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

Forgotten ureteral stents: an avoidable morbidity

Objective: To assess the clinical presentation of forgotten ureteral stents and highlight the etiological factors resulting in the retention of these stents. Study Design: Observational study. Place and Duration of Study: Department of Urology, Armed Forces Institute of Urology, Rawalpindi, from January 2010 to June 2011

Methodology: Thirty-eight patients, with forgotten ureteral stents, retained for more than 6 months duration, were enrolled. A detailed evaluation was performed, along with the questions regarding the patients' opinion about the ureteral stents. They were specially asked whether they knew about the stents or were they formally informed regarding the stents. Subsequently, the patients were managed according to their clinical condition

Results: The male to female ratio was 2.1:1 aged 23 - 69 years, mean being 40.24 +/- 12.59 years. The time of presentation after the ureteral stenting was 7 - 180 months [mean = 28.89 +/- 33.435 years]. Seven patients [18.4%] reported with chronic kidney disease, including ESRD in two cases. Recurrent UTI was seen in 28 cases [73.6%], calculus formed over the stents in 20 cases [52.6%], and stent fragmented in 5 patients [13.1%]. Majority of patients, [n = 23, 60.5%], were not even aware of the placement of these stents while 8 [21.0%] knew but were reluctant about its removal. In 3 cases [7.8%], the relatives knew about the stent but never informed the patients. The stent had been removed in 2 cases [5.2%], but the other broken fragment was missed. One case [2.6%] each had a misconception about the permanent placement of the stents like cardiac stents and regarding degradation of the stents in situ

Conclusion: Forgotten ureteral stents produce clinical features ranging from recurrent UTI to ESRD. This preventable urological complication is primarily due to the unawareness or ignorance of the patients and their relatives regarding the stent

Inverted papilloma of ureter: a rare cause of hydronephrosis

A case of hydronephrosis with a rare underlying cause in a 35 years old male is described. He reported with pain in the left lumbar region with a past history of left ureterolithotomy. The ultrasound and IVU studies were suggestive of left hydronephroureter. CT Scan showed left hydronephroureter with narrowing at the lower end of left ureter. Ureterorenoscopy [URS] confirmed polypoidal lesions in the left lower ureter, completely obliterating the lumen and involving the whole circumferential wall of the lower ureter. The biopsy of the lesion revealed an inflammatory polyp. Accordingly open surgical intervention was planned. Excision of the lower third of left ureter with ureteric reimplantation was done with a Boari flap. The histopathology report of the lower third of ureter confirmed inverted papilloma of ureter. The patient made a smooth postoperative recovery

Pattern of malignant renal tumours using 2004 who classification of renal tumours on radical nephrectomy

Objective: To determine the type of malignant renal tumours subjected to radical nephrectomy at a tertiary care urology unit using the 2004 WHO classification for renal tumours. Methods: It was an observational study conducted at Department of Urology, AFIU Rawalpindi, from October 2008 to September 2010. The study included 92 patients with malignant renal tumours of both genders aged above 15 years. The histopathological types and grades were recorded along with the gross tumour presentation. The data was entered in structured proforma and analysed for descriptive statistics using SPSS-14. Results: Over the span of 24 months study, 92 cases of malignant renal tumours were subjected to radical nephrectomy. The age was 16–82 [57.23 +/- 14.61] Years and male to female ratio was 2.1:1. The lesions were mostly unifocal [96.7%] and 58.6% affecting the right side. The commonest malignant renal tumour encountered was the conventional clear cell renal carcinoma [78.2%]. The other tumours in descending order were the transitional cell carcinoma [7.6%], papillary [chromphilic] renal cell carcinoma [6.5%], renal cell carcinoma unclassified [3.2%], chromophobe renal cell carcinoma [2.1%], Wilm's tumour and oncocytoma [1.7%]. T1 lesions were found in 42 cases [45.6%], T2 lesions in 25 cases [27.1%], T3a lesions in 17 cases [18.4%] each, while 8 cases [8.6%] had T3b lesions. Four cases had high and 3 had low grade lesions in transitional cell carcinoma. Wilm's tumour had favourable prognosis, 1 case had oncocytoma limited to kidney. Among the rest, 26 [28.2%] were G1, 35 [38%] were G2, 16 [17.3%] were G3, and 6 [6.5] were G4. Conclusion: The commonest type of the malignant renal neoplasm remains the clear cell [conventional] renal cell carcinoma. The lesions from T1 to T3 are amenable to radical nephrectomy and may not include the ipsilateral adrenalectomy as well. The grade may range from G1 to G4

