Clinical Profile of Urogenital Fistula in Kathmandu Model Hospital.

BACKGROUND: To determine the causes of fistula and to share our experience in treating urogenital fistula and its surgical outcome. METHODS: This was a retrospective study done at Kathmandu Model Hospital from January 2014 to June 2019 including 261 patients operated for fistula. The patients were analyzed for age, type of fistula, cause, treatment and surgical outcome. RESULTS: Out of 261 patients operated, 59.38% cases had obstetric fistula, 38.69% had iatrogenic and 1.92% had traumatic fistula. Most of the patients with obstetric fistula were between 21 to 25 years of age whereas iatrogenic fistulae were between 46-50 years of age. The majority (54.84%) of obstetric fistulae were vesicovaginal fistula (54.84%) while the commonest type (77.36%) of iatrogenic fistula was vault fistula after abdominal hysterectomy. CONCLUSIONS: This study showed that obstructed and neglected labor was still the major cause of genitourinary fistula in Nepal nevertheless iatrogenic fistula following pelvic surgery is increasing. The surgical outcome of repair of fistula was good.

Initial Experience of Retroperitoneoscopic Surgery in Benign Renal Diseases.

BACKGROUND: To review our early experience to determine the feasibility, efficacy and clinical outcomes of retroperitoneoscopic surgery in benign renal diseases. METHODS: This is a prospective observational study carried out between December 2014 to March 2018. Among 14 patients enrolled in the study, 9 cases of nonfunctioning kidney underwent retroperitoneoscopic simple nephrectony, 4 cases of benign renal cortical cysts underwent decortication of cysts and one case of pelviureteric junction obstruction underwent Anderson Hynes pyeloplasty. RESULTS: Retroperitoneoscopic nephrectomy, renal cyst decortication and A-H pyeloplasty were performed in 13 patients successfully. The procedure in one patient of RP nephrectomy converted to open surgery due to dense perinephric and hilar adhesions. Which resulted to failure to progress. The mean operative time of RP nephrectomy, decortications and pyeloplasty were 206.4 (150-248), 67.5 (60-80) and 275 minutes, average blood loss was 96.7 (50-120), 27.5 (20-30) and 70 ml, and the mean hospital stay were 3.5 (3-4), 2 (2-2) and 4 days respectively. The perioperative period was uneventful. CONCLUSIONS: Retroperitoneoscopic surgery is feasible and safe in benign renal diseases. Because of reduced post operative pain and less chances of bowel injury, retroperitoneoscopic surgery is gaining more popularity.

Managing Ureterovaginal Fistulas following Obstetric and Gynecological Surgeries.

BACKGROUND: Iatrogenic ureteric injuries leading to fistula are rare but devastating complications of obstetric and gynecological surgeries. The aim of the study was to review the demography of ureterovaginal fistula (UVF) and its surgical outcome in Kathmandu Model Hospital. METHODS: This is a review of 15 patients of ureterovaginal fistula who were referred to department of Obstetrics and Gynaecology of Kathmandu Model Hospital from Feb 2014 to Sept 2017. We reviewed the demography, causes and surgical outcome of ureterovaginal fistula (UVF). Ten patients who had complete blind end at the distal ureter, underwent Lich-Gregoir extravesical ureteroneocystostomy. In other five patients, guide wire was successfully negotiated beyond the fistula site, however retrograde double J stenting could be done in only four patients. RESULTS: All the patients had distal ureteric injury close to vesicoureteric junction leading to ureterovaginal fistula. Among them, majority were due to post-hysterectomy in 60% (n=9) followed by obstetrical procedures in 40% (n=6). Fourteen patients (93%) had successful closure of the fistula with complete preservation of renal function. Retrograde double J stenting was possible in patients who were referred earlier within two weeks of the onset of injury. CONCLUSIONS: Iatrogenic injury to the distal ureter during surgery was the leading cause for the ureterovaginal fistula. Endoscopic management with ureteric stents was still possible if the patients were referred earlier following primary surgery.

Post-transplant small cell carcinoma arising in the native kidney of renal transplant recipient.

Small cell carcinoma (SCC) originating from kidney is extremely rare. To date, there has been no reported case of primary SCC of renal transplant recipients' (RTRs)' own kidney. Here, we report the first case of primary SCC of RTRs' own kidney. Resection of bilateral native kidneys, possessing whole length of ureters and small cuffs of bladder along with a neoplasm located in her right kidney, was performed on a 68-year-old female patient, five years after renal transplantation. The immuno-histochemical result confirmed mixed SCC of the right kidney (SCC combined with little transitional cell carcinoma). Postoperatively, platinum-based adjuvant chemotherapy (Cisplatin combined with Gemcitabine) was given, and the patient is still alive with well-functioning transplanted kidney.

Mortality rate prediction by Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM), Portsmouth POSSUM and Colorectal POSSUM and the development of new scoring systems in Chinese colorectal cancer patients.

BACKGROUND: The aim of this study was to compare the Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM), Portsmouth POSSUM (P-POSSUM), and Colorectal POSSUM (Cr-POSSUM) for predicting surgical mortality in Chinese colorectal cancer patients and to create new scoring systems to achieve better prediction. METHODS: Data from 903 patients undergoing surgery for colon and rectal cancers from 1992 to 2005 at Peking University Third Hospital were included in this study. POSSUM, P-POSSUM, and Cr-POSSUM were used to predict mortality. Stepwise logistic regression was used to develop the modified P-POSSUM and Cr-POSSUM. Their performances were tested by receiver operating characteristic curve, Hosmer-Lemeshow statistic, and observed:expected ratio. RESULTS: The actual inpatient mortality was 1.0% (9 of 903). The predicted mortality of POSSUM, P-POSSUM, and Cr-POSSUM were 5.6%, 2.8%, and 4.8%, respectively, which were significantly higher than the actual mortality in our cohort. The predicted mortality of the modified P-POSSUM and Cr-POSSUM was very close to the observed mortality. Both the modified models offered better accuracy than P-POSSUM. CONCLUSIONS: The predicted mortality of POSSUM, P-POSSUM, and Cr-POSSUM were significantly higher than the observed mortality in our patients. The modified P-POSSUM and Cr-POSSUM models provided an accurate prediction of inpatient mortality rate in colorectal cancer patients in China.