cases. Majority of cases [84.67%] underwent surgery. Histopathology revealed fibro-adenoma in 30.66%, fibrocystic disease in 15.33% and carcinoma in 35.33% cases as main disorders. All six male patients had gynaecomastia. In our set up, frequency of carcinoma of breast is increasing as compared to benign lesions. However, overall benign problems are more frequent than breast cancer

Hepatic hydatid cyst and omentoplasty

Hydatid cyst liver is a disease, which has been subjected to great diversity as far as the surgical treatment is concerned. A descriptive study was carried out to determine the results of omentoplasty in the management of hydatid cyst liver. A group of 23 patients were included in the study. 16 were adult males and 7 were adult females. Mean age of the patients was 36 years. Intra- operative assessment of the hydatid cyst liver showed 91.3% solitary cysts. Univesicular cysts were 43.3% and multivesicular cysts 52.1%. 86.9% cysts were located in the right lobe of liver. All were subjected to omentoplasty. Post-operatively 4.3% showed bile leakage and 17.3% wound infection. The bile leakage was managed conservatively and it regressed in 4 days. No haematoma or deep abscess was documented. Follow up of the patients showed significant clinical and radiological improvement

Male Pseudohermaphroditism

An unusual case of a 40-year-old infertile male is presented. On examination he had cryptorchidism with other normal secondary sexual characters. Ultrasonography and computerized tomography raised the suspicion of tumour in the right abdominal testis. On exploration, a uterus with cervix, fallopian tubes and abdominal testes were detected. This was confirmed histopathologically. Chromosomal analysis revealed 46XY