Bladder outlet obstruction in a 5 years boy

We report a 5 years old boy with bladder outlet obstruction secondary to a fibroepithelial polyp of prostatic urethra. The micturating cystourethrogram showed a filling defect in the posterior urethra. Cystourethroscopy revealed a polyp in the prostatic urethra proximal to the verumontanum. Transurethral resection was done and histopathology confirmed fibroepithelial polyp of the urethra

rare complication of forgotten ureteral stent

A 35 years old lady presented with history of something coming out of the genitalia for the last 5 days. She also had history of pain in the left lumbar region which was initially investigated but the patient did not follow-up. About 15 years ago she also underwent left ureteric reimplantation. On examination, a stick like tube was protruding out of the urethral meatus which was fixed to the underlying vesical calculus. The calculus was evident radiologically and on ultrasound. The projecting portion of the stick like tube was cut and the vesical calculus with the inner portion of the tube was removed by open procedure. On evaluation of the specimen, it was found that the vesical calculus was fixed to the plastic tube which had concretions around it. This plastic tube had been placed after the ureteric reimplantation done 15 years age and the patients was not aware of it

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

Allergic broncho-pulmonary aspergillosis presenting as flitting opacities on chest radiograph

Allergic broncho-pulmonary aspergillosis [ABPA] is hypersensitivity reaction to Aspergillus fumigatus in the bronchial tree of young asthmatic patients. A 28 years old female patient presented with one year history of fever with generalised body aches and pains and had already received treatment for pulmonary tuberculosis. Her chest radiograph showed flitting opacities in both lung fields with a TLC of 13.2 x10[9]/L having 25% eosinophils and ESR of 87 mm at first hour. Her serum IgE were markedly raised and CT scan of the chest showed dilated large and medium sized bronchi forming mucocoeles, finger in glove appearance and nodular shadowing in the lung parenchyma. Sputum also showed fungal hyphae by direct microscopy. All the findings were consistent with the diagnosis of ABPA, which responded to oral Itraconazole and Prednisolone. ABPA is a potentially destructive lung disease requiring high index of suspicion for an early diagnosis to prevent irreversible lung damage

Ruptured ovarian teratoma presenting as peritonitis

A 55-year-old lady reported to the surgical OPD with clinical findings of acute peritonitis. Emergency laparotomy was performed. The peritoneal cavity was full of purulent material, however, the gut was normal. An 8 x 6 cm thick walled cyst was found in the left ovary with a minute perforation and purulent fluid coming out of it. Thorough peritoneal lavage along with left oophorectomy was performed. The postoperative recovery was smooth. Histopathology confirmed benign cystic teratoma of ovary

Acute acalculous perforated cholecystitis

A case of acute acalculous perforated cholecystitis with acute generalized peritonitis in a middle aged cachectic man, presenting late in a moribund condition, is reported. He underwent emergency laparotomy [subtotal cholecystectomy], went into multi-organ failure and was managed accordingly. The patient recovered in about 2 weeks and was followed-up regularly

Clinico-pathological profile and outcome of inhalational burns

To determine clinico-pathological profile and outcome of inhalational burns in a specialized burns treatment unit. Case-series. The Department of Plastic Surgery and Burns Centre Unit, Combined Military Hospital, Kharian Cantonment in March 2005. Patients of inhalational burns were included and evacuated within 30 hours of accident to the specialized burns centre after immediate resuscitation. Total Body Surface Area [TBSA] involved in burns was calculated. Complete blood count and renal profile along with serum albumin and total proteins was obtained. Portable chest radiographs and bronchoscopic examination was conducted. Escarotomies were carried and wounds were covered with split thickess skin grafts. Ventilatory support was used as needed. Comparison of the clinico-pathological profile of surviving and fatal cases was done for significance using t-test. There were 19 patients of inhalational burns, 8 [42%] of whom expired. The mean percentage of TBSA in 11 surviving patients was 50 +/- 10.87 and 70 +/- 15.46 in fatal cases. The mean haemoglobin [Hb] on admission was 15.8 +/- 1.6 g/dL and after fluid resuscitation it became 11.4 +/- 1.5 g/dL. The mean Total Leucocyte Count [TLC] in surviving patients was 9.6 +/- 6.1x10[9]/L and 1.5 +/- 2.3x10[9]/L in fatal cases [p=0.001]. The mean platelet count of surviving patients was 205 +/- 63x10[12]/L while in fatal cases was 58 +/- 48x10[12]/L [p=0.05]. The serum urea levels in surviving patients was 4.3 +/- 2 mmol/L while in fatal cases was 8.6 +/- 0.9 mmol/L [p=0.05]. The serum creatinine levels were 98.2 +/- 16.5 micro mol/L in the survivor group and 249.5 +/- 76 micro mol/L in the mortality group [p=0.05]. The serum total protein in surviving patients was 63 +/- 8 g/dL while in mortality cases it was 57 +/- 7 g/L. Serum albumin in the survivor group was 36.7 +/- 5 g/L and 35 +/- 4 g/L in fatal cases. Significant in Hb, protein and albumin levels. All the expired patients had acute respiratory distress syndrome while acute renal failure with multi-organ failure co-existed in 6 patients. Inhalational burns injury cases multi-system injury with high mortality. Body area involvement, total leucocyte count, platelet count, serum area and serum creatinine are important indicators of survival

