Results of separate anastomoses of multiple renal arteries with recipient external iliac artery in renal transplant surgery

To evaluate the results of separate anastomoses of multiple arteries of the donor kidney with the external iliac artery of the recipient in renal transplant surgery. A descriptive study conducted at department of Urology and Renal Transplantation, Foundation University Medical College, Fauji Foundation Hospital, Rawalpindi and Hearts International Hospital, Rawalpindi from January 2005 to December 2007. Living voluntary kidney donors having multiple renal arteries as seen on preoperative screening. During regular renal transplant surgery, donors having multiple renal arteries as diagnosed on preoperative computerized tomographic renal angiography were selected for further study. Such kidneys from volunteer donors were harvested and no ex vivo bench surgery was performed to unit these multiple renal arteries. An arterial punch was used to make separate arteriotomies on the external iliac artery of the recipient and anastomoses of the multiple renal donor arteries were carried out separately with the external iliac artery in an end to side manner using 7/0 prolene suture. Of the fifty grafts harvested, 38 had two renal arteries arising from the aorta and reaching the renal hilum [Group I]. These were anastomosed separately to the external iliac artery. Nine grafts had triple renal arteries, two running to the hilum and one entering into the lower pole [Group II]. All these three arteries were anastomosed in an end to side manner with the external iliac artery. Three grafts had one main renal artery and a tiny upper polar cortical vessel incapable of anastomoses [Group III]. The small upper polar cortical artery was sacrificed and the main renal artery was anastomosed with the external iliac artery. One release of vascular clamps perfusion of the graft was observed. Diuresis of the graft was notices. Color Doppler study of the graft was carried out on third postoperative day. Serum creatinine of the recipient was determined on alternate days for one week, after a month and then regularly at three months interval for two years. Early and late vascular and urological complications were observed over a period of two years. A total of 50 kidneys with multiple renal arteries were harvested. On release of vascular clamps, reperfusion of all the allograft occurred within 5 to 75 seconds [mean: 30 seconds]. Diuresis from the graft started in 1/2 to 8 minutes [mean 3.5 minutes]. One of the recipients in Group I developed sudden decline of urine output 2 hours postoperatively and a color Doppler scan showed lack of perusion. On re-exploration a positional kink of the arteries was found which was corrected. Color doppler study on third postoperative day revealed normal perfusion of all the grafts. Serum creatinine of all the recipients steadily came down and reached normal values within a week. Serum creatinine levels remained within normal range over two years of follow-up. None of the patients developed postoperative hypertension or other vascular complications during the follow-up period. Three patients in Group I developed lymphocele requiring percutaneous aspiration. Two patients in Group II had wound infection. Performing separate anastomoses for multiple renal arteries of the donor with the external iliac artery of the recipients in renal transplant surgery is a safe, easy to perform and practical with minimal complications. The renal arterial anatomy of the donor kidney should be evaluated by the spiral computed tomographic angiography, prior to harvesting it in the host and this angiography should be available in all renal transplant surgery units

Urethral catheterization

[1] To assess the theoretical and practical knowledge of young doctors about urethral catheterization. [2] To evaluate the experience and level of confidence of young doctors regarding the urethral catheterization in various tertiary care centers of Rawalpindi and Islamabad. Sep 2009 to Feb 2010. Tertiary Care Centre, Fauji Foundation Hospital, Rawalpindi. A questionnaire was distributed among 400 young doctors working as interns in various tertiary care teaching hospitals of Rawalpindi and Islamabad. We obtained the information about observation, assistance, performance and knowledge of young doctors about urethral catheterization. Questionnaire was distributed to about 400 young doctors working as interns in different teaching hospitals of Rawalpindi and Islamabad. Among the 400 doctors, 20 [5%] doctors never observed the male urethral catheterization and 35 [8.75%] doctors never observed female urethral catheterization. While among these 400 doctors 159 [38.75%] doctors never assisted male urethral catheterization and 175 [43.75%] doctors never assisted female urethral catheterization. Moreover 205 [51.25%] doctors never performed the male urethral catheterization and 185 [46.25%] doctors never performed female urethral catheterization. Training of young doctors about UC is not adequate. There is a need to train the young interns properly on this aspect. A senior resident or registrar of department should demonstrate the procedure in front of young interns before they are allowed to practice and first few catheterizations should be supervised by senior residents. Other alternate is the use of manikens for training of house officers

