Simultaneous pancreas and kidney transplantation: first report from Shahid Beheshti University of Medical Sciences and review of anesthesia considerations

We report a 33 year-old woman presented with signs and symptoms of severe uncontrolled diabetes mellitus and chronic renal failure [diabetic nephropathy]. She was prepared for emergency simultaneous pancreas and kidney transplantation [SPK] using hemodialysis and after compensating for the acid - base abnormality. She was discharged from the hospital about 3 week after the surgery with good renal and pancreatic function. A 2-month follow-up revealed no complication and a good renal and pancreatic function. Due to the importance of this kind of treatment and several anesthetic considerations of SPK we present this case report along with some pearls about related anesthetic view points

Early continence after open and laparoscopic radical prostatectomy with sutureless vesicourethral alignment an alternative technique, 8 years experience

We reviewed urinary outcomes after sutureless vesicourethral alignment in open radical prostatectomy [ORP] and laparoscopic radical prostatectomy [LRP]. Charts of 324 patients who underwent sutureless ORP [n = 188] and LRP [n = 136] were reviewed. After prostatectomy, a 22-to 24-F silicon Foley catheter was passed into the bladder via the preserved bladder neck. The Foley balloon was filled, and mild traction was applied to appose the bladder neck to the urethral stump. The Foley catheter was fixed to the patient's leg. No cystostomy was placed. The follow-up period ranged from 12 to 60 months. The mean operative time was 65 minutes in ORP and 260 minutes in LRP. Blood transfusion was significantly less frequent with LRP [9.6% versus l9.7%, P = .02]. The mean postoperative catheterization durations were 12 days in ORP and 13 days in LRP. Complete continence was achieve in 293 patients [90.4%] after 3 months of follow-up [88.9% in LRP and 91.5% in ORP, P = .78]. The continence rate improved to 96.3% in LRP and 95.2% in ORP at 1 year [P = .52]. Bladder neck stricture rate was 13.6% [12.8% in ORP versus 14.7% in LRP, P = .87]. Sutureless vesicourethral alignment during ORP and LRP is a promising approach with minimum urinary extravasation, a high rate of continence, and an acceptable rate of stricture. This technique could be considered as an alternative in anatomically demanding situations

Transperitoneal laparoscopic partial nephrectomy using a new technique

We report our experience with a new technique for transperitoneal laparoscopic partial nephrectomy with the kidney turned upside down intraoperatively. Laparoscopic partial nephrectomy was performed in 10 patients with upper pole lesions through a transperitoneal approach. Once complete mobilization of the kidney was achieved, it was rotated 180 degrees around the horizontal axis, so that the upper pole was positioned inferiorly. After performing partial nephrectomy, the resection bed was sutured by 2-0 polyglactin sutures and application of Hem-o-Lok clips. Then, the kidney was returned into its normal position and fixed to the abdominal wall. We performed laparoscopic partial nephrectomy on 9 patients with a contrast-enhancing upper pole kidney mass and 1 patient with a nonfunctioning upper pole. The median tumor size was 58 mm [range, 41 mm to 92 mm]. The median operative time was 206 minutes [range, 114 to 262 minutes] and the mean warm ischemia time was 30 minutes [range, 22 to 35 minutes]. One patient underwent surgical exploration due to bleeding 6 hours after the operation. Prolonged urine leakage [more than 7 days] was observed in 1 patient, which responded to ureteral stent insertion. Surgical margins were negative in all of the patients. Renal cell carcinoma was histologically diagnosed in patients with a kidney tumor. Laparoscopic upper pole partial nephrectomy had acceptable results while the kidney was turned upside down intraoperatively, in terms of operative time and complications. This approach facilitates the procedure by achieving a better field of vision