Open extraperitoneal mesh repair for abdominal wall hernias in females

To determine the outcome of treatment in terms of infection and recurrence using open extraperitoneal mesh repair technique. Quasi-experimental study. The department of General Surgery, Combined Military Hospital, Bahawal Nagar Cantonment, from February 2006 to November 2008. Female patients with abdominal wall hernias with defect of 4 cm or more were studied. A history of previous surgery along with clinical findings on examination like size of defect and previous scar were noted. At surgery, hernial sacs were carefully opened and omental and intestinal adhesions were carefully separated. Polypropylene mesh was placed over extraperitoneal space and secured with interrupted vicryl 2/0 sutures. Redivac drains were placed over the mesh and the fascial repair. The patients were discharged on the 3rd - 4th postoperative day and were followed-up at 3 monthly intervals for postoperative sequelae like seroma, haematoma, infection and recurrence. There were 32 cases with a mean age of 41.25 +/- 10.79 years. The mean follow-up period was 15.78 +/- 9.02 months. Previous abdominal surgical intervention was found in 16 [50%] cases. Out of those, 14 [43.7%] had defects through the previous scar. A history of multiple caesarean sections alone, or in combination with either hysterectomy or laparotomy in the last 5 years was present in 7 patients. There were 12 [37.5%] cases of paraumbilical hernia, 4 [12.5%] of a recurrent paraumbilical hernia, 5 [15.6%] epigastric hernia, 2 [6.2%] mix hernia, 7 [21.8%] incisional hernia and 1 [3.1%] each of Spigelian hernia and postlaparoscopic cholecystectomy portal [paraumbilical] hernia. The mean size of the defect was 4.9 cm in primary paraumbilical hernias and 7.2 cm in recurrent paraumbilical hernias. The mean size of the defect in incisional hernias was 9.4 cm, larger than all other types. Superficial wound infection was seen in only 1 morbidly obese [BMI > 30] patient. No case of seroma, haematoma, deep seated abscess or recurrence was noted in the follow-up period. Abdominal wall hernias are common in female patients, especially those with previous surgical intervention. Open extraperitoneal mesh repair with placement of redivac drains is an effective method for the management of abdominal wall hernias with a smaller complication rate and less recurrence

Primary perisplenic hydatid cyst

Splenic parasitic cysts due to flat worm Ecbinococi resuling in hydatid disease are a rare presentation as primary site even in the endemic regions. Primary splenic parasitic cysts have an incidence of 0.5-4%. A 21-year-old male with pet dogs at home, presented with 3 months history of gradually increasing discomfort in the left hypochondrium and tender splenomegaly. He had marked eosinophilia with normal liver function tests and positive serum IgM Echinococcus antibodies. Ultrasonography showed a cyst in the hilar region of spleen having septations with internal echos. An upper midline laparotomy was performed and a perisplenic cyst was removed along with spleen from the sub-diaphragmatic location. Histopathological examination confirmed acellular fibrous wall of hydatid cyst with germinal layer and scolices in the centre. Postoperatively, patient was continued on oral Albendazole for one month

Cholecysto-hydatid cyst fistula

We present a case of recurrent hydatid cyst liver in a 32-year-old female. Previous surgery was performed 8 years ago elsewhere. Pre-operative assessment at presentation revealed a 110 x 105 mm hydatid cyst in the right lobe of the liver. On exploration, a 5 mm fistulous communication was found between the hydatid cyst and the gallbladder. Patient was subjected to endocystectomy [partial cystectomy], cholecystectomy and closure of the fistula followed by obliteration of the cavity with omentum. Postoperative recovery was uneventful

Retroperitoneal masses: different clinical scenarios

We present two cases of retroperitoneal masses with different presentations and outcomes. The first case was a 22 years old primigravida lady who underwent emergency caesarean section for preterm premature rupture of membranes with breach. On the operating table, a large retroperitoneal mass was identified and the biopsy confirmed Burkitt's lymphoma. Post operative chemotherapy did not have a favourable result and the patient had a fatal outcome. The other case was a 15 years old boy who had a progressively increasing retroperitoneal mass. Exploratory laparotomy revealed a hard, fixed, unresectable tumour extending into the mesentery of the small gut, biopsies were taken which showed tuberculosis. Post operative antituberculosis treatment had a marked response and the tumour disappeared after 6 months

Paroxysmal nocturnal hemoglobinuria

Paroxysmal Nocturnal Hemoglobinuria [PNH] literally means to have episodes of hemoglobin in the urine during the night. It is a Coomb's negative rare hemolytic disorder characterized by non-malignant clonal expansion of haemopoietic stem cells due to acquired genetic mutations. A 30 years old male patient presented with 5 years history of transfusion dependent anemia with intermittent episodes of passing dark colored urine in the morning. Blood complete picture showed decreased hemoglobin and reticulocytosis upto 30%. Coomb's test was negative with unconjugated hyperbilirubinemia and markedly raised serum LDH. Urine analysis showed marked hemosiderinuria and flow cytometry revealed 60% RBCs deficient for CD-59, confirming the diagnosis of paroxysmal nocturnal hemoglobinuria. The management of the patient depends on whether anemia is due to hemolysis or as consequence of impaired erythropoiesis. Corticosteroids at a dose of 0.25-1 mg/kg/day was selected as it is amongst the various treatment options in patients with predominant hemolysis