Assessment of hindrances in offering prayers in catheterised patients

To determine the difficulties which hinder the Muslim patients with urinary catheters in offering regular prayers and help then solve those difficulties. A descriptive study. The study was conducted in the department of Urology Foundation University Medical College and Fauji foundation Hospital Rawalpindi from July 2008 to December 2009. Muslim ambulant and mentally alert patients between the age 20 to 70 having a urinary catheter [urethral or suprapubic] were included in the study. 500 volunteer patients from both genders fulfilling the inclusion criterion were included in the study. Patients were given a questionnaire and asked about their regularity regarding offering of prayers before the insertion of urinary catheter and any change in that aspect after the catheter was placed. They were asked to mention the hindrance faced by them in offering their regular prayers after they got the urinary catheter. Before insertion of the urinary catheter 39.2% patients were offering their prayers regularly, while after having been catheterized only 0.4% patients remained regular in their prayers. 30% mentioned about the urinary leakage alongside the catheter as a hindrance to prayers. 28% said they did not know how to perform Wudhu [washing of arms up to elbows, face and feet, and touching the hair on the front of the head with water] while they had a catheter inserted. 12% described urethral pain as a hindrance to offer prayers. Remaining 29.6% gave no reason for abandoning regular prayers. However, all the patients wished they could pray. Those patients were guided. Patients complaining of pain due to catheter were treated. Those who could give no reason were counseled. A positive approach on the part of the patients was observed after these measures. Muslim patients having a urinary catheter can offer regular prayers. Urinary catheter is not a hindrance to prayers. Patients need to be counseled accordingly

Laparoscopic ureterolithotomy: an experience of 15 cases

To review our experience of laparoscopic ureterolithotomy and revisit its indications in the current era of minimally invasive urologic surgery. A descriptive study. The study was conducted at the department of Urology, Foundation University Medical College and Fauji Foundation Hospital, Rawalpindi from January 2007 to December 2009. We performed laparoscopic ureterolithotomies on fifteen patients for large [1.5-2.5 cm], impacted upper and middle ureteric calculi. In 10 patients laparoscopic ureterolithotomy was adopted as a primary procedure, four patients had stones resistant to Extracorporeal Shockwave Lithotripsy [ESWL], while one patient had failed ureterorenoscopy [URS]. An extraperitoneal approach was selected in all the patients. There were 11 patients with upper ureteric calculi and four with midureteric calculi, the procedure was successful in 14 cases. One patient required conversion to open ureterolithotomy. The average operating time was 50 minutes. The average hospital stay was 2.5 days. There was no major complication. One patient had persistent drain for four days. IVU at three months follow-up was normal in all cases. Laparoscopic ureterolithotomy in selected cases is a good minimally invasive procedure. Large, impacted, hard calculi which are resistant to ESWL and difficult to fragment endoscopically without flexible ureteroscopes and holmium laser can be managed by this technique

Ureteric injuries in gynaecological surgery: an experience of 19 cases

To review the ureteric injuries resulting from gynaecological surgery presenting to Fauji Foundation Hospital Rawalpindi and discuss their management. A retrospective descriptive study. The study was conducted at the department of Urology Foundation University Medical College and Fauji Foundation Hospital Rawalpindi during July 2004 to June 2009. The present study was conducted at the department of Urology Foundation University Medical College and Fauji Foundation Hospital Rawalpindi during July 2004 to June 2009. Case files of all those patients who were managed during this period in our hospital for ureteric injury sustained in a gynaecological procedure were perussued in detail. It was found out whether the ureteric injury occurred in Fauji Foundation Hospital Rawalpindi or the patient sustained such injury in a peripheral hospital and was referred here for management. Information was obtained regarding the patients' age, type of gynaecological surgery, level and type of ureteric trauma and the time of its recognition. In case of those patients referred from peripheral hospitals the mode of presentation was found out from the available data. The investigations performed and the treatment offered was thoroughly reviewed for all these cases presenting with ureteric injury. A total of 19 patients of ureteric injury afflicted during hysterectomy were managed during this period in our hospital. The patients1 age ranged from 34 to 55 years [mean age: 42.5 years]. 14 patients sustained ureteric injury during abdominal hysterectomy for fibroids. Five cases had ureteric injury while undergoing a radical hysterectomy. Seven patients had previous caesarian section. 17 patients had the ureteric injury involving the last five cm of the ureter while in two patients the ureter was injured approximately 10 cm from the ureterovesical junction. Four ureteric injuries occurred during abdominal hysterectomy at Fauji Foundation Hospital Rawalpindi. These four injuries were recognized by the gynaecologist during the procedure and were managed by the urologist by ureteroureteric anastomosis over a stent [two cases] and by ureteric reimplant over a stent [two cases]. Fifteen cases were referred to us from peripheral hospitals. In these patients the period from occurrence of ureteric injury to presentation at Fauji Foundation Hospital Rawalpindi ranged from two weeks to seven months [mean: 2.5 months]. Eleven of these patients had severed ureter and presented with constant urinary leakage from the vagina in addition to normal voiding. Three ladies had a flank pain and tenderness on the affected side and one lady who came from a peripheral hospital had swinging pyrexia, unilateral flank pain and tenderness. These four cases had unilateral ligation of the ureter and did not have any urinary leakage. After open surgical exploration and ureteric reimplant all these fifteen cases had uneventful recovery. Ureteric injuries are not uncommon in gynaecological surgery. Every effort should be made to avoid this complication. Injuries recognized during gyaenecological surgery should be managed without delay while cases coming late require thorough evaluation and surgical management