Laparoscopic adrenalectomy ten-year experience, 67 procedures

The purpose of this study was to evaluate the short-term and long-term results of laparoscopic adrenalectomies carried out in our center. A total of 67 laparoscopic adrenalectomies were performed during the 10 years between 1995 and 2005 at Shahid Labbafinejad Medical Center. A transperitoneal lateral approach was used in 65 [97.0%] of the patients, and retroperitoneal approach was used in 2 [3.0%]. The clinical characteristics and the outcomes were reviewed in a retrospective study. Indications for laparoscopic adrenalectomy in our patients were as follows: pheochromocytoma in 28 patients [41.8%], aldosterone-producing adenoma in 15 [22.4%], pseudocyst in 6 [9.0%], Cushing syndrome [macronodular adrenocortical hyperplasia] in 5 [7.5%], nonfunctioning adenoma [incidentaloma] in 5 [7.5%], myelolipoma in 2 [3.0%], almost normal adrenal tissue in 2 [3.0%], adrenal cyst in 2 [3.0%], adenocarcinoma in 1 [1.4%], and schwannoma in 1 [1.4%]. The mean operative time for unilateral cases was 149.0 A +/- 36.1 minutes. The mean intraoperative blood loss was 126 A +/- 36 mL. Conversion rate to open surgery was 7.5%. Reoperation due to hemorrhage was performed in 1 patient. Laparoscopic adrenalectomy is a safe procedure in some adrenal tumors and a reasonable option for selected large adrenal tumors when complete resection is technically feasible and there is no evidence of local invasion

Posttransplant lymphoproliferative disorders in kidney transplant recipients. An Iranian multicenter experience

Limited data with adequate sample size exist on the development of posttransplant lymphoproliferative disorder [PTLD] in living donor kidney recipients. We conducted a retrospective cohort study on the data of 10 transplant centers to identify the incidence of PTLD in Iran. Data of 9917 kidney transplant recipients who received their kidneys between 1984 and 2008 were reviewed. Fifty-one recipients [0.5%] who developed PTLD were evaluated with a median follow-up of 47.5 months [range, 1 to 211] months. Patients with PTLD represented 24% of all posttransplant malignancies [51 out of 211 cases]. There was no relationship between PTLD and sex [P = .20]. There were no statistically significance differences considering the age at transplantation between patients with and without PTLD. The late-onset PTLD [70.6%] occurred more frequently compared to the early form. There was no signification relationship between early-onset and late-onset groups in terms of clinical course and outcome. In patients who received azathioprine, PTLD was more frequent when compared to those who received mycophenolate mofetil [P < .001]. The lymph nodes were the predominantly involved site [35.3%], followed by the gastrointestinal tract, brain, kidney allograft, lung, ovary, vertebrae, and palatine. Age at diagnosis and the time from transplantation to diagnosis were comparable for various involvement sites of PTLDs. The overall mortality in this series of patients was 51.0%. Posttransplant lymphoproliferative disorder is a rare but devastating complication and long-term prognosis can be improved with early recognition and appropriate therapy

En Bloc Kidney Transplantation from Pediatric Cadaveric Donors to Adult Recipients

The shortage of cadaveric donors for kidney transplantation has led to the expansion of the criteria used for donor selection, such as the use of pediatric cadaveric donors. In this study we reviewed our results of en bloc kidney transplantation of pediatric cadaveric donors to adults. From May 2001 to May 2005, 245 cadaveric kidney transplants have been performed in our hospitals. Seven of these were en bloc kidney transplantations in adult recipients from marginal pediatric donors [age < 5 years, donor weight < 15 kg, high creatinine clearance, or kidney length < 8 cm]. We reviewed their records. Follow-up [range, 3 to 24 months] included ultrasonography, dimercaptosuccinic acid renal scintigraphy, and magnetic resonance imaging. Serum levels of creatinine ranged between 0.8 m/dL to 1.9 mg/dL during the follow-up period. One patient died of myocardial infarction 3 months postoperatively. One-year graft and patient survivals were both 85.7%. Complications included acute tubular necrosis in 1 patient [managed by conservative therapy and dialysis for 2 weeks], renal vein thrombosis in 1 [treated by anticoagulation], and subcutaneous hematoma in 1. There were no urologic complications. Median size of the grafts was 7.2 cm preoperatively that reached 9.6 cm, 3 months postoperatively [P =.018]. Twelve months following operation, the median size of the grafts reached 11 cm [P =.045]. En bloc pediatric kidney transplantation is a safe and suitable alternative for adult recipients. One-year graft and patient survivals are acceptable and complication rate is low

