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

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

Deep vein thrombosis in pelvic and femoral fractures in earth quake victims

The aim of this prospective cum descriptive study was to determine the frequency of deep vein thrombosis using Duplex ultrasound scan, in a group of earth quake victims of 08 October, 2005. All these patients belonged to the high mountain northern areas of Pakistan and were admitted in Combined Military Hospital Rawalpindi with pelvic and/ or femoral fractures without additional risk factors for DVT. None of the patients had prior thromboprophylaxis. Study was conducted in thirty female patients admitted in Family wing of Combined Military Hospital Rawalpindi from Oct 2005 to Feb 2006. Although we managed about 75 such cases, only 30 could be assessed for DVT by duplex ultrasound scan partly due to excessive work load on part of Ultrasound department but also because of early post operative mobilization of the patients as per policy, thus offering little chance of having positive results. Out of thirty patients studied, DVT was found in 01[3.3%] patient, who belonged to Balakot and had pelvic fracture. Clinically she was asymptomatic and had no signs of DVT, but her duplex scan revealed calf veins involvement on the right side, with extension of the thrombus in to the femoral veins as well. Another patient with bilateral upper femoral fractures had painful swelling of both thighs, but her duplex scan for DVT was normal. The percentage of DVT observed in patients belonging to the northern areas is low in comparison to both our urban population research data as well the internationally conducted studies. Factors responsible might be dietary, racial or geographical, either alone or in combination, which need to be determined in focused, prolonged studies