Leiomyoma of the urinary bladder with bladder stone

Leiomyoma of the urinary bladder is a rare benign mesenchymal tumour. We describe here a case of leiomyoma of the urinary bladder in a 65-year-old gentleman who presented with haematuria, passage of clots and combined obstructive and irritative urinary symptoms. The investigations revealed a vesical calculus and a mass on the left lateral wall of the urinary bladder. Cystolitholapaxy and transurethral resection of the tumour was performed. Histopathological report of the resected tumour revealed a leiomyoma of the urinary bladder. So far, a leiomyoma of the urinary bladder and a concomitant vesical calculus have not been described in literature

Urological complications of intrauterine contraceptive device

To elucidate the urological complications of Intrauterine contraceptive device [IUCD]. This study was conducted in Fauji Foundation Hospital Rawalpindi to elucidate. The urological complications of IUCD presenting to Urology department from January 2002 to December 2006. During this period 12 ladies having IUCDs presented with lower urinary tract symptoms [LUTS]. After thorough work up, 6 patients were managed surgically and the remaining 6 were managed conservatively. In all cases the IUCDs were inserted by paramedics. Out of six cases managed surgically, 3 patients had developed complete intravesical migration of device with stone formation. While in two other patients there was partial migration of the IUCD and stone formation over the migrated component of the device. One patient had simultaneously two IUCDs, one in uterus and another in bladder. We successfully performed cystolitholapaxy and retrieved four IUCDs in these patients endoscopically. A large vesical stone and the entombed IUCD in one of our patients were also removed endoscopically. The patient who presented with two IUCDs also got the vesical IUCD removed endoscopically. In remaining six cases, the IUCDs were in proper location and the cause of LUTS in these patients was urinary tract infection. These patients were successfully managed conservatively. Insertion of IUCD necessitates regular follow-up to confirm its correct position. Migration of an IUCD warrants prompt removal, even in asymptomatic patients. Cases presenting with UTI with undisplaced IUCD should be managed with appropriate antimicrobial therapy

Renal transplant in a patient with augmentation cystoplasty

A 20 years old girl, had undergone surgery for meningocele six weeks after birth, suffered from neurogenic bladder dysfunction. She underwent an augmentation ileocystoplasty and was trained to perform clean intermittent self catheterization [CISC]. After two years she developed renal failure secondary to recurrent urinary tract infections and she was started on chronic hemodialysis. On account of repeated line sepsis, a live related donor renal transplant was performed. About three months after renal transplantation she reported in emergency with an episode of graft rejection secondary to severe infection and later on complicated by leakage of urine from the renal pelvis of the allograft into the peritoneal cavity suggestive of a rent. A percutaneous nephrostomy of the allograft was performed which facilitated healing of the rent in the renal pelvis. The nephrostomy was withdrawn and patient started voiding through urethral catheter and gradually returned to CISC

Electrocoagulation versus suture-ligation of lymphatics in kidney transplant recipient surgery

To compare electrocoagulation versus suture-ligation of the lymphatics in kidney transplant operation of the recipient in terms of operating time, cost effectiveness, drainage from renal bed and incidence of lymphocele. This prospective comparative study was conducted at the department of Urology and Kidney Transplantation, Hearts International Hospital Rawalpindi during a period of two and a half years [January 2003 to July 2005] by a single surgical team. All patients who underwent kidney transplant during this period and did not fall into exclusion criteria were included in the study. Ninety Cases of End-stage Renal Disease undergoing kidney transplant were randomly divided into two equal groups. Patients in the group A had their lymphatics electrocoagulated and divided in the preparation of external iliac vessels for allograft anastomoses, while the patients in group-B underwent suture-ligation and division of the lymphatics covering the external iliac vessels. The average operating time was reduced in group-A. Also, no suture material was used for this step. Over all anesthesia time was also less. There was no significant difference in the quantities of postoperative drainage from the wound. There was no incidence of lymphocele development in group-A [0%]. While one patient [2.2%] in group-B had a moderate lymphocele which was aspirated and there was no recurrence. Cut off point of the study was six months from the day of surgery. Electro-coagulation and division of lymphatics coursing over the external iliac vessels is an attractive procedure. It saves time, is cost-effective, the postoperative wound drainage is not a problem and the procedure is not associated with increased incidence of lymphocele