Prediction of prostatic involvement by transitional cell carcinoma of the bladder using pathologic characteristics of the bladder tumor

The aim of this prospective study is to determine the relationship between the pathologic characteristics of the transitional cell carcinoma [TCC] of the bladder and prostatic involvement. Sixty men with bladder TCC underwent standard radical cystoprostatectomy and were enrolled in this study. Vascular and perineural invasion, maximum diameter of the tumor, presence of carcinoma in situ, distance between the tumor and the bladder neck, and grade and local stage of the tumor were recorded and their relation with prostatic involvement was studied. In addition, hydronephrosis and age of the patients were included in the analysis. The mean age of the patients was 63.9 +/- 11.1 years. Of 60 men included in this study, 15 patients were found to have prostatic involvement with TCC [25%]. Univariate statistical analyses showed that vascular invasion and the distance between the tumor and the bladder neck were significantly related to the prostatic involvement [P = .007; P < .001]. But, in the logistic regression, only the distance between the tumor and the bladder neck was significantly related to the prostatic involvement [P = .001]. This study suggests that the probability of prostatic involvement in patients with bladder TCC tumors near the bladder neck is high. Prostate-sparing or capsule-sparing cystectomy should be avoided in such patients

Gil-vernet antireflux surgery in treatment of lower pole reflux

Prevalence of ureter and kidney duplication is roughly 1 per 125 people, and is associated with vesicoureteral reflux to lower pole in about 45% of cases. From antireflux surgical principles viewpoint, standard antireflux surgeries can be performed in these kidneys without releasing ureters from each other. We studied the results of Gil-Vernet antireflux surgery in 12 patients with duplicated collecting system and lower pole reflux. Between 1996 and 2000, 12 patients with unilateral duplicated system underwent Gil-Vernet antireflux surgery. There were 8 [67%] females and 4 [33%] males with a median age of 5.6 years. Of the patients, 50% had unilateral lower pole reflux in duplex system and 50% had bilateral reflux. Twelve patients with lower pole reflux in duplicated system, and overall, 18 refluxing renal units were treated, using Gil-Vernet antireflux surgery. In 11 [92%] patients, upper pole orifices were non-refluxing and without ureterocele. One [8%] patient had upper pole ureterocele that was treated by a small medial incision in the same session. Median hospital stay was 4 days, and median follow-up was 10 months, in 10 patients who were followed. Of patients, 80% and of refluxing units, 94% improved. Overall, success rate was 88%. Gil-Vernet antireflux surgery is a simple technique, associating with minimum ureteral manipulation for releasing them. Accordingly, we recommend Gil-Vernet antireflux surgery as the first line surgical modality for duplicated ureters with lower pole reflux, without upper pole ureterocele

Acute urinary retention in children

Acute urinary retention in children is a relatively rare entity. There are a variety of causes that are poorly defined in the literature. We review our cases of acute urinary retention in children at three major pediatrics centers in Iran. Between 1996 and 2003, children [up to 14 years old] who had been referred due to acute urinary retention were examined. Urinary retention was defined as inability to empty the bladder volitionally for more than 12 hours with a urine volume greater than expected for age or a palpably distended bladder. All data from the patients' past medical history, physical examination, and laboratory and radiographic assessments were collected. Also, cystourethroscopy and urodynamic procedures had been carried out according to patient's conditions. Patients with secondary urinary retention, including those with surgical history, immobility or chronic neurological disorders, mental retardation, and drugs or narcotics consumption were excluded from study. There were 86 patients meeting the inclusion criteria, consisting of 58 males with a median age of 4 years [range 1 month to 14 years] and 58 females with a median age of 4 years [range 4 month to 14 years]. Etiologies were lower urinary tract stone in 27.9%, neurological disorders in 10.4%, trauma in 10.4%, local inflammatory causes in 9.1%, urinary tract infection in 7.4%, ureterocele in 7.4%, benign obstructing lesions in 5.8%, iatrogenic in 5.8%, constipation in 4.6%, imperforated hymen in 3.5%, and large prostate utricle, urethral foreign body, and rhabdomyosarcoma each in 1 case [1.1%]. The most common cause of acute urinary retention was lower urinary tract stone in our pediatric cases. Ureterocele and stone were the main findings in girls and boys, respectively, and urinary retention in boys was twice as prevalent as that in girls

