Radical cystectomy in patients with transitional cell carcinoma urinary bladder

Objective:To find out various presentations, types of operations performed, perioperative complications, pathological staging and oncological outcome of patients with transitional cell carcinoma [TCC] urinary bladder treated with radical cystectomy

Study design: Descriptive case series

Place and Duration of study: Department of Urology Jinnah Postgraduate Medical Centre Karachi, from January 2009 to December 2014

Methodology: All patients who underwent radical cystectomy with bilateral pelvic iliac lymphadenectomy due to muscle invasive transitional cell carcinoma of bladder with or without adjuvant or neo-adjuvant chemotherapy or radiotherapy from January 2009 to December2014 with minimum of two years follow up, were included in the study. Patients with proven metastasis were excluded. Clinical presentations, details of surgeries, post-operative complications, pathological staging and oncological outcomes were recorded

Results: Thirty-two patients were operated. Age ranged from 35 to 70 year. There were.28 males [87.5%] and 04 females [12.5%] patients. Painless hematuria was the most common clinical presentation. Most [81.2%] of the patients were diagnosed as muscle invasive transitional cell carcinoma on first trans-urethral resection of bladder growth [TURBT]. Radical cystectomy with standard pelvic lymph node dissection [PLND] and ileal conduit were performed in all patients. Two [6.2%] patients died in perioperative period. Fourteen [43.8%] patients developed complications. Pathological staging revealed non-organ confined disease with positive lymph node in six [18.6%] patients. Disease free survival [DFS] was noted in 68.7% of patients. Over-all survival was 65.6%

Conclusion: Radical cystectomy in patients with potentially invasive or invasive TCC bladder helped in achieving long term survival in majority of the patients

Delayed single stage perineal posterior urethroplasty

To determine the delayed single stage perineal posterior urethroplasty for treatment of posterior urethral stricture/distraction defect. Descriptive case series. Department of Urology, Jinnah Postgraduate Medical Centre, Karachi, from January 2009 to December 2011. Patients were selected for delayed single stage perineal posterior urethroplasty for treatment of posterior urethral stricture / distraction defect. All were initially suprapubically catheterized followed by definitive surgery after at least 3 months. Thirty male patients were analyzed with a mean follow-up of 10 months, 2 patients were excluded as they developed failure in first 3 months postoperatively. Mean patient's age was 26.25 +/- 7.9 years. On follow-up, 7 patients [23.3%] experienced recurrent stricture during first 10 months. Five [16.6%] patients were treated successfully with single direct visual internal urethrotomy. Two patients [6.6%] had more than one direct visual internal urethrotomy and considered failed. Re-do perineal urethroplasty was eventually performed. The overall success rate was 93.3% with permissive criteria allowing single direct visual internal urethrotomy and 76.6% with strict criteria allowing no more procedures postoperatively. Posterior anastomotic urethroplasty offers excellent long-term results to patients with posterior urethral trauma and distraction defect even after multiple prior procedures

Open dismembered pyeloplasty for uretero-pelvic junction obstruction

To report our experience with open dismembered pyeloplasty for uretero-pelvic junction obstruction. Retrospective study was conducted in the Department of Urology, Jinnah Postgraduate Medical Centre, Karachi for a period of five and half years from May, 2006 to December, 2011. All patients with uretero-pelvic junction obstruction were entered into a database to record patients clinical features, diagnostic tools, operative and post-operative details and follow-up. Over a five-years period, 13 procedures were performed. After clinical evaluation all patient had extensive haematological and radiological workup for diagnosis of uretero-pelvic junction obstruction. All were subjected to open pyeloplasties, out of these 13 patients; one had an aberrant lower pole vessel compressing uretero-pelvic-junction. All procedures were stented. Repair was done with 3/0 vicryl sutures all patients were catheterized and wound drained. Mean operating time was 60 - 100 minutes with about 100cc blood loss requiring no transfusion. The mean follow up was one year. One patient developed post-operative haematuria and was managed conservatively. Two patients developed fever secondary to urinary tract infection despite adequate treatment of urinary tract infection according to culture and sensitivity pre-operatively. One patient developed surgical emphysema detected post-operatively, which required tube thoracostomy. Neither patient developed recurrent symptoms nor had any evidence of obstruction on the renogram on follow-up. Objectively all patients were followed up by intravenous urogram, stress renogram, Urine C/S. Subjective and objective follow-up revealed success in 100% of patients whereas success is defined as no or minimal holder on DTPA renogram, improving renal function and decreasing dilatation on successive intravenous urogram. All patients had a mean post-operative hospital stay of 02 - 04 days Folley catheter was removed after 10-days, double-j- stents were removed after two to three weeks. Our success rate following open pyeloplasty with limited follow-up was 100%. It is comparable with International data. Recent international trend is toward Uretro-pelvic Junction Obstruction [UPJO] repair with laparoscopic approach, they are claiming success rate of 95%

Arterio venous fistula experience at a tertiary care hospital in Pakistan

To evaluate the two year patency rate of functioning arteriovenous fistula. This prospective case series study was conducted at Department of Urology, Jinnah Postgraduate Medical Centre, Karachi, from 1[st] January 2009 to 31[st] December, 2010. Patients were chosen for CBRC arteriovenous fistula at wrist and patients undergoing other types of vascular access or secondary fistula formation were excluded. One hundred and eighty two patients underwent arteriovenous fistula formation. The mean +/- SD age was 63 +/- 13 years and there were 102 [56%] males and 80 [44%] females. 12.6% fistulae failed within first month without dialysis. The primary patency rate was 66.5% at three months and 57.7% at six months. Failing arteriovenous fistula was managed by new arteriovenous fistula in our series. 28.6% patients had redo arteriovenous fistula. This study demonstrated a poor outcome for fistulas in diabetic patients. Fifteen out of 23 [65.2%] who failed primarily were diabetics and out of these diabetics 13 [86.7%] failed in first three months. Infection and burst fistulae were found in nine [4.9%], pseudo aneurysm in 3.2%, fever 4.9%, peri-operative failure 0.55% and burst fistulae 3.2%. One-third of radiocephalic fistulas fail within two years. The outcome is worse for women and diabetic patients. This information may be useful in assessing and counseling patients with end-stage renal failure. Arteriovenous fistula is the better and ideal choice for haemodialysis. A Radiocephalic fistula in forearm seems to have better results as comparison to cubital fossa arteriovenous fistula. End to side anastomosis results are better than side to side anastomosis

Outcome of urethro cutaneous fistula repair

To evaluate the outcome of urethro cutaneous fistula repair. This was a prospective study conducted in department of urology Jinnah Postgraduate Medical Centre [JPMC], Karachi. Seventeen cases with urethrocutaneous fistulas were enrolled in this study. In 12 [75%] we did the simple repair and second layer with dartos, in 03 [16.7%] OIU and silicone catheterization was done, but they recurred then repair with tunica vaginalis cover was performed and 02 [8.3%] patient underwent OIU plus simple repair with dartos. The mean age was 25.58 +/- 6.2 years, in 11 post hypospadiasis was the cause of urethrocutaneous fistula. Recurrence was observed in four patients. Two patients after post hypospadias repair; one after stricture peno-scrotal and one after post infection, boil at base of penis had recurrence. Two patients with simple repair and 2[nd] layer with dartos had recurrence, two patients treated with OIU had recurrence and after that repair with tunica vaginalis cover was performed with no recurrence and none of the patients treated with OIU plus simple repair with dartos had recurrence. Circumferential incision around the fistula opening, tension free closure with fine PDS suture is the key for successful treatment of urethral fistula