benefits of outpatient surgery over surgery in the hospital: report of 4177 urologic outpatient operations

From 1983 until 1987, 4177 outpatient urologic procedures were performed at Shahid Labbafi Nejad Medical Center. 34% of the cases were open surgical, while 66% were endourologic procedures. There was no surgical complication related to the outpatient aspect of the procedure. Rate of infection in open surgical cases was almost zero. The number of procedures was increased each succeeding year. Also more difficult cases [like penile prosthesis, epididymovasostomy, priapism, sphincterotomy,...] were included in the program. We recommend outpatient surgery as one of the best approaches to make surgery much more economic and if properly done, still offer better quality care to the patient

Important diagnostic and surgical points in horseshoe kidney surgery

From April, 1983 until December, 1987, 15 patients with horseshoe kidneys underwent surgery in Shahid Labbafi Nejad Medical Center. Pyelolithotomy was done in 11 cases, pyeloplasty in 2 cases, and nephrectomy in 2 cases. Symphysiotomy was performed in 14 of these patients. Preoperative angiography was not done in any of the cases and midline transperitoneal approach was utilized in all of the cases. We consider angiography an unnecessary invasive procedure in the great majority of the horseshoe kidney operations. Midline transperitoneal approach is far superior to flank approach in horseshoe kidney surgery. We also prefer symphysiotomy in these cases, since it improves drainage from horseshoe kidney pelvices

decrease in the incidence of syphilis in Iran and the effect of Islamic rules in controlling sexually-transmitted diseases

Venereal diseases are still a common problem in today's world. Even though tremendous advances are being made in medicine and large budgets are being spent to control sexually transmitted diseases [STD], especially in western countries, these diseases are still yet very common, and today AIDS has been added to the threats posed by STD to human life. The status of syphilis was evaluated in Iran in the years before and after the Islamic Revolution by comparing RPR test results in blood specimens obtained for transfusions from all groups of the society. RPR positivity was 0.6% for the years 1974-76, while it was only 0.2% for the years 1985-87, demonstrating a sharp decline. Divine laws, especially those offered by Islamic rules, are much more effective than present expensive medical measures to control venereal diseases, and can return sexual health to the human society

new approach to vesicoureteral reflux persisting after posterior urethral valve ablation using gilvernet antireflux technique

Classic antireflux procedures on children with a history of posterior urethral valve does not usually yield good results and often ends up with ureteral obstruction and even permanent urinary diversion. From 1981 through 1988, 21 boys with history of posterior urethral valve [PUV] underwent evaluation for vesicoureteral [VU] reflux; 17 boys had VU reflux. Following valve ablation, reflux disappeared in nine cases. Eight boys continued to have reflux [average follow up after valve ablation was 17 months]. The grade of refluxes was IV or higher in all of the cases. Gil-Vernet antireflux procedure was performed in these boys. VU reflux disappeared in 11 of 12 refluxing ureters in these eight boys postoperatively. An excellent success rate [91.7%] was seen without upper tract deterioration in any of the cases. Average follow up was six months with the longest being 13 months. This is the first report of the application of Gil-Vernet antireflux technique in persistent reflux following valve ablation and seems a breakthrough in management of PUV reflux, eliminating the need for preliminary diversion as performed in the past. We recommend this simple, highly effective approach as the procedure of choice in management of VU refluxes following valve ablation in